Extrahepatic complications of liver transplantation.

The massive surgical assault associated with hepatic transplantation makes a high frequency of complications almost inevitable. In this review of 225 patient records, selected at random from cases of liver transplantation in Pittsburgh over a 2 1/2 year period ending in January 1985, 87.2% of patients experienced at least one significant complication that threatened their survival or that of the graft and that often prolonged their hospitalization. Familiarity with the complications may facilitate earlier recognition, with consequently early and more effective management in future cases

A simplified technique for the treatment of simple pleural effusions

This technique for the drainage of simple pleural effusions is simple, safe and effective. It requires little more skill than the ability to perform a thoracentesis or central venous line placement. It appears ideal for both the bedridden patient who cannot sit for repetitive thoracocentesis and for the ambulatory patient who need not be tied down with a chest tube and underwater seal system. We stress that the system is functional only for simple transudates and will provide unsatisfactory drainage of thick or bloody effusions

Influence of selected patient variables and operative blood loss on six-month survival following liver transplantation.

A group of 118 adults who underwent primary, orthotopic transplantation of the liver over a 4-year period served as the subjects of a detailed examination of their ability to survive the first 6 months as a function of their preoperative condition. As a result, a scoring system was developed empirically in an attempt to separate very high-risk from relatively low-risk patients. The scoring method is based on the high degree of correlation between survival probability and various patient characteristics. It allows for additional scoring to account for the dramatic effect of operative blood loss on the eventual outcome. The curve that best describes the relationship between patient scores and survival probability is sigmoidal in shape. Many patients will have scores located on the curve between the inflection points. They represent a group whose relative risk is difficult to estimate but for whom operative blood loss or the occurrence of surgical complications may prove particularly telling

The course of type 1 hepato-renal syndrome post liver transplantation

Background. Hepato-renal syndrome (HRS) is a functional form of renal failure that occurs in patients with end-stage liver disease. Previously considered fatal without liver transplantation, treatment with vasoconstrictors and albumin has been demonstrated to improve renal function in patients with type 1 HRS. Liver transplantation is still considered the definitive treatment for HRS. However, the renal recovery rate and those factors that predict recovery post orthotopic liver transplantation have not been determined. Methods. We reviewed the hospital course of 28 patients who met the International Ascites Club criteria for type I HRS and who underwent orthotopic liver transplant. The patients' demographic and pre- and post-operative laboratory data were recorded; patients were followed for 4 months post-transplantation or until death. Results. The MELD score of the patients was 30±6. The mean duration of HRS prior to liver transplantation was 37±27 days. HRS resolved in 16 patients (58%). The mean time to resolution of HRS was 21±27 days, with a range of 4-110 days. Eight (50%) patients in whom the HRS resolved were undergoing pre-transplantation dialysis. The age of the recipients (49±10 vs 56±12; P = 0.05), the total bilirubin level on post-operative day 7 (6.0±4.3 vs 10.1±5.9mg/dl; P = 0.04), alcoholic liver disease and the requirement for post-transplant dialysis were predictors of resolution of HRS by univariate analysis. Only alcoholic liver disease and post-transplant dialysis were independent (negative) predictors of resolution of HRS. Seven of the 12 (58%) patients who developed chronic renal insufficiency remained dialysis dependent. The pre-operative serum creatinine was non-significantly higher in the non-resolvers who remained dialysis dependent compared to those who did not require long-term dialysis (3.0±1.0 vs 2.3±0.4 mg/dl; P = 0.1) Four patients died; in three of these patients the HRS had resolved prior to their death. Conclusion. HRS is not always cured by orthotopic liver transplant. Pre-transplantation dialysis or a long waiting period should not preclude transplantation in patients with HRS. HRS may not resolve in patients with alcoholic liver disease. We were unable to accurately define that group of patients with HRS who required long-term dialysis and could theoretically benefit from combined liver-kidney transplantation. © The Author [2005]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved

Incidence, risk factors and causes of death in an HIV care programme with a large proportion of injecting drug users.

Objectives  To identify factors influencing mortality in an HIV programme providing care to large numbers of injecting drug users (IDUs) and patients co-infected with hepatitis C (HCV). Methods  A longitudinal analysis of monitoring data from HIV-infected adults who started antiretroviral therapy (ART) between 2003 and 2009 was performed. Mortality and programme attrition rates within 2 years of ART initiation were estimated. Associations with individual-level factors were assessed with multivariable Cox and piece-wise Cox regression. Results  A total of 1671 person-years of follow-up from 1014 individuals was analysed. Thirty-four percent of patients were women and 33% were current or ex-IDUs. 36.2% of patients (90.8% of IDUs) were co-infected with HCV. Two-year all-cause mortality rate was 5.4 per 100 person-years (95% CI, 4.4-6.7). Most HIV-related deaths occurred within 6 months of ART start (36, 67.9%), but only 5 (25.0%) non-HIV-related deaths were recorded during this period. Mortality was higher in older patients (HR = 2.50; 95% CI, 1.42-4.40 for ≥40 compared to 15-29 years), and in those with initial BMI < 18.5 kg/m(2) (HR = 3.38; 95% CI, 1.82-5.32), poor adherence to treatment (HR = 5.13; 95% CI, 2.47-10.65 during the second year of therapy), or low initial CD4 cell count (HR = 4.55; 95% CI, 1.54-13.41 for <100 compared to ≥100 cells/μl). Risk of death was not associated with IDU status (P = 0.38). Conclusion  Increased mortality was associated with late presentation of patients. In this programme, death rates were similar regardless of injection drug exposure, supporting the notion that satisfactory treatment outcomes can be achieved when comprehensive care is provided to these patients

Near-IR variability properties of a selected sample of AGB stars

We present the results of a near-infrared monitoring programme of a selected sample of stars, initially suspected to be Mira variables and OH/IR stars, covering more than a decade of observations. The objects monitored cover the typical range of IRAS colours shown by O-rich stars on the Asymptotic Giant Branch and show a surprisingly large diversity of variability properties. 16 objects are confirmed as large-amplitude variables. Periods between 360 and 1800 days and typical amplitudes from 1 to 2 magnitudes could be determined for nine of them. In three light curves we find a systematic decrease of the mean brightness, two light curves show pronounced asymmetry. One source, IRAS 07222-2005, shows infrared colours typical of Mira variables but pulsates with a much longer period (approx. 1200 days) than a normal Mira. Two objects are ither close to (IRAS 03293+6010) or probably in (IRAS 18299-1705) the post-AGB phase. In IRAS 16029-3041 we found a systematic increase of the H-K colour of approximately 1 magnitude, which we interpret as evidence of a recent episode of enhanced mass loss. IRAS 18576+0341, a heavily obscured Luminous Blue Variable was also monitored. The star showed a continued decrease of brightness over a period of 7 years (1995 - 2002).Comment: 9 pages + 3 appendix, 36 figures, photometry table, accepted in Astronomy & Astrophysic

From Welfare to Warfare: The Arbitration of Host-Microbiota Interplay by the Type VI Secretion System.

The health of mammals depends on a complex interplay with their microbial ecosystems. Compartments exposed to external environments such as the mucosal surfaces of the gastrointestinal tract accommodate the gut microbiota, composed by a wide range of bacteria. The gut microbiome confers benefits to the host, including expansion of metabolic potential and the development of an immune system that can robustly protect from external and internal insults. The cooperation between gut microbiome and host is enabled in part by the formation of partitioned niches that harbor diverse bacterial phyla. Bacterial secretion systems are commonly employed to manipulate the composition of these local environments. Here, we explore the roles of the bacterial type VI secretion system (T6SS), present in ~25% of gram-negative bacteria, including many symbionts, in the establishment and perturbation of bacterial commensalism, and symbiosis in host mucosal sites. This versatile apparatus drives bacterial competition, although in some cases can also interfere directly with host cells and facilitate nutrient acquisition. In addition, some bacterial pathogens cause disease when their T6SS leads to dysbiosis and subverts host immune responses in defined animal models. This review explores our knowledge of the T6SS in the context of the "host-microbiota-pathogen" triumvirate and examines contexts in which the importance of this secretion system may be underappreciated

Acquired immunologic tolerance: with particular reference to transplantation

The first unequivocally successful bone marrow cell transplantation in humans was recorded in 1968 by the University of Minnesota team of Robert A. Good (Gatti et al. Lancet 2: 1366–1369, 1968). This achievement was a direct extension of mouse models of acquired immunologic tolerance that were established 15 years earlier. In contrast, organ (i.e. kidney) transplantation was accomplished precociously in humans (in 1959) before demonstrating its feasibility in any experimental model and in the absence of a defensible immunologic rationale. Due to the striking differences between the outcomes with the two kinds of procedure, the mechanisms of organ engraftment were long thought to differ from the leukocyte chimerism-associated ones of bone marrow transplantation. This and other concepts of alloengraftment and acquired tolerance have changed over time. Current concepts and their clinical implications can be understood and discussed best from the perspective provided by the life and times of Bob Good