Başkent Üniversitesi Makaleler
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Item Massive Pulmonary and Intracardiac Embolism During Liver Transplantation(Başkent Üniversitesi, 2010-06) Sheiner, Patricia; Martins, Paulo N.; Kim-Schluger, Leona; Rodriguez-Davalos, Manuel; Martins, Ann-Britt; Krachkova, Nathalia; Facciuto, MarceloDespite prolonged coagulation times and thrombocytopenia associated with end-stage liver disease, formation of thrombi in the circulation seems to occur more frequently during liver transplant than during any other type of major surgery. Here, we report a case of massive pulmonary and intracardiac embolism that resulted in cardiac arrest and intraoperative death. This was diagnosed by transesophageal echocardiography and occurred shortly after induction of anesthesia and initiation of continuous veno-venous hemofiltration without the concomitant use of antifibrinolytic drugs. We discuss the physiologic changes associated with cirrhosis and liver transplant, and review the literature.Item Recurrence of Hepatitis C Virus (Genotype 4) Infection After Living-Donor Liver Transplant in Egyptian Patients(Başkent Üniversitesi, 2009-09) Kamel, Sanaa; El-Gabaly, Hatem; Yosry, Ayman; Abdel-Rahman, Mahasen; Esmat, Gamal; El-Serafy, Magdy; Omar, Ashraf; Doss, Waheed; Zayed, Nagla; Said, Mohamed; Ismail, Tamer; Hosny, Adel; Marawan, Ebrahem; El-Malt, Osama; Kamel, Refaat Refaat; Hatata, Yaser; El-Taweel, Ahmad; Ghali, Ahmad; Sabri, HusseinObjectives: The recurrence of hepatitis C virus infection after liver transplant is common and may endanger both graft and patient survival. We investigated the frequency and outcome of and risk factors for the recurrence of that virus after living-donor liver transplant in hepatitis C virus positive recipients. Materials and Methods: Seventy-four adult hepatitis C virus positive subjects were monitored for 36 months after living-donor liver transplant and demographic and laboratory data for the recipients and donors were evaluated. Recurrent hepatitis C virus infection was diagnosed on the basis of viral replication revealed by polymerase chain reaction after transplant, elevated levels of transaminases, and the results of liver biopsy. Results: Hepatitis C virus recurrence was identified in 31.1% of the patients studied. Histopathologic recurrence was mild, and 91% of the subjects had a fibrosis score of ≤ F2. No recipient exhibited cirrhosis or clinical decompensation during follow-up. Recurrent hepatitis C virus infection was associated with pretransplant and posttransplant viral load and antibody positive to hepatitis B core antigen. No other risk factors (sex, donor or recipient age, pretransplant Child-Pugh or Model for End-Stage Liver Disease scores, immunosuppressive drug therapy, and treatment with pulse steroids) were significantly correlated with the frequency of hepatitis C virus recurrence, the grade of the histologic activity index, or the stage of fibrosis. Conclusions: In living-donor liver transplant recipients, patient and graft survival rates associated with hepatitis C virus (genotype 4) related cirrhosis were comparable to those in deceased-donor liver transplant recipients reported in the literature. Recurrent infection with hepatitic C virus after living-donor liver transplant was mild. After transplant, a higher viral load and the presence of antibody to hepatitis B core antigen could be risk factors for hepatitis C virus recurrence. Long-term follow-up in a large number of patients is required.Item De Novo Inflammatory Bowel Disease After Pediatric Orthotopic Liver Transplant: A Case Report(Başkent Üniversitesi, 2009-09) Dehghani, Seyed Mohsen; Malek-Hosseini, Seyed Ali; Geramizadeh, Bita; Kakaei, Farzad; Bahador, Ali; Eshraghian, AhadObjectives: The improvement of pre-existing inflammatory bowel disease after orthotopic liver transplant might be anticipated. However, both the exacerbation of inflammatory bowel disease and de novo inflammatory bowel disease after orthotopic liver transplant (despite sufficient allograft immunosuppressive therapy) have been described. Materials and Methods: We present a case of ulcerative colitis in a pediatric liver transplant recipient. Results: A 13-year-old boy with cryptogenic liver cirrhosis received an orthotopic liver transplant from a deceased donor. Five months later, he presented with watery diarrhea and abdominal distention. He was treated with the immunosuppressive agents tacrolimus (0.15 mg/kg/d) and mycophenolate mofetil (20 mg/kg/d). A general physical examination revealed a boy with stable vital signs and without fever. The only positive finding was enlargement of the abdomen without tenderness. Many pus cells and a few red blood cells were detected in the patient’s stool, but the results of a stool culture for bacteria were negative. Because of his chronic diarrhea, this patient underwent colonoscopy, which revealed diffuse erythematous mucosa, multiple ulcers, exudate, and pseudo¬polyps with a diffuse loss of vascularity. Those findings are indicators of colitis. The results of histopathologic examination of the colonic mucosa suggested ulcerative colitis. The patient was treated with mesalamine and prednisolone, and a repeat colonoscopy revealed an improvement in his bowel disease. Conclusions: De novo inflammatory bowel disease should be considered in patients in whom chronic diarrhea develops after an orthotopic liver transplant. We suggest that colonoscopy and biopsy should always be performed if other causes of diarrhea have been excluded.Item Successful Management of Necrotizing Pancreatitis by Percutaneous Necrosectomy After Orthotopic Liver Transplant for Paracetamol Induced Acute Liver Failure: A Case Report(Başkent Üniversitesi, 2009-06) Manas, Derek M.; White, Steve A.; Lochan, Rajiv; Charnley, Richard M.; French, Jeremy J.; Al-Mukhtar, Ahmed; Hudson, MarkObjectives: Acute pancreatitis, which can develop after any whole-organ transplant, is often associated with immunosuppression. Pancreatitis that complicates a liver transplant can be a significant problem that results in a high mortality rate. Materials and Methods: We describe the successful use of minimally invasive techniques to treat severe acute pancreatitis. To our knowledge, this is the first reported case in which major laparotomy was precluded by the use of percutaneous necrosectomy to manage necrotizing pancreatitis in a liver transplant recipient. We also briefly review the published literature on severe acute pancreatitis in liver transplant recipients. Results: Our patient, who had a Model for End-Stage Liver Disease score of 39 when transplanted and an Acute Physiology and Chronic Health Evaluation II score of 19 when infected necrosis in his pancreas was diagnosed, recovered completely after 92 days of hospitalization. He underwent 2 percutaneous drainage procedures and 3 percutaneous necrosectomies to treat his pancreatic complication. A review of the literature revealed that severe acute pancreatitis significantly increases morbidity and mortality in liver transplant recipients. Unlike necrotizing pancreatitis, which develops outside the context of liver transplant where there is a distinct shift towards minimally invasive procedures, infected necrosis associated with fulminant liver failure or a liver transplant is usually treated with open necrosectomy. Conclusions: Severe acute pancreatitis in liver transplant recipients should be managed exactly as it is in patients who have not received a liver transplant. Anatomically guided minimally invasive necrosectomy appears to be beneficial, especially when patients are critically unwell, as they are following a liver transplant.Item Forkhead Box P3 (FOXP3) mRNA Expression Immediately After Living-Donor Liver Transplant(Başkent Üniversitesi, 2009-03) Sakamoto, Rieko; Inomata, Yukihiro; Nishimori, Aya; Yoshimoto, Kazuhiko; Ramirez, Manuel E. Zeledon; Asonuma, KatsuhiroObjectives: The forkhead box P3 (FOXP3) gene is considered to be the master gene of regulatory T cells. The significance of regulatory T cells in liver transplant has been investigated in previous reports, but quantitative FOXP3 messenger RNA (mRNA) expression after living-donor liver transplant has not been assessed. The objective of this study was to determine whether the human FOXP3 gene is a good marker for regulatory activity in T cells in living-donor liver transplant recipients during the immediate posttransplant period. Materials and Methods: In peripheral blood mononuclear cells of 15 living-donor liver transplant recipients during the first month after transplant, we measured the population of CD4+CD25+ T cells using flow-assisted cell sorting and the expression of FOXP3 mRNA using real-time polymerase chain reaction. Results: Fold induction of FOXP3 mRNA significantly increased on postoperative day 7 (3.3-fold) compared with the reference preoperative value (P < .01) but returned to baseline by 28 days after transplant. The population of CD4+CD25+ T cells did not change significantly. Expression of FOXP3 mRNA on days 14, 21, and 28 were lower in recipients with acute cellular rejection within 60 days after living-donor liver transplant. Conclusions: Increased expression of FOXP3 mRNA immediately after living-donor liver transplant might be influenced by activation of T cells including regulatory T cells and other T cells. However, after stabilization of these activation profiles, it seems likely that FOXP3 mRNA expression is associated with graft acceptance. Further studies are necessary with measurement of FOXP3 mRNA expression at appropriate sampling points.Item Pulmonary Complications and Mortality After Liver Transplant(Başkent Üniversitesi, 2008-12) Bozbas, Serife Savas; Haberal, Mehmet; Karakayali, Hamdi; Sevmis, Sinasi; Arslan, Nevra Gullu; Ergur, Figen Ozturk; Eyuboglu, Fusun OnerObjectives: Pulmonary complications after liver transplant significantly affect mortality and morbidity; however, their relation has not been clearly established. We sought to determine pulmonary complications during the early and late term after liver transplant and identify risk factors for mortality. Materials and Methods: At our institution, 130 liver transplant patients (mean age, 40.1 ± 14.6 years; 71.1% male) were retrospectively evaluated, and 114 adult orthotopic liver transplant patients were included. Cause of liver disease, pulmonary function test results, arterial blood gas analyses, surgery duration, length of stay in the intensive care unit and the hospital, pulmonary complications, and mortality causes were noted. Results: Pulmonary complications were detected in 48 patients (42.1%), pneumonia in 24 patients (21.1%), and pleural effusion in 21 patients (18.4%). Development of pulmonary complications was found to be significantly related to survival (P = .001). Fifty-two patients (45.6%) were smokers, a significant predictor of pulmonary complications (P = .03). There was no relation between pulmonary function test results and orthodeoxia and pulmonary complications and mortality. Early and late survival rates were significantly lower in patients in whom a microorganism was isolated on deep tracheal aspirate culture, while early survival was significantly reduced in the presence of a pleural effusion (P < .005). Conclusions: Pulmonary complications after liver transplant are common. Care must be taken to determine preoperative risk factors, and patients should be observed closely for development of respiratory complications after liver transplant.Item Liver Transplant For Budd-Chiari Syndrome Caused by Paroxysmal Nocturnal Hemoglobinuria(Başkent Üniversitesi, 2008-09) Yedibela, Süleyman; Hohenberger, WernerObjectives: Paroxysmal nocturnal hemoglobinuria is a rare acquired nocturnal disorder of the hematopoietic stem cells. The major causes of associated morbidity and mortality are chronic intravascular hemolysis, pancytopenia, and venous thrombosis. Patients: We report on a 20-year-old man with advanced Budd-Chiari syndrome caused by paroxysmal nocturnal hemoglobinuria, who underwent an emergency liver transplant. Results: At the time of this writing, the patient has good primary hepatic function, and, although not receiving specific medication, shows no signs of pancytopenia. Anticoagulation with low-dose acetylsalicylic acid was initiated. Forty-eight months after the transplant, there are no signs of thromboembolic complications affecting the liver. Conclusions: Liver transplant is an appropriate treatment for Budd-Chiari syndrome caused by paroxysmal nocturnal hemoglobinuria. Supplemented by long-term low-dose anticoagulation treatment, liver transplant is superior to other surgical options, particularly when liver disease is advanced.Item Somatostatin and Propranolol to Treat Small-for-Size Syndrome that Occurred Despite Splenic Artery Ligation(Başkent Üniversitesi, 2007-12) Özden, Ilgin; Alper, Aydin; Bilge, Orhan; Emre, Ali; Kaymakoğlu, Sabahattin; Yavru, Ayşen; Salmaslioğlu, Artür; Pinarbaşi, Binnur; Kara, MelihWe report our success with somatostatin and propranolol to treat small-for-size syndrome that occurred despite splenic artery ligation. A 48-year-old woman with cirrhosis due to autoimmune hepatitis underwent living-donor liver transplant; her graft-to-body weight ratio of the right lobe was 0.91%. After arterial reperfusion, portal pressure and flow were 24 cm H20 and 2.22 L/min (ie, 360 mL/100g graft/min), respectively. Following splenic artery ligation, the portal pressure decreased to 16 cm H20 and portal flow to 1.74 L/min (ie, 282 mL/100g graft/min). On the second postoperative day, small-for-size syndrome was diagnosed based on the marked prolongation of prothrombin time (international normalized ratio, 4.4), hyperbilirubinemia (359.1 micromol/L), rapid escalation of transaminases (alanine aminotransferase 2488 U/L, aspartate aminotransferase 1075 U/L) and very high portal flow rate (> 90 cm/sec). Oral propranolol (40 mg/day b.i.d.) and somatostatin infusion (250-µg bolus followed by perfusion at a rate of 250 µg/h for 5 days) were started. Prothrombin time and transaminase levels began to decrease the following day, although the bilirubin level increased to 495.9 µmol/L before returning to normal. The patient was discharged in excellent health 5 weeks after surgery. Despite reduction of portal pressure by splenic artery ligation, small-for-size syndrome may develop in patients with persistent high portal flow. To the best of our knowledge, this is the first report of the successful treatment of small-for-size syndrome by somatostatin and propranolol in the clinical setting.Item HCV Antibody Quantitative Levels in Liver Transplant Patients: Do They Have Any Relevance in Clinical Practice?(Başkent Üniversitesi, 2006-06) Jain, Ashok; Menegus, Marilyn; Mohanka, Ravi; Orloff, Mark; Abt, Peter; Mantry, Parvez; Bozorgzadeh, AdelObjectives: Hepatitis C virus (HCV) is not directly cytopathic to the hepatocytes; however, host immune response against the virus does cause hepatic injury. Production of the HCV antibody is a host immune response to a viral antigen. The currently used HCV antibody assay is a qualitative, not quantitative, assessment. In this study, we sought to quantitatively estimate HCV antibody levels in patients who had undergone liver transplantations at the University of Rochester Medical Center, Rochester, New York, and correlate these levels with HCV RNA viral load, genotype, severity of recurrence, and anti-HCV treatment. Materials and Methods: From 39 liver transplantation patients, we obtained 141 blood samples for quantitative HCV RNA to measure HCV antibody levels quantitatively. Results: Most antibody levels were within a narrow range with a mean of 32.9 ± 5.1. Samples with undetectable RNA had a mean antibody level of 31.4 ± 8.0, and samples with a positive RNA had mean level of 33.0 ± 4.6. The mean antibody levels were significantly higher for patients with genotype 1 (n = 33) compared with those with genotype 2 (n = 5) (33.2 vs 29.1; P = .007). No correlation was found between antibody levels and severity of hepatic injury with regard to hepatitis activity index or fibrosis score. Six patients with no response to anti-HCV treatment had no change in their mean antibody levels (33.7 vs 34.5). Ten patients who responded to anti-HCV therapy had lower mean levels after therapy, but the changes were not significant (34.2 vs 30.4). Conclusions: Antibody levels in this study did not correlate with viral load or hepatic injury. However, genotype-2 patients had significantly lower levels compared with genotype-1 patients, and patients who responded to anti-HCV therapy demonstrated decreased antibody levels.Item Normal Fonksiyon Gösteren Nakil Karaciğerlerde Çok Erken Dönem Kan Akım Değişiklikleri(Başkent Üniversitesi, 2008-01) İ. Işıklar; M. HaberalAmaç: Karaciğer transplantasyonu sonrasında splaknik hemodinamik değişiklikler hala tartışmalıdır. Bu çalışmada ameliyat sırasında ve ameliyat sonrası 1. günde elde olunan arteriyel, portal ve hepatik ven kan akım değerleri karşılaştırıldı. Materyal ve Metod: Çalışma grubumuzu 39 karaciğer alıcısı (12 kadın 27 erkek) oluşturdu. 30 hastaya canlıdan parsiyel, 9 hastaya kadavradan karaciğer nakili yapıldı. Vasküler anastomozlar yapıldıktan hemen sonra ameliyat sırasında ve ameliyattan sonraki 1.günde karaciğer Doppler tetkiki gerçekleştirildi. Portal ve hepatik ven akım hızları, hepatik arter rezistif indeksi, sistolik hızı, hepatik arter ve portal venden akım volümü ölçümleri aynı radyolog tarafından yapıldı. Akım volümü ölçümü 26 hastada uygulandı. Ameliyat sırasında saptanan ölçümler ameliyat sonrasındaki değerlerle karşılaştırıldı. İstatistik analizi için ‘paired samples’ t-test kullanıldı. Sonuçlar: Portal ven hızları erken dönemde artma eğiliminde iken, değişim istatistiksel olarak anlamlı bulunmadı (P= 0.541). Hepatik arter hızlarında ameliyat sırasındaki değerlere göre anlamlı olmayan azalma saptandı (92.83±43.29 cm/sn vs 79.57±41.70 cm/sn p= 0.06). Hepatik ven hız ölçümleri ameliyattan 1.güne kadar benzer değerler gösterdi (47.41±24.65 cm/sn vs 44±15.83 cm/sn p=0.4). Yorum: Hepatik rezistif indeksler ameliyattan sonra 1. günde istatistiksel olarak önemli derecede düşüş gösterdi (0.76±0.13 vs 0.68±0.14 p=0.011). Portal ven volümleri intraoperatif değerlere göre erken ameliyat sonrası dönemde istatistiksel olarak anlamlı şekilde artış göstermiştir (0.95±0.83 L/dak vs 2.00±1.32 L/dak p=0.003 ). Hepatik arter akım volümleri ameliyat sonrası 1.günde istatistiksel olarak anlamlı şekilde artış göstermiştir (0.10± 0.08 L/dak vs 0.19±0.17 L/dak p= 0.003). Bizim çalışmamızda ameliyat sırasında elde olunan değerlere göre, ameliyat sonrası 1. günde hepatik arter ve portal ven akım volümlerinde artış ve hepatik rezistif indekslerde azalma izlendi. Bulgularımızın ışığında ameliyat sırasında karaciğer parankiminin yüksek rezistansı ve düşük hepatik arter ve portal ven akımı cerrahi erken vasküler komplikasyon açısından yanlış yönlendirmemeli ve bu değerlerin 12-24 Summary Change in Blood Flow of the Transplanted Liver From Surgery to the First Postoperative Day Objectives: Short-term changes in splanchnic hemodynamics after liver transplant are still unclear and not well understood. In this report, we analyzed the arterial, portal, and hepatic vein blood flow parameters of the transplanted liver from the intraoperative period to first postoperative day Methods: Thirty-nine recipients (12 women and 27 men) were included in the study. Thirty recipients received living-related partial liver transplants and 9 recipients received a liver from a deceased donor. A Doppler examination was done for each patient after the vascular anastomosis had been completed during surgery and within 24 hours of the transplant. Portal and hepatic vein flow velocities, resistive indices, peak systolic velocities from the hepatic artery, and flow volume of the hepatic artery and portal vein were measured by 1 experienced radiologist. Flow volumes were measured in 26 patients. The values obtained during surgery were compared with postoperative measurements. A paired samples t test was used to analyze the data. Results: Hepatic vein velocities were similar (47.41 ± 24.65 cm/sec vs 44 ± 15.83 cm/sec; P = .4). Portal vein velocities tended to increase within the early postoperative period, but this difference was not statistically significant (P = .541). Hepatic artery velocities decreased, but this difference was not statistically significant (92.83 ± 43.29 cm/sec vs 79.57 ± 41.70 cm/sec; P = .06). Hepatic resistive indices significantly decreased on the first postoperative day (0.76 ± 0.13 vs 0.68 ± 0.14; P = .011). When intraoperative and early postoperative flow volume of the portal vein was compared in 26 patients, the volume was found to increase (0.95 ± 0.83 L/min vs 2.00 ± 1.32 L/min; P = .003). Flow volume of the hepatic artery in 30 patients also increased (0.10 ± 0.08 L/min vs 0.19 ± 0.17 L/min; P = .003). Conclusions: When intraoperative values were compared with values on the first postoperative day, hepatic resistive indices tended to decrease, while flow volume of the portal vein and the hepatic artery increased in transplanted livers. This implies that the intraoperative high resistance of liver parenchyma and the low portal and hepatic artery flow should not mislead surgeons to consider that early vascular complications are occurring; these findings will return to normal levels in 12 to 24 hours after surgery.