One-year Actuarial Survival Research Articles

The impact of microsurgical hepatic arterial reconstruction on the outcome of liver transplantation for congenital biliary atresia

Hepatic artery thrombosis (HAT) after liver transplantation for biliary atresia (BA) is a serious complication that most often leads to retransplantation (re-OLT). The purpose of the present study was: (1) to identify risk factors associated with HAT and (2) to analyze the impact of recently introduced microsurgical hepatic arterial reconstruction (MHR) on the incidence of HAT, subsequent need for re-OLT, and patient survival. A retrospective review of 194 patients transplanted for BA was performed. One hundred and sixty-six patients (group 1) underwent conventional arterial reconstruction and 28 (group 2) had MHR. Actuarial survival for patients with HAT was significantly worse than for patients without HAT at 1, 2, and 5 years (71%, 61%, and 57% versus 85%, 85%, and 85%, P = 0.0007). Stepwise logistic regression analysis revealed that the risk of HAT correlated best with the type of arterial reconstruction (P = 0.007) followed by pretransplant bilirubin concentration (P = 0.04) and the number of acute rejection episodes (P = 0.03). In group 1, 32 patients developed HAT (19%), and of these, 18 underwent re-OLT for HAT. No patient in group 2 developed HAT (P = 0.006 versus group 1). One-year actuarial patient survival was 81% in group 1 and 100% in group 2 (P = 0.02). In OLT for BA, (1) the predominant risk factor for HAT is the technique of arterial reconstruction, and (2) MHR markedly reduces the incidence of HAT and the need for re-OLT while improving patient survival.

Balloon aortic valvuloplasty in elderly patients at high risk for surgery, or inoperable

Although aortic valve replacement is undoubtedly the treatment of choice for aortic valve stenosis, balloon aortic valvuloplasty may represent the only possible treatment for some frail elderly patients who may have additional medical problems. We evaluated immediate and 1-year results of balloon aortic valvuloplasty in 86 patients > or = 80 years with severe aortic stenosis. Mean age was 84 +/- 3 years. Forty-four % were 85 years or older. Mean gradient decreased from 68 to 26 mm Hg and valve area increased from 0.53 to 0.96 cm2 (P<0.05). There were two per-procedural deaths. No local vascular complication was observed. During the follow-up (13 +/- 9 months), 27 patients died, four had repeat balloon aortic valvuloplasty and eight underwent aortic valve replacement. Persistent clinical improvement was observed in 78% of the surviving patients. One-year actuarial survival rate was 73%. Balloon aortic valvuloplasty appears to be a safe and valuable technique in cases where surgery cannot be performed or carries a very high risk.

Cardiac transplantation: An eight-year experience

From June 1985 to June 1993, a total of 199 orthotopic (2 retransplanted) and one heterotopic cardiac transplants were performed in patients whose ages ranged from 17to 66(average 53)years. There were 175 (87.5%) males and 25 (12.5%) females. The aetiology of end-stage heart disease included: ischaemic heart disease 138 (69%); idiopathic cardiomyopathy 53 (26.5%); valvular disease 7 (3.5%); and adriamycininduced cardiomyopathy in 2 (1%). At the time of surgery, 56 (26.5%) patients were in United Network for Organ sharing (UNOS) Status I (ICU, intra-aortic balloon other assists, inotropic support) and 144 (72%) were UNOS Status II. The majority of donors were local or within the state. Two immunosuppressive protocols have been utilised, viz., conventional triple drug therapy and OKT3 induction. The mean rejection has been 2.5 episodes/patient. The majority of these episodes, (72 %) occurred within the first three months. Of the 1.8 infectious episodes per patient, opportunistic organisms predominated with a 98 per cent recovery. We have experienced 53 postoperative deaths. Currently, 147 (73.5%) recipients are alive and well. Our one-year actuarial survival is approximately 82per cent, the five year figure being 64 per cent. Tampa General Hospital is, at present, one of the most active cardiac transplant centres in the USA. Our eightyear experience has allowed us to mature through our learning curve to become an established, successful cardiac transplant program.

Cocaine-associated chest pain: one-year follow-up.

To determine the one-year mortality and incidence of myocardial infarction (MI) post-hospital discharge or ED release for patients with cocaine-associated chest pain. A prospective, observational study of an inception cohort of consecutive patients who presented to one of four municipal hospital EDs with cocaine-associated chest pain. Patients were followed for one year from the end of the enrollment period. Main outcome parameters were the one-year actuarial survival and the frequency of nonfatal MI. Mortality data were available for all 203 patients at a mean of 408 days. Additional clinical information was available for 185 patients (91%). There were six deaths (one-year actuarial survival 98%; 95% CI, 95-100%); none from MI. Nonfatal MI occurred in two patients (1%; 95% CI, 0-2%). Continued cocaine use was common (60%; 95% CI, 52-68%) and was associated with recurrent chest pain (75% vs 31%, p < 0.0001). No MI or death was reported for patients who claimed to have ceased cocaine use. Patients who presented with cocaine-associated chest pain commonly continued to use cocaine after discharge. Urgent evaluation of coronary anatomy or cardiac stress tests may not be necessary for patients for whom MI is ruled out and who do not have recurrent potentially ischemic pain. The subsequent risk for MI and death in this group appears to be low. Intervention strategies should emphasize cessation of cocaine use.

One-Stage Surgery of Coronary Arteries and Abdominal Aorta in Patients With Impaired Left Ventricular Function

Coronary artery disease (CAD) is common in patients with abdominal aortic aneurysms (AAA). Some patients will present with the combination of unstable angina, impaired left ventricular function, and a large symptomatic (ie, leaking, expanding) AAA. In this subgroup of high-risk patients, aortic cross-clamping may have a deleterious effect on cardiac function, whereas coronary artery bypass graft surgery before aneurysmectomy (staged operation) carries the risk of perioperative aneurysm rupture. One-stage surgery, ie, myocardial revascularization and simultaneous aortic aneurysm repair, has been proposed in this situation. This article summarizes our results with the combined one-stage approach in patients with symptomatic CAD, impaired left ventricular function, and large symptomatic aortic aneurysms or severe aortic occlusive disease. As yet, this cohort is the largest reported in the English literature. In 25 patients (24 men) with a mean age of 69.4 years (range, 55 to 80 years), we performed combined open heart and intra-abdominal aortic surgery. Eighteen patients had severe three-vessel disease and impaired left ventricular function (ejection fraction, < 35%). In addition, 3 of these patients had severe aortic valvular stenosis and/or insufficiency. Seven patients had one- or two-vessel disease with a low left ventricular ejection fraction in the range of 15% to 30%. All patients were in New York Heart Association functional class III or IV. Twenty-one of 25 patients had symptomatic infrarenal AAA (perianeurysm hematoma was present in 9 patients, and 12 patients had signs of beginning perforation). Four patients with aortoiliac occlusive disease and limb ischemia were simultaneously operated on. The surgical procedure started with the performance of coronary artery bypass graft surgery. After completion of myocardial revascularization, aortic aneurysm repair was performed while extracorporeal circulation was continued for mechanical cardiac assist until aortic surgery was fully accomplished. An average of 3.3 (3 to 5) coronary bypass grafts were placed, including 17 internal thoracic artery grafts. In addition, three aortic valves were replaced. In the abdominal aortic position, 12 straight tube grafts and 13 bifurcation grafts were implanted, and three renal and two carotid arteries were simultaneously repaired. The total time of surgery varied from 2.3 to 8.5 hours, with a mean time of 3.9 +/- 1.4 hours. One intraoperative myocardial infarction occurred despite open grafts. Intensive care unit treatment lasted 1 to 13 days, with a mean of 3.6 +/- 2.5 days. Three patients (12%) died after surgery--1 because of acute renal failure induced by an adverse reaction to heparin, 1 because of myocardial infarction, and 1 because of multiorgan failure. One-year actuarial survival rate was 88%, which compares favorably with survival after isolated AAA surgery in this high-risk patient subgroup and equals survival in patients with severe CAD and severely depressed myocardial function. One-stage surgery is a possible approach to highly symptomatic patients with severe multivascular disease and has acceptable early morbidity and mortality. Patients with severely impaired left ventricular function and unstable CAD carry a high risk of left heart failure and/or myocardial infarction during abdominal aortic surgery. Extracorporeal circulation protects the heart from the hemodynamic changes after aortic clamping or declamping during abdominal aortic surgery. The present study demonstrates that one-stage procedure is a reasonable option for this patient subgroup.

Critical issues in pediatric lung transplantation

Forty children (aged 1 to 18 years, 27 female and 13 male) have undergone heart-lung (21), double lung (17), and single lung (2) transplant procedures at our center from 1985 through April 1994. The indications for transplantation have been diverse, primary pulmonary hypertension (10), cystic fibrosis (11), congenital heart disease (10), arteriovenous malformation (3), emphysema (1), graft-versus-host disease (1), rheumatoid lung (1), cardiomyopathy (1), desquamative interstitial pneumonitis (1), and Proteus syndrome (1). The actuarial 1-year survival was 73% (mean follow-up 2 years). One-year actuarial survival for disease groups ranged from 60% for cystic fibrosis to 90% for congenital heart disease. We have identified six issues critical to the patient and programatic survival of pediatric lung transplantation. Our experience and management strategies in these areas are reviewed. Cytomegalovirus : Cytomegalovirus disease developed in six of eight patients with cytomegalovirus mismatching (donor +/recipient -) and in seven of 32 patients who survived more than 30 days (23%). All but cytomegalovirus donor -/recipient-patients were treated with ganciclovir for 4 weeks after transplantation. Obliterative bronchiolitis : Obliterative bronchiolitis developed in seven of 32 (25%) patients who survived more than 30 days. Obliterative bronchiolitis was manifest within the first posttransplantation year as a rapid decline in small airway function. Aggressive augmentation of immunosuppression has been used with little success. Posttransplantation lymphoproliferative disease : Posttransplantation lymphoproliferative disease developed in five of 32 (15%) patients who survived more than 30 days developed. One patient died (17% mortality) despite retransplantation. In four patients the disease resolved with reduction in immunosuppression alone, and one required the addition of interferon alfa. Cystic fibrosis : We have changed our management strategies to avoid triple drug immunosuppression, perioperative blood and bronchial cultures, aggressive antimicrobial therapy, and exclusion of patients with panresistant organisms; this has resulted in elimination of infectious mortalities thus far in the pediatric cystic fibrosis group. Airways : In 21 heart-lung recipients with tracheal anastomoses we have had no airway complications. The double and single lung transplant recipients accounted for 34 bronchial and one tracheal anastomoses. Three (9%) bronchial stenoses developed. Two were treated with silicone stents and one with balloon dilation. Finances : The average charge for lung transplant evaluation was $18,000 and for transplantation, $175,000. (J T horac C ardiovasc S urg 1995;109:60-5)

Surgical Treatment of Diabetes Mellitus with Pancreas Transplantation

The authors compared results and morbidity in insulin-dependent diabetes mellitus (IDDM) patients undergoing preemptive pancreas transplantation (PTx) either before dialysis or before the need for a kidney transplant with IDDM patients undergoing conventional combined pancreas-kidney transplantation (PKT) after the initiation of dialysis therapy. Combined PKT has become accepted generally as the best treatment option in carefully selected IDDM patients who either are dependent on dialysis or for whom dialysis is imminent. With improving results, the timing of PKT relative to the degree of nephropathy is evolving. However, it is not well established that the advantages of preemptive PTx can be achieved without incurring a detrimental effect on graft function or survival. Over a 4-year study period, data on the following 3 recipient groups were collected prospectively and analyzed retrospectively: 1) 38 IDDM patients undergoing combined PKT while on dialysis (PKT:D); 2) 44 IDDM patients undergoing preemptive PKT before dialysis (PKT:ND); and 3) 20 IDDM patients undergoing solitary PTx. All patients underwent whole organ PTx with bladder drainage and were treated with quadruple immunosuppression. Actuarial 1-year patient survival is 100%, 98%, and 93%, respectively. One-year actuarial PTx survival (insulin-independence) is 92%, 95%, and 78%, respectively. The incidence of rejection, infection, operative complications, readmissions, and total hospital days was similar in the three groups. Long-term renal and pancreas allograft function and quality of life were similarly comparable. Rehabilitation potential favored the solitary PTx and PKT:ND groups. Preemptive PKT or solitary PTx performed earlier in the course of diabetes is associated with good results, facilitated rehabilitation, and may prevent further diabetic complications.

Epstein-Barr virus hepatitis after liver transplantation.

The purpose of this study was to review our experience with Epstein-Barr virus (EBV) hepatitis after liver transplantation. During a 68-month period, we performed 668 liver transplants and 585 patients. We identified 11 patients (2 percent), including 5 adults and 6 children with EBV hepatitis after liver transplantation. The diagnosis of EBV hepatitis was established by evaluating allograft biopsies. The histology was confirmed by the use of polymerase chain reaction technology. The average time of diagnosis after liver transplantation was 45 days. Eight of eleven cases occurred within the first six months after transplantation. After the diagnosis of EBV hepatitis, treatment consisted of a decrease in immunosuppression plus antiviral therapy and intravenous immunoglobulin. The one-year actuarial survival for patients with EBV hepatitis, was 73 percent (8 of 11). Two patients died of progressive multi-organ EBV involvement. To determine the risk of developing EBV hepatitis, we reviewed our experience with the administration of antilymphocyte preparations in 585 patients. The patients found to have a significantly greater risk of developing EBV hepatitis included those receiving more than one course of antilymphocyte therapy or greater than a total dose of 70 milligrams of OKT3 in a single course. EBV hepatitis after liver transplantation is an infrequent event, which may be treated successfully. The occurrence of EBV hepatitis appears closely linked to the use of antilymphocyte preparations.

Cardiac surgery in the very elderly

To determine the results of cardiac surgery in the very elderly. A retrospective study of 56 very elderly patients (mean age 82 years, range 79-89 years) undergoing open heart surgery between 1988 and 1991. Thirty-three patients had coronary artery bypass grafting, 12 had valve replacement alone and 11 had valve replacement with an associated procedure. St Francis Xavier Cabrini Hospital, Melbourne--a large private hospital. There were four in-hospital deaths (7%). The one-year actuarial survival rate was 88%. Of the 49 survivors, 92% were in New York Heart Association (NYHA) Class III or IV before operation, whereas 96% were in NYHA Class I or II a mean of 15 months after operation. In very elderly patients with medically refractory cardiac symptoms, cardiac surgery has a tolerable mortality and provides excellent relief of symptoms.

Early experience with sequential bilateral lung transplantation

We performed 20 sequential bilateral lung transplantation in 19 consecutive patients from April 1990 to May 1992. Perioperative mortality was low (2 patients). One-year actuarial survival was 70%. All survivors had normal blood oxygen tension (82 mm Hg, mean) while breathing room air and continuing improvement of pulmonary function. Bronchial dehiscence did not occur. Stents were implanted in 7 patients to control bronchial stenosis. Aggressive treatment of graft rejection has been effective in preventing obliterative bronchiolitis.

Adrenocortical carcinoma in surgically treated patients: a retrospective study on 156 cases by the French Association of Endocrine Surgery.

Because of the rarity of adrenocortical carcinoma, survival rates and prognosis for patients who have undergone operation are not well known. The purpose of the French Association of Endocrine Surgery was to evaluate these factors in all patients treated during a 12-year period by its members. One hundred fifty-six patients (95 women, 61 men) with a mean age of 47 years were included. Functional symptoms were found in 52% of patients, and hormonal studies revealed secreting tumors in 62% of cases. Ninety-four percent of the patients underwent resection of the adrenal tumor, and 20% of them had extensive resection because of invasive cancers. Complete resection was achieved in 127 patients (81%) and incomplete resection in 29 patients. Mean tumor weight was 714 gm (range, 12 to 4750 gm), and the mean diameter was 12 cm (range, 3 to 30 cm). The results of the tumor staging were stage I, eight patients (5%); stage II (local disease), 75 patients (48%); stage III (locoregional disease), 39 patients (25%); and stage IV (metastases), 34 patients (22%). The 5-year actuarial survival rates were 34% overall, 42% in curative group, 53% in local cancer group, 24% in regional disease group, and 27% in the reoperated group. One-year actuarial survival rate of the palliative group was 9% (median survival, 6 months). Multivariate analysis showed that better prognosis occurred in patients younger than 35 years of age (p = 0.01) and in patients with androgen-secreting tumors, precursor-secreting tumors, or nonsecreting tumors (p = 0.003). Mitotane improved the survival rate only in patients with metastases who received it after operation (vs non-mitotane-treated patients [p < 0.05]). In this study age, extent of disease, aspect of the surgical resection, and type of hormonal secretion influenced survival.

Current trends in lung transplantation

Heart-lung transplantation remains the only therapeutic option for patients with combined end-stage cardiopulmonary disease. Because of the scarcity of heart-lung donors, we have been investigating other surgical alternatives for patients with end-stage vascular and parenchymal lung disease. From June 1989 through June 1991, 48 patients underwent pulmonary transplantation. Seventeen of the 48 patients underwent single lung transplantation. Of the 17 patients in the single lung group, eight patients had pulmonary hypertension and nine had parenchymal lung disease. Four of the 17 patients underwent repair of a cardiac defect with single lung transplantation. One-year actuarial survival was 68%. Pulmonary function has been excellent. The forced expiratory volume in 1 second was 79.6 +/- 13.6 (percent predicted), forced expiratory flow 25%-75% was 72.6 +/- 14.5 (percent predicted), and arterial oxygen tension was 82.8 +/- 10.06 mm Hg when measured at annual follow-up in a group of eight patients without obliterative bronchiolitis. Pulmonary artery pressures of systemic level or greater in the group with pulmonary vascular disease were normal at annual catheterization. Most patients had at least one episode of allograft rejection. Actuarial freedom from rejection at the end of 3 months was 30%. Three of the 17 single lung patients receiving lung lobes were children. Two children received living-related lobe transplants and one neonate received a lobe from a 2-year-old cadaver donor. Single lung transplantation is an effective therapeutic option for selected patients with vascular or parenchymal lung disease. Expanding indications will permit more individuals to receive transplants from the existing donor pool. Living-related and cadaver lobe transplantation will also increase the options available to children in need of lung transplantation.

Fifteen years' experience with renal transplantation in systemic amyloidosis.

At our center 62 renal transplantations (31 living donor and 31 cadaveric donor grafts) have been performed in 58 patients with amyloid renal disease since 1974. The amyloidosis was secondary to rheumatic disease in 74% of the patients. Predialytic transplantation was performed in 28% of the patients. Mean follow-up time was 5.1 years (0.3-14.5 years). One-year actuarial patient survival was 79%, decreasing to 65% after 5 years. First graft survival was 74% at 1 year and 62% at 5 years. Patient death with a functioning graft caused 16 out of 25 graft losses. Infections caused 11 out of 18 deaths (61%), more than half of them within 3 months. Renal transplant amyloid was diagnosed in about 10% of the cases (6/62); however, only about 3% of the grafts (2/62) were lost. These long-term results encourage transplantation in amyloid renal end-stage disease.

Fifteen years' experience with renal transplantation in systemic amyloidosis

Abstract. At our center 62 renal transplantations (31 living donor and 31 cadaveric donor grafts) have been performed in 58 patients with amyloid renal disease since 1974. The amyloidosis was secondary to rheumatic disease in 74 % of the patients. Predialytic transplantation was performed in 28% of the patients. Mean follow-up time was 5.1 years (0.3–14.5 years). One-year actuarial patient survival was 79%, decreasing to 65% after 5 years. First graft survival was 74 % at 1 year and 62 % at 5 years. Patient death with a functioning graft caused 16 out of 25 graft losses. Infections caused 11 out of 18 deaths (61 %), more than half of them within 3 months. Renal transplant amyloid was diagnosed in about 10% of the cases (6/ 62); however, only about 3% of the grafts (2/62) were lost. These long-term results encourage transplantation in amyloid renal end-stage disease.

EVIDENCE THAT COMBINED PROCUREMENT OF PANCREAS AND LIVER GRAFTS DOES NOT AFFECT TRANSPLANT OUTCOME

We compared outcome after pancreas and liver transplantation when both organs were retrieved from the same donor to outcome when only one or the other organ was retrieved. A total of 166 cadaver pancreata were transplanted at our institution between November 1984 and August 1989; 64 were obtained from donors in whom the liver was also donated (LD), and 102 were retrieved from non-liver donors (non-LD). Of the 64 LD pancreata, 53 were the entire organ with a segment of duodenum and 11 were segmental. Both the superior mesenteric artery (SMA) and celiac axis (CA) were retained with the pancreas in 13, while in 40 pancreata the CA was retrieved with the liver and the blood supply to the pancreas was reconstructed [end-to-side anastomosis of splenic artery (SA) to SMA in 11 and a Y-graft of donor iliac bifurcation to SA and SMA in 29]; a graft of common iliac vein was used to extend the portal vein in 10. The technical failure rate was 8/64 (12%) in LD pancreata, and 13/102 (13%) in non-LD pancreata (P greater than 0.1). The overall pancreas allograft survival rate at 1 year was 76% for pancreata obtained from LD (n = 64) and 64% for technically successful transplanted pancreata obtained from non-LD (n = 102, P greater than 0.1). One-year actuarial patient survival was 95% in the LD group and 90% in the non-LD group (P greater than 0.1). Among the 64 livers from pancreas donors (PD), 20 were transplanted at our hospital, 42 were transported to other institutions, and 2 were not transplanted. Follow-up information regarding 47 primary orthotopic adult, whole liver PD recipients (18 at our hospital, 29 at other institutions) was available for analysis and was compared with information concerning 62 adult recipients of primary orthotopic whole livers from non-PD transplanted during the same period at our institution. The total PNF rate among 47 PD liver allografts was 2/47 (4%), compared with 1/62 (1%) for the livers from non-PD (P greater than 0.1). The technical failure rate for the PD group was 1/47 (2%) versus 5/62 (8%) in the non-PD group (P greater than 0.1). The overall liver allograft survival rate at 1 year was 75% for livers obtained from PD (n = 47) and 81% for livers obtained from non-PD (n = 62, P greater than 0.1). One-year actuarial patient survival was 88% in the PD group and 81% in the non-PD group (P greater than 0.1). We concluded that simultaneous procurement of liver and pancreas grafts had no significant detrimental effect on the rate of technical failure, or on allograft or patient survival after either pancreas or liver transplantation.

The Stanford experience with high-dose etoposide cytoreductive regimens and autologous bone marrow transplantation in Hodgkin's disease and non-Hodgkin's lymphoma: Preliminary data

Seventy-seven Hodgkin's disease and non-Hodgkin's lymphoma (NHL) patients received high-dose etoposide in combination with cyclophosphamide and either fractionated total body irradiation (TBI) (n = 28) or carmustine (n = 49) prior to autologous bone marrow transplantation. Marrow from NHL patients was purged in vitro with a panel of monoclonal B- and T-cell antibodies and complement. Six toxic deaths (8%) occurred, all in patients who received carmustine. With a median follow-up of 1 year, 57 patients are alive and free from progressive disease. The 1-year actuarial survival and freedom from progression are 85 and 73% in fractionated TBI/etoposide/cyclophosphamide-treated patients and 79 and 72% in carmustine/etoposide/cyclophosphamide-treated patients. Forty-five of these patients participated in prospective trials for which eligibility criteria were (1) less than 25% curability with conventional therapy; (2) achievement of minimal disease state with conventional therapy; and (3) transplantation early in the course of disease. One-year actuarial survival for 18 patients with relapsed Hodgkin's disease is 80% and for 21 relapsed intermediate and high-grade NHL patients, 70%. One NHL Burkitt's patient was transplanted on a protocol for high-risk intermediate and high-grade NHL in first remission. Five patients with follicular mixed or small cleaved NHL were also transplanted in first remission.

OPTIMAL PERIOPERATIVE IMMUNOSUPPRESSION IN CARDIAC TRANSPLANTATION USING RABBIT ANTITHYMOCYTE GLOBULIN

A randomized trial of RATG (polyclonal) vs. OKT3 (monoclonal) antibody prophylaxis was carried out in 82 cardiac transplant recipients who, in addition, received baseline immunosuppression with cyclosporine, azathioprine and prednisone. One-year actuarial survival was comparable between groups (95% and 98%). The incidence of moderate or severe rejection within the first 30 days of transplant was over 7 times greater in patients receiving OKT3 vs. those receiving RATG. Patients receiving OKT3 were more likely to have repeated episodes of rejection and the mean time to rejection for patients receiving OKT3 was shorter (33 days) than for RATG patients (67 days). At 120 days, 52% of RATG patients were free of rejection while only 37% of the OKT3 patients were rejection-free. There was no difference in the incidence of major or minor bacterial or viral infection between groups. Patients receiving OKT3 showed a less-prolonged depression of the CD3 and CD4 T cell subsets than did those receiving RATG. Significant hemodynamic side-effects were seen after the first dose of OKT3 and there was a 5% incidence of aseptic meningitis associated with its use.

Presensitization and the renal allograft recipient.

We examined data from the New England Organ Bank to characterize the influence of patient sensitization on allograft survival, and our current crossmatching strategy. To evaluate our recipient eligibility criteria, we compared computer-predicted crossmatch results to 3622 actual crossmatches. A computer-predicted positive crossmatch was highly predictive of an actual positive crossmatch, for patients with a percentage reactive antibody of 40% of more (positive predictive value 91-99%), thus obviating the need to perform the actual crossmatch. Given the high prevalence of sensitized patients on our waiting list, very few individuals are inappropriately excluded from consideration for an available organ. In contrast, a negative computer prediction was never sufficiently predictive of a negative crossmatch to dispense with the actual crossmatching procedure. We also compared graft survival in patients with positive antidonor crossmatches using historical (greater than 6 months old) sera with those with negative historical crossmatches (or with no history of humoral sensitization). One-year actuarial graft survival in the first group was 61.0 +/- 6.0%, compared with 85.2 +/- 1.4% in those without positive historical crossmatches (P less than 0.001). This adverse effect of a positive historical crossmatch was true in both first transplants (n = 41, 1-year graft survival 67.9 +/- 7.4% vs. 86.2 +/- 1.6%, P less than 0.05) and in regrafted individuals (n = 29, 1-year graft survival 50.7 +/- 9.8% vs. 78.9 +/- 3.7%, P less than 0.01). The inability to accurately predict negative crossmatches, and the possible adverse effect of positive historical crossmatches on graft survival, represent potential obstacles to a goal of national organ sharing.

Comparison between duodenal button and duodenal segment in pancreas transplantation.

Two technical modifications have been suggested for whole-pancreas transplantation with bladder drainage. The duodenal button technique (DB [Madison]) and the duodenal segment technique (DS [Iowa]) are the most commonly performed procedures (1,2). From December 1985 until May 1988 we performed 32 combined pancreas-kidney transplants using DB and DS techniques in 17 and 15 patients, respectively. Bladder leaks, pancreatitis, bleeding episodes, and surgically related infections were all decreased with the duodenal segment technique. Metabolic acidosis was more common with DS but was easily managed with oral sodium bicarbonate. The one-year actuarial graft survival with DB is less when compared with DS (76.1% vs. 87.5%). Three technical graft losses occurred with DB vs. none with DS. One graft was lost in each group to rejection. Our results indicate that the duodenal segment technique of bladder implantation adds safety to whole-pancreas transplantation and must now be considered the procedure of choice.

Cardiac Transplantation in Patients over 60 Years of Age

Cardiac transplant programs have routinely excluded patients over 55 years of age from consideration as transplant candidates. The Texas Heart Institute modified this policy of using age as a contraindication to transplantation. Between July, 1982, and August, 1987, a total of 200 cardiac transplants were performed, 28 (14%) of which were in patients over 60 years of age, the eldest being 66 years old at the time of transplant. Our immunosuppressive regimen consisted primarily of cyclosporine and prednisone. In 1985, azathioprine was added in an effort to decrease dosages of cyclosporine, thereby decreasing its associated nephrotoxicity. The incidences of rejection and infection were 1.2 and 1.4 episodes/patient, respectively, for those over 60 years of age versus 1.7 and 1.3 episodes/patient, respectively, for those less than 60 years of age. Of the 28 patients, 23 are alive and well. Four deaths were caused by infection, and the other by diffuse coronary arteritis. The one-year actuarial survival for patients over 60 years of age was 83%, compared with 75% for the other transplant patients. We conclude that persons over 60 years of age can undergo cardiac transplantation with results equal to or perhaps better than those of other heart transplant patients. Our experience suggests that advanced age should not be considered a major contraindication to cardiac transplantation.