Başkent Üniversitesi Yayınları
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Item Leukoencephalopathy Syndrome After Living-donor Liver Transplantation(Başkent Üniversitesi, 2011-04) Umeda, Yuzo; Fujiwara, Toshiyoshi; Yagi, Takahito; Utsumi, Masashi; Sato, Daisuke; Yoshida, Ryuichi; Shinoura, Susumu; Sadamori, Hiroshi; Matsuda, HiroakiObjectives: Leukoencephalopathy syndrome is a neurologic complication after organ transplantation caused predominantly by the neurotoxic effects of immunosuppressive agents on cerebral white matter. We determined the incidence and features of leukoencephalopathy syndrome in recipients after living-donor liver transplantations. Materials and Methods: We retrospectively investigated 205 patients who had a living-donor liver transplantation performed at our institution between August 1998 and October 2008. Results: Leukoencephalopathy syndrome developed in 7 of 205 patients (3.9%) and in 4.7% of the 150 patients treated with tacrolimus-based immunosuppression after their living-donor liver transplantation. The underlying diseases were alcoholic cirrhosis in 3 cases, viral cirrhosis in 2, biliary atresia in 1, and Wilson disease in 1. Time to clinical onset after tacrolimus medication was 15.6 days (range, 6-30 days). The neurologic symptoms included headache, confusion, myoclonus, seizures, and visual disturbances. The mean serum trough level of tacrolimus at clinical onset was not very high (11.7 ng/mL [range, 6.0-14.2 ng/mL]). T2-weighted magnetic resonance imaging in all cases showed diffuse high signal in the white matter of the frontal, parieto-occipital, and temporal lobes. Treatment with antihypertensives, anticonvulsants, and withdrawal of tacrolimus resulted in amelioration of symptoms and magnetic resonance imaging abnormalities. Six patients showed complete recovery, while the seventh had residual rigidity and cognitive impairment caused by hypoxia during a convulsion. Conclusions: Tacrolimus neurotoxicity can occur despite low trough levels; it depends on variations in pharmacokinetics, such as absorption and maximum concentration level. Early diagnosis and treatment of leukoencephalopathy syndrome should contribute to complete remission.Item Sorafenib As Adjuvant Therapy For High-Risk Hepatocellular Carcinoma in Liver Transplant Recipients: Feasibility and Efficacy(Başkent Üniversitesi, 2010-12) Saab, Sammy; Busuttil, Ronald W.; Finn, Richard S.; McTigue, MichaelObjectives: Liver transplant can be a definitive treatment for hepatocellular carcinoma. However, recurrence limits long-term survival. Sorafenib is the first agent to improve survival for patients with advanced hepatocellular carcinoma. Materials and Methods: A retrospective, case- control match analysis was performed, along with assessment of safety and tolerability. The endpoints of the study were recurrence incidence, episodes of rejection, and disease-free overall survival. Eight patients who underwent liver transplant for hepatocellular carcinoma between May 2007 and April 2009, and tolerated adjuvant therapy with sorafenib were matched with patients who did not receive sorafenib according to age, sex, year of transplant, tumor burden, and presence of vascular invasion. Results: During follow-up, there were no episodes of rejection in either group. Eight patients were able to tolerate a predetermined duration of therapy. During a mean (± standard deviation [SD]) follow-up of 17.75 ± 6.26 months, 1 of 8 patients (12.5%) treated with sorafenib developed hepatocellular carcinoma recurrence. During a mean (± SD) follow-up of 31.63 months (± 22.30 months), 4 of 8 matched controls (50.0%) developed hepatocellular carcinoma recurrence. Disease-free 1-year survival for sorafenib and control group was 85.7% and 57.1%. Overall, 1-year survival for sorafenib and control group was 87.5% and 62.5%. Conclusions: Our study demonstrates the safety and potential benefit of sorafenib in reducing the incidence of hepatocellular carcinoma recurrence and in extending disease-free and overall survival for high-risk liver transplant recipients. A prospective trial is needed to fully assess the role sorafenib as prophylaxis against hepatocellular carcinoma recurrence.Item Acute Gastric Variceal Bleeding During Orthotopic Liver Transplant(Başkent Üniversitesi, 2010-09) Shapiro, David P.; Aniskevich, Stephen; Shine, Timothy S.We present a case of intraoperative gastric variceal bleeding during liver transplant. After an uneventful induction and surgical dissection, our patient developed hemodynamic instability during the anhepatic phase. We believe that an increase in portal pressures, owing to clamping of the portal system, led to spontaneous variceal rupture; however, placement of an oral gastric tube or transesophageal echocardiography probe may have contributed to this also. After intraoperative banding, the patient was stabilized and surgery proceeded uneventfully. The patient had no long-term sequelae. Anesthesiologists involved in the care of patients with end-stage liver disease should be aware of this infrequent intraoperative complication and be prepared to treat it appropriately.Item CTLA4 CT60 A/G Gene Polymorphism in Liver Transplant Recipients(Başkent Üniversitesi, 2010-09) Azarpira, Negar; Daraie, Masumeh; Aghdaie, Mahdokht Hosein; Malekhosseini, Seyed AliObjectives: Cytotoxic T-lymphocyte antigen 4 (CTLA4) has a critical role in the down-regulation of the immune response. We retrospectively examined the association between acute rejection and the single nucleotide polymorphism A/G in the CTLA-4 CT60 gene in liver transplant recipients. Materials and Methods: Fifty-one liver transplant recipients with at least 3 months’ follow-up were selected and genotyped for CTLA-4 CT60 polymorphism (HpyCH4 IV). The association of each genotype with allograft acute rejection was evaluated. Results: The mean age of patients was 27.9 ± 15.17 years (minimum, 1 year, maximum, 55 years), with 39% male and 61% female. Overall, 17 recipients (33.3%) experienced acute rejection within the first 3 months after a liver transplant. In our study, 50% of the patients (n=26) have G/A , 31% (n=16) have A/A, and 17% have G/G genotypes (n=9). Distribution of alleles was not different according to underlying liver disease. There also was no difference in sex, age, and distributions of CTLA-4 CT60 alleles with acute rejection episodes. Conclusions: CT60 A/G dimorphism within the 3'-UTR of CTLA4 gene does not influence acute rejection development in liver transplant. However, organ rejection is determined by a combination of several genetic traits rather than a single gene. Therefore, more studies with larger patient numbers are necessary to investigate the effect of combinations of genetic phenotypes involved in this process.Item Impact of Multislice Spiral Computed Tomography on Donor Selection and Surgical Planning in Living-Related Liver Transplant(Başkent Üniversitesi, 2010-06) Salama, Ibrahim Abdel Kader; Aal, Sayed Abdel; Korayem, Enas Mohamed; Dessouky, Basma Abdel MoneimObjectives: Living-donor liver transplant is used with increasing frequency to help compensate for the increasing shortage of deceased-donor liver grafts. However, donor safety is a primary concern, and selection of the preoperative imaging modality is important in preserving donor’s health by excluding unsuitable candidates, and tailoring the surgical procedure according to anatomic variations. In this study, we evaluate the impact of multislice spiral computed tomography on potential donor selection and surgical planning before living-related liver transplant. Materials and Methods: One-hundred seventy-five potential living-liver donors (62 women and 113 men; age range, 23-34 years; mean, 32 years) were included in our study. All subjects underwent multiphasic multislice spiral computed tomography. Postcontrast acquisitions were obtained for the arterial and venous phases. There were 139 potential donors for the right lobe and 36 potential donors for the left lateral segment. All data were analyzed to detect vascular variants, exclude focal liver lesions, and determine hepatic volume, and preoperative findings were correlated with intraoperative findings in 65 patients. Results: Of the 175 potential liver donors evaluated with multislice spiral computed tomography, 56 (32%) were excluded for the following reasons: portal vein anomalies in 11 (19.6%), hepatic venous anomalies in 9 (16.1%), fatty liver in 17 (30.3%), small liver volume in 12 (21.4%), and a focal lesion in the liver in 7 (12.5%). Of the 65 candidates, surgical planning and technique were modified in 24 donors and recipients, in 23 candidates, and the donor only in 1 candidate. Conclusions: Multislice spiral computed tomography provides parenchymal, vascular, and volumetric preoperative evaluation of potential donors for living-related liver transplant and has an effect on surgical planning: It allows the surgeon to reduce postoperative complications by modifying the surgical technique.Item Liver Transplant: A Primer(Başkent Üniversitesi, 2010-06) Movahedi, Zohreh; Saab, Sammy; Holt, Curtis D.Liver transplant has been accepted as a successful therapeutic option for patients with end-stage liver disease. Patient and graft survival has incrementally increased over the past 2 decades, mainly because of immunosuppressive regimens. However, the nonspecific nature of immunosuppressive agents is associated with an increased risk of development of opportunistic infections, renal impairment, metabolic derangements, neurotoxicity, de novo malignancies, and recurrence of the primary disease. Immunosuppressive regimen pharmacologic classes include calcineurin inhibitors, anti-metabolites, mTOR inhibitors, steroids, and antibody-based therapies. These agents affect T-cell–dependent B-cell activation, and target different sites in the T-cell activation cascade by inhibiting T-cell activation or causing T-cell depletion. The goals of immunosuppression in solid-organ transplant are to prevent allograft rejection as well as optimize allograft function, prolong patient survival, and improve patient quality of life. Therefore, it is essential to carefully select the immunosuppressive regimen that will result in significant improvements in long-term liver transplant patients’ survival and quality of life.Item Effect of Liver Transplant on Pulmonary Functions in Adult Patients with Alpha 1 Antitrypsin Deficiency: 7 Cases(Başkent Üniversitesi, 2010-03) Kashyap, Randeep; Orloff, Mark; Jain, Ashokkumar B.; Patil, Vrishali; Sheikh, Baber; Apostolakos, Michael; Ryan, CharlotteObjectives: Alpha 1 antitrypsin (A1A) is a 52 kD glycoprotein that is mainly synthesized in the liver. As a major protease inhibitor, it binds to and neutralizes neutrophil elastase, thereby limiting the damage to the normal tissues after an inflammatory response. A deficiency in A1A leads to end-stage liver disease, both in children and in adults. In addition, the deficiency also has a detrimental effect in the lungs of the adult population. Alpha 1 antitrypsin deficiency is corrected with hepatic replacement; however, the changes in pulmonary functions have not been studied before and after liver transplant. The purpose of this study was to observe the changes in the pulmonary functions of patients who underwent liver transplant for the treatment of A1A deficiency. Materials and Methods: Nine patients underwent liver transplant for A1A deficiency. Seven patients (5 men, 2 women; mean age, 49.95 ± 7.09 years) had their pulmonary function tests available before the liver transplant (mean, 5.6 ± 3.4; range, 0.9-10.1 months) and after the liver transplant (mean, 30.3 ± 18.4, range 7.8-48.1 months) for analysis. Results: The mean, preliver, transplant, FEV1 was 2.69 ± 0.9 L, which was nearly unchanged after the liver transplant to a mean of 2.7 ± 1.2 L. During the mean total interval of nearly 3 years, an estimated decline of 250 mL in FEV1 was expected. Conclusions: It appears from the results of our study that liver transplant probably prevented the progression of pulmonary disease in A1A-deficient patients. Further study and close, postliver, transplant follow-up is warranted to support our initial findings.Item Role of Ischemic Preconditioning in Liver Transplant: A Review of Literature(Başkent Üniversitesi, 2010-03) Macedo, Francisco Igor Bulcão; Miranda, Luiz Eduardo CorreiaInterruption of blood flow and subsequent organ reperfusion lead to significant tissue damage. This well-studied phenomenon is recognized as ischemia/reperfusion injury. Ischemic preconditioning refers to a mechanism in which a prior, short, ischemic period induces some protection against a subsequent prolonged ischemic and reperfusion damage. The mechanisms involved in ischemic preconditioning and its applications for clinical and basic research are discussed in this paper.Item Interventional Radiology in Liver Transplant(Başkent Üniversitesi, 2008-06) Boyvat, Fatih; Haberal, Mehmet; Karakayali, Hamdi; Aytekin, CuneytAn increased number of transplant centers now actively perform deceased-donor as well as living-related liver transplants. Although postoperative vascular and nonvascular complications after liver transplant have been well documented, early diagnosis and intervention are important to increase graft and recipient survival. With improvements in interventional radiologic techniques and a multidisciplinary approach to liver transplant, management of complications by percutaneous and endovascular techniques is possible with less morbidity and mortality. This article outlines the recent developments in, and applications of, interventional radiologic techniques in liver transplant patients.Item Lymphedema Tarda After Liver Transplantation: A Case Report and Review of the Literature(Başkent Üniversitesi, 2006-12) Saab, Sammy; Nguyen, Stephen; Collins, James; Kunder, Gregg; Busuttil, Ronald W.We present a patient with lymphedema that developed after orthotopic liver transplantation. The cause of the posttransplant lymphedema was likely related to a developmental abnormality of the lymphatic system that was exaggerated by refractory chylous ascites. A peritoneal fluid with a milky appearance, chylous ascites is rich in triglyceride and is caused by the obstruction or disruption of abdominal lymphatic channels. It is a rare complication that may develop after trauma or abdominal surgery or as a result of a malignant disease [1], and it is even more uncommon after liver transplantation [2]. Therapy for chylous ascites involves treating its underlying cause. In the patient we describe, lymphedema tarda, which was diagnosed 6 months after liver transplantation, was likely caused by chylous ascites and a developmental abnormality of the lymphatic system.