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M J Moritz

Publications and source records attributed to M J Moritz.

At least 37 records · Page 2Linked to original sources
PubMed1997

Reproductive function after liver transplantation.

Successful pregnancy outcomes are possible after liver transplantation. Although there are risks to the mother and fetus, there has not been an increased incidence of malformations noted in the newborn of liver recipients. Close, coordinated care involving the hepatologist, surgeon, and high-risk obstetrician is essential to ensure a favorable outcome. Immunosuppression peripartum should be maintained at appropriate levels. Of note, a small subset of recipients may suffer worsened graft function during pregnancy. Recurrent liver disease, especially viral hepatitis, and CMV infection appear to pose significant risks to mother and offspring, respectively, although the magnitude of the risks is unknown. It therefore would seem prudent to consider pregnancy only in female liver recipients who have passed at least 1 year with stable graft function. In addition, new immunosuppressive regimens further add to the lack of information regarding pregnancy safety. The NTPR is an ongoing database to collect information and pregnancy outcomes. That information should be helpful in counseling recipients and in pregnancy management.

Cytomegalovirus↗
PubMed1997

Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation.

Female solid organ recipients with good graft function generally tolerate pregnancy well. However, the combination of mother, fetus, transplanted organ, and immunosuppressive and other medications increases the complexity of management and raises the specter of adverse outcomes. For the mother, considerations include the nature of the original disease (i.e. genetic risk of transmission), co-morbid conditions which increase pregnancy risk (i.e. hypertension, diabetes, renal insufficiency), and long-term maternal prognosis. For the fetus, questions include the adequacy of maternal physiology (cardiac, renal, glycernic control, etc.), exposure to medications, and exposure to infectious agents. The transplanted organ must accommodate the increased workload of pregnancy and the needs of the fetus. The delicate balance between immunosuppression and rejection may be altered by the pregnancy. The impact of pregnancy on recurrent disease can also be an issue. Medication issues include changes in drug pharmacokinetics and the potential for adverse effects on the fetus. These effects could include chromosomal aberrations, structural malformations, organ-specific toxicity, intrauterine growth retardation, and immune system development. For female kidney recipients there are sufficient data to demonstrate a direct relationship between creatinine levels before and during pregnancy and risk of graft loss in the postpartum period. Pregnancy itself does not appear to adversely affect stable graft function. Among liver recipients, those with recurrent viral hepatitis may have deterioration of graft function with subsequent pregnancies. These recipients should be apprised accordingly, as maternal deaths have occurred in this setting. Postpartum depression and potential for medication noncompliance require vigilance. The safety of pregnancy from the NTPR analysis to date has been largely derived from the experience with CsA-based regimens. For recipients on CsA there have been good maternal outcomes without any specific or predominant malformation patterns in the offspring. For the general population, malformations occur in approximately 3% of live births. To date, there is no indication that this incidence has increased despite the complex medical regimens of transplant recipients. Data are accruing with tacrolimus and Neoral. Continuing data entry and continued follow-up of off-spring will allow for further recommendations, especially in light of the new medications and combinations. Recipients should be advised to wait one to 2 years after transplant before considering pregnancy. Those with stable graft function, and with no rejection, graft dysfunction, or deterioration should still be apprised of the high risk of prematurity and low birthweight, although maternal risks appear low. These are high-risk pregnancies, requiring close communication and cooperation between the high-risk obstetrician and the transplant team. The use of the FDA pregnancy categories should not be the sole reason for choosing a particular immunosuppressive drug. Agents such as Neoral and tacrolimus would appear to offer some advantage as blood levels can be measured. At present, no safety guidelines can be given for mycophenolate mofetil, OKT3, or ATG. Identification of prepregnancy factors predictive of higher risks and appropriate counseling and management guidelines are major NTPR goals, and depend on the continued assistance and cooperation of the transplant community.

Cause of Death↗
PubMed1996

National Transplantation Pregnancy Registry: report on outcomes in cyclosporine-treated female kidney transplant recipients with an interval from transplant to pregnancy of greater than five years.

Successful renal transplantation enables previously infertile females to conceive and carry a pregnancy. Much of the reported data on posttransplantation pregnancy accrued before the advent of cyclosporine, when steroids and azathioprine were the mainstays of maintenance immunosuppression. One factor affecting pregnancy outcome in kidney recipients is the length of time from transplantation to conception or transplant interval. It has been recommended that patients wait at least 2 years posttransplantation to conceive, as transplant intervals of shorter duration have had less favorable outcomes. Some have suggested that extended transplant intervals (> 5 years) paradoxically result in adverse outcomes. We have extracted data on cyclosporine-treated recipients with transplant intervals longer than 5 years from the National Transplantation Pregnancy Registry, and report 17 pregnancies from 15 recipients (transplant interval, 5.9 +/- 0.9 years). There were 13 live births (76.5%) and four spontaneous abortions (23.5%). The mean gestational age was 37.7 +/- 2.04 weeks and mean birth weight was 2,753 +/- 679 g. Prematurity occurred in 30.8%, low birth weight in 15.4%, very low birth weight in 7.7%, and neonatal complications in 15.4%. There were no maternal or neonatal deaths. The mean serum creatinine before pregnancy was 1.31 mg/dL, and there was no significant change during or after pregnancy. There were no rejections during or up to 3 months postpartum. Graft survival at 2 years was 100%. We conclude that most pregnancy outcomes in cyclosporine-treated recipients with transplant intervals greater than 5 years are favorable for the newborn, recipient, and graft.

Analysis of Variance↗
PubMed1995

National Transplantation Pregnancy Registry: analysis of pregnancy outcomes in female liver transplant recipients.

Outcomes from 48 pregnancies in 34 female liver transplant recipients were analyzed. Data were collected via interviews, questionnaires, and hospital records. All recipients were treated with cyclosporine-based immunosuppression except 2 patients treated with FK506 and 2 treated with no immunosuppression. The age at conception was 26.1 +/- 5.9 years (mean +/- SD) with a transplant interval (time from transplantation to conception) of 2.9 +/- 2.5 years. There were 49 outcomes (1 set of twins): miscarriage 9 (18%), therapeutic abortion 4 (8%), and live birth 36 (74%). No stillbirths or ectopic pregnancies were reported. Of the 36 live births, the gestational age was 36.9 +/- 3.5 weeks, the birthweight was 2,604 +/- 698 grams, 39% were premature (< 37 weeks), and 31% had low birthweight (< 2,500 grams). No birth defects or neonatal deaths (< 28 days) were reported. The newborn complication rate was 17% (n = 6), 5% in premature infants. The incidence of drug-treated hypertension was 46%; pre-eclampsia 21%; infectious complications 26%; and Caesarean section 47%. Recipients with hypertension had a higher proportion of premature infants (71%) than normotensive patients (38%) (P = .04 by Fisher's exact test). Acute rejection was diagnosed in 6 pregnancies, 2 of which were ended by therapeutic abortion. Four recipients who continued their pregnancies were treated with increased immunosuppression for rejection, and all delivered livebirths. There were two grafts lost within 6 months of pregnancy. The only maternal death occurred in a patient who required retransplantation for recurrent C hepatitis 3 months afte therapeutic abortion and died 6 months later. The other recipient with graft loss was successfully retransplanted for chronic rejection 6 months after delivery. We draw the following conclusions: (1) female liver transplant recipients can safely undergo pregnancy, although there is a high rate of premature and low birthweight infants; (2) pregnancies in this population should be considered high-risk and require close monitoring of liver function; and (3) altered graft function during pregnancy should be thoroughly investigated.

Adult↗
PubMed1995

Utility of intra-access pressure monitoring in detecting and correcting venous outlet stenoses prior to thrombosis.

Vascular access thrombosis is a major problem for hemodialysis patients. Over 7.75 years, we performed intra-access venous pressure monitoring at zero dialyzer blood flow (VP0), correlated VP0 with access anatomy angiographically, and examined the effect of two levels of stenosis, 50% and > 65% luminal diameter reduction (% D) as selection criteria for referral and elective angioplasty or surgical revision upon access outcomes. Summary receiver outcome curves for absolute intra-access pressure (VP0) and intra-access pressure normalized for systemic pressure (VP0/systolic BP) were constructed to evaluate sensitivity and specificity and compared to recirculation and duplex color-flow Doppler. Access outcomes included thrombosis, revision, replacement, and angioplasty rates that were normalized per 100 patient years (100 pt-yrs). During the 7.75 year long study period totaling 832 patient-access years of risk, the percentage of prosthetic bridge grafts increased from 65% to 80%. SROC showed better sensitivity for normalized (VP0/systolic BP) than absolute intra-access pressure (VP0) in grafts. Recirculation had poor predictive power in prosthetic bridge grafts compared to VP0. Predictive power of recirculation was superior to VP0 in native arteriovenous fistulae. The angioplasty rate correlated inversely with the degree of luminal reduction used as selection criterion for referral for angioplasty or surgical revision. A strong inverse relationship between thrombosis rate and the angioplasty rate (R2 = 0.99) but not between thrombosis rate and the number of angiograms performed (R2 = 0.39) was noted. A consistent, yet evolving, intensive graft maintenance protocol produced a 70% decrease in the thrombosis rate, a 79% decrease in the access replacement rate, and an increase in the average age of patent usable vascular accesses from 1.97 to 2.98 years that was associated with a 13-fold increase in the angioplasty rate. We conclude that vascular access monitoring with VP0/systolic BP provides excellent selection criteria for angiographic referral. Intervention for stenotic lesions > 50% D using angioplasty or surgical revision markedly reduces thrombosis and access replacement rates.

Angiography↗
PubMed1995

Parenthood after liver transplantation.

In conclusion, data from the NTPR support the concept that female liver transplant recipients can safely undergo pregnancy, and male recipients are able to father pregnancies. The true incidence of malformations in both populations needs to be further studied. Female liver recipients have a high rate of premature and low-birth-weight infants. Therefore, pregnancies in the female population must be considered high risk and require close monitoring of liver function. Our data and other reports suggest that altered graft function during pregnancy may represent rejection and must be thoroughly investigated. Data from female CsA kidney recipients and from case reports of liver CsA recipients would suggest that increased doses of CsA may be required during pregnancy. The confounding effects of renal function, hypertension, and combinations of drugs make the interpretation of newborn outcomes and the relationship to immunosuppressive regimens difficult to interpret. To date, an increase in congenital anomalies has not been reported in newborns of liver recipients. Therefore, although subtle effects on reproduction may occur, it seems that favourable pregnancy outcomes can be expected for most liver transplant recipients, but further study is needed as the sample size has been small.

Adult↗
PubMed1994

National transplantation Pregnancy Registry--outcomes of 154 pregnancies in cyclosporine-treated female kidney transplant recipients.

Outcomes of pregnancies from 115 female kidney transplant recipients maintained on cyclosporine before and during pregnancy were obtained from questionnaires, hospital records, and telephone interviews. The mean age of conception was 29 years with a mean transplant interval of 2.2 years. There were 156 outcomes (2 sets of twins): ectopic 1%, therapeutic abortion 12%, miscarriage 16%, stillborn 2.6%, live birth 68.6%. The incidence of prematurity (< 37 weeks) was 56%, and that of low birthweight (< 2500 g) 49.5%. Complications occurred in 21.7% of newborns, but with only 1 neonatal death. Liveborn infants had a mean gestational age of 35.6 weeks (term 37-42 weeks) and a mean birthweight of 2407 g. The incidence of drug-treated hypertension prior to pregnancy was 51.7%; of diabetes prior to pregnancy, 11.7%; of preeclampsia, 24.8%; and of rejection during pregnancy or within 3 months postdelivery 14.5%. When infants born to women with or without a given risk factor were compared, mothers with pregnancy drug-treated hypertension had significantly lower-birth-weight infants (2250 vs. 2603 g, P = 0.028 by Wilcoxon). Similarly, mothers with prepregnancy creatinine > or = 1.5 mg/dl had smaller infants (2090 vs. 2505 g, P = 0.031 by Wilcoxon). There was a trend toward lower birth-weight in infants of diabetic recipients. Of 107 recipients interviewed, 12(11%) experienced graft loss, 8 associated with graft dysfunction or rejection during pregnancy. There was 1 graft loss during pregnancy due to rejection and 8 grafts were lost within 2 years of the pregnancy. There was one maternal death 4.3 years postpregnancy. For the 8 recipients who lost their graft within 2 years of pregnancy, outcomes included 1 miscarriage and 7 live births. The 7 live births had a mean gestational age of 35.7 weeks and a mean birth-weight of 2194 g. Five of 8 recipients who had graft loss within 2 years of pregnancy were in the drug-treated hypertensive group. Prepregnancy factors that appear to increase the risk to the newborn of a female kidney transplant recipient include maternal drug-treated hypertension, diabetes, and serum creatinine > or = 1.5 mg/dl. More data are needed before specific prepregnancy predictors for maternal graft loss can be determined in this population.

Birth Weight↗
PubMed1994

Arterial abnormalities following orthotopic liver transplantation: arteriographic findings and correlation with Doppler sonographic findings.

OBJECTIVE: We studied the findings on conventional arteriography in patients who had suspected graft ischemia after orthotopic liver transplantation to determine the value of a single Doppler signal in predicting these lesions. MATERIALS AND METHODS: We retrospectively reviewed selective visceral arteriograms with abnormal findings from 20 adults who had suspected graft ischemia after orthotopic liver transplantation and a single Doppler signal from the hepatic artery at the porta hepatis on sonograms obtained before arteriography. Arteriographic abnormalities were categorized according to morphology and location as follows: stenosis of recipient's hepatic artery, occlusion or stenosis of the transplanted extrahepatic artery, and occlusion or stenosis of the transplanted intrahepatic artery. RESULTS: Twenty-three arteriographic abnormalities were detected: four recipient celiac axis stenoses, seven extrahepatic occlusions, nine extrahepatic stenoses, and two occlusions and one stenosis of the transplanted intrahepatic artery. Six of the extrahepatic occlusions, two of the extrahepatic stenoses, and none of the recipient artery stenoses or the intrahepatic occlusions or stenoses were correctly diagnosed on the basis of Doppler findings. One patient with both an extrahepatic stenosis and an extrahepatic occlusion was thought to have an intrahepatic occlusion, and two patients with mild (< 50%) extrahepatic stenoses and one with an intrahepatic occlusion were thought to have an extrahepatic occlusion. CONCLUSION: A wide spectrum of abnormalities in the recipient's celiac axis or the transplanted arteries that may be associated with graft ischemia after orthotopic liver transplantation are often not detected or findings are misinterpreted on routine Doppler examination. In patients with suspected graft ischemia, visceral arteriography should be performed promptly to confirm the diagnosis and to allow early intervention.

Adult↗
PubMed1993

Factors associated with severe intracranial hypertension in candidates for emergency liver transplantation.

Cerebral edema is the leading cause of death in patients with fulminant hepatic failure (FHF). Emergency OLT is often a life-saving therapy for FHF but severe cerebral edema is a contraindication to transplantation. We attempted to identify clinical and biochemical factors associated with the development of severe intracranial hypertension in FHF. Fever, psychomotor agitation, and arterial hypertension were more frequently observed preceding episodes of severe intracranial hypertension, and more than 50% of FHF patients with uncontrolled intracranial hypertension sustained severe brain injury in our series. These observations suggest that vigorous treatment of fever, arterial hypertension, and agitation are important aspects of the intensive care management of FHF patients to maintain their OLT candidacy.

Adult↗
PubMed1993

Hemodynamics of failing dialysis grafts.

Pressures were measured in the graft and the central vein during 104 consecutive angiographic examinations of failing hemodialysis grafts. Stenosis severity greater than 40% led to a statistically significant rise in graft pressure. In grafts in which all stenoses were of 40% or less severity, the systolic pressures in the venous and arterial limbs of the grafts were 31% +/- 16 and 45% +/- 17, respectively, of systemic systolic pressure. In grafts in which the highest grade of stenosis was greater than 40%, pressures in the venous and arterial limbs of the grafts were 53% +/- 25 and 75% +/- 24, respectively, of systemic systolic pressure. Graft thrombosis tended to occur at a higher degree of lumen reduction (but at similar pressures) with central vein stenoses compared with venous anastomotic stenoses. Dialysis graft pressures can help determine the hemodynamic importance of stenoses and the need for intervention. Percutaneous intervention should achieve arterial and venous limb pressures of less than 50% and 33% of systemic pressure, respectively.

Angiography, Digital Subtraction↗
PubMed1993

Rapid development of lymphoma following liver transplantation in a recipient with hepatitis B and primary hemochromatosis.

We report a case of a posttransplant lymphoproliferative disorder (PTLD) which presented in a liver allograft shortly after transplantation. The patient, who had been transplanted because of cirrhosis due to primary hemochromatosis and chronic hepatitis B infection (HBV), developed early recurrent HBV in the graft, and 2 months after transplantation, liver biopsies showed a malignant large-cell lymphoma. The neoplastic cells demonstrated Epstein-Barr virus DNA by in situ hybridization. The patient died 3.5 months posttransplant due to liver failure. At autopsy, the liver showed nodules of malignant lymphoma, massive hepatic necrosis, and iron overload, but no evidence of rejection. This report suggests that the grafted liver can be the site of PTLD in recurrent HBV and hemochromatosis.

Adult↗