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Biomedical subjects

R H Wiesner

Publications and source records attributed to R H Wiesner.

At least 235 records · Page 13Linked to original sources
PubMed1990

Hilar biliary strictures after liver transplantation: cholangiography and percutaneous treatment.

Nonanastomotic hilar bile duct strictures developed in 16 of 152 patients who underwent liver transplantation. The type of pretransplantation liver disease did not significantly affect the likelihood of hilar stricture formation. Possible causes of hilar biliary strictures include hepatic artery occlusion, ductopenic arteriopathic rejection, and cytomegalovirus infection; however, five of the 16 patients had hilar strictures without these complications. Hilar strictures developed within 3 months after transplantation in 11 of the 16 patients. Strictures began as a slight common hepatic duct irregularity and progressed to mucosal cast formation and later to firm strictures. Fifteen of the 16 patients underwent percutaneous stricture dilation. Of 12 patients who no longer have stents, four have had no stricture recurrence for 12-30 months. Eight patients have had to undergo retransplantation or have died. Percutaneous dilations were most likely to result in patient bile ducts if strictures developed within 3 months after transplantation and in the absence of pretransplantation primary sclerosing cholangitis, ductopenic arteriopathic rejection, cytomegalovirus infection, or hepatic artery thrombosis.

Adolescent↗
PubMed1990

Intrapulmonary vascular dilatations (IPVD) in liver transplant candidates. Screening by two-dimensional contrast-enhanced echocardiography.

Intrapulmonary vascular dilatations (IPVD) are extrahepatic complications of acute and chronic liver disorders that can result in severe hypoxemia. Contrast-enhanced (CE) echocardiography provides a noninvasive method to detect right-to-left shunting associated with IPVD. We prospectively studied 40 consecutive liver transplant candidates to determine the relationship between CE echocardiography, arterial blood gases, and standard pulmonary function tests. Two patients had technically unacceptable results of echocardiographic studies. Thirty-eight patients had acceptable results of studies; seven (18.4 percent) of 38 were hypoxemic (PaO2 less than 70 mm Hg). Thirty-one patients (81.6 percent) had PaO2 greater than or equal to 70 mm Hg. Positive CE echocardiograms suggesting IPVD were found in five (13.2 percent) of 38. Three (9.7 percent) of the 31 patients with PaO2 greater than or equal to 70 mm Hg had positive CE echocardiograms. Two (28.6 percent) of the seven hypoxemic patients had positive CE echocardiography. Mean PaO2 and pulmonary function parameters were not significantly different between those with positive CE echocardiogram compared with those with normal CE echocardiograms. We conclude that for our group of liver transplant candidates, (1) IPVD as suggested by CE echocardiography were not uncommon (13.2 percent), and (2) positive CE echocardiography could be documented in patients who were not hypoxemic (9.7 percent).

Adult↗
PubMed1990

Congestive gastropathy and other upper endoscopic findings in 81 consecutive patients undergoing orthotopic liver transplantation.

Pretransplant endoscopic findings in 81 consecutive patients with nonalcoholic liver disease were examined to determine the spectrum of abnormalities encountered, with particular attention to mucosal changes consistent with congestive gastropathy. Abnormalities were observed in 75 patients (93%). Twenty-three patients (28%) had findings suggestive of congestive gastropathy: petechiae, focal and diffuse intense erythema, with or without erosions, edematous mucosa with a fine white reticulated or mosaic pattern, and cherry red spots resembling vascular malformations. Congestive gastropathy was the second most common abnormality identified after esophageal varices (66 patients, 81%). Other abnormalities included gastric varices in 13 patients (16%), esophagitis in seven (9%), gastric ulcers in six (7%), duodenal ulcer in 11 (14%), postsclerotherapy esophageal ulceration in 10 (12%), and a postsclerotherapy symptomatic esophageal stricture in one. The prevalence of congestive gastropathy has provided a stimulus for our prospective evaluation of gastric mucosal disease before and after liver transplantation or portosystemic shunt.

Chronic Disease↗
PubMed1990

UW solution improves duration and quality of clinical liver preservation.

Prolonged liver preservation (up to 17 hours) with UW solution had no adverse effect on perioperative blood loss or results of postoperative serum biochemistry studies. After use of this solution, biliary and vascular complications as well as evidence of histologic damage were less. The advantages of the extended preservation time permit liver transplantation to be done as a semi-elective procedure; more patients can be waiting at home instead of near the transplant center. The availability of UW solution also makes it possible to send grafts long distances throughout the nation. Furthermore, surgeons can arrange for backup patients in case the recipient proves to be inoperable. This capability should reduce organ wastage, even before the time limits of preservation with UW solution have been determined definitely. We feel that UW solution undoubtedly has improved both the duration and quality of liver graft preservation.

Adenosine↗
PubMed1989

Efficacy of liver transplantation in patients with primary biliary cirrhosis.

No controlled trials have been performed to assess the efficacy of liver transplantation. Because of the marked improvement in survival after liver transplantation since 1981, random assignment of patients to a control group not undergoing transplantation is considered clinically inappropriate. To assess the efficacy of liver transplantation in patients with primary biliary cirrhosis, we compared survival in 161 patients with this diagnosis who had undergone a liver transplantation with survival in patients with the same diagnosis who had been treated conservatively. The comparison was performed with use of a recently developed statistical technique, the Mayo model. All patients had undergone liver transplantation between March 1980 and June 1987 and were followed for a median of 25 months. Three months after liver transplantation, the Kaplan-Meier survival probabilities in the recipients were substantially higher than the Mayo-model "simulated-control" survival probabilities (P less than 0.001). At two years, the Kaplan-Meier survival probability was 0.74, whereas the mean Mayo-model survival probability was 0.31. The patients who were at low risk according to the Mayo model had the best probability of survival after liver transplantation; however, patients at all risk levels who had undergone liver transplantation had higher probabilities of survival that those who had not. We conclude that liver transplantation is an efficacious treatment in patients with advanced primary biliary cirrhosis.

Follow-Up Studies↗
PubMed1989

Floxuridine-induced sclerosing cholangitis: an ischemic cholangiopathy?

A 43-year-old man underwent abdominoperineal resection of a rectal adenocarcinoma, and left hepatic lobectomy for a single metastasis. He then received hepatic artery infusions of floxuridine. The tumor did not recur, but sclerosing cholangitis and liver failure developed which necessitated orthotopic liver transplantation. In the hilus of the native liver, obstructive arteriopathy and portal venopathy were found. These lesions probably had been caused by drug-induced intravascular thrombosis. Thus, the sclerosing cholangitis that develops in many patients after floxuridine infusion may be ischemic rather than toxic. The patient described here is well, 14 months after orthotopic liver transplantation. Therefore, in some cases of floxuridine-induced cholangitis, liver transplantation appears to be indicated despite a history of metastasizing carcinoma.

Adult↗
PubMed1989

Primary sclerosing cholangitis: natural history, prognostic factors and survival analysis.

The natural history of primary sclerosing cholangitis was assessed in 174 patients; 37 were asymptomatic and 137 had symptoms related to underlying liver disease. At the time of diagnosis, the mean age was 39.9 years, 66% of the primary sclerosing cholangitis patients were male and 71% had associated inflammatory bowel disease, most commonly chronic ulcerative colitis. Long-term follow-up (mean: 6.0 years; range: 2.7 to 15.5 years) was available in all patients. During follow-up, 59 (34%) of the patients died: 55 in the symptomatic group and four in the asymptomatic group. Median survival from the time of diagnosis of primary sclerosing cholangitis at the Mayo Clinic was 11.9 years. Survival in the asymptomatic group was significantly decreased compared with that in a control population matched for age, race and sex. Multivariate analysis (Cox proportional hazards regression modeling) revealed that age, serum bilirubin concentration, blood hemoglobin concentration, presence or absence of inflammatory bowel disease and histologic stage on liver biopsy were independent predictors of high risk of dying. The development of a multivariate statistical survival model is a major step in identifying individual primary sclerosing cholangitis patients at low, moderate and high risk of dying. Such models will be useful for stratifying patients in therapeutic trials, in patient counseling and in patient selection and timing of liver transplantation.

Adult↗
PubMed1989

Prospective evaluation of esophageal varices in primary biliary cirrhosis: development, natural history, and influence on survival.

The aims of our prospective study were to determine the development and natural history of esophageal varices and variceal bleeding in patients with primary biliary cirrhosis. As part of a controlled clinical study, 265 patients with primary biliary cirrhosis who did not have esophageal varices at entry were followed for a median of 5.6 yr. The mean age was 49 yr (range 26-75 yr), 89% were women, and 69% had advanced histologic stage disease (stage 3-4) on liver biopsy at study entry. All patients were screened annually for esophageal varices by barium esophogram or endoscopy, or both; endoscopy was used to diagnose all episodes of esophageal variceal bleeding. Esophageal varices developed in 83 (31%) patients, and 40 (48%) of those with esophageal varices experienced one or more episodes of esophageal variceal bleeding. Cox regression analysis indicated that only serum bilirubin and histologic stage were associated independently with time to development of esophageal varices. In patients who developed esophageal varices, 33% and 41% developed esophageal variceal bleeding at 1 and 3 yr, respectively. After development of esophageal varices, 1- and 3-yr survival estimates were 83% and 59%, respectively. After the initial variceal bleeding episode, survival estimates were 65% and 46% at 1 and 3 yr and were dependent on Child's classification. These findings are important in considering indications for prophylactic therapy for esophageal varices in primary biliary cirrhosis and may influence timing of liver transplantation.

Adult↗
PubMed1989

The first 100 liver transplantations at the Mayo Clinic.

Between March 1985 and June 1987, the first 100 liver transplantations at the Mayo Clinic were performed in 83 patients (primarily adults). The most frequent diagnoses were chronic active hepatitis (in 24 patients), primary sclerosing cholangitis (in 22), and primary biliary cirrhosis (in 20). The median operating time was 406 minutes, and the median usage of erythrocytes was 13.2 units. A venovenous bypass was used in all patients older than 10 years of age. Hepatic artery thrombosis occurred in 10% of the 100 transplants. A choledochocholedochostomy was done in 58 patients and a choledochojejunostomy in 25 patients. Revision of the biliary anastomosis was necessary in 9 of the 83 patients (11%). Rejection, diagnosed by clinical and histologic criteria, occurred in 50 patients (60%) and was treated with a corticosteroid bolus, followed by OKT3 (monoclonal antibody) treatment if necessary. Selective bowel decontamination helped prevent infections; only 16 bacteremias occurred, 1 of which was caused by a gram-negative organism. Fungal infections were rare. Cytomegalovirus infection occurred in 47 patients (57%). Of the 83 patients, 16 required retransplantation, in 11 of whom graft rejection had occurred. One- and 2-year patient survival was 83% and 70%, respectively. Although problems still remain, liver transplantation is a reasonable option for patients with end-stage liver disease.

Academic Medical Centers↗
PubMed1989

Assessment of nutritional status of patients with end-stage liver disease undergoing liver transplantation.

Nutritional assessment factors (including dietary history, anthropometric and biochemical measurements, and evaluation of immunocompetence) were retrospectively reviewed in 74 patients undergoing an initial liver transplantation procedure. The patients were subdivided into four categories on the basis of type of liver disease: chronic active hepatitis (N = 24), primary sclerosing cholangitis (N = 22), primary biliary cirrhosis (N = 20), and acute or subacute hepatitis (N = 8). Our nutritional assessment data indicated that malnutrition was present preoperatively in all liver transplantation groups but that each group had distinct characteristics. The group with primary biliary cirrhosis seemed to have the best hepatic synthetic function despite extreme wasting of muscle and fat. On the basis of all criteria, the group with acute hepatitis was the most malnourished of the various disease groups. Aggressive nutritional support, which includes adequate intake of nutrients and supplementation of vitamins and trace minerals, should be encouraged for all potential liver transplant patients.

Adult↗
PubMed1989

Blood bank support of a liver transplantation program.

Successful implementation of a liver transplantation program is dependent on extensive blood bank support. Careful planning, organization, and coordination of the blood bank and other clinical services are necessary. In our first 100 orthotopic liver transplantations, our median intraoperative erythrocyte use was 12.6 units, and 30% of the erythrocytes were provided by intraoperative cell salvage. Thus, the need for homologous blood and the number of donors to whom recipients were exposed were reduced. Use of intraoperative cell salvage and expansion of our erythrocyte inventory through the use of AS-1 preservative helped us meet the demands of the liver transplant program without compromising the availability of blood products for all other surgical and medical patients.

Blood Banks↗
PubMed1989

Application of the Mayo primary biliary cirrhosis survival model to Mayo liver transplant patients.

Liver transplantation is considered lifesaving for selected patients with end-stage primary biliary cirrhosis (PBC). A mathematical model to predict survival in the patient with PBC who has not undergone transplantation would be valuable for improving selection of patients for and timing of transplantation and for providing control information for assessment of the efficacy of transplantation. The Cox regression method and data from 312 Mayo Clinic patients with PBC were used to develop a model based on age, total serum bilirubin, serum albumin, prothrombin time, and severity of edema. When cross-validated on an independent set of 106 Mayo patients, the model accurately predicted their survival. It was similar to two other published survival models in terms of risk measurement but had the advantage of not necessitating liver biopsy. The model was used to assess the efficacy of liver transplantation by comparing the Kaplan-Meier survival of 32 Mayo patients after transplantation with the average model prediction of survival without transplantation. Beyond 3 months after transplantation, Kaplan-Meier survival probabilities were significantly greater than control survival predicted by the model (P less than 0.001). Examples of using the model for aiding in selection of patients for and timing of transplantation are provided.

Age Factors↗
PubMed1989

Endotheliitis in hepatic allografts.

Endotheliitis (EN) is a feature of hepatic allograft rejection, characterized by the adherence of immunocytes to the endothelium of veins, often leading to endothelial damage, endophlebitis, and, sometimes, panphlebitis. We found EN at least once in 28 of 41 allografts (68%) that had survived 6 months or longer. In approximately half the affected cases, the condition recurred. The EN was mild in most instances; moderate or severe manifestations were found in only 13% of the cases. The histologic changes were present for about 1 week in approximately half the cases; a duration of more than 2 weeks was noted in 17%, and then EN usually persisted. After retransplantation, recurrence of EN was observed in all of nine cases. We were unable to establish specific clinicopathologic and laboratory correlations for EN. The immunocytes in EN consisted mainly of helper and suppressor/cytotoxic T cells as well as natural killer cells. Sometimes, the immunocytes assumed a blastlike appearance; in these instances, the condition was severe. Such blastlike changes may be specific for EN. The immunocytes were attached to the endothelium by pseudopodia, broad bases, or both; some also were interconnected by cytoplasmic bridges. Underlying endothelial cells often showed evidence of cytoplasmic damage. The pathogenesis of EN is not completely understood; the immunocytes probably attach themselves to antigenic epitopes. Their nature, however, has not been clearly identified; HLA-A, B, and C and HLA-DR were displayed in areas of EN, but the antigens also were found in vessels without EN.

Endothelium, Vascular↗
PubMed1989

Incidence, distribution, and outcome of episodes of infection in 100 orthotopic liver transplantations.

Of 83 patients who underwent 100 orthotopic liver transplantations, 53 had a single transplant procedure and at least 6 months of follow-up. In this main study group of 53 patients, major infections developed in 28 (53%) (a mean of 1.8 major episodes per infected patient). Of 51 major infections, 27 were bacterial, 19 were viral, 3 were protozoan, and 2 were fungal. Of the 27 bacterial infections, 22 (81%) occurred in the first 2 months after transplantation. Of the 40 bacterial isolates in the 27 bacterial infections, gram-positive aerobic bacteria were isolated in 26 (65%), anaerobic bacteria in 8 (20%), and aerobic gram-negative bacteria in 6 (15%). Only 1 of 16 bacteremic episodes was due to a gram-negative aerobic bacterium. Cytomegalovirus (CMV) infection occurred in 30 of the 53 patients (57%) and was symptomatic and invasive in 18. CMV infection was diagnosed a mean of 26 days after transplantation. Infections due to Pneumocystis carinii occurred later (2 to 3 months after transplantation). Death from infection occurred in 4 of the 53 patients (8%). In the group of 16 patients with two or more liver transplantations, fungal infection occurred in 2 and CMV infection in 13. In all 16 patients who underwent more than one liver transplantation, a major infection developed. The observations made in the main study group were consistent with findings in 13 patients with one liver transplantation but less than 6 months of follow-up. Infection is a major complication after liver transplantation, generally occurring in the first 2 months. Our observations suggest that the use of selective bowel decontamination may be associated with a relatively lower incidence of gram-negative aerobic bacterial infections.

Bacterial Infections↗
PubMed1989

Immunohistologic pattern of the portal T-lymphocyte infiltration in hepatic allograft rejection.

Monoclonal antibodies were used to identify helper T cells (TH) and suppressor/cytotoxic T cells (TS/C) in liver allograft biopsy specimens obtained 7,21,90,180, and 365 days postoperatively and then annually or during episodes of graft dysfunction and after treatment of rejection episodes. Biopsy specimens were obtained from 70 hepatic allografts from patients treated with cyclosporine and corticosteroids. Rejection was diagnosed by the presence of appropriate laboratory and light microscopic findings and at least 16 weeks of follow-up to exclude other causes of graft dysfunction. Three immunohistologic patterns were noted: no or only a trace of T lymphocytes, predominantly TH infiltrate with or without a small amount of TS/C cells (portal TH), and a mixture of TH with an equal or greater number of TS/C infiltrate (portal mix). Of 68 biopsy specimens obtained during quiescent periods, only 3 had a portal tract T-lymphocyte infiltrate. Of 30 protocol biopsy specimens, 24 contained such an infiltrate a mean of 12.4 days before biochemical and routine histologic indications of rejection in the allograft. At the time of the rejection episode, 33 biopsy specimens were immunohistologically labeled; portal tract T-lymphocyte infiltrate was predominantly TH in 8 and a mixture of TH and TS/C in 25. All rejection episodes with a predominantly TH pattern responded to methylprednisolone. Of the 25 rejection episodes with a portal mix pattern, only 3 responded to methylprednisolone. Eighty-seven biopsy specimens were obtained more than 10 days after treatment of rejection.(ABSTRACT TRUNCATED AT 250 WORDS)

Antibodies, Monoclonal↗
PubMed1989

Evaluation of preoperative hematology-coagulation screening in liver transplantation.

We retrospectively reviewed the results of preoperative hematology-coagulation studies in 66 patients who underwent orthotopic liver transplantation-24 with the primary diagnosis of chronic active hepatitis (CAH), 22 with primary sclerosing cholangitis (PSC), and 20 with primary biliary cirrhosis (PBC). The mean prothrombin time was above normal in all three diagnostic groups, patients with CAH having the highest values. The mean activated partial thromboplastin time was normal in patients with PSC or PBC but elevated in those with CAH. Fibrinogen levels were above normal in patients with PBC but decreased in 1 patient (5%) with PSC and 10 (42%) with CAH. Mean platelet counts were below normal in 68% and 55% of patients with PSC and PBC, respectively, but in 96% of those with CAH. The mean Ivy bleeding time was normal in patients with PSC or PBC but prolonged in those with CAH. Patients with PSC or PBC had normal mean activity levels of factors II, V, VII, IX, and X, whereas those with CAH had below normal mean values for factors II and VII. The antithrombin III activity level was normal in patients with PSC or PBC but reduced in those with CAH. Thus, patients with CAH have a greater derangement in results of clotting studies in comparison with those who have PSC or PBC, but the use of blood did not differ among the three diagnostic groups.

Antithrombin III↗