Distal splenorenal shunts for the treatment of severe thrombocytopenia from portal hypertension in children

Profound thrombocytopenia resulting from portal hypertension may exacerbate gastrointestinal bleeding, precipitate spontaneous bleeding, preclude surgical intervention for associated disorders, and severely limit life-style because of the danger of splenic injury. Although splenectomy can reverse the thrombocytopenia, the procedure should be avoided in children. We reviewed our experience with distal splenorenal shunting (DSRS) in children, particularly when performed for the sole purpose of reversing severe thrombocytopenia resulting from portal hypertension. DSRS was performed in 11 children between the ages of 7 and 15 years: five for severe thrombocytopenia (group 1), four for advanced hypersplenism and congenital hepatic fibrosis prior to renal transplantation (group 2), and two for esophageal bleeding (group 3). One child in group 1 with severe heart disease and Child’s class C cirrhosis due to hepatitis C died of progressive cardiac failure and was excluded from further analysis. Of the eight remaining patients in groups 1 and 2, four children had congenital hepatic fibrosis, two had portal vein thrombosis, one had hepatitis B, and one had Wilson’s disease. After DSRS, the mean platelet count increased from 37,000 ±18,000 to 137,600 ±81,000 (P = 0.01). The platelet count improved significantly in all seven children with presinusoidal portal hypertension or stable cirrhosis but did not increase in the child with hepatitis Band Child’s class B cirrhosis. The white blood cell count increased from an average of 3.3 ±1.1 to 5.4 ± 2.6 (P= 0.02). There were no postoperative complications in this group. The improved platelet count allowed the four children with congenital hepatic fibrosis and renal failure to undergo renal transplantation with full posttransplant immunosuppression including azathioprine. Postoperative Doppler ultrasound examination demonstrated shunt patency at 6 months in all cases. Spleen size decreased appreciably in all children in groups 1 and 2. All children were able to resume full activity including contact sports. In summary, DSRS effectively controls profound thrombocytopenia resulting from presinusoidal portal hypertension or stable cirrhosis without sacrificing the spleen and should be the treatment of choice for this condition. Presented at the British Association of Pediatric Surgeons Annual International Congress, Istanbul, Turkey, July 22–25, 1997.     

Cystic fibrosis and portal hypertension: Distal splenorenal shunt can prevent the need for future liver transplant

BackgroundThe management of portal hypertension (PHT) in children with well compensated cirrhosis and cystic fibrosis (CF) is controversial. We present our experience with distal splenorenal shunting (DSRS) for the treatment of PHT as an alternative to liver transplantation (LT).MethodsBetween 2008 and 2017, 5 CF children underwent a DSRS at a pediatric hepatobiliary and transplantation referral center. LT (n = 9) was reserved for patients with decompensated cirrhosis. Statistical analysis was done using the paired t-test (p < 0.05 considered significant).ResultsMean PELD/MELD score was significantly lower for DSRS patients than LT (3 ± 6 vs 28 ± 4, p < 0.001). All 5 DSRS patients had grade III–IV varices. One bled prior to surgery. After DSRS, spleen size decreased significantly from 8.4 ± 1.5 cm to 4.4 ± 1.8 cm (p = 0.019). Mean platelet count remained stable (87.8 ± 48 to 91.8 ± 35, p = 0.9). There were no postoperative complications. No DSRS patient experienced variceal bleeding following shunt creation. Liver function tests remained stable in the DSRS group, and no patient required a liver transplant (median follow up 4.65 years, range 1.24–7.79).ConclusionsPatients with cystic fibrosis who have well-compensated cirrhosis and symptomatic portal hypertension can be palliated with distal splenorenal shunting and do not need liver transplants. These patients can undergo shunting with minimal morbidity.Type of studyCase series with no comparison group.Level of evidenceIV.     

Effects of early antiplatelet therapy after splenectomy with gastro‐oesophageal devascularization

Background

This study aimed to explore the effects of early antiplatelet therapy (APT) for portal vein thrombosis (PVT) in patients with cirrhotic portal hypertension after splenectomy with gastro‐oesophageal devascularization.

Methods

We retrospectively analysed 139 patients who underwent splenectomy with gastro‐oesophageal devascularization for portal hypertension due to cirrhosis between April 2010 and December 2016. Based on the post‐operative platelet values, we used two different APT regimens: APT was started when platelet counts were increased to 200 × 10⁹/L or above (group A, n = 64) or 300 × 10⁹/L or above (group B, n = 75). We took note of the patients’ clinical symptoms, operative factors and biochemical indicators.

Results

Platelet count, mean platelet volume, D‐dimer and pancreatic fistula were closely related to the development of PVT. Early APT was an independent protective factor for PVT. The incidence of post‐operative PVT was 15.1% (21/139) overall, 4.7% (3/64) in group A and 24% (18/75) in group B; there was a significant difference between groups A and B (χ² = 10.042, P = 0.002).

Conclusion

Platelet count, mean platelet volume, D‐dimer and pancreatic fistula were independent risk factors for the development of PVT after splenectomy with gastro‐oesophageal devascularization. Selection of the appropriate timing for early APT according to the post‐operative platelet count was feasible. Moreover, the use of aspirin combined with dipyridamole was safe and effective for early prevention of PVT.     

The prediction of portal pressure: A multivariate analysis of clinical data and intraoperative portal pressure

Portal pressures were estimated non-invasively in 100 patients who underwent hepatic resection and completely fulfilled the 21 variables evaluated. Ten variables were selected from among all those in the univariate analysis, and a stepwise discriminant analysis revealed four independent significant variables, namely: The indocyanine green dye retention test at 15 min (ICGR15); the prothrombin time index; the platelet count; and the globulin fraction. An equation to estimate the portal pressure was made using the coefficients in the analysis, the reliability of which was confirmed (r=0.70484,P=0.0001). The univariate analysis revealed ten significant variables to discriminate portal hypertension, defined as a portal pressure of over 200 mmH₂O. A multiple logistic regression analysis of these variables revealed two independent variables, being ICGR15 and the platelet count. Thus, we consider that our equation for estimating portal pressure is potentially useful, and that the platelet count and ICGR15 are the most significant parameters in discriminating between the presence or absence of portal hypertension. Moreover, a platelet count of less than 120×10³/mm³ and an ICGR15 value of more than 15% correlated well with portal hypertension.     

Incidence and Management of Leukopenia/Neutropenia in 233 Kidney Transplant Patients Following Single Dose Alemtuzumab Induction

BackgroundThe purpose of this study was to determine the incidence and management strategies for post-transplant leukopenia/neutropenia in kidney recipients receiving alemtuzumab induction during the first year following transplantation.MethodsWe prospectively identified 233 adult patients who underwent kidney transplantation with alemtuzumab induction at a single institution. The incidence and severity of leukopenia (white blood cell count [WBC] ≤2500/mm³) and neutropenia (absolute neutrophil count [ANC] ≤500/mm³) were evaluated at 1, 3, 6, and 12 months post-transplantation. We determined any association with cytomegalovirus (CMV) infection, graft rejection, and infections requiring hospitalization. We also reviewed interventions performed, including medication adjustments, treatment with granulocyte stimulating factor, and hospitalization.ResultsThe combined incidence of either leukopenia or neutropenia was 47.5% (n = 114/233) with an average WBC nadir of 1700 ± 50/mm³ at 131.0 ± 8.5 days and an average ANC nadir of 1500 ± 100/mm³ at 130.4 ± 9.6 days. No significant difference in graft rejection, CMV infection, or infections requiring hospitalization was found in the leukopenia/neutropenia group vs the normal WBC group (P = .3). The most common intervention performed for leukopenia/neutropenia group was prophylactic medication adjustment. Six patients (5.2%) required a change in >1 medication. The majority of these patients also required granulocyte stimulating factor (61.5%; 32/52), with an average of 2.5 doses given. A total of 25 patients (21.9%) required hospitalization due to leukopenia/neutropenia with an average length of stay of 6 days.ConclusionsKidney transplant patients receiving alemtuzumab induction required significant interventions due to leukopenia/neutropenia in the first year post-transplantation. These results suggest the need for additional studies aimed at defining the optimum management strategies of leukopenia/neutropenia in this population.     

Long-term efficacy of partial splenic embolization in children

Purpose: To elucidate the role of partial splenic embolization (PSE) procedures, long-term outcome was assessed in terms of the recurrence of thrombocytopenia.Methods: A retrospective study was performed after 41 PSE procedures in 36 patients for hypersplenism owing to portal hypertension. The underlying disease was biliary atresia in 32 patients, extrahepatic portal obstruction in 3, and idiopathic cirrhosis in 1.Results: The average volume embolized was 70.1%. The patients were followed up from 20 days to 182 months (average, 70.8 months). Five patients subsequently died, and 6 underwent liver transplantation. The causes of death or the reasons for liver transplantation were not related to hypersplenism. Eleven patients (30.6%) had recurrence of thrombocytopenia (<100,000/mm³). There was no significant difference in the volume embolized or platelet count before PSE between the patients with and without recurrence of thrombocytopenia. The peak value of platelet count after PSE was significantly lower in the patients with recurrence of thrombocytopenia (P = .0091). In 17 of 24 survivors without liver transplantation, platelet counts remained normal throughout the follow-up period.Conclusions: PSE is a safe and effective procedure. Hematologic indices improved in all 36 patients after PSE, and its long-term efficacy was shown in 70% of the survivors.     

Surgical Treatment of Massive Splenomegaly and Severe Hypersplenism Secondary to Extrahepatic Portal Venous Obstruction in Children

Purpose Massive splenomegaly with severe hypersplenism can occur as a late complication of portal hypertension (PH) caused by extrahepatic portal venous obstruction (EHPVO) in children. Severe hypersplenism is often refractory to treatment with endoscopic sclerotherapy (EST) and shunt surgery. We report our experience of managing this disorder surgically. Methods We performed splenectomy and esophagogastric devascularization via laparotomy in 14 children with an average age of 9.7 years. Upper gastrointestinal endoscopy had shown esophageal varices of varying grade, and EST had been done for patients with a history of bleeding. The indications for surgery were pain and discomfort caused by a large spleen greater than 15 cm below the costal margin, and intractable symptomatic hypersplenism with a total leukocyte count <2500/mm³ and a platelet count <50 000/mm³, or both. Results Postoperative recovery was uneventful and the leukocyte and platelet counts reverted to normal. After follow-up for 1–5 years, all 14 children were asymptomatic, with improved growth and nutrition and no reported episodes of gastrointestinal bleeding, sepsis, or encephalopathy. Conclusion Splenectomy with devascularization is effective for children with massive splenomegaly and severe hypersplenism secondary to EHPVO.     

Transjugular intrahepatic portosystemic shunt vs. small-diameter prosthetic H-graft portacaval shunt: Extended follow-up of an expanded randomized prospective trial

We report herein the results of extended follow-up of an expanded randomized clinical trial comparing transjugular intrahepatic portosystemic shunt (TIPS) to 8 mm prosthetic H-graft portacaval shunt as definitive treatment for variceal bleeding due to portal hypertension. Beginning in 1993, through this trial, both shunts were undertaken as definitive therapy, never as a “bridge to transplantation.” All patients had bleeding esophageal/gastric varices and failed or could not undergo sclerotherapy/banding. Patients were excluded from randomization if the portal vein was occluded or if survival was hopeless. Failure of shunting was defined as inability to shunt, irreversible shunt occlusion, major variceal rehemorrhage, hepatic transplantation, or death. Median follow-up after each shunt was 4 years; minimum follow-up was 1 year. Patients undergoing placement of either shunt were very similar in terms of age, sex, cause of cirrhosis, Child’s class, and circumstances of shunting. Both shunts provided partial portal decompression, although the portal vein-inferior vena cava pressure gradient was lower after H-graft portacaval shunt (P<0.01). TIPS could not be placed in two patients. Shunt stenosis/occlusion was more frequent after TIPS. After TIPS, 42 patients failed (64%), whereas after H-graft portacaval shunt 23 failed (35%) (P <0.01). Major variceal rehemorrhage, hepatic transplantation, and late death were significantly more frequent after TIPS (P <0.01). Both TIPS and H-graft portacaval shunt achieve partial portal decompression. TIPS requires more interventions and leads to more major rehemorrhage, irreversible occlusion, transplantation, and death. Despite vigilance in monitoring shunt patency, TIPS provides less optimal outcomes than H-graft portacaval shunt for patients with portal hypertension and variceal bleeding. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 21–24, 2000.     

Successful surgical treatment for hepatic encephalopathy caused by a pancreatic siphon: Report of a case

We report herein the case of a 39-year-old man with cirrhosis of the liver who developed hepatic encephalopathy and progressive diabetes caused by a pancreatic siphon after undergoing a distal splenorenal shunt (DSRS) for a variceal hemorrhage.Radiologic occlusion was judged to be inappropriate because of the extensive DSRS. The DSRS was surgically closed 6 years after the operation to restore portal perfusion. To alleviate the portal hypertension, splenectomy and gastric devascularization were performed, which proved successful, as the encephalopathy disappeared completely, the ammonia levels decreased, liver function improved, and the diabetes subsided. Our experience indicates that a small percentage of cirrhotic patients who undergo DSRS with longterm followup may develop various undesirable complications, although some of these patients benefit from a combination of surgical shunt occlusion, splenectomy, and gastric devascularization.     

The distal splenorenal shunt: an update on experience of 106 cases

This paper analyzes experience with 106 patients treated primarily with DSRS during a ten year period. Operative mortality was 5% of cases. Shunt patency was evaluated by postoperative angiography in 70 patients. A shunt thrombosis and a recanalization of the splenic vein were noted in a patient who had a Britton's operation resulting in a side-to-side shunt. In the other 31 cases, shunt patency was indirectly confirmed by the absence of varices at postoperative or long-term endoscopic examination. At postoperative check, esophageal varices had disappeared in only 19% of patients. However, this rose to 60% at long-term check-up. Ten patients bled from varices in the postoperative period (9%). During the follow-up period, no patient bled from varices, while five patients bled from gastroduodenal lesions (5%). During the postoperative period, 52% of cases had ascites. In the long-term, ascites developed in only 15% of cases and was well controlled by standard medical treatment. Analysis of the actuarial curve showed a 5-year survival rate of 63%. During the follow-up period, 17% of patients experienced at least one episode of acute encephalopathy. Chronic encephalopathy appeared in 14% of cases: ten patients suffered a mild form (10%) and four (4%) a moderate form. No patient had severe chronic encephalopathy. DSRS is effective as treatment of portal hypertension with a low long-term morbidity despite a more troublesome early postoperative period.     

Portosystemic shunt for the treatment of portal vein thrombosis following orthotopic liver transplantation

Abstract The efficacy of the portosystemic shunt operation for the treatment of portal vein thrombosis following orthotopic liver transplantation was demonstrated. From 1 July 1988 to 31 December 1991 42 portosystemic shunt operations were performed at our centre. In six of these cases portal vein thrombosis after orthotopic liver transplantation (OLT) was the indication for the procedure. All the patients retained adequate liver function but they demonstrated manifestations of significant portal hypertension, mainly variceal rebleeding. Two of the patients were children. Three patients underwent distal splenorenal shunt (DSRS), one mesocaval and one side-to-ide splenorenal shunt and the last one side-to-ide splenorenal shunt which was converted to DSRS 2 weeks later. All these patients were doing well after 30 months mean follow-up time without rebleeding or other signs of portal hypertension and none had so far required retransplantation.     

Remembering Dr. Jim Gillespie as a world adventurer, master surgeon, and invaluable mentor

Introduction

Polytetrafluoroethylene (PTFE)-covered transjugular intrahepatic portosystemic shunt (TIPS) stents purportedly provide superior patency. This study was undertaken to determine whether covered stents provide better long-term patency and outcomes after TIPSs.

Methods

Patients with portal hypertension undergoing TIPS at a large teaching hospital from 2001 to 2010 were studied. Median data are presented.

Results

Two hundred forty-six patients underwent TIPS; 70 received uncovered stents, and 176 received covered stents. Patients who received uncovered stents had more severely impaired liver function (41% were Child class C cirrhotics). The follow-up was longer with uncovered stents (48 vs 24 months, P < .01). Reinterventions for stenosis were undertaken in 33% with uncovered stents versus 19% with covered stents (P = .01). Shunt dysfunction occurred in 57% with uncovered stents versus 21% covered (P = .05). A deterioration of hepatic function occurred in 31% with uncovered stents versus 30% with covered (P = .32). Survival with uncovered stents was 31 months versus 33 months with covered stents (P = .55, Kaplan-Meier).

Conclusions

Covered stents may improve patency but do not mitigate postshunt hepatic dysfunction and do not improve survival.     

Azathioprine-induced leukopenia—Clinical significance in renal transplantation

A retrospective analysis of 160 consecutive renal transplants was carried out to determine the incidence and clinical significance of azathioprine-induced leukopenia (AIL). AIL was defined as a peripheral white blood cell count (WBC) of ≦5000/mm³ in the post-transplantation period necessitating a reduction in dose of azathioprine by at least 25% in the absence of sepsis or other obvious causes of leukopenia. Correlation of the mean WBC during the first 10 days after transplantation and subsequent azathioprine tolerance was determined. Twenty-five percent of transplant recipients developed AIL. Incidence was not affected by age, sex, or race, but was increased in cadaver kidney recipients. The principal factors that predisposed patients to AIL were poor early renal function and absence of pretransplant splenectomy. AIL may be anticipated in patients who demonstrate poor bone marrow reserve after high-dose steroid stimulation in the early post-transplant period (mean 10 day post-transplant WBC ≦ 10,500/mm³). Overall graft and patient survival was decreased in patients with AIL. Patients with AIL who had not previously undergone splenectomy had the poorest graft survival.     

Recent advances in the management of variceal bleeding

A prospective randomized trial of selective distal splenorenal shunt (DSRS)versus H-graft interposition total shunt at Emory Hospital in 1971 showed DSRS to be superior to a total shunt in shunt patency, prevention of variceal bleeding, preserving hepatic cell function, preserving the quality of life and patient survival. These results were particularly evident in the non-alcoholic patients. In the alcoholic patients, there was a greater loss of hepatic portal perfusion. In a later phase of the study, it was found that pancreatic veins formed a pathway of collaterals to the shunt, that is a socalled pancreatic siphon. In order to prevent loss of portal and pancreatic flow through the siphon, a total spleno-pancreatic disconnection was developed, whereby the hormone diversion is expected to be diminished. This report is the gist of a paper read by W. D. W. at the 85th Annual Meeting of the Japanese Surgical Society, Sendai, Japan, 1985     

Selective distal splenorenal shunt without requiring splenopancreatic disconnection with the use of the external iliac vein graft: a preliminary report.

BACKGROUND: Distal splenorenal shunt (DSRS) with splenopancreatic disconnection (SPD) is an ideal operation for permanent control of variceal bleeding. However, it is a very complicated procedure, and DSRS without SPD has a functional disadvantage: It gradually loses its selectivity and portal blood flow. To overcome these conditions, we designed a new technique--modified DSRS, which is easy to perform and maintains long-term selectivity of the shunt. METHODS: Modified DSRS was performed by using an external iliac vein graft without treating small pancreatic tributaries of the splenic vein. It was applied in 4 cases, and shunt patency and selectivity were examined by angiography during follow-up periods (6-76 months). RESULTS: Modified DSRS was technically more feasible and less complicated than DSRS with SPD. Every attempt was successful. There was no operative mortality, and all the patients were discharged from the hospital in good condition. The shunts were patent in all of them, and the selectivity of the shunt was maintained better in comparison to standard DSRS. CONCLUSIONS: Modified DSRS is a much easier and safer technique than standard DSRS. We consider this procedure to be the best method for surgical management of portal hypertension causing esophageal and gastric varices.     

An evaluation of splenopancreatic disconnection as a modification of the distal splenorenal shunt, studied in nonalcoholic patients by sequential angiography

To evaluate the validity and complications of modifying the distal splenorenal shunt (DSRS) by performing splenopancreatic disconnection (SPD), hemodynamic changes in the portal system were assessed by visceral angiography in 93 patients with nonalcoholic portal hypertension during early postoperative follow-up after DSRS. There were 40 patients who underwent DSRS alone and 53 who underwent DSRS plus SPD. Early follow-up angiography showed that portal vein perfusion was well maintained, and that the diameter of the portal vein had decreased significantly by the same degree in both groups. Hepatofugal collaterals for the shunt had developed to a greater extent in the DSRS group, while they were almost completely absent in the DSRS with SPD group. Nevertheless, partial portal vein thrombosis was not detected in the DSRS group, although it was seen in seven (13.2%) of the patients who underwent DSRS plus SPD, in whom the left proximal splenic vein was not visible. The proximal splenic vein was seen in significantly less of the DSRS with SPD patients (47.2%) than the DSRS group patients (85%). In conclusion, SPD more effectively prevented the early postoperative development of collateral pathways for the shunt compared with standard DSRS; however, the possible stagnation of blood flow in the left proximal splenic vein may predispose to a risk of partial portal vein thrombosis developing during the early postoperative period after DSRS with SPD.     

The changing spectrum of treatment for variceal bleeding.

OBJECTIVE: The objective of this study was to assess the impact of endoscopic therapy, liver transplantation, and transjugular intrahepatic portosystemic shunt (TIPS) on patient selection and outcome of surgical treatment for this complication of portal hypertension, as reflected in a single surgeon's 18-year experience with operations for variceal hemorrhage. SUMMARY BACKGROUND DATA: Definitive treatment of patients who bleed from portal hypertension has been progressively altered during the past 2 decades during which endoscopic therapy, liver transplantation, and TIPS have successively become available as alternative treatment options to operative portosystemic shunts and devascularization procedures. METHODS: Two hundred sixty-three consecutive patients who were surgically treated for portal hypertensive bleeding between 1978 and 1996 were reviewed retrospectively. Four Eras separated by the dates when endoscopic therapy (January 1981), liver transplantation (July 1985), and TIPS (January 1993) became available in our institution were analyzed. Throughout all four Eras, a selective operative approach, using the distal splenorenal shunt (DSRS), nonselective shunts, and esophagogastric devascularization, was taken. The most common indications for nonselective shunts and esophagogastric devascularization were medically intractable ascites and splanchnic venous thrombosis, respectively. Most other patients received a DSRS. RESULTS: The risk status (Child's class) of patients undergoing surgery progressively improved (p = 0.001) throughout the 4 Eras, whereas the need for emergency surgery declined (p = 0.002). The percentage of nonselective shunts performed decreased because better options to manage acute bleeding episodes (sclerotherapy, TIPS) and advanced liver disease complicated by ascites (liver transplantation, TIPS) became available (p = 0.009). In all Eras, the operative mortality rate was directly related to Child's class (A, 2.7%; B, 7.5%; and C, 26.1 %) (p = 0.001). As more good-risk patients underwent operations for variceal bleeding, the incidence of postoperative encephalopathy decreased (p = 0.015), and long-term survival improved (p = 0.012), especially since liver transplantation became available to salvage patients who developed hepatic failure after a prior surgical procedure. There were no differences between Eras with respect to rebleeding or shunt occlusion. Distal splenorenal shunts (p = 0.004) and nonselective shunts (p = 0.001) were more protective against rebleeding than was esophagogastric devascularization. CONCLUSIONS: The sequential introduction of endoscopic therapy, liver transplantation, and TIPS has resulted in better selection and improved results with respect to quality and length of survival for patients treated surgically for variceal bleeding. Despite these innovations, portosystemic shunts and esophagogastric devascularization remain important and effective options for selected patients with bleeding secondary to portal hypertension.     

Pre-Liver Transplant: Tips Versus Distal Splenorenal Shunt

Recurrent variceal bleeding in liver transplant candidates with end-stage liver disease can complicate or even prohibit a subsequent transplant procedure (OLT). Endoscopic sclero-therapy and medical therapy are considered as first-line management with surgical shunts reserved for refractory situations. Surgical shunts can be associated with a high mortality in this population and may complicate subsequent OLT. The transjugular intrahepatic portosystemic shunt (TIPS) has been recommended in these patients as a bridge to OLT. This is a new modality that has not been compared with previously established therapies such as the distal splenorenal shunt (DSRS). In this study we report our experience with 35 liver transplant recipients who had a previous TIPS (18 patients) or DSRS (17 patients) for variceal bleeding. The TIPS group had a significantly larger proportion of critically ill and Child-Pugh C patients. Mean operating time was more prolonged in the DSRS group (P=0.014) but transfusion requirements were similar. Intraoperative portal vein blood flow measurements averaged 2132±725 ml/min in the TIPS group compared with 1120±351ml/min in the DSRS group (P<0.001). Arterial flows were similar. Mean ICU and hospital stays were similar. There were 3 hospital mortalities in the DSRS group and none in the TIPS group (P=0.1). We conclude that TIPS is a valuable tool in the management of recurrent variceal bleeding prior to liver transplantation. Intra0Perative hemodynamic measurements suggest a theoretical advantage with TIPS. In a group of patients with advanced liver disease we report an outcome that is similar to patients treated with DSRS prior to liver transplantation. The role of TIPS in the treatment of nontransplant candidates remains to be clarified.     

Splenic artery ligation and distal splenorenal shunt in schistosomiasis

BACKGROUND: A prospective study was carried out to evaluate the results of distal splenorenal shunt (DSRS) with or without splenic artery ligation (SAL) in patients with schistosomal portal hypertension. MATERIALS AND METHODS: Thirty patients were divided into two groups: 15 were submitted to DSRS (Group I) and the other 15 were submitted to DSRS + SAL (Group II). They were observed for 24 months. Clinical and laboratory features were analyzed. RESULTS: There was neither mortality nor clinical manifestation of portosystemic encephalopathy in both groups. Recurrent hemorrhage and thrombosis incidence had no statistical difference. Although patients in Group II presented higher levels of postoperative pain and fever, spleen size reduction was higher than in Group I. White blood cells and platelets were increased in patients who underwent DSRS + SAL, even though there was no statistically significant difference between the groups. An increase in bilirubin was observed on the first postoperative day. Arterial blood ammonia and liver function were similar in both groups. Endoscopic control showed reduction in size of varices or their disappearance in 80 and 93% of patients from Groups I and II, respectively. CONCLUSIONS: Although SAL associated with DSRS was responsible for increasing postoperative morbidity, it did not increase the incidence of shunt thrombosis and improved white blood cells and platelets count as well as reduced the spleen size. Therefore, the authors believe that SAL associated with DSRS is an effective treatment for schistosomal portal hypertension. Besides, it should be performed when a large spleen and hypersplenism are present.     

Pretransplant CD4 Count Influences Immune Reconstitution and Risk of Infectious Complications in Human Immunodeficiency Virus–Infected Kidney Allograft Recipients

In current practice, human immunodeficiency virus–infected (HIV⁺) candidates with CD4 >200 cells/mm³ are eligible for kidney transplantation; however, the optimal pretransplant CD4 count above this threshold remains to be defined. We evaluated clinical outcomes in patients with baseline CD4 >350 and <350 cells/mm³ among 38 anti–thymocyte globulin (ATG)–treated HIV‐negative to HIV⁺ kidney transplants performed at our center between 2006 and 2013. Median follow‐up was 2.6 years. Rates of acute rejection and patient and graft survival were not different between groups. Occurrence of severe CD4 lymphopenia (<200 cells/mm³), however, was more common among patients with a baseline CD4 count 200–349 cells/mm³ compared with those transplanted at higher counts (75% vs. 30% at 4 weeks [p = 0.04] and 71% vs. 5% at 52 weeks [p = 0.001], respectively, after transplant). After adjusting for age, baseline CD4 count of 200–349 cells/mm³ was an independent predictor of severe CD4 lymphopenia at 4 weeks (relative risk [RR] 2.6; 95% confidence interval [CI] 1.3–5.1) and 52 weeks (RR 14.3; 95% CI 2–100.4) after transplant. Patients with CD4 <200 cells/mm³ at 4 weeks had higher probability of serious infections during first 6 months after transplant (19% vs. 50%; log‐rank p = 0.05). These findings suggest that ATG must be used with caution in HIV⁺ kidney allograft recipients with a pretransplant CD4 count <350 cells/mm³.