William A. Sterling

Morbidity and mortality after operation in nonbleeding cirrhotic patients

The purpose of this study has been to provide information on the mortality and morbidity rates for operation on nonbleeding cirrhotic patients and to identify factors that portend a grave prognosis. A review of 102 cirrhotic patients who underwent a variety of major therapeutic operations revealed a mortality rate of 19.6 percent. Mortality rates were significantly increased (p less than 0.05) by emergency operation (45.8 percent), gastrointestinal related operation (27.6 percent), ascites (37.5 percent), a bilirubin concentration greater than 3.5 mg (44.4 percent), a prothrombin time increase greater than 2 seconds (36.1 percent), a partial thromboplastin time increase greater than 2 seconds (50 percent), an alkaline phosphatase concentration greater than 70 units (40.9 percent), an operative blood loss greater than 1,000 ml (33.3 percent), and the presence of one or more postoperative complications (39.6 percent). Mortality rates were not increased after extremity, genitourinary, or gynecologic operations, an albumin concentration less than 3 g, a serum glutamic oxalacetic transaminase concentration greater than 40 units, hepatomegaly, and a history of previous gastrointestinal bleeding. When significant risk factors were added, mortality rates were significantly associated (p less than 0.001): zero to one factors 5.1 percent, two to three factors 19.4 percent, four to five factors 33.3 percent, and more than six factors 66.7 percent. The complication rate was 47.1 percent and included liver failure (42.2 percent), sepsis (18.6 percent), and bleeding (8.8 percent). Thus, in cirrhotic patients a clear need for operation must exist, liver function must be optimized preoperatively, and the most simple and expeditious procedure must be performed to avoid excessive blood loss and postoperative complications.

Gastrointestinal and hepatic complications affecting patients with renal allografts

Of 126 renal allograft recipients, 34 were found to have gastrointestinal and hepatic complications. In order of frequency, these included: mild liver dysfunction, severe hepatitis usually associated with cytomegalovirus infection, peptic ulceration complicated by bleeding, intestinal obstruction, and pancreatitis. These complications did not appear to influence the long-term survival or function of the renal allograft, but proved to be fatal when massive infection of cytomegalovirus affected the gastrointestinal tract and especially the liver. Gastrointestinal and pancreatic complications occurring in renal allograft recipients can be managed in the same manner as in patients who are not receiving immunosuppression. When surgical intervention is required, it should be performed promptly. The fact that these patients are receiving immunosuppressive therapy should not be a contraindication to early surgical intervention. When the presence of ulcerative lesions of the gastrointestinal mucosa, pancreatitis, or hepatitis is confirmed, the possibility of these lesions being caused by viral agents, especially cytomegalovirus, should be considered and attempts to confirm this diagnosis should be made. If cytomegalovirus infection is confirmed and the patient is experiencing rejection of the allograft, careful consideration should be given to immediate discontinuation of immunosuppressive therapy followed by removal of the renal allograft. In this way the relentless and fatal course of the cytomegalovirus infection seen in some of the patients reported in this study may be avoided.

Gastrointestinal hemorrhage secondary to cytomegalovirus after renal transplantation: A case report and review of the problem

Generalized cytomegalovirus infection was associated with massive and ultimately fatal upper gastrointestinal bleeding in a renal allograft recepient and persisted even after subtotal gastric resection. The surgical specimen and the remaining stomach at autopsy revealed multiple superficial ulcerations with cytomegalic inclusion bodies within the gastric mucosa. Renal failure in the terminal stages of the patients illness required hemodialysis but did not seem to be the sole result of allograft rejection, suggesting that the renal dysfunction may be caused by the systemic viral infection.

Intraabdominal operations in patients with leukemia

We reviewed results of intraabdominal operations in 23 patients with acute or chronic leukemia to address morbidity, mortality, and factors associated with complications. We found a higher mortality rate among those who had emergency procedures as opposed to elective procedures. Three of four patients who needed reoperation and all four patients with ischemic or perforated viscus died, all from sepsis. Factors such as age, preoperative leukocyte or granulocyte count, or preoperative use of steroids or antineoplastic drugs did not affect the outcome. We therefore recommend early surgical intervention in these patients, even in the face of granulocytopenia, thrombocytopenia, or active medical treatment.

Clinical Evaluation of Equine Antithymocyte Globulin in Recipients of Renal Allografts: Analysis of Survival, Renal Function, Rejection, Histocompatibility, and Complications

Equine antithymocyte globulin combined with azathioprine and prednisone as immunosuppressive therapy in 50 transplant recipients prolonged allograft survival and seemed to modify the severity of rejection episodes. Although nine patients died from a variety of causes, only three kidneys were lost to rejection, one of which was hyperacute. There were no serious untoward hematologic or systemic effects caused by the ATG, and all patients completed the course of therapy. Infection, a serious and frequent complication of transplant patients, was encountered no more often than in other transplant series not using ALG. The data pertaining to the clinical value of ATG, although suggestive in terms of its immunosuppressive effects, is still not conclusive; and a definitive answer to this question awaits further evaluation in a series of cadaveric recipients in a randomized-double-blind study.

THE IMMUNOSUPPRESSIVE EFFECT OF ANTILYMPHOCYTE SERA PRODUCED BY SENSITIZATION WITH DIFFERENT LYMPHOID TISSUES

SUMMARY Sera against mouse splenic cells, lymph node lymphocytes, and thymocytes were prepared in the rabbit, with and without adjuvant, by different routes of sensitization. The sera were compared by their effects in vivo on allograft survival and in vitro by their lymphocytotoxic titers. With this schedule of immunization and dosage, the thymus was the best source for the preparation of antilymphoid tissue sera, especially when adjuvant was included. Neither the lymphocytotoxic titer in vitro nor the acute lymphopenic effect in vivo was useful in predicting the immunosuppressive potential of a serum.

Retrospective analysis of 100 consecutive patients undergoing related living donor renal transplantation.

One hundred consecutive patients receiving related donor kidneys were analyzed in regards to graft and patient survival, morbidity, mortality, histocompatibility and rehabilitation. The average followup was 3 years and 2 months with a minimum post transplant evaluation of one year. Donor morbidity was minimal and the mortality nil. Recipient mortality was 17%, all of which occurred after the first two post transplant months. The most serious life threatening complications after transplantation were due to infection. The greatest morbidity was secondary to aseptic necrosis. The overall graft survival at one year was 94%, 2 years—87%, 3 years—81% and 4 and 5 years—72%. Separation of patients according to tissue typing revealed 95% of recipients with A and B matched kidneys to be alive 5 years later compared to 55% of patients receiving C and D matched kidneys. Rehabilitation was good to excellent in 76% of the living patients and poor in only 4%. These results suggest related donor renal transplantation to be the treatment of choice for patients with chronic renal failure excluding only those individuals who are exceptionally high risks in terms of morbidity and mortality.

Scientific paperKidney transplantation in patients with end stage congenital renal disease: Report of eighteen cases and review of the organ transplant registry

Eighteen patients with end stage congenital renal disease requiring kidney transplantation constituted 12 per cent of the transplantation recipients at this institution over the past six years. The post-transplantation course in this group was remarkably satisfactory, with a 94 per cent graft survival at three years. In addition, we analyzed survival data from over 9,900 patients in the Organ Transplant Registry and demonstrated that transplant recipients with end stage congenital renal disease have equal or better five year patient survival compared with those with acquired end stage renal disease. Only those patients with adult polycystic disease had a less satisfactory prognosis, probably because of age-related factors. In contrast, there were few statistical correlations between renal allograft survival, age, and original disease.

Kidney transplantation in patients with end stage congenital renal disease: Report of eighteen cases and review of the organ transplant registry

Eighteen patients with end stage congenital renal disease requiring kidney transplantation constituted 12 per cent of the transplantation recipients at this institution over the past six years. The post-transplantation course in this group was remarkably satisfactory, with a 94 per cent graft survival at three years. In addition, we analyzed survival data from over 9,900 patients in the Organ Transplant Registry and demonstrated that transplant recipients with end stage congenital renal disease have equal or better five year patient survival compared with those with acquired end stage renal disease. Only those patients with adult polycystic disease had a less satisfactory prognosis, probably because of age-related factors. In contrast, there were few statistical correlations between renal allograft survival, age, and original disease.

Pyeloileocystostomy for ureteral necrosis in pediatric renal transplant recipient

A pediatric renal transplant patient who had ureteral necrosis treated initially by nephrostomy followed by a subsequent pyeloileocystostomy is reported. This unusual approach to a renal transplant complication is recommended, but only when other methods cannot be utilized.