RESUMEN
Thrombotic microangiopathy (TMA) after kidney transplantation is an uncommon and challenging cause of graft dysfunction and is associated with early graft loss. An idiosyncratic endothelial reaction to calcineurin inhibitors (CNIs) has been implicated as a frequent cause of TMA. This reaction is marked by uncontrolled activation of complement and subsequent cellular destruction. Usual therapy consists of withdrawal of the inciting drug and plasmapheresis to minimize levels of circulating complement. Recently, eculizumab, a monoclonal antibody to complement component C5, has been used for the treatment of atypical hemolytic uremic syndrome. Belatacept, an inhibitor of T cell costimulatory protein CTLA-4 has been used in immunosuppression strategies aimed at minimization of CNI. Here we report the first case of treatment of CNI-associated TMA/hemolytic uremic syndrome with withdrawal of tacrolimus and initiation of both belatacept and eculizumab. The case describes a favorable clinical course for both graft and patient, and is accompanied by a review of the literature.
Asunto(s)
Abatacept/uso terapéutico , Anticuerpos Monoclonales Humanizados/uso terapéutico , Inhibidores de la Calcineurina/efectos adversos , Inmunosupresores/uso terapéutico , Microangiopatías Trombóticas/tratamiento farmacológico , Síndrome Hemolítico Urémico Atípico/complicaciones , Humanos , Trasplante de Riñón/efectos adversos , Masculino , Plasmaféresis/efectos adversos , Complicaciones Posoperatorias/inducido químicamente , Microangiopatías Trombóticas/inducido químicamente , Adulto JovenRESUMEN
Liver transplantation (LTx) is an established treatment modality for patients with end-stage liver disease, metabolic disorders, and patients with acute liver failure. When a graft fails after primary LTx, retransplantation of the liver (reLTx) is the only potential cure. ReLTx accounts for 7%-10% of all LTx in the United States. Early causes of graft failure for which reLTx may be indicated include primary graft nonfunction and vascular inflow thrombosis. ReLTx in such cases in the early postoperative period is usually straightforward as long as an appropriate secondary allograft is secured in a timely fashion. Late indications may include ischemic cholangiopathy, chronic rejection, and recurrence of the primary liver disease. ReLTx performed in the late period is often more complex and selection criteria are more stringent due to the persistent shortage of organs. The question of whether to retransplant patients with recurrent hepatitis C remains controversial, but these practices are likely to change as the epidemic progresses and new treatments evolve. We also present recent results with reLTx from Yale-New Haven Transplant Center and early results with the use of living donors for reLTx.
Asunto(s)
Toma de Decisiones , Trasplante de Hígado , Reoperación , Hepatitis C/cirugía , Humanos , Estados UnidosRESUMEN
The inclusion of donor middle hepatic vein (MHV) in right-lobe living-donor grafts and the need for reconstruction of the MHV tributaries have long been controversial areas in living-donor liver transplantation. We report technical details in restoration of venous drainage of the anterior sector (segments V and VIII) of the right lobe of the liver graft using a preserved MHV from the recipient liver, and address the issue of reconstruction of donor MHV tributaries without use of an interposition graft. We review clinical situations in which restoration of outflow drainage of the anterior segment of the liver graft should be considered.
Asunto(s)
Venas Hepáticas/fisiología , Trasplante de Hígado/métodos , Donadores Vivos , Preservación de Órganos/métodos , Adulto , Anastomosis Quirúrgica/métodos , Humanos , Hígado/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Abdominal wall closure after liver transplantation is not always feasible and may result in increased intra-abdominal pressure along with associated complications. Various temporary closure techniques as well as open wound management have been used to address this complex problem. The aim of this series was to describe an approach to definitive wound closure of the open abdomen in liver transplant patients. METHODS: We performed a retrospective review of all liver transplant patients at our institution from September 2005 to November 2007. The management of the open abdomen in 10 liver transplant patients was reviewed, and a novel approach described to manage these defects. RESULTS: Ten patients with open wounds were closed during the study period using human acellular dermal matrix (HADM). There were 7 men and 3 women of median age 55 years. Average size of HADM was 235 cm(2). The median follow-up is 10 months with no incidence of evisceration or hernia. In 1 patient, the graft failed along the lateral side due to infection; it dislodged during vacuum-assisted closure dressing change in another patient at 5 months after closure. Fascial closure was not possible due to organ edema (n = 3), a large liver (n = 4) or wound infection with dehiscence (n = 3). CONCLUSIONS: HADM can be used for primary wound closure in both clean and contaminated wounds as an alternative to an open abdomen post-liver transplantation.