Primary Biliary Cirrhosis PBC

PBC has a relatively predictable natural history and accurate prognostic models. The most important variable, common to all prognostic models, is the serum total bilirubin level. Shapiro et al. (Gut, 1979 20 137-145) reported that patients with PBC typically have a long and stable course, followed by an accelerated preterminal phase of hyperbilirubinemia, with a mean survival time of 1.4 years in patients with bilirubin of more than 10 mg dL. The Mayo Clinic PBC survival model is based on...

Intraoperative Management

The surgical procedure can be divided into four sequential time periods hepatectomy, anhepatic, reperfusion, and postreperfusion. During the hepatectomy, the liver is dissected and prepared for removal. There is a potential for massive hemorrhage because of preexisting coagulopathy, portal hypertension, and potentially difficult surgical dissection. Laboratory (prothrombin time OT , partial thromboplastin time PTT , fibrinogen, and platelet count) and or thromboelastography results guide...

Timing Of Kidney And Pancreas Transplantation

Due to the current availability of dialysis technology, an increasing number of patients with ESRD are surviving much longer now than they did in the past. Subsequently, a large portion of Medicare's budget is spent in providing dialysis and access for dialysis. Furthermore, dialysis has become an imperfect modality, fraught with problems of poor quality of life, demands of long periods of repeated exhausting therapy, loss of vascular access, complications of access surgery, and decreased...

Operative and Postoperative Care and Complications

Pulmonary complications or orthotopic liver transplantation. Mayo Clin Proc 1993 68 427-434. Basadonna GP, Matas AJ, Gillinghan KJ, et al. Early versus late acute renal allograft rejection Impact on chronic rejection. Transplantation 1993 55 993-995. Bronster DJ, Emre S, et al. Neurological complications of orthotopic liver transplantation. Mt Sinai J Med 1994 61 63-69. Canzanello VJ, Schwartz L, Taler SJ, Textor SC, Wiesner RH, Porayko MK, et al. Evolution...

Vivek Kaul Kenneth D Rothstein Santiago J Munoz Jorge Ortiz and Cosme Manzarbeitia

The outcome of organ transplantation is an extremely complex phenomenon, being the result of an interaction between two different biological systems, those of the donor and the recipient. It is logical, therefore, that any discussion that attempts to describe the process of recipient evaluation must be initiated with a comprehensive assessment of donor and recipient variables. The benefits of matching donors to recipients are manifold. Stratifying prospective donor-recipient combinations...

Cosme Manzarbeitia Michael K McGuire and Rohit Moghe

The goal of immunosuppression in transplant patients is to prevent acute and chronic rejection of the transplanted organ, while avoiding opportunistic infections and the adverse effects of immunosuppressive therapy (see Fig. 17.1). Combinations of immunosuppressants are used to affect different immune-system activators and to provide immunosuppressive synergy, using the lowest effective doses of immunosuppressants to reduce the potential for adverse drug events and drug interactions....

Vascular Complications

Renal artery stenosis is a late complication most commonly associated with living related or living unrelated kidney transplants. The lower incidence in cadaveric transplants is related to the use of a Carrel patch. The Carrel patch is a cuff of aortic tissue surrounding the orifice of the renal artery in which one can sew the anastomosis to the patch, thus avoiding stenosis of the renal artery orifice. In general, the overall incidence is falling due to decreased use of the internal iliac...

Cardiovascular Issues

Hypertension after transplantation is seen in 50-75 of patients in the first weeks and months following surgery. Frequently a patient's essential hypertension is unmasked by correction of his or her hyperdynamic state and worsened by the administration of tacrolimus or cyclosporine. Tacrolimus causes less hypertension than cyclosporine. The additive effect of corticosteroids and calcineurin inhibitors in the exacerbation of hypertension mandates reduction in immunosuppression whenever...

Preface

Replacement of diseased tissue with new, healthy tissue is not a new dream. Mankind entertained this idea since even before written history, the concept of repair and replacement of body portions being quite prevalent in the lore of primitive people. Legend speaks of the saints, Cosmas and Damian, transplanting a gangrenous leg from one human to another. In medieval times, belief in magical powers began to decline as resurgence in the investigative spirit took precedence. In the nineteenth...

Evaluation Of The Kidney Transplant Recipient 411 General Indications

The most common conditions that lead to chronic renal failure and end-stage renal disease (ESRD) requiring dialysis and evaluation for kidney transplantation (KT) are outlined in Table 4.1. Diabetes mellitus (DM) is the most common indication for renal transplantation. This is complicated by the fact that patients with DM on dialysis have a very high mortality. Some of these patients may be candidates for a combined kidney-pancreas transplant in its different modalities, as outlined later in...

Pretransplant Coordinators Role

Potential transplant candidates are referred to transplant centers most often by their nephrologist, gastroenterologist, or hepatologist. The evaluation process begins before the initial visit. The transplant coordinator obtains baseline information, including past medical history, past surgical history, etiology of disease, lab studies and psychosocial evaluation from the referring physician prior to meeting the potential recipient. Additional information is gathered at the first meeting and...

Nayere Zaeri and lerachmiel Daskal

The transplant professional counts heavily on the contributions of the pathologist for diagnosis before and after transplantation. While it is not the purpose of this manual to offer a description of all the conditions that lead to end-stage organ disease, it is important to offer an overview of posttransplant pathology as it pertains to diagnosis and management of acute rejection and other conditions that cause allograft dysfunction in the postoperative period. Finally, due to the sparse and...

David J Reich Cosme Manzarbeitia Radi Zaki Jorge A Ortiz and Sergio Alvarez

Late complications specific to liver transplantation include technical complications, recurrent liver disease, and chronic hepatic rejection, in addition to the side effects of long-term immunosuppression that affect recipients of any type of organ transplant (discussed in Chapter 18). Evaluation of allograft dysfunction in the liver recipient with long-term follow-up requires screening for hepatic artery thrombosis or stenosis, biliary problems, recurrent disease, rejection, and infection. All...

Hepatectomy and Bypass

A bilateral subcostal incision with a midline extension to the xiphoid process is routinely used. After dividing the round and falciform ligaments, a large, self-retaining upper abdominal retractor is placed, which aids greatly in the exposure of the entire liver and, more importantly, the suprahepatic vena cava. The liga-mentous attachments of the liver are then dissected, including the left and right triangular ligaments, as well as the gastrohepatic ligament. The hilar dissection then...

Radi Zaki and Shuin Lin Yang

The many regimens of immunosuppression vary mostly by center. The most common regimen at our Center is described here. Induction therapy with mono- or polyclonal antibodies (Daclizumab, Basiliximab, ATGAM , Thymoglobulin ) varies from center to center. We commonly use Daclizumab induction, which has minimal side effects. The theory of induction prior to transplantation is a controversial topic. Induction therapy is not universally accepted and is dependent on center bias. It is generally...

Juan Oleaga

With the development of new and improved imaging modalities and less invasive percutaneous techniques, diagnostic and interventional radiology have an increasing and significant role in the pre- and posttransplant evaluation and management of transplant donors and recipients. The main role of radiological evaluation of potential donors and recipients is to determine the presence of coexistent conditions that will increase the risk of, preclude, or alter transplantation. The multimodality...

Arthur J Geller

Bile Leak Ercp

UPPER AND LOWER GASTROINTESTINAL ENDOSCOPY In general, cancer must be ruled out in all patients awaiting organ transplantation. The endoscopist plays a definite role in this, especially in patients with end-stage liver disease. Upper gastrointestinal endoscopy is indicated in the preoperative evaluation of patients awaiting orthotopic liver transplantation. The rationale for performing this procedure in patients with advanced liver disease is to demonstrate the presence of lesions...

Laparoscopic Donor Nephrectomy

Operation Port Transplant

Despite the advantages of living donor renal transplantation, donors that undergo the open donor operation frequently are asked to forego approximately 10 of their annual income, experience significant pain, and pay out-of-pocket expenses for travel, housing, and child care. Prolonged recuperative time, pain, and cosmetic results are, therefore, disincentives to traditional live kidney donation. Thus, the laparoscopic living donor nephrectomy was specifically designed to address the significant...