Fernando Acosta - Academia.edu (original) (raw)
Papers by Fernando Acosta
Transplantation Proceedings, 1999
Transplantation Proceedings, 1999
Transplantation Proceedings, 1999
British Journal of Surgery, 1995
Long-term results of 13 liver transplantations in patients with a previous diagnosis of type I fa... more Long-term results of 13 liver transplantations in patients with a previous diagnosis of type I familial amyloid polyneuropathy (FAP) are presented. The diagnosis of type I FAP was based on the presence of a biochemical marker in the plasma (TTR-Met-30 in 11 patients, TTR-Ala-71 in two). Maximum follow-up is 28 months and the survival rate stands at 11 of 13 patients. Two patients died from sepsis at 2 and 6 months. TTR disappeared from plasma in all cases. Neurological status improved in all eight patients undergoing transplantation more than 6 months previously, although electromyographic studies showed a slight improvement only in the six with follow-up of more than 1 year. All 13 patients showed a hyperdynamic haemodynamic pattern with a high incidence (four patients) of the use of venovenous bypass due to haemodynamic intolerance. Two patients also received transplants by the ‘piggy-back’ technique. In conclusion, liver transplantation may be useful in the treatment of certain patients with FAP to halt and improve the neurological consequences of the disease.
Transplantation, 1997
Familial amyloidotic polyneuropathy type I (FAP I) is a hereditary systemic amyloidosis usually i... more Familial amyloidotic polyneuropathy type I (FAP I) is a hereditary systemic amyloidosis usually involving the peripheral nervous system. In this paper we report our experience regarding the survival and the evolution of the sensory motor syndrome of the extremities and autonomic dysfunction in four siblings with the Ala-71 variant who were treated by liver transplantation (LT). The four siblings are alive 2-5 years after LT. After the operation, the seriated determinations of TTR-Ala-71 variant showed a constant decrease in serum levels in all cases. Our results support the proposal that LT should be indicated especially in forms with early clinical onset (3rd and 4th decades) and rapid progress to stop the neurological deterioration of the patients.
... Pubmed 18. Fishbein TM, Fiel IM, Emre S, et al. Use of livers with microvesicular fat safely ... more ... Pubmed 18. Fishbein TM, Fiel IM, Emre S, et al. Use of livers with microvesicular fat safely expands the donor pool. ... Liver Transpl 2002;8:725-9. Pubmed. Ramírez, P a ; Ríos, A a ; Sánchez Bueno, F a ; Robles, R a ; Pons, JA a ; Acosta, F a ; Parrilla, P a. a Unidad de Trasplantes. ...
Transplantation Proceedings, 2000
British Journal of Surgery, 1993
Biliary tract complications were analysed after 54 orthotopic liver transplantations performed in... more Biliary tract complications were analysed after 54 orthotopic liver transplantations performed in 49 patients over a 2-year period. Reconstruction of the bile duct consisted of end-to-end choledochocholedochostomy over a T tube in 47 cases and Roux-en-Y choledochojejunostomy in seven (two for sclerosing cholangitis, one for secondary biliary cirrhosis, four retransplants). The T tube was withdrawn 12–16 weeks after operation in all but two patients (2–3 weeks). There was no intraoperative mortality. Eight patients (16 per cent) died during the first month and the 1-year actuarial survival rate was 75 per cent. Early biliary complications (up to 3 months after operation) consisted of five bilomas, for which ultrasonographically guided drainage was effective in three and surgical drainage necessary in two. Late biliary complications (3 months onwards) consisted of biliary peritonitis following T tube removal (four patients; reoperation was required in all four) and necrosis of the bile duct secondary to a late arterial thrombosis (one). The incidence of reoperation as a result of early biliary complications was low (two patients), but higher for biliary peritonitis following T tube removal.
Transplantation Proceedings, 1999
Surgical Endoscopy and Other Interventional Techniques, 1997
Background: An effort was made to present our experience with thoracoscopy in the diagnosis and m... more Background: An effort was made to present our experience with thoracoscopy in the diagnosis and management of pericardial effusions. Methods: Twenty-two partial pericardiectomies were performed with the thoracoscopic approach in patients with pericardial effusions, the etiology of which was uremic (n= 7), neoplastic (n= 8), idiopathic (n= 5), septicemia (n= 1), and postpericardiotomy (n= 1). All cases had grade III-IV/IV radiological cardiomegaly and ultrasonographic confirmation of the effusion. We found hemodynamic compromise in 17 patients. The operation, requiring the insertion of three trocars, enabled us to remove a large part (approximately 6 × 10 cm) of the left anterolateral side of the pericardium and aspirate the effusion contents for diagnostic and therapeutic purposes. Results: In five cases we found coexisting pleural effusions. The pericardial effusion had a mean volume of 817 ml, which was serous in 11 cases, hematic in six, serohematic in four, and purulent in one. Cytology of the pericardial effusion was positive for neoplasia in four cases (one pulmonary neoplasia, two breast carcinomas, and one lymphoma). We observed conversion to grade I/IV cardiomegaly in 16 cases and a return to normality in the other six, with the absence of ultrasonographic effusion in all cases. There was no recurrence during the mean follow-up period of 20.5 months (range: 2–47). Conclusions: The thoracoscopic management of pericardial effusions is a simple and effective technique that allows us to create a large pericardial window that drains the effusion definitively, determines its etiology, and explores and treats coexisting pleural lesions, all without recurrences.
Transplantation Proceedings, 2002
A CUTE renal failure (ARF) is a frequent medical complication affecting patients with end-stage l... more A CUTE renal failure (ARF) is a frequent medical complication affecting patients with end-stage liver disease and orthotopic liver transplantation (OLT). It is associated with an increase in post-transplant mortality. 1 Therefore it is important to detect which patients are at greatest risk and the factors related to the OLT procedure, so that preventive measures may be taken. 2 The objectives of this study were (1) to determine the incidence of ARF in the first week post-OLT in a group of OLT recipients in our hospital; and (2) to analyze its relationship with different perioperative variables that may be prognostic factors.
Anesthesia and Analgesia, 2000
We evaluated the efficacy of the prophylactic administration of epsilon-aminocaproic acid and tra... more We evaluated the efficacy of the prophylactic administration of epsilon-aminocaproic acid and tranexamic acid for reducing blood product requirements in orthotopic liver transplantation (OLT) in a prospective, double-blinded study performed in 132 consecutive patients. Patients were randomized to three groups and given one of three drugs prophylactically: tranexamic acid, 10 mg. kg(-1). h(-1); epsilon-aminocaproic acid, 16 mg. kg(-1). h(-1), and placebo (isotonic saline). Perioperative management was standardized. Coagulation tests, thromboelastogram, and blood requirements were recorded during OLT and in the first 24 h. There were no differences in diagnosis, Child score, or preoperative coagulation tests among groups. Administration of packed red blood cells was significantly reduced (P = 0.023) during OLT in the tranexamic acid group, but not in the epsilon-aminocaproic acid group. There were no differences in transfusion requirements after OLT. Thromboembolic events, reoperations, and mortality were similar in the three groups. Prophylactic administration of tranexamic acid, but not epsilon-aminocaproic acid, significantly reduces total packed red blood cell usage during OLT. In a randomized study of 132 consecutive patients undergoing liver transplantation, we found that tranexamic acid, but not epsilon-aminocaproic acid, reduced intraoperative total packed red blood cell transfusion.
Kidney International, 2006
The objective of this study was to determine the risk factors of postoperative acute renal failur... more The objective of this study was to determine the risk factors of postoperative acute renal failure (ARF) in orthotopic liver transplantation (OLT). We reviewed 184 consecutive OLT. Postoperative ARF was defined as a persistent rise of 50% increase or more of the S-creatinine (S-Cr). The patients were classified as early postoperative ARF (E-ARF) (first week) and late postoperative ARF (L-ARF) (second to fourth week). Preoperative variables were age, sex, comorbidity, indication for OLT, Child-Pugh stage, united network for organ sharing status, analysis of the blood and urine, and donor's data. Intraoperative variables were systolic arterial pressure, mean arterial pressure, pulmonary capillary wedge pressure, cardiac index, and systemic vascular resistance index. Surgical technique, number of blood products transfused, need for adrenergic agonist drugs, and intraoperative complications were also important. Postoperative variables were duration of stay in the intensive care unit, time on mechanic ventilation, liver graft dysfunction, need for adrenergic agonist drugs, units of blood products infused, episodes of acute rejection, re-operations, and bacterial infections. Firstly we carried out a univariate statistical analysis, and secondly a logistic regression analysis. The risk factors for E-ARF were: pretransplant ARF (odds ratio (OR) ¼ 10.2, P ¼ 0.025), S-albumin (OR ¼ 0.3, P ¼ 0.001), duration of treatment with dopamine (OR ¼ 1.6, P ¼ 0.001), and grade II-IV dysfunction of the liver graft (OR ¼ 5.6, P ¼ 0.002). The risk factors for L-ARF were: re-operation (OR ¼ 3.1, P ¼ 0.013) and bacterial infection (OR ¼ 2.9, P ¼ 0.017). The development of E-ARF is influenced by preoperative factors such as ARF and hypoalbuminemia, as well as postoperative factors such as liver dysfunction and prolonged treatment with dopamine. The predicting factors of L-ARF differ from E-ARF and correspond to postoperative causes such as bacterial infection and surgical re-operation.
Transplantation Proceedings, 2000
Transplantation Proceedings, 2003
The objective of this study was to evaluate the effect of the surgical technique on postoperative... more The objective of this study was to evaluate the effect of the surgical technique on postoperative renal function during the first week after liver transplantation (OLT). We performed a retrospective study of 184 consecutive OLT. Criteria for acute renal failure were: serum creatinine > 1.5 mg/dL, an increase by 50% in the baseline serum creatinine, or oliguria requiring renal replacement therapy. The distribution of patients according to the surgical technique was: standard (n = 84), venovenous bypass (n = 20), and piggyback (n = 80). Other variables analyzed were: intraoperative requirement for blood products, treatment with adrenergic agonists, intraoperative complications, and postreperfusion syndrome. Univariate analysis showed the following parameters to be significantly related to postoperative renal failure: intraoperative fresh frozen plasma and cryoprecipitate requirements, intraoperative complications, postreperfusion syndrome, need for noradrenaline or dobutamine, standard surgical technique versus piggyback (39% vs 18%, P < .01) and venovenous vs piggyback (50% vs 18%, P < .01). Logistic regression analysis identified the following variables as having independent prognostic value: (1) Standard surgical technique vs piggyback (OR = 3.3, P = .01); (2) venovenous vs piggyback (OR = 4.7, P = .02); and (3) > 20 U cryoprecipitate requirement (OR = 1.04, P = .01). In conclusion, compared with the piggyback technique, the standard surgical technique appears to be an independent risk factor for postoperative acute renal failure. When venovenous bypass is used in patients who do not tolerate trial clamping of inferior vena cava, it does not reduce the incidence of postoperative renal failure. Finally, the piggyback technique significantly reduces the probability of acute renal failure after liver transplantation.
Transplantation Proceedings, 1999
Biliary complications following liver transplantation are a cause of significant morbidity and mo... more Biliary complications following liver transplantation are a cause of significant morbidity and mortality. During the period 1988-1993 ten cases of biliary complications occurred after 98 transplantations in 78 children. The complications were four bile leaks, three intrahepatic biliary strictures (one with recurrent cholangitis), two anastomotic biliary strictures (one with recurrent cholangitis) and one recurrent cholangitis. All leaks occurred within 6 weeks of transplantation whereas all strictures and cholangitic episodes occurred after 3 months. Two biliary complications (20%) - one intrahepatic and one anastomotic stricture - developed secondary to hepatic artery thrombosis. The incidence of biliary complications was 13.2% with whole liver grafts as compared to 6.7% with partial liver grafts and it was 4.3% with duct-to-duct anastomosis as compared to 12.0% with Roux-en-Y hepatico-jejunostomy. Seven children required intervention for management of biliary complications and three were managed conservatively. There were no deaths related to the biliary complications.
Transplantation Proceedings, 1999
European Journal of Clinical Microbiology & Infectious Diseases, 2003
The aim of the present study was to investigate the potential synergy between meropenem and levof... more The aim of the present study was to investigate the potential synergy between meropenem and levofloxacin in vitro and in experimental meningitis and to determine the effect of meropenem on levofloxacin-induced resistance in vitro. Meropenem increased the efficacy of levofloxacin against the penicillin-resistant pneumococcal strain KR4 in time-killing assays in vitro and acted synergistically against a second penicillin-resistant strain WB4. In the checkerboard, only an additive effect (FIC indices: 1.0) was observed for both strains. In cycling experiments in vitro, levofloxacin alone led to a 64-fold increase in the MIC for both strains after 12 cycles. Addition of meropenem in sub-MIC concentrations (0.25×MIC) completely inhibited the selection of levofloxacin-resistant mutants in WB4 after 12 cycles. In KR4, the addition of meropenem led to just a twofold increase in the MIC for levofloxacin after 12 cycles. Mutations detected in the genes encoding for topoisomerase IV (parC) and gyrase (gyrA) confirmed the levofloxacin-induced resistance in both strains. Addition of meropenem was able to completely suppress levofloxacin-induced mutations in WB4 and led to only one mutation in parE in KR4. In experimental meningitis, meropenem, given in two doses (2×125 mg/kg), produced a good bactericidal activity (−0.45 Δlog10 cfu/ml·h) comparable to one dose (1×10 mg/kg) of levofloxacin (−0.44 Δlog10 cfu/ml·h) against the penicillin-resistant strain WB4. Meropenem combined with levofloxacin acted synergistically (−0.93 Δlog10 cfu/ml·h), sterilizing the CSF of all rabbits.
Transplantation Proceedings, 1999
Transplantation Proceedings, 1999
Transplantation Proceedings, 1999
British Journal of Surgery, 1995
Long-term results of 13 liver transplantations in patients with a previous diagnosis of type I fa... more Long-term results of 13 liver transplantations in patients with a previous diagnosis of type I familial amyloid polyneuropathy (FAP) are presented. The diagnosis of type I FAP was based on the presence of a biochemical marker in the plasma (TTR-Met-30 in 11 patients, TTR-Ala-71 in two). Maximum follow-up is 28 months and the survival rate stands at 11 of 13 patients. Two patients died from sepsis at 2 and 6 months. TTR disappeared from plasma in all cases. Neurological status improved in all eight patients undergoing transplantation more than 6 months previously, although electromyographic studies showed a slight improvement only in the six with follow-up of more than 1 year. All 13 patients showed a hyperdynamic haemodynamic pattern with a high incidence (four patients) of the use of venovenous bypass due to haemodynamic intolerance. Two patients also received transplants by the ‘piggy-back’ technique. In conclusion, liver transplantation may be useful in the treatment of certain patients with FAP to halt and improve the neurological consequences of the disease.
Transplantation, 1997
Familial amyloidotic polyneuropathy type I (FAP I) is a hereditary systemic amyloidosis usually i... more Familial amyloidotic polyneuropathy type I (FAP I) is a hereditary systemic amyloidosis usually involving the peripheral nervous system. In this paper we report our experience regarding the survival and the evolution of the sensory motor syndrome of the extremities and autonomic dysfunction in four siblings with the Ala-71 variant who were treated by liver transplantation (LT). The four siblings are alive 2-5 years after LT. After the operation, the seriated determinations of TTR-Ala-71 variant showed a constant decrease in serum levels in all cases. Our results support the proposal that LT should be indicated especially in forms with early clinical onset (3rd and 4th decades) and rapid progress to stop the neurological deterioration of the patients.
... Pubmed 18. Fishbein TM, Fiel IM, Emre S, et al. Use of livers with microvesicular fat safely ... more ... Pubmed 18. Fishbein TM, Fiel IM, Emre S, et al. Use of livers with microvesicular fat safely expands the donor pool. ... Liver Transpl 2002;8:725-9. Pubmed. Ramírez, P a ; Ríos, A a ; Sánchez Bueno, F a ; Robles, R a ; Pons, JA a ; Acosta, F a ; Parrilla, P a. a Unidad de Trasplantes. ...
Transplantation Proceedings, 2000
British Journal of Surgery, 1993
Biliary tract complications were analysed after 54 orthotopic liver transplantations performed in... more Biliary tract complications were analysed after 54 orthotopic liver transplantations performed in 49 patients over a 2-year period. Reconstruction of the bile duct consisted of end-to-end choledochocholedochostomy over a T tube in 47 cases and Roux-en-Y choledochojejunostomy in seven (two for sclerosing cholangitis, one for secondary biliary cirrhosis, four retransplants). The T tube was withdrawn 12–16 weeks after operation in all but two patients (2–3 weeks). There was no intraoperative mortality. Eight patients (16 per cent) died during the first month and the 1-year actuarial survival rate was 75 per cent. Early biliary complications (up to 3 months after operation) consisted of five bilomas, for which ultrasonographically guided drainage was effective in three and surgical drainage necessary in two. Late biliary complications (3 months onwards) consisted of biliary peritonitis following T tube removal (four patients; reoperation was required in all four) and necrosis of the bile duct secondary to a late arterial thrombosis (one). The incidence of reoperation as a result of early biliary complications was low (two patients), but higher for biliary peritonitis following T tube removal.
Transplantation Proceedings, 1999
Surgical Endoscopy and Other Interventional Techniques, 1997
Background: An effort was made to present our experience with thoracoscopy in the diagnosis and m... more Background: An effort was made to present our experience with thoracoscopy in the diagnosis and management of pericardial effusions. Methods: Twenty-two partial pericardiectomies were performed with the thoracoscopic approach in patients with pericardial effusions, the etiology of which was uremic (n= 7), neoplastic (n= 8), idiopathic (n= 5), septicemia (n= 1), and postpericardiotomy (n= 1). All cases had grade III-IV/IV radiological cardiomegaly and ultrasonographic confirmation of the effusion. We found hemodynamic compromise in 17 patients. The operation, requiring the insertion of three trocars, enabled us to remove a large part (approximately 6 × 10 cm) of the left anterolateral side of the pericardium and aspirate the effusion contents for diagnostic and therapeutic purposes. Results: In five cases we found coexisting pleural effusions. The pericardial effusion had a mean volume of 817 ml, which was serous in 11 cases, hematic in six, serohematic in four, and purulent in one. Cytology of the pericardial effusion was positive for neoplasia in four cases (one pulmonary neoplasia, two breast carcinomas, and one lymphoma). We observed conversion to grade I/IV cardiomegaly in 16 cases and a return to normality in the other six, with the absence of ultrasonographic effusion in all cases. There was no recurrence during the mean follow-up period of 20.5 months (range: 2–47). Conclusions: The thoracoscopic management of pericardial effusions is a simple and effective technique that allows us to create a large pericardial window that drains the effusion definitively, determines its etiology, and explores and treats coexisting pleural lesions, all without recurrences.
Transplantation Proceedings, 2002
A CUTE renal failure (ARF) is a frequent medical complication affecting patients with end-stage l... more A CUTE renal failure (ARF) is a frequent medical complication affecting patients with end-stage liver disease and orthotopic liver transplantation (OLT). It is associated with an increase in post-transplant mortality. 1 Therefore it is important to detect which patients are at greatest risk and the factors related to the OLT procedure, so that preventive measures may be taken. 2 The objectives of this study were (1) to determine the incidence of ARF in the first week post-OLT in a group of OLT recipients in our hospital; and (2) to analyze its relationship with different perioperative variables that may be prognostic factors.
Anesthesia and Analgesia, 2000
We evaluated the efficacy of the prophylactic administration of epsilon-aminocaproic acid and tra... more We evaluated the efficacy of the prophylactic administration of epsilon-aminocaproic acid and tranexamic acid for reducing blood product requirements in orthotopic liver transplantation (OLT) in a prospective, double-blinded study performed in 132 consecutive patients. Patients were randomized to three groups and given one of three drugs prophylactically: tranexamic acid, 10 mg. kg(-1). h(-1); epsilon-aminocaproic acid, 16 mg. kg(-1). h(-1), and placebo (isotonic saline). Perioperative management was standardized. Coagulation tests, thromboelastogram, and blood requirements were recorded during OLT and in the first 24 h. There were no differences in diagnosis, Child score, or preoperative coagulation tests among groups. Administration of packed red blood cells was significantly reduced (P = 0.023) during OLT in the tranexamic acid group, but not in the epsilon-aminocaproic acid group. There were no differences in transfusion requirements after OLT. Thromboembolic events, reoperations, and mortality were similar in the three groups. Prophylactic administration of tranexamic acid, but not epsilon-aminocaproic acid, significantly reduces total packed red blood cell usage during OLT. In a randomized study of 132 consecutive patients undergoing liver transplantation, we found that tranexamic acid, but not epsilon-aminocaproic acid, reduced intraoperative total packed red blood cell transfusion.
Kidney International, 2006
The objective of this study was to determine the risk factors of postoperative acute renal failur... more The objective of this study was to determine the risk factors of postoperative acute renal failure (ARF) in orthotopic liver transplantation (OLT). We reviewed 184 consecutive OLT. Postoperative ARF was defined as a persistent rise of 50% increase or more of the S-creatinine (S-Cr). The patients were classified as early postoperative ARF (E-ARF) (first week) and late postoperative ARF (L-ARF) (second to fourth week). Preoperative variables were age, sex, comorbidity, indication for OLT, Child-Pugh stage, united network for organ sharing status, analysis of the blood and urine, and donor's data. Intraoperative variables were systolic arterial pressure, mean arterial pressure, pulmonary capillary wedge pressure, cardiac index, and systemic vascular resistance index. Surgical technique, number of blood products transfused, need for adrenergic agonist drugs, and intraoperative complications were also important. Postoperative variables were duration of stay in the intensive care unit, time on mechanic ventilation, liver graft dysfunction, need for adrenergic agonist drugs, units of blood products infused, episodes of acute rejection, re-operations, and bacterial infections. Firstly we carried out a univariate statistical analysis, and secondly a logistic regression analysis. The risk factors for E-ARF were: pretransplant ARF (odds ratio (OR) ¼ 10.2, P ¼ 0.025), S-albumin (OR ¼ 0.3, P ¼ 0.001), duration of treatment with dopamine (OR ¼ 1.6, P ¼ 0.001), and grade II-IV dysfunction of the liver graft (OR ¼ 5.6, P ¼ 0.002). The risk factors for L-ARF were: re-operation (OR ¼ 3.1, P ¼ 0.013) and bacterial infection (OR ¼ 2.9, P ¼ 0.017). The development of E-ARF is influenced by preoperative factors such as ARF and hypoalbuminemia, as well as postoperative factors such as liver dysfunction and prolonged treatment with dopamine. The predicting factors of L-ARF differ from E-ARF and correspond to postoperative causes such as bacterial infection and surgical re-operation.
Transplantation Proceedings, 2000
Transplantation Proceedings, 2003
The objective of this study was to evaluate the effect of the surgical technique on postoperative... more The objective of this study was to evaluate the effect of the surgical technique on postoperative renal function during the first week after liver transplantation (OLT). We performed a retrospective study of 184 consecutive OLT. Criteria for acute renal failure were: serum creatinine > 1.5 mg/dL, an increase by 50% in the baseline serum creatinine, or oliguria requiring renal replacement therapy. The distribution of patients according to the surgical technique was: standard (n = 84), venovenous bypass (n = 20), and piggyback (n = 80). Other variables analyzed were: intraoperative requirement for blood products, treatment with adrenergic agonists, intraoperative complications, and postreperfusion syndrome. Univariate analysis showed the following parameters to be significantly related to postoperative renal failure: intraoperative fresh frozen plasma and cryoprecipitate requirements, intraoperative complications, postreperfusion syndrome, need for noradrenaline or dobutamine, standard surgical technique versus piggyback (39% vs 18%, P < .01) and venovenous vs piggyback (50% vs 18%, P < .01). Logistic regression analysis identified the following variables as having independent prognostic value: (1) Standard surgical technique vs piggyback (OR = 3.3, P = .01); (2) venovenous vs piggyback (OR = 4.7, P = .02); and (3) > 20 U cryoprecipitate requirement (OR = 1.04, P = .01). In conclusion, compared with the piggyback technique, the standard surgical technique appears to be an independent risk factor for postoperative acute renal failure. When venovenous bypass is used in patients who do not tolerate trial clamping of inferior vena cava, it does not reduce the incidence of postoperative renal failure. Finally, the piggyback technique significantly reduces the probability of acute renal failure after liver transplantation.
Transplantation Proceedings, 1999
Biliary complications following liver transplantation are a cause of significant morbidity and mo... more Biliary complications following liver transplantation are a cause of significant morbidity and mortality. During the period 1988-1993 ten cases of biliary complications occurred after 98 transplantations in 78 children. The complications were four bile leaks, three intrahepatic biliary strictures (one with recurrent cholangitis), two anastomotic biliary strictures (one with recurrent cholangitis) and one recurrent cholangitis. All leaks occurred within 6 weeks of transplantation whereas all strictures and cholangitic episodes occurred after 3 months. Two biliary complications (20%) - one intrahepatic and one anastomotic stricture - developed secondary to hepatic artery thrombosis. The incidence of biliary complications was 13.2% with whole liver grafts as compared to 6.7% with partial liver grafts and it was 4.3% with duct-to-duct anastomosis as compared to 12.0% with Roux-en-Y hepatico-jejunostomy. Seven children required intervention for management of biliary complications and three were managed conservatively. There were no deaths related to the biliary complications.
Transplantation Proceedings, 1999
European Journal of Clinical Microbiology & Infectious Diseases, 2003
The aim of the present study was to investigate the potential synergy between meropenem and levof... more The aim of the present study was to investigate the potential synergy between meropenem and levofloxacin in vitro and in experimental meningitis and to determine the effect of meropenem on levofloxacin-induced resistance in vitro. Meropenem increased the efficacy of levofloxacin against the penicillin-resistant pneumococcal strain KR4 in time-killing assays in vitro and acted synergistically against a second penicillin-resistant strain WB4. In the checkerboard, only an additive effect (FIC indices: 1.0) was observed for both strains. In cycling experiments in vitro, levofloxacin alone led to a 64-fold increase in the MIC for both strains after 12 cycles. Addition of meropenem in sub-MIC concentrations (0.25×MIC) completely inhibited the selection of levofloxacin-resistant mutants in WB4 after 12 cycles. In KR4, the addition of meropenem led to just a twofold increase in the MIC for levofloxacin after 12 cycles. Mutations detected in the genes encoding for topoisomerase IV (parC) and gyrase (gyrA) confirmed the levofloxacin-induced resistance in both strains. Addition of meropenem was able to completely suppress levofloxacin-induced mutations in WB4 and led to only one mutation in parE in KR4. In experimental meningitis, meropenem, given in two doses (2×125 mg/kg), produced a good bactericidal activity (−0.45 Δlog10 cfu/ml·h) comparable to one dose (1×10 mg/kg) of levofloxacin (−0.44 Δlog10 cfu/ml·h) against the penicillin-resistant strain WB4. Meropenem combined with levofloxacin acted synergistically (−0.93 Δlog10 cfu/ml·h), sterilizing the CSF of all rabbits.