Başkent Üniversitesi Yayınları
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Item Neuromuscular Complication After Liver Transplant in Children: A Single-Center Experience(Başkent Üniversitesi, 2010-03) Dehghani, Seyed Mohsen; Malek-Hosseini, Seyed Ali; Haghighat, Mahmood; Bahador, Ali; Kazemi, Kourosh; Gholami, Siavash; Inaloo, Soroor; Honar, NaserObjectives: Neurologic complications are a significant cause of morbidity in children after liver transplant. In this study, we sought to evaluate the neurologic complications in children after liver transplant. Materials and Methods: All children aged younger than 18 years old who had undergone liver transplant between June 2004 and June 2007 were included in this prospective study. There were 30 boys (62.5%) and 18 girls (37.5%) (mean age, 9.6 ± 4.3 years; mean duration of follow-up, 21.6 ± 9.4 months). The most common indications for liver transplant were biliary atresia (n=12, 25%), Wilson disease (n=7, 14.6%), tyrosinemia (n=7, 14.6%), progressive familial intrahepatic cholestasis (n=6, 12.5%), and autoimmune cirrhosis (n=5, 10.4%). Results: Immunosuppressive medication consisted tacrolimus (n=44, 91.7%) or cyclosporine (n=4, 8.3%) combined with mycophenolate mofetil (n=33, 68.7%) and prednisolone (n=18, 37.5%). The most-common neurologic complications were tremor (n=8, 16.7%), convulsions (n=6, 12.5%), insomnia (n=6, 12.5%), headache (n=5, 10.4%), muscle cramps (n=5, 10.4%), paresthesia (n=3, 6.2%), and weakness (n=3, 6.2%). Conclusions: We conclude that the most-common neurologic complication after liver transplant in children in contrast to other studies is tremor, same as adult patients. This may be due to higher rate of use of tacrolimus in our patients.Item Hepatic Abscesses After Liver Transplant: 1997–2008(Başkent Üniversitesi, 2009-12) Malek-Hosseini, Seyed Ali; Janghorban, Parisa; Nikeghbalian, Saman; Salahi, Roohallah; Salahi, Heshmatallah; Bahador, Ali; Kakaie, Farzad; Kazemi, KorushObjectives: Infectious complications (such as liver abscesses) remain one of the major causes of posttransplant morbidity and mortality. Management may be problematic and is often based on experience with hepatic abscess in nontransplant patients. We reviewed our experience with hepatic abscess in liver transplant recipients to assess their presentation, clinical features, treatment, and outcome. Materials and Methods: A retrospective review of all liver transplant in Shiraz transplant center from September 1997 through September 2008 was performed. Hepatic abscess was defined as a parenchymal hepatic lesion consistent with abscess (as described by a radiologist), positive liver or concurrent blood cultures, or both (within 24 hours), and compatible clinical findings. Results: Of 560 liver recipients, we identified 5 patients (23-42 y) who had experienced 7 episodes of hepatic abscess, 30-240 days after transplant. All patients had received liver from deceased donors. Biliary reconstruction was done by duct-to-duct anastomosis in 4 and hepatico-jejunostomy in 1 case. Pretransplant diagnoses included hepatitis B cirrhosis, autoimmune hepatitis (2 cases), Caroli disease, and cryptogenic cirrhosis. Liver aspirates showed E. coli in 4 cases, and Aspergillus in 1 case. The main predisposing factor was bile-to-duct anastomosis stricture in 3, diabetes mellitus in 2, and hepatic artery thrombosis in 1 of the patients. Two patients died owing to liver and multiorgan failure, despite percutaneous and operative drainage with broad spectrum antibiotics and antifungals. Conclusions: Hepatic abscess, a rare complication after liver transplant, was associated with hepatic artery thrombosis, biliary anastomosis stricture, and diabetes mellitus. Mortality was higher than in patients who had not undergone transplant. Prolonged antibiotic therapy and drainage are required to improve the outcome in these patients.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 Effects of Surgical Technique on Postoperative Renal Function After Orthotopic Liver Transplant(Başkent Üniversitesi, 2009-03) Gholami, Siavosh; Malek-Hosseini, Seyed Ali; Nikeghbalian, Saman; Salahi, Heshmatollah; Bahador, Ali; Kazemi, Kourosh; Kakaei, Farzad; Rajaei, ElnazObjectives: The classic technique for orthotopic liver transplant consists of the total excision of the retrohepatic inferior vena cava during native hepatectomy. Controversy about the effects of the classic technique on postoperative renal function continues. The aim of this study was to evaluate the effects of the chosen hepatectomy technique on postoperative renal function. Materials and Methods: Of 253 patients who received an orthotopic liver transplant between June 2006 and July 2008 in the Shiraz transplant unit, only 15 underwent operation with the classic technique. Patient demographics and factors including cold ischemic time, warm ischemic time, operative time, transfusions, blood loss, and early postoperative renal function were assessed retrospectively. The criteria for acute renal failure were a serum creatinine level of > 133 µmol/L (1.5 mg/dL), an increase in the baseline serum creatinine level by 50%, or oliguria requiring renal replacement therapy. Results: All patients received a liver from a deceased donor, and none required venovenous bypass during the operation. The minimum mean arterial blood pressure value of the patients during clamping was 65 ± 19 mm Hg. The mean preoperative plasma creatinine level was 87.51 ± 39.78 µmol/L (0.99 ± 0.45 mg/dL). During the first week after transplant, 7 patients (46.6%) experienced acute renal failure, and 3 of those 7 required renal replacement therapy. By the sixth postsurgical month, 4 of those 7 patients had died (1 from adult respiratory distress syndrome, 2 from sepsis, and 1 from recurrent cholangiocarcinoma). In all other patients, the plasma creatinine level had returned to the normal range by the third postsurgical week 3 or during short-term follow-up. Conclusions: Use of the classic technique for orthotopic liver transplant may increase the rate of postoperative renal failure, but that complication usually resolves during short-term follow-up.Item Effect of D-Penicillamine on Liver Fibrosis and Inflammation in Wilson Disease(Başkent Üniversitesi, 2008-12) Kazemi, Kourosh; Malek-Hosseini, Seyed Ali; Dehghani, Seyed Mohsen; Kakaei, Farzad; Dehghani, Masood; Nejatollahi, Seyed Mohammad Reza; Bahador, Ali; Salahi, Heshmatollah; Nikeghbalian, Saman; Geramizadeh, BitaBackground: Wilson disease is a disorder of copper metabolism characterized by copper overload. A mutation in the ATP7B gene causes dysfunction of ATP7B protein and a reduction in copper excretion into the bile in hepatocytes. Excess copper accumulation leads to liver injury. D-penicillamine primarily can inhibit fibrogenesis and prevent the appearance of scar lesions in the liver. We studied this phenomenon in our patients. Materials and Methods: Pathology slides from the explanted livers of 26 patients diagnosed as having Wilson disease with hepatoneurologic manifestations between 2000 and 2008 who had undergone a liver transplant were investigated retrospectively. Patients were divided into 2 groups according to their history of D-penicillamine use before transplant. The degree of fibrosis and inflammation were classified as mild (1), moderate (2), and severe (3), and were reviewed by an impartial hepatopathologist. Results: Of 26 patients (20 male, 6 female) who had Wilson disease with a mean age of 17.6 ± 8.6 years, 69% (18/26) had a history of D-penicillamine use before liver transplant from 6 months to 9 years (mean, 3.4 ± 2.7 years). In the D-penicillamine group, 14 patients (77%) had grade 1 fibrosis. Grade 2 and 3 fibrosis was seen in 5.6% and 16% of patients, respectively. In D-penicillamine group, inflammation was grade 3 in 44% (8/18), grade 2 in 44% (8/18), and grade 1 in 11% of the patients (2/18). In the non–D-penicillamine group (8 patients), grades of fibrosis were grade 3 (62%), grade 2 (25%), and grade 1 (12%); 87% of the patients had grade 2 and 3 inflammation. The degree of fibrosis was significantly lower in the D-penicillamine group than it was in the non–D-penicillamine group (P < .05). Conclusion: D-penicillamine may reduce the rate of liver fibrogenesis in patients with Wilson disease.Item Prevalence and Risk Factors of Renal Dysfunction After Liver Transplant: A Single-Center Experience(Başkent Üniversitesi, 2008-03) Dehghani, Seyed Mohsen; Malek-Hosseini, Seyed Ali; Jalaeian, Hamed; Gholami, Siavash; Taghavi, Seyed Ali Reza; Derakhshan, AliObjectives: Renal dysfunction is one of the most significant complications after liver transplant. It is attributed mainly to nephrotoxicity caused by calcineurin inhibitors. We evaluated the renal functioning in liver transplant recipients alive for at least 6 months after liver transplant. Materials and Methods: One hundred seventy patients (108 male [63.5%], 62 female [36.5%]; mean age, 31.4 ± 13.3 years; age range, 13-61 years) were included in this study. Patients who had undergone a liver transplant between 1994 and 2006 at the Organ Transplantation Center of the Shiraz University of Medical Sciences in Shiraz, Iran, and had been alive for at least 6 months after surgery were included. Data were collected regarding age, sex, body mass index, underlying liver disease, graft type, immunosuppressive medications, serum creatinine levels, and glomerular filtration rate before, 1, and 6 months after liver transplant. Renal dysfunction was defined as a serum creatinine level above 132.6 µmol/L or a glomerular filtration rate less than 60 mL/min/1.73 m2, based on our reference range. Glomerular filtration rate was calculated using the Schwartz formula (glomerular filtration rate mL/min/1.73 m2 = K × Ht (cm) / Cr mg/dL). Data were analyzed with SPSS software. Results: The mean follow-up was 25.9 ± 23.5 months (range, 6-156 months). The main indications for liver transplant were cryptogenic cirrhosis (n=42), hepatitis B infection (n=34), autoimmune cirrhosis (n=30), Wilson’s disease (n=21), and primary sclerosing cholangitis (n=18). The mean pretransplant glomerular filtration rate was 93.7 ± 35.6 mL/min/1.73 m2. The mean glomerular filtration rates in the first and sixth months after liver transplant were 81.6 ± 29.3 mL/min/1.73 m2 and 83.6 ± 32.9 mL/min/1.73 m2. Sex, body mass index, type of immunosuppressive medication, and underlying liver disease were not predictors of renal dysfunction (P > .05). Posttransplant renal dysfunction was significantly more common in older patients (ie, those aged 38.8 years and older) (P = .0001) and those with a family history of renal disease (P < .05). Conclusions: Renal dysfunction may be a significant problem for patients after liver transplant, and early detection of renal dysfunction in patients after liver transplant is important. Of all the risk factors studied here, only older age and family history of renal disease were correlated with development of renal dysfunction after liver transplant.Item Acute Renal Failure in the First 100 Orthotopic Liver Transplant Patients in Southern Iran(Başkent Üniversitesi, 2007-12) Rais-Jalali, Ghanbar-Ali; Malek-Hosseini, Seyed Ali; Salahi, Heshmatolah; Bahador, Ali; Nikeghbalian, Saman; Roozbeh, Jamshid; Behzadi, Saeed; Daniali, Farzad; Sagheb, Mohammad MahdiPostoperative acute renal failure is a frequent and serious medical complication following orthotopic liver transplant. Here, we report our experiences with liver transplant recipients who developed acute renal failure in the early period following orthotopic liver transplant. Among 100 liver transplants performed between April 1993 and January 2004, we retrospectively analyzed 91 patients (mean age, 29.9 ± 14.0 years) who had undergone orthotopic liver transplant. The underlying causes of liver failure were cryptogenic liver cirrhosis (n=27), viral hepatitis (n= 21) (hepatitis-B–related liver cirrhosis [n=13], hepatitis-C–related liver cirrhosis [n=7], and hepatitis-B– and C–related liver cirrhosis [n=1]), autoimmune hepatitis (n=18), Wilson’s disease (n=10), primary sclerosing cholangitis (n=8), biliary atresia (n=3), Budd-Chiari syndrome (n=2), and primary biliary cirrhosis (n=2). The immunosuppressive regimen included mycophenolate mofetil (azathioprine for 10 patients), cyclosporine, and steroids. Six patients received a combination of tacrolimus and steroids. Ten patients (10.9%) experienced acute renal failure, 7 (70%) were men, and none of them required renal replacement therapy and/or died. Four patients were diagnosed as having cryptogenic liver cirrhosis; 2 with hepatitis-C–related liver cirrhosis, 2 with autoimmune liver cirrhosis; 1 with primary biliary cirrhosis; and 1 hepatitis-B–related liver cirrhosis. Six patients were Child-Pugh's classification C, and the others were B. The rate of postoperative acute renal failure in our patients was relatively low when compared with other series, and our outcomes were good.