Biomedical subjects

A D Pinna

Publications and source records attributed to A D Pinna.

At least 19 recordsLinked to original sources

PubMed2006

Use of porcine dermal collagen graft (Permacol) for hernia repair in contaminated fields.

BACKGROUND: Complicated hernias often involve contaminating surgical procedures in which the use of polypropylene meshes can be hazardous. Prostheses made of porcine dermal collagen (PDC) have recently been proposed as a means to offset the disadvantages of polypropylene meshes and have since been used in humans for hernia repairs. The aim of our study was to evaluate the safety and efficacy of incisional hernia repair using PDC as a mesh in complicated cases involving contamination. METHODS: A prospective study of hernia repair of complicated incisional hernias with contamination using PDC grafts was carried out at the Department of General, Emergency and Transplant Surgery of St Orsola-Malpighi University Hospital. RESULTS: From January 2004 up to the writing of this article, seven patients were treated for complicated incisional hernias with a PDC prosthesis. In six out of seven patients a bowel resection was carried out. There were not surgical complications. Morbidity was 14.2%. No recurrences and wound infections were observed. CONCLUSIONS: Incisional hernioplasty using PDC grafts is a potentially safe and efficient approach in complicated cases with contamination.

Abdominal Cavity↗

PubMed2006

Artificial neural network is superior to MELD in predicting mortality of patients with end-stage liver disease.

BACKGROUND: Despite its accuracy, the model for end-stage liver disease (MELD), currently adopted to determine the prognosis of patients with liver cirrhosis, guide referral to transplant programmes and prioritise the allocation of donor organs, fails to predict mortality in a considerable proportion of patients. AIMS: To evaluate the possibility to better predict 3-month liver disease-related mortality of patients awaiting liver transplantation using an artificial neural network (ANN). PATIENTS AND METHODS: The ANN was constructed using data from 251 consecutive people with cirrhosis listed for liver transplantation at the Liver Transplant Unit, Bologna, Italy. The ANN was trained to predict 3-month survival on 188 patients, tested on the remaining 63 (internal validation group) unknown by the system and finally on 137 patients listed for liver transplantation at the King's College Hospital, London, UK (external cohort). Predictions of survival obtained with ANN and MELD on the same datasets were compared using areas under receiver-operating characteristic (ROC) curves (AUC). RESULTS: The ANN performed significantly better than MELD both in the internal validation group (AUC = 0.95 v 0.85; p = 0.032) and in the external cohort (AUC = 0.96 v 0.86; p = 0.044). CONCLUSIONS: The ANN measured the mortality risk of patients with cirrhosis more accurately than MELD and could better prioritise liver transplant candidates, thus reducing mortality in the waiting list.

Area Under Curve↗

PubMed2006

High incidence of allograft dysfunction in liver transplanted patients treated with pegylated-interferon alpha-2b and ribavirin for hepatitis C recurrence: possible de novo autoimmune hepatitis?

BACKGROUND: Interferon may trigger autoimmune disorders, including autoimmune hepatitis, in immunocompetent patients. To date, no such disorders have been described in liver transplanted patients. METHODS: 9 of 44 liver transplanted patients who had been receiving pegylated-interferon alpha-2b and ribavirin for at least 6 months for hepatitis C virus (HCV) recurrence, developed graft dysfunction despite on-treatment HCV-RNA clearance in all but one case. Laboratory, microbiological, imaging and histological evaluations were performed to identify the origin of graft dysfunction. The International Autoimmune Hepatitis scoring system was also applied. RESULTS: In all cases infections, anastomoses complications and rejection were excluded, whereas the autoimmune hepatitis score suggested a "probable autoimmune hepatitis" (score from 10 to 14). Three patients developed other definite autoimmune disorders (overlap anti-mitochondrial antibodies (AMA)-positive cholangitis, autoimmune thyroiditis and systemic lupus erythematosus, respectively). In all cases, pre-existing autoimmune hepatitis was excluded. Anti-lymphocyte antibodies in immunosuppressive induction treatment correlated with the development of the disorder, whereas the use of granulocyte colony-stimulating factor to treat interferon-induced neutropenia showed a protective role. Withdrawal of antiviral treatment and treatment with prednisone resulted in different outcomes (five remissions and four graft failures with two deaths). CONCLUSIONS: De novo autoimmune hepatitis should be considered in differential diagnosis along with rejection in liver transplanted patients developing graft dysfunction while on treatment with interferon.

Aged↗

PubMed2006

Intraoperative coagulation evaluation of ischemia-reperfusion injury in small bowel transplantation: a way to explore.

BACKGROUND AND AIM OF STUDY: The success of intestinal transplantation is affected by the extreme susceptibility of the small bowel to ischemia-reperfusion (I/R) injury. Platelet aggregation decreases after reperfusion in small intestinal ischemia and liver transplantation. Thromboelastography (TEG) is a coagulation test performed whole on blood. The aims of this study were to assess coagulation derangements during bowel transplantation to define appropriate modalities of intraoperative coagulation monitoring. A secondary endpoint was to determine whether measurements of coagulation derangements were useful to estimate small intestinal I/R injury. MATERIALS AND METHODS: We recruited 19 patients who had undergone elective small bowel transplantation for primary short-gut syndrome. We divided our patients into two groups depending on their reperfusion injury as evaluated with a biopsy after reperfusion: group A composed of eight patients who had a reperfusion injury: group B composed of 11 patients who did not experience this problem. We measured five thromboelastogram indicators (r, k, angle, MA, CL30) at defined intervals: dissection phase (T1), vascular anastomoses phase (T2) as well as 30 minutes (T3) and 120 minutes (T4) after reperfusion during the intestinal reconstruction phase. RESULTS: We did not observe any significant difference between intraoperative blood loss, core temperature, or volume of fluid fresh frozen plasma, or platelet administration. Angle and MA were decreased significantly among patients with reperfusion injury. DISCUSSION: Patients showed a hypocoagulation pattern during all the manipulations. This derangement did not depend on the ischemia time. In patients with I/R injury the angle and MA did not change during ischemia, but did change significantly upon reperfusion. Several mechanisms may cause coagulation derangements. During the ischemic period, there may be damage to the vascular bed of the ischemic organ. When arterial blood passes through the damaged vascular bed after reperfusion, platelet activation occurs to varying degrees, resulting in reduced platelet function. CONCLUSION: Further studies are needed to confirm this preliminary work, which was limited by the low number of patients, in order to elucidate relevant mechanisms and develop predictive algorithms.

Anastomosis, Surgical↗

PubMed2006

Analysis of cardiovascular, acid-base status, electrolyte, and coagulation changes during small bowel transplantation.

The analysis of intraoperative hemodynamic, metabolic, and coagulation disorders of the recipients in relation to the newly reperfused organ during intestinal transplantation is necessary for an optimal patient management during small bowel transplantation (SBT). The interaction may be minor or may lead to postreperfusion syndrome, producing intense hemodynamic instability, important metabolic changes, and coagulation disorders. This research is based upon experience with 27 patients who underwent SBT. We observed significant decreases in PAM and IRVS after reperfusion in accordance with minor changes of mean pulmonary artery pressure, central venous pressure, and pulmonary capillary wedge pressure. The fall in pH upon revascularization was associated with a concomitant rise in partial carbon dioxide pressure probably due to the increased metabolic activity of the new organ. We found a significant increase in K levels, a rise that may be due to the output of metabolic products by the donor intestine. Patients displayed an hypocoagulative pattern, a derangement that did not seem to depend on ischemia time. It is possible that the same factors supporting the initial TEG pattern endure throughout the surgical procedure. The important and significant maximum amplitude indicator variation between the initial value and that after reperfusion may relate to the release of hypocoagulative factors superimposed on background abnormalities. These interesting metabolic disorders presumably reflected graft function and may provide predictive indices for a good outcome.

Acid-Base Equilibrium↗

PubMed2006

Prometheus system: a technological support in liver failure.

The Prometheus system is a plasma filtration treatment coupling adsorption and hemodialysis (FPSA) aimed to blood purification in liver failure. After separation through an albumin-permeable membrane, plasma enters a secondary circuit where protein-bound toxic substances are removed by two adsorbers; p01, a neutral resin, and p02, an anion exchanger. Plasma is then returned to the venous line, where a high-flux hemodialyzer removes water-soluble substances. We used the Prometheus system in 12 patients with acute or acute-on-chronic liver insufficiency: eight cirrhosis, one posttransplant dysfunction, and three secondary liver insult (two cardiogenic shock and one rhabdomyolysis). All patients were severely hyperbilirubinemic, hypercholemic, and hyperammonemic. Twenty-eight sessions each lasting 340 +/- 40 minutes were performed (2.5/patient). The mean total bilirubin decreased from 33.6 +/- 20 to 22.2 +/- 13.6 mg/dL (P < .001); the reduction ratios for cholic acid and ammonia were 48.6% and 51.6%, respectively. The pre- to postsession urea reduction was 57.6% +/- 9.5% and creatinine 42.7% +/- 10%. A significant reduction was observed in the circulating levels of soluble interleukin (IL) 2 receptor (pre: 2687.2 +/- 1434.7; post: 1977.1 +/- 602 Ul/ml; P < .001) and in IL 6 (pre: 56.1 +/- 11.1; post: 35.9 +/- 10.3 pg/mL, P = .05). During treatments the hemodynamics were stable. Two patients received liver transplantations. The secondary liver insult was completely overcome in all three patients. The overall survival at 30 days was 41.6% (5/12 patients). Prometheus, based on FPSA, produced high clearance for protein-bound and water soluble markers, which resulted in high treatment efficacy.

Acute Disease↗

PubMed2006

Combined liver transplants: main characteristics from the standpoint of anesthesia and support in intensive care.

Combined transplants with the liver represent a small number of associated pathologies with little chance of resolving with a single transplant. The small case number prevents us from establishing homogeneous criteria for the procedure. The insertion of the Model for End-Stage Liver Disease in the preoperative evaluation of the patients awaiting liver transplant has definitely increased the number of combined liver-kidney transplants, which have reached more significant numbers. The number of heart-liver transplants is still too low to establish the efficacy of the measure. The multiorgan transplant with the liver represents a rare event entrusted to a series of case reports, each one of which has a history unto itself. Our experience in this field includes 14 combined liver-kidney, six combined heart-liver, and two multiorgan transplants with liver among 36 intestine transplants. We have examined the main pre-, intra-, and postsurgical problems for each one of these transplants, particularly relating to the anesthetic and intensive-care aspects.

Anesthesia↗

PubMed2006

Successful treatment of rhinomaxillary form of mucormycosis infection after liver transplantation: a case report.

Mucormycosis is a rare opportunistic infection, usually associated with immunocompromised states. Several conditions such as hematologic malignancy (leukemia, lymphoma, myeloma), solid organ transplantation, diabetes mellitus, corticosteroid therapy, or chemotherapy predispose patients to infection. The aim of this study was to present a single case of mucor infection after 900 consecutive liver transplantations. Rhinomaxillary mucormycosis must be suspected in a transplant recipient showing fever, maxillary swelling, and edema. This condition can be successfully treated with early diagnosis and a combination of aggressive surgery and antifungal therapy.

Antifungal Agents↗

PubMed2006

Surgical approach to complicated intestinal failure for benign disease in adult patients: transplantation or surgical rehabilitation?

Surgical approaches to complicated benign intestinal failure are gaining acceptance, especially in the pediatric population. Less international experience has been obtained in adult patients, who are usually treated with total parenteral nutrition (TPN). An intestinal rehabilitation program was started in our institution with comprehensive medical rehabilitation, surgical bowel rescue, and transplantation. Among 38 adult patients referred by our gastroenterologists for bowel rehabilitation and surgically treated in our institution, 92.2% received TPN on admission. After careful evaluation, 71% underwent transplantation. Five patients died, but 18 recipients were completely weaned off TPN at follow-up. Eleven patients underwent surgical resection of the affected bowel and a subsequent program of intestinal rehabilitation: they were all alive and weaned off TPN at discharge. At a 2-year mean follow-up, deaths occurred only in the transplant population. Therefore, intestinal surgical rescue, if successful, is optimal in adult patients.

Adolescent↗

PubMed2006

Acute renal failure requiring renal replacement therapy after orthotopic liver transplantation.

OBJECTIVES: Acute renal failure (ARF) is a severe complication in patients undergoing orthotopic liver transplantation (OLT), which predicts a poor outcome. The aim of this study was to analyze risk factors for the development of ARF, including severity of illness, onset time of ARF prognostic factors of outcome, and mortality in a group of critically patients requiring renal replacement therapy (RRT). METHODS: Retrospective analysis of 240 consecutive liver transplant cases from 1999 to 2001 admitted to the intensive care unit (ICU) was performed to identify risk factors for ARF development after OLT. The analyzed factors were: age, sex, CrS, BUN, diuresis, sepsis, hypovolemia, cardiac failure, nephrotoxic drugs (cyclosporine or FK506, antibiotics), hyperbilirubinemia, associated diseases (DM, CRF), onset time of renal failure and progressiveness, timing of RRT, number of days of RRT, and mortality. We examined variables upon admission to the ICU, before the first RRT, and on the last ICU day before resignation or death. We used Students' t test. Quantitative parameters were expressed as mean values +/- SD. RESULTS: Of the 240 patients, 20 (8.3%) experienced ARF needing renal replacement therapy during the postoperative period. The results of our study suggested that ARF among patients undergoing RRT conferred an excessive risk of in-hospital death: eight patients died (40%). This increased risk cannot be explained solely by a more pronounced severity of illness. CONCLUSION: Our results provide strong evidence that ARF presents a specific, independent risk factor for a poor prognosis.

Acute Disease↗

PubMed2006

Combined liver-kidney transplantation with preformed anti-HLA antibodies: a case report.

A pretransplant positive cross-match is a contraindication for kidney transplantation, unlike in liver transplantation (OLT). In combined liver kidney transplantation (LKT) it is hypothesized that liver can protect kidney from rejection. We report the case of a 35-year-old woman on renal replacement therapy with gastrointestinal tract compression due to a hematoma following spontaneous liver rupture (May 2004). She was affected by amyloidosis, treated with a bone marrow autotransplantation (2001). The liver rupture was surgically untreatable, so an LKT was proposed. Panel-reactive antibody was 80% to 100% (complement dependent cytotoxicity) with specific anti-HLA antibodies (enzyme-linked immunosorbent assay). A compatible donor was found (July 2004). The cross-match before LKT was positive for B and T cells (score 8): an emergency OLT was performed. Immediately after liver reperfusion the cross-match result was less positive (6) for T cells. After 6 hours it was negative for T and slightly positive for B cells (4): the kidney was transplanted. The immunosuppressive therapy was: alemtuzumab, steroids, and tacrolimus. Renal function immediately recovered. On day 7 a rejection episode was successfully treated by increasing steroids (intravenous bolus). At discharge hepatic and renal function were normal (creatinine 1 mg/dL). They are stable after 1 year. This case showed LKT efficacy even in complex immunological situations. Many immunological mechanisms, still not defined, are hypothesized about the protective role of the liver. This case confirmed experimental data that highlighted that in vivo in humans a cross-match can change from positive to negative after OLT giving highly sensitized patients the possibility for LKT.

Adult↗

PubMed2006

The use of prostaglandins in the immediate postsurgical liver transplant period.

INTRODUCTION: Experimental evidence has suggested that prostaglandins have positive effects on hepatic perfusion after transplantation. However, randomized clinical trials have failed to show their usefulness to decrease the incidence of primary nonfunction. In order to demonstrate its therapeutic role, we performed a clinical study in which PGE1 was administered only after the appearance of posttransplant liver dysfunction. MATERIALS AND METHODS: Forty patients with macroscopic signs of hypoperfusion or lacking bile production at the end of the operation (n = 24) or with an increase in transaminases and fall in biliary production in the first 24 hours postsurgery (n = 16) were administered alprostadil (PGE1; 0.01 mug/kg/min to the maximum plateau of 0.06 mug/kg/min). We measured the mean values of aspartate aminotransferase (AST), alanine aminotransferase (ALT), activated thromboplastin time-ratio (aPTT-r), international normalized ratio (INR), bilirubin, creatinine and plasma nitrogen, PaO(2)/FiO(2) at the start of the treatment and every 6 hours for 48 hours, and daily diuresis. RESULTS: There appeared to be a significant decrease in AST, INR, aPTT-r, and creatinine clearance (P < .05), while there was a significant rise in the blood urea nitrogen (P < .001). ALT and bilirubin did not show significant variations. The PaO(2)/FiO(2) ratio showed a significant decrease (P < .001) in pulmonary vasodilatation. CONCLUSIONS: Prostaglandins used in the manner in our study showed a significant efficiency to improve liver dysfunction after transplantation.

Alprostadil↗

PubMed2006

Combined liver-kidney transplantation: the experience of the University of Bologna and the case of preoperative positive cross-match.

Combined liver and kidney transplantation (CLKT) has been increasingly used in recent years: 13 of our 19 cases were performed in the last 2 years being 3.2% of our liver transplantation (LT) and kidney transplantation (KT) activity. Only three of them were not on hemodialysis and the scheduling of a CLKT meant being at the top of the waiting list. We accepted only ideal donors and had no case of liver and only one case of kidney delayed graft function. Two deaths occurred during the first postoperative month, due to acute respiratory distress syndrome and multiorgan failure, both in patients with adult polycystic disease who were in poor nutritional condition due to a late indication for CLKT. We had two late deaths, one due to a native kidney tumor at 7 years and one at 8 years due to alcoholic cirrhosis recurrence. The late survival of our patients was 77.3% with all surviving patients showing good liver and kidney function. We planned not to do the KT in the case of a positive preoperative cross-match; but the only positive case became negative 8 hours after LT when we performed the KT. The patient is well after 2 years. The liver does not always protect the kidney if there are preformed antibodies, but we should try every possible technique not to lose the possibility of doing both transplants, because in case of LT alone the patients loses his top position on the CLKT waiting list and often waits years for a kidney.

Adult↗

PubMed2006

Combined liver-kidney transplantation--S. Orsola experience: nephrological aspects.

Combined liver kidney transplantation (LKT) has the potential to provide a complete recovery of liver and kidney failure; the literature reports an increase in LKT in the last few years and an improvement in patient and graft survival. In our experience 15 patients underwent LKT from 1997 to 2005. The mean age was 50 +/- 9 years (range 34 to 63). The patients were affected by viral (n = 9), alcoholic (n = 1), polycystic (n = 2), cholangitis (n = 1), cholestatic (n = 1), or amyloidotic (n = 1) chronic hepatopathy. Chronic renal failure (CRF) was due to polycystic kidney disease (n = 4), IgA (n = 2), interstitial nephropathy (n = 2), glomerulonephritis (n = 4), amyloidosis (n = 1), vascular nephropathy (n = 1), of unknown end-stage renal disease (n = 1). Twelve of 15 patients were on renal dialysis treatment, three patients had moderate/severe CRF. Two patients had previously been transplanted (kidney). All patients were selected based upon blood group identity and negative cross-match before kidney transplant. Histocompatibility matching (HLA) was not included in the selection criteria. We did not observe delayed graft function. After a mean follow-up was 23 +/- 32 months (range 5 to 99), 12 subjects show, normal hepatic and renal function. At the beginning of our experience two patients in bad clinical condition died within 3 months because of sepsis, and one died because of a malignancy after 7 years. Both organs were functioning well in the deceased patients. Survival analysis confirms LKT efficacy: at 5 years follow-up patient survival is 86%, graft survival censored for death 100%. Only two subjects had an acute rejection episode in the first year; the kidney rejection incidence was lower than that reported for an isolated kidney transplant (13% vs 21%).

Adult↗

PubMed2006

Protective effect of portal vein arterialization in acute liver failure induced by hepatectomy in normal and fatty liver rat.

AIM: We sought to determine whether an additional supply of oxygenated blood achieved by partial portal vein arterialization (PPVA) was protective on normal or fatty liver (FL) in rats with acute liver failure (ALF) induced by hepatectomy. METHODS: Sprague-Dawley rats with normal or FL were segregated either to receive or not to undergo PPVA after hepatectomy. FL was induced by feeding a choline-deficient diet (5 days). PPVA was performed by anactamasing the left renal artery to the splenic vein with a stent following a left nephrectomy and splenectomy; the control rats underwent left nephrectomy and splenectomy only. Liver injury was evaluated by the serum alanine aminotransferase (ALT) level. The animals were sacrificed at 24 hours, 48 hours, and 7 days to collect blood and liver tissue samples for biochemical analysis. The 7-day survival was assessed in separate experimental groups. RESULTS: PPVA significantly increased Po2 and oxygen saturation in the portal blood compared to non PPVA rats. PPVA significantly improved the 7-day survival compared with controls in both groups: hepatectomy of normal liver (90% vs 30%) and hepatectomy of FL (75% vs 25%). Serum ALT levels were slightly lower in the PPVA groups compared with the non-PPVA groups without a significant difference. Prothrombin activity decreased soon after hepatectomy in the normal and the FL liver groups but recovered rapidly thereafter without differences between the PPVA and non-PPVA treated animals. CONCLUSION: An additional supply of arterial oxygenated blood through a PPVA promotes rapid resolution of ALF after partial hepatectomy in rats with normal or fatty livers, significantly improving 7-day survivals compared to hepatectomy controls.

Anastomosis, Surgical↗

PubMed2006

Recovery from liver dysfunction after adult isolated intestinal transplantation without liver grafting.

PURPOSE: We sought to evaluate liver function recovery after isolated intestinal transplantation in adults with irreversible intestinal failure. PATIENTS AND METHODS: Over a 5-year period, we transplanted 34 adult patients, 25 of whom received an isolated intestinal graft, 4 a multivisceral graft without a liver, and 5, a multivisceral graft with a liver. Among the group of patients transplanted with the isolated graft we selected 14 recipients with pretransplant liver dysfunction, namely, a serum bilirubin >2 mg/dL (normal value: 1.2) and/or transaminases >100 IU/mL (NV, 37/40). Other inclusion criteria were total parenteral nutrition, period > 3 months, no diagnosis of portal hypertension or cirrhosis. Two patients had biopsy-proven liver fibrosis. RESULTS: At discharge, all patients recovered liver function to normal values: mean bilirubin blood level was 0.9 +/- 0.96 mg/dL (range: 0.3-1.6) and mean transaminases were 26 +/- 9 and 31 +/- 18 IU/mL (range: 10-44/27-65). After a mean follow-up of 2 years, only one patient has an elevated alanine aminotransferase level without clinical signs of liver disease. Type of pretransplant liver disease did not impact on survival rates. CONCLUSION: In selected cases, an isolated intestinal or a multivisceral graft without a liver can represent a "liver salvage therapy" for an early failing liver in patients with irreversible intestinal failure. Pretransplant liver disease is not a negative prognostic factor.

Adult↗

PubMed2006

Liver transplantation with the Meld system: a prospective study from a single European center.

The efficacy of the Meld system to allocate livers has never been investigated in European centers. The outcome of 339 patients with chronic liver disease listed according to their Meld score between 2003 and 2005 (Meld era) was compared to 224 patients listed during the previous 2 years according to their Child score (Child era). During the Meld era, hepatocellular carcinomas (HCCs) had a 'modified' Meld based on their real Meld, waiting time and tumor stage. The dropouts were deaths, tumor progressions and too sick patients. The rate of removals from the list due to deaths and tumor progressions was significantly lower in the Meld than in the Child era: 10% and 1.2% versus 16.1% and 4.9%, p < 0.05. The 1-year patient survival on the list was significantly higher in the Meld era (84% vs. 72%, p < 0.05). The prevalence of transplantation for HCC increased from 20.5% in the Child to 48.9% in the Meld era (p < 0.001), but between HCCs and non-HCCs of this latter era the dropouts were comparable (9.4% vs. 14.9%, p = n.s.) as was the 1-year patient survival on the list (83% vs. 84%, p = n.s.). The Meld allocation system improved the outcome of patients with or without HCC on the list.

Carcinoma, Hepatocellular↗

PubMed2005

Fatal cytomegalovirus necrotising enteritis in a small bowel transplantation adult recipient with low pp65 antigenaemia levels.

Although advances in immunosuppressive therapy have led to increased survival of solid organ transplantation recipients, it is well established that current protocols have been associated with an increased risk of developing tissue-invasive infections. In particular, cytomegalovirus still represents an important cause of morbidity. We report a case of cytomegalovirus infection involving the graft ileum with documented necrotising enteritis that developed after small bowel transplantation. The patient, a 56-year-old Caucasian female with a postsurgery short bowel syndrome, underwent a small bowel transplantation. Immunosuppression was maintained by combination of tacrolimus, steroids and daclizumab. Both the donor and the recipient were serologically negative for cytomegalovirus IgG. Nevertheless, ganciclovir prophylaxis was given for 21 days after surgery, as standard procedure. On hospital day 174, routine pp65 antigenaemia resulted positive (14/200,000 peripheral blood leukocytes). The patient was asymptomatic and preemptive ganciclovir therapy was instituted. In the following 3 days, due to a cytomegalovirus antigenaemia increase, ganciclovir was changed to foscarnet with subsequent virological response (7/200,000 peripheral blood leukocytes, on day 181). Two days later, the patient complained of acute abdominal pain and she underwent surgery for the diagnosis. Since the intraoperative findings consisted of a diffuse acute purulent peritonitis, the intestinal graft, together with native rectum, was removed. Biopsy specimens showed evidence of tissue-invasive cytomegalovirus infection. Postsurgery, the patient developed septic shock and died on day 198 as a consequence of multiple organ failure.

Aged↗