Brown, DW

Starzl, TE

English

PubMed

Name not available

Radionuclides in the postoperative management of orthotopic human organ transplantation

Donald W. Brown

Thomas E. Starzl

Crossref

Radiology

Radionuclides in the Postoperative Management of Orthotopic Human Organ Transplantation

D-Scholarship@Pitt

[Reprinted from RADIOLOGY, Vol. 92, Ko. :.!, Pages 373-376, February, 1969.J Copyrighted 1969 by the Radiological Society of North America. Incorporated Radionuclides in the Postoperative Management of Orthotopic Human Organ Transplantation 1 DONALD W. BROWN, M.D., and THOMAS E. STARZL, Ph.D., M.D. FOR SEVERAL years an active program in human organ transplantation has been conducted at our institution (1-3), and since March 1962, 214 patients have re-ceived renal transplants. Two thirds of these transplanted kidneys are still func-tioning and most of these patients are living nearly normal lives. In addition, limited success has been achieved in liver transplantation (4-6). Of 14 recipients of orthotopic cadaveric human liver trans-plants, 5 are living. Several spleen trans-plants have also been performed (7-9); although these patients survived, the pro-cedures were not beneficial. The transplantation team has found the 131I-Hippuran renogram and 197Hg-chlor-merodrin renal scan helpful in many cases of renal transplantation. The 99mTc-sulfide liver scan has proved valuable in the post-operative management of patients sub-jected to liver transplantation, and in two of the spleen transplant cases the radio-isotope scan offered a means of visualizing the transplanted organ. RENAL TRANSPLANTATION In a transplanted kidney which is func-tioning well, a nearly normal renogram pattern can be recorded following the intra-venous injection of 50 ~Ci of l3lI-labe1ed Hippuran. The probe is positioned an-teriorly over the kidney which can be lo-cated by palpation in the pelvis. The tail end of the recorded curve will be somewhat elevated compared to the usual renogram because of the proximity of the bladder which will contain a relatively large amount of the radioactivity injected. In several patients acute oliguria or anuria has developed at varying times in the postoper-ative course. Clinically, it may be diffi-cult to tell whether this is caused by renal arterial insufficiency, rejection of the kidney, or ureteral obstruction. In all three situations, the renogram becomes ab-normal. In severe rejection or in cases where the renal artery is kinked, the reno-gram will be low and almost fiat. In cases of milder rejection, the renogram shows an obstructive pattern with a normal early phase which continues to ascend without development of the usual excretion pat-tern. This same pattern is seen in ureteral obstruction. The renogram is usually preceded by the performance of a 197Hg-chlormerodrin renal scan. Two hundred microcuries of mer-cury-197 are injected intravenously, and one hour later the scan is performed. In a normally functioning transplanted kidney, a sharp outline is recorded. In cases of renal artery insufficiency and also in cases of severe rejection, the kidney becomes less and less well visualized with more and more of the mercury being taken up in the liver and spleen. Serial tests are helpful in as-sessing the progress of some of these pa-tients. SPLEEN TRANSPLANTATION Two patients with spleen transplants have been studied. One boy who was suffering from agammaglobulinemia and repeated severe disabling pulmonary infec-tions received a transplant of his mother's spleen in an attempt to colonize his body with immunologically productive lympho-cytes from the mother. The surgical pro-cedure was technically successful, but there was no real evidence of an increase in im-mune globulins of maternal origin. Even-1 From the Division of Nuclear Medicine and Department of Surgery, University of Colorado Medical Center, and Veterans Administration Hospital, Denver, Colo. Presented at the Fifty-fourth Scientific Assembly and Annual Meeting, Chicago, Ill., Dec. 1-6, 1968. Supported by USPHS Grants HE-09112, HE-07735, AM-06344, AM-07772, AI-04152, FR-00051, FR-00069, F05-TW-ll54, and AEC Research Contract AT(1l-1)-1472. RADIOLOGY 92: 373-376, February 1969. (J.C.) 373 374 DONALD W. BROWN AND THOMAS E. STARZL February 1969 • Fig. 1. Anteroposterior and right lateral nmTc-sulfide liver scans in a patient ten months after orthotopic cadaveric liver transplantation, show-ing normal function and configuration. tually, immunosuppression was stopped and the transplant involuted. The second case was one in which a father's spleen was transplanted into his son, who was suffering from hemophilia. Four days later, the transplanted spleen ruptured, necessitating its removal. In both cases, the radioiso-tope scan permitted excellent visualization of the transplanted organ. In the first, the spleen gradually disappeared from the scan as it became atrophic. In the second case, the splenic hemorrhage was not vis-ualized since it was extracapsular and did not indent the spleen. LIVER TRANSPLANTATION In caring for patients after orthotopic hepatic transplantation, it became evident that crucial and incisive information on organ size and function could be obtained with serial liver scans. Of even greater importance, localized intrahepatic lesions such as abscesses and infarcts could be accurately identified and followed (4, 5, 10). Only with the recent introduction of short-lived isotopes for liver scanning has it been possible to perform frequent serial scans safely. In our patients we have used 99mTc-sulfide particles. The technic of prep-aration was slightly modified from that de-scribed by Stern and Patton and their as-sociates (11, 12). An intravenous dose of 800 /JCi per scan is used in children and 2 to 3 mCi in adults. This gives a radiation dose to the liver of 0.8 rads per scan . Scanning was done with 3- and 5-inch crystal rectilinear scanners in dogs and pa-tients, respectively. In children and dogs, a high-energy, fine-focus collimator was used at a speed of 150 em per minute and a line spacing of 0.2 inch. Immobility of the subject for approximately twenty minutes is required for a technically satisfactory scan with the 5-inch crystal scanner, but more recently we have employed a 10-crystal rectilinear scanner in patients, which requires less than two minutes per view. The central role which this diagnostic technic has come to occupy in the post-transplantation period of such patients has prompted us to investigate the various factors that might influence liver scans. Dogs were subjected to common duct or hepatic artery ligation, portal-to-systemic venous diversion, and orthotopic homo-transplantation to treated or untreated recipients. These animal studies are re-ported in detail elsewhere (10). In essence our results showed that frequent serial in-jections of 99mTc sulfide caused no detect-able deleterious effect in dogs. We also found that bile duct ligation and hepatic artery ligation resulted in no acute change in the liver scan except for the appearance of a large anterocentro defect due to dis-tension of the gallbladder in the former. Undoubtedly, if progressive biliary cir-rhosis had developed in these animals, other changes would have been noted. Eck fistulas were produced in 3 dogs. In these the scans showed a definite and progressive diminution in liver size and the development of areas of diminished radioisotope uptake, conforming to the hepatic atrophy noted at autopsy. Dogs treated with orthotopic Vol. 92 RADIONUCLIDES IN ORTHOTOPIC HUMAN ORGAN TRANSPLANTATION hepatic transplantation and sUbjected to serial scanning showed changes similar to those noted in the patients described below. In patients who are doing well after or-thotopic hepatic transplantation, serial 99mTc-sulfide scans have been obtained about once weekly for four to six weeks Fig. 2. Anteroposterior and right lateral 88mTc-sulfide liver scan in a patient two months after orthotopic cadaveric liver transplantation, clearly demonstrating infarction and abscess formation in the right lobe. and then less and less often as the patient's condition improved, but at least once a month in all patients. ~o detectable del-eterious effect or morbidity has been asso-ciated with these repeated scans. One little girl received 25 scans during the more than thirteen months of her life following liver transplantation. She finally suc-cumbed to widespread metastasis from the hepatoma present preoperatively. At the time of autopsy, no changes attributable to radiation or the technetium sulfide could be demonstrated (Fig. 1). In several of the patients who received hepatic transplants in the latter half of 1967 infarction devel-oped, complicated by abscess formation in the right lobe of the liver. Technical re-visions in the surgical procedure seem to have eliminated this complication in later cases (5). In these patients the liver scan clearly demarcated these lesions, assisting the institution of appropriate surgical drainage (Fig. 2). Rejection has devel-Fig. 3. Anteroposterior 98mTc-sul-fide liver scan after orthotopic cadav-eric liver transplantation, demon-strating a swollen liver with a decrease in hepatic concentration and an in-crease in extrahepatic deposition of isotope in the reticuloendothelial cells of the bone marrow and lungs. oped in other patients. Their scans dem-onstrate swelling of the liver as well as decreased hepatic concentration of isotope and increased extrahepatic deposition in the reticuloendothelial cells of the bone marrow and lungs (Fig. 3). These changes were identical to the pattern seen in cir-rhosis except for the absence of spleens, most of which had been removed at the time of surgery. In several instances, this picture reverted completely to normal as the rejection process was brought under control. There developed in 2 patients increasing jaundice, serum chemical abnormalities, and deteriorating scans. Clinically, it was not possible to tell whether they were suffering from intrahepatic or extrahepatic biliary obstruction. After intravenous in-jection of 1311 rose bengal, serial scans were performed over a forty-eight-hour period (13), and serial counts were taken over the head, liver, heart, and lower abdomen (14). The scans revealed no excretion of rose bengal into the intestinal tract, and blood-to-liver ratios were consistent with intra-hepatic obstruction. Both patients proved eventually to be suffering from re-jection, and liver biopsy in one of them dis-closed dilated biliary canaliculi and other 376 DONALD W. BROWN AND THOMAS E. STARZL February 1969 changes consistent with an intrahepatic type of obstruction. SUMMARY Nuclear medicine can play an important role in the postoperative management of patients subjected to orthotopic human organ transplantation. Changes in the radioisotope renogram and renal scan aid in evaluation of the function of trans-planted kidneys but have proved to be of limited value in assessing the etiology of impaired function. In transplanted livers, infarctions and abscesses can be demar-cated, and the development of rejection demonstrated by the 99mTc-sulfide scan. University of Colorado Medical Center 4200 East Ninth Avenue Denver, Colo. 80220 REFERENCES 1. STARZL, T. E.: Experience in Renal Trans-plantation. Philadelphia, Saunders, 1964. 2. MARcmoRo, T. L., ET AL. Renal Transplanta-tion at the University of Colorado. Transplantation (Suppl.) 5: 831-836, July 1967. 3. STARZL, T. E., ET AL.: Heterologous Antilym-phocyte Globulin, Histocompatibility Matching, and Human Renal Homotransplantation. Surg., Gynec. & Obst. 126: 1023-1035, May 1968. 4. STARZL, T. E., ET AL.: Extended Survival in 3 Cases of Orthotopic Homotransplantation of the Human Liver. Surgery 63: 549-563, April 1968. 5. STARZL, T. E., ET AL.: Orthotopic Homotrans-plantation of the Human Liver. Ann. Surg. 168: 392-414, September 1968. 6. STARZL, T. E., BRETTSCHNEIDER, L., PENN,!., BELL, P., GROTH, C. G., BLANCHARD, H., KAsmWAGI, N., AND PUTNAM, C. W.: Orthotopic Liver Transplan-tation in Man. Proceedings of the Transplantation Society. (In press.) 7. STARZL, T. E., ET AL.: Clinical Experience with Organ Transplantation. South. M. J. 58: 131-147, February 1965. 8. MARcmoRo, T. L., ET AL.: Splenic Homo-transplantation. Ann. New York Acad. Sc. 120: 626-651, Nov. 30, 1964. 9. HATHAWAY, W. E., MULL, M. M., GITHENS, J. H., GROTH, C. G., MARcmORO, T. L., AND STARZL, T. E.: Spleen Transplant in Classical Hemophilia. Transplantation. In press. 10. GROTH, C. G., BROWN, D. W., CLEAVELAND, J. D., CORDES, D. J., BRETTSCHNEIDER, L., AND STARZL, T. E.: Radioisotope Scanning in Experi-mental and Clinical Orthotopic Liver Transplantation. Surg., Gynec. & Obst. 127: 808-816, October 1968. 11. PATTON, D. D., GARCIA, E. N., AND WEBBER, M. M.: Simplified Preparation of Technetium 99m Sulfide Colloid for Liver Scanning. Am. J. Roentgenol. 97: 880-885, August 1966. 12. STERN, H. S., McAFEE, J. G., AND SUBRA-MANIAN, G.: Preparation, Distribution and Utilization of Technetium-99m-Sulfur Colloid. J. Nuclear Med. 7: 665-675, September 1966. 13. EYLER, W. R., ScHUMAN, B. M., DUSAULT, L. A., AND HINSON, R. E.: Rose Bengal 1-131 Liver Scan. An Aid in the Differential Diagnosis of Jaundice. J.A.M.A. 194: 990-992, Nov. 29, 1965. 14. BLAHD, W. H. ed.: Nuclear Medicine. New York, McGraw-Hill Book Co., 1965, pp. 288-292. 

Radionuclides in the postoperative management of orthotopic human organ transplantation.

http://d-scholarship.pitt.edu/3564/1/31735062124320.pdf

Radionuclides in the postoperative management of orthotopic human organ transplantation.

Abstract

Similar works

Full text

Available Versions

Name not available

Name not available

Crossref

D-Scholarship@Pitt