Robert S. Brown

Outcome of patients with renal insufficiency undergoing liver or liver-kidney transplantation.

Renal insufficiency (RI) is a common finding with end-stage liver disease. RI is generally not regarded as a contraindication to liver transplantation. However, the impact of RI on outcome following transplantation and the role of combined liver-kidney transplant are not well understood. The effect of RI on patients with fulminant hepatic failure (FHF) or chronic liver disease (cirrhosis) was investigated using the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Liver Transplantation Database. Patients were analyzed based on the presence of RI, defined as creatinine >1.6 mg/dl, or on dialysis. Patients undergoing liver-kidney transplantation were analyzed separately. For patients with FHF, the RI group had a lower patient survival rate at 1 year (50% vs. 83%, P=0.04) and tended to have a lower graft survival rate (50% vs. 71%). Stay in the intensive care unit (ICU) was prolonged in the RI group but hospital stay was not. Among patients with cirrhosis, RI did not affect patient survival, except for patients on dialysis or those with liver-kidney transplants. One-year patient and graft survival rates were 65% and 60% for the dialysis group, 74% and 70% for the liver-kidney transplant group, 89% and 86% for RI patients not on dialysis, and 89 and 84% for non-RI patients. ICU and hospital stays were prolonged for all of the RI groups compared with the non-RI patients. Patients with RI had higher rates of posttransplant dialysis; however, the differences tended to equalize after 4 weeks. We conclude that RI in FHF and RI requiring dialysis or liver-kidney transplantation in cirrhosis predict lower posttransplant patient and graft survival rates. Patients with RI have longer hospital and ICU stays and an increased need for dialysis, which likely increases the cost of transplantation. Whether liver-kidney transplantation improves outcome and thus represents an appropriate use of cadaver kidneys requires further study.

A population-based cohort study comparing laparoscopic cholecystectomy and open cholecystectomy

A population-based cohort study comparing laparoscopic cholecystectomy and open cholecystectomy

Incidence and significance of Aspergillus cultures following liver and kidney transplantation

Aspergillus infection is a rare but devastating complication following solid organ transplantation, with mortality rates that approach 100%. Aspergillus species (sp) are also ubiquitous in our environment and may contaminate culture plates. To determine the significance of positive Aspergillus cultures, we analyzed all positive cultures from the liver and kidney transplant services at our center for the treatments used and clinical outcomes. Aspergillus sp. were cultured from 4.5% of liver and 2.2% of kidney transplant recipients. A. fumigatus was the most common isolate, followed by A. niger and A. flavus. The lung was the most common site of positive cultures. Body fluids (ascites, pleural fluid) were common sources of positive cultures but were never associated with clinical disease. Positive brain biopsies occurred in 10% of patients. Analysis of risk factors for significant infection revealed that cultures with >2 colonies or more than one site of infection were predictive of significant infection and portended a poor prognosis even with aggressive therapy. Two or fewer colonies from a single site likely represented contamination and may be followed with repeat cultures. The high mortality rate associated with Aspergillus sp. infections in transplant recipients highlights the need for better anti-fungal prophylaxis and treatment.

Enterococcal bacteremia after transjugular intrahepatic portosystemic shunts (TIPS)

The objective of this study was to analyze a series of patients with Enterococcus faecium infection following transjugular intrahepatic portosystemic shunts (TIPS) in order to define the risk factors, outcome, and role of treatment including hepatic transplantation. This study is a case series from a tertiary referral center for liver transplantation. The medical records of four patients referred to one teaching hospital in San Francisco between 1990 and 1995 for evaluation or management of Enterococcal infection following TIPS were reviewed. A review of the microbiology records of all 314 patients who underwent TIPS at that institution and a MEDLINE search were performed to assess whether any other cases existed. The effect of therapy on survival was assessed, in particular, the repeated use of TIPS and prolonged courses of antibiotics. All four patients had thrombosis of their TIPS at the time of diagnosis of enterococcal bacteremia. All were treated with prolonged courses of intravenous antibiotics. One patient had echocardiographic evidence of subacute bacterial endocarditis with chronic aortic insufficiency. In all cases, liver transplantation was contraindicated in the acute setting because of uncontrolled endovascular infection. Two of four patients survived; these were the only two patients who had had a successful repeat TIPS. Enterococcal bacteremia is a rare complication following TIPS but carries a high mortality. It usually occurs in the setting of technically difficult TIPS with shunt thrombosis. Management should be focused on long term antibiotics and attempts at reestablishment of portal decompression with another TIPS. Liver transplantation should not be considered until the infection is cleared. Prophylaxis for Enterococcus species should be considered in technically difficult or unsuccessful TIPS.

Cardiovascular Function in Shock Responses to Volume Loading and Isoproterenol Infusion

Hemodynamic responses to volume loading with infusion of dextran-40 and myocardial stimulation with isoproterenol in 23 patients in shock from hemorrhage, trauma, or sepsis, and 10 healthy controls were studied. Responses of the control were moderate to dextran and marked to isoproterenol. Shock patients were divided into three groups according to the response of the cardiac index to dextran-40: group I, >50% increase; group II, 15 to 50% increase; group III, <15% increase or a decrease. The central venous pressure of patients who responded to dextran (group I) generally rose moderately and that of those who failed to respond (group III) increased without improvement of cardiac index or stroke index, suggesting myocardial failure. Group II showed cardiac improvement at the expense of marked increase in venous pressure, suggesting relative cardiac insufficiency.Group I failed to respond to isoproterenol infusion, indicating that circulatory failure primarily resulted from failure of venous return. All group III patients responded markedly to isoproterenol. It is concluded that a significant number of patients in shock from hemorrhage, trauma, and sepsis exhibit signs of cardiac insufficiency. The ability of these hearts to respond to isoproterenol suggests that depletion or altered metabolism of endogenous catecholamines in part underlies this insufficiency. Further-more, it is suggested that cardiac insufficiency may contribute to the death of a significant number of patients with severe hemorrhagic and septic shock.

Comparative Evaluation of Sympathomimetic Amines in Clinical Shock

Comparative hemodynamic measurements were obtained in a series of 17 shock patients before and during infusion of four sympathomimetic amines. Cardiac output increased significantly only during infusion of isoproterenol. Cardiac work and mean arterial pressure were increased during administration of all four agents. Increased central venous pressure, central blood volume, total peripheral resistance, and stroke volume were observed during norepinephrine and metaraminol infusion. Methoxamine increased central venous pressure and peripheral resistance in these patients.Individual patient responses were analyzed in terms of their response to methoxamine. Hemodynamic changes characteristic of ventricular failure were observed in four patients who received methoxamine. Reversal of this pattern of ventricular failure was noted during infusion of agents with an inotropic effect. A hypothesis which explains these hemodynamic changes is discussed.

Pathology of the Kidney

In the second edition, Dr Heptinstall has updated a book whose first edition had already become the basic text of renal pathology. He has added about 50% more material and a considerable number of newer references to an already voluminous bibliography. Of importance to his fans, he has not lost the technique of providing concise summaries of important findings by others, including the raw data on which conclusions have been based, then adding his own experience and opinions in a manner that enables the reader to gain both a knowledge of and a feel for the topic. It is a pathology text that is not boring to the nonpathologist. In this edition, Dr Heptinstall has called on Dr Robert T. McCluskey to contribute a new chapter that provides an excellent description of the experimental immunologic models of renal disease and their pertinence to human nephritides. Drs Kendrick A. Porter and