Burnett Kelly

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A pig model of venous neoinitimal hyperplasia in polytetrafluoroethylene dialysis grafts 1 1The Society of Black Academic Surgeons expresses its appreciation to Dr. Walter Pories and the editorial staff of Current Surgery for their interest in the Society and the publication of these abstracts

Current Surgery, Sep 1, 1999

Purpose: Vascular access dysfunction is a major cause of morbidity and hospitalization in the hem... more Purpose: Vascular access dysfunction is a major cause of morbidity and hospitalization in the hemodialysis population. In the United States, $1 billion per year is spent managing the vascular complications of hemodialysis. Venous neointimal hyperplasia (VNH), with subsequent venous stenosis and thrombosis at the graft-vein anastomosis, constitutes 75% of failed polytetrafluoroethylene vascular grafts. To understand both the pathogenesis and potential

Continuous Improvement in Solid Organ Transplantation in Infants and Children

Springer eBooks, 2017

Wiskott-Aldrich syndrome: life-threatening haemorrhage from aneurysms within the liver, small bowel mesentery and kidney, requiring both surgical and radiological intervention

PubMed, Oct 1, 2000

Wiskott-Aldrich syndrome (WAS) is a rare, generally X-linked recessive condition, originally desc... more Wiskott-Aldrich syndrome (WAS) is a rare, generally X-linked recessive condition, originally described by Wiskott in 1937 as a triad of discharging ears, eczema and thrombocytopoenia. Aldrich included bloody diarrhoea in his report of 1954, with severe immunodeficiency and predisposition to malignancy being recognised subsequently. The incidence currently quoted is approximately 4 per million live male births, although there is some regional variation. We report the case of a long-term survivor who had massive haemorrhage from an intrahepatic aneurysm and, on a separate occasion, the right kidney.

Hemodialysis vascular access dysfunction: from clinical stenosis to specific cell types

PubMed, May 28, 2003

Hemodialysis vascular access dysfunction is a major cause of morbidity and hospitalization in the... more Hemodialysis vascular access dysfunction is a major cause of morbidity and hospitalization in the hemodialysis population at a cost of over USD 1 billion per annum. Most hemodialysis grafts fail due to a venous stenosis (venous neointimal hyperplasia) which then results in thrombosis of the graft. Despite the magnitude of the clinical problem there are currently no effective therapies for this condition. The current review (a) describes the pathogenesis and pathology of venous stenosis in dialysis access grafts and (b) discusses the development and application of novel therapeutic interventions for this difficult clinical problem. Special emphasis is laid on the fact that PTFE dialysis access grafts could be the ideal clinical model for testing out novel local therapies to block neointimal hyperplasia.

A single center experience with extrahepatic cholangiocarcinomas

Surgery, Oct 1, 2001

Few large Western series on cholangiocarcinoma have been reported in the literature. We reviewed ... more Few large Western series on cholangiocarcinoma have been reported in the literature. We reviewed 40 consecutive cases of extrahepatic cholangiocarcinomas referred to a single center. From 1992 until 2000, 40 patients with extrahepatic cholangiocarcinomas were evaluated. The charts of all patients were reviewed to evaluate predictors of survival. Survival was calculated with the Kaplan-Meier method. Forty patients were referred for management of extrahepatic cholangiocarcinomas. Tumors were located in the distal common duct in 3 (7.5%), mid duct in 5 (12.5%), and at the bifurcation in 32 (80%). Surgical resection was attempted in 32 (80%) patients and was curative in 9 (22.5%), palliative in 11 (27.5%), and diagnostic in 12 (30%). Mean survival for all patients was 21.1 +/- 5.1 months and on the basis of tumor stage was 71.4 +/- 15.4, 39.7 +/- 10.6, 19.2 +/- 2.9, 3.9 +/- 1.8, and 6.9 +/- 1.3 months for stages I, II, III, IVA, and IVB, respectively. Mean survival was 51.1 +/- 13.5 months versus 10 +/- 1.8 months in those with curative and noncurative resections, respectively. The presence of a portal mass was associated with a reduction in mean survival from 28.4 +/- 7.2 months to 6.0 +/- 1.9 months. Extrahepatic cholangiocarcinoma remains a dismal disease with only a 22.5% chance of a curative surgical resection, achieving a 5-year survival rate of 44.4%. Only the absence of a portal mass was predictive of a possible curative resection and long-term survival.

Cholangiocarcinoma

Blackwell Publishing Ltd eBooks, Jan 14, 2009

Traumatic Pneumatosis Cystoides Intestinalis with Portal Venous Air Embolism

Journal of Trauma-injury Infection and Critical Care, 1997

Wolters Kluwer Health may email you for journal alerts and information, but is committed to maint... more Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. ... Skip Navigation Links Home &gt; January ...

Ciliated hepatic foregut cysts in children

Pediatric Surgery International, Sep 16, 2009

Ciliated hepatic foregut cyst (CHFC) is a rare foregut developmental malformation usually diagnos... more Ciliated hepatic foregut cyst (CHFC) is a rare foregut developmental malformation usually diagnosed in adulthood; however, rare cases have been reported in the pediatric population. CHFC can transform into a squamous cell carcinoma resulting in death despite surgical resection of the isolated malignancy. We report the presentation, evaluation, and surgical management of a symptomatic 17-year-old girl found to have a 6.5 × 4.5 centimeter CHFC and suggest that all patients with suspected CHFC undergo prompt evaluation and complete cyst excision.

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External beam radiation attenuates venous neointimal hyperplasia in a pig model of arteriovenous polytetrafluoroethylene (PTFE) graft stenosis

International Journal of Radiation Oncology Biology Physics, Sep 1, 2002

Purpose: Hemodialysis vascular access dysfunction is an enormous clinical problem that causes gre... more Purpose: Hemodialysis vascular access dysfunction is an enormous clinical problem that causes great morbidity and costs well over one billion dollars per annum. The vast majority of hemodialysis vascular access dysfunction occurs as a result of venous stenosis and thrombosis at the graft-vein anastomosis. At a cellular level, this venous stenosis is the result of venous neointimal hyperplasia (VNH). There are, unfortunately, no effective therapies for VNH. The purpose of this study was to assess the role of external radiation therapy in preventing VNH and venous stenosis. Methods and Materials: Seven-centimeter polytetrafluoroethylene loop grafts were placed bilaterally between the femoral artery and vein of 12 Yorkshire Cross pigs. One side was treated with a single 16-Gy dose of external beam radiation with a linear accelerator, while the contralateral side served as an internal control. Swine were killed after 28 days, and the grafts were carefully dissected out and removed. Neointimal hyperplasia and luminal stenosis were then assessed morphometrically at the graft-vessel anastomoses. Results: External beam radiation therapy significantly reduced the amount of luminal stenosis at the graft-vein anastomosis, with minimal local and systemic toxicity. Conclusions: External beam radiation therapy could be a useful and clinically relevant local treatment for venous stenosis in polytetrafluoroethylene dialysis grafts.

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Split Liver Transplantation

Transplantation Proceedings, Mar 1, 2006

Seventy-five thousand Americans develop organ failure each year. Fifteen percent of those on the ... more Seventy-five thousand Americans develop organ failure each year. Fifteen percent of those on the list for transplantation die while waiting. Several possible mechanisms to expand the organ pool are being pursued including the use of extended criteria donors, living donation, and split deceased donor transplants. Cadaveric organ splitting results from improved understanding of the surgical anatomy of the liver derived from Couinaud. Early efforts focused on reduced-liver transplantation (RLT) reported by both Bismuth and Broelsch in the mid-1980s. These techniques were soon modified to create both a left lateral segment graft appropriate for a pediatric recipient and a right trisegment for an appropriately sized adult. Techniques of split liver transplantation (SLT) were also modified to create living donor liver transplantation. Pichlmayr and Bismuth reported successful split liver transplantation in 1989 and Emond reported a larger series of nine split procedures in 1990. Broelsch and Busuttil described a technical modification in which the split was performed in situ at the donor institution with surgical division completed in the heart beating cadaveric donor. In situ splitting reduces cold ischemia, simplifies identification of biliary and vascular structures, and reduces reperfusion hemorrhage. However, in situ splits require specialized skills, prolonged operating room time, and increased logistical coordination at the donor institution. At UCLA over 120 in situ splits have been performed and this technique is the default when an optimal donor is available. Split liver transplantation now accounts for 10% of adult transplantations at UCLA and 40% of pediatric transplantations.

Fulminant Hepatic Failure from Primary Hepatic Lymphoma: Successful Treatment with Orthotopic Liver Transplantation and Chemotherapy

Transplantation, Oct 1, 2005

Systemic lymphomas may involve the liver but rarely cause fulminant hepatic failure (FHF). Acute ... more Systemic lymphomas may involve the liver but rarely cause fulminant hepatic failure (FHF). Acute liver failure from primary hepatic lymphoma (PHL) is even less common with most patients succumbing to the sequelae of FHF before the correct diagnosis is made. We report a patient who underwent successful orthotopic liver transplant (OLT) and chemotherapy for FHF secondary to PHL. This previously-well male developed profound coagulopathy and encephalopathy 6 weeks after the onset of jaundice and fatigue. Workup failed to reveal the underlying cause of his liver failure and the patient soon required urgent OLT. Pathologic evaluation of his explanted liver revealed a malignant T-cell rich, large B-cell non-Hodgkin&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s lymphoma with widespread hepatocellular necrosis. The patient made an excellent clinical recovery and is undergoing CHOP-Rituxan chemotherapy. This scenario demonstrates that lymphoma should be considered in the differential diagnosis of FHF without clear etiology because of the potential for intervention with transplant and chemotherapy.

Aggressive venous neointimal hyperplasia in a pig model of arteriovenous graft stenosis

Kidney International, Dec 1, 2002

Aggressive venous neointimal hyperplasia in a pig model of data, it has been estimated that vascu... more Aggressive venous neointimal hyperplasia in a pig model of data, it has been estimated that vascular access dysfuncarteriovenous graft stenosis. tion is responsible for approximately 20% of all hospital-Background. Vascular access dysfunction is the most imporizations in the ESRD population [2] at a total cost of tant cause of morbidity and hospitalization in the hemodialysis approximately 1.7 billion dollars per year [3]. The most population in the United States at a cost of well over one billion common form of vascular access procedure performed dollars per annum. Venous neointimal hyperplasia characterized by stenosis and subsequent thrombosis, is the major cause in chronic hemodialysis patients in the United States is of polytetrafluoroethylene (PTFE) dialysis graft failure. Despite the arteriovenous polytetrafluoroethylene (PTFE) graft, the magnitude of the problem, there are currently no effective which accounts for approximately 70% of all hemodialytherapies for the prevention or treatment of venous neointimal sis access [4]. Unfortunately, the current one-and twohyperplasia in PTFE dialysis grafts. We believe that this is partly due to the lack of a validated large animal model of arteriove-year primary patency rates for arteriovenous PTFE dialnous stenosis that could be used to test out novel interventions. ysis grafts are a dismal 50% and 25%, respectively [4]. Methods. Seven-centimeter PTFE loop grafts were placed Graft thrombosis is the cause of 80% of all vascular access between the femoral artery and vein of domestic pigs. The grafts dysfunction and in over 90% of thrombosed grafts the were removed at 2, 4, 7, 14 and 28 days after surgery and subunderlying pathology is a stenosis due to venous neointijected to a detailed histological and immunohistochemical examination. mal hyperplasia (VNH), either at the venous anastomotic Results. Significant neointimal hyperplasia and venous stesite or in the proximal vein [5]. nosis developed by 28 days at the graft-vein anastomosis. There We and others have previously shown that venous was minimal neointimal hyperplasia at the graft-artery anastoneointimal hyperplasia (VNH) in the setting of arteriomosis. Venous neointimal hyperplasia (VNH) was characterized by (a) the presence of smooth muscle cells/myofibroblasts; (b) venous hemodialysis grafts is characterized by smooth angiogenesis within both the neointima and adventitia; and (c) muscle cells, neointimal and adventitial microvessels and the presence of an active macrophage cell layer lining the PTFE extracellular matrix components [6-10] However, degraft material. These results are very similar to the human spite a reasonable knowledge of the pathology of VNH, lesion previously described by us in dialysis patients. there are still no effective interventions for either the Conclusions. We have developed and validated a pig model of venous neointimal hyperplasia that is very similar to the prevention or treatment of hemodialysis vascular access human lesion. We believe that this is an ideal model in which dysfunction. This is particularly unfortunate, as VNH in to test out novel interventions for the prevention and treatment the setting of hemodialysis grafts appears to be a far more of clinical hemodialysis vascular access dysfunction. aggressive lesion as compared to the more common arterial neointimal hyperplasia that occurs in peripheral bypass grafts. Compare the 50% one year primary patency Hemodialysis vascular access dysfunction is the single in PTFE dialysis access grafts with an 88% five year patmost important cause of morbidity in the 230,000 hemoency for aortoiliac grafts [11] and a 70 to 80% one year dialysis patients in the United States [1]. Using Medicare patency for femoro-popliteal grafts [12]. Venous stenoses in the setting of dialysis access grafts also have a poorer

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Hemodialysis Vascular Access Dysfunction: From Pathophysiology to Novel Therapies

Blood Purification, 2003

Venous neointimal hyperplasia in polytetrafluoroethylene dialysis grafts

Kidney International, Jun 1, 2001

Venous neointimal hyperplasia in polytetrafluoroethylene dial-Hemodialysis vascular access dysfun... more Venous neointimal hyperplasia in polytetrafluoroethylene dial-Hemodialysis vascular access dysfunction is the single ysis grafts. most important cause of morbidity in the hemodialysis Background. Vascular access dysfunction is the most imporpopulation (currently 200,000 and growing at a rate of tant cause of morbidity and hospitalization in the hemodialysis 7% per annum) [1]. It has been estimated that vascular population in the United States at a cost of $1 billion per access dysfunction is responsible for approximately 20% annum. Venous neointimal hyperplasia (VNH) characterized of all hospitalizations in the end-stage renal disease popby stenosis and subsequent thrombosis accounts for the overulation [2] at a cost of $1 billion per annum. The most whelming majority of pathology resulting in polytetrafluoroethylene (PTFE) dialysis graft failure. Despite the magnitude common form of vascular access procedure performed of the problem and the enormity of the cost ($1 billion), there in chronic hemodialysis patients in the United States is are currently no effective therapies for the prevention or treatthe arteriovenous polytetrafluoroethylene (PTFE) graft, ment of venous neointimal hyperplasia in PTFE dialysis grafts. comprising as much as 83% of all hemodialysis accesses Methods. Tissue samples were collected from the graft-vein [3]. The current one-year primary patency rate for PTFE anastomosis of stenotic PTFE grafts during surgical revision. dialysis grafts is 40 to 50%, with a two-year patency rate Specimens were graded using standard light microscopy and of approximately 25% [4, 5]. Graft thrombosis is the immunohistochemistry for the magnitude of neointimal hypercause of 80% of all vascular access dysfunction, and in plasia and for the expression of specific cell types, cytokines, and matrix proteins. over 90% of thrombosed grafts, the underlying pathology Results. VNH was characterized by the (1) presence of is a stenosis either at the venous anastomotic site or in the smooth muscle cells/myofibroblasts, (2) accumulation of extradownstream (proximal) vein [6]. Despite the enormity of cellular matrix components, (3) angiogenesis within the neothis problem, however, there are currently no effective intima and adventitia, and (4) presence of an active macrointerventions for either the prevention or treatment of phage cell layer lining the PTFE graft material. Platelet-derived venous stenosis in PTFE dialysis grafts [7, 8]. This is growth factor (PDGF), basic fibroblast growth factor (bFGF), probably caused by a lack of knowledge about the pathoand vascular endothelial growth factor (VEGF) were expressed physiology underlying venous stenoses in PTFE grafts, by smooth muscle cells/myofibroblasts within the venous neoespecially at a cellular and molecular level [7]. intima, by macrophages lining both sides of the PTFE graft, and by vessels within the neointima and adventitia. Few studies have attempted to analyze the pathology Conclusions. Our results suggest that macrophages, specific of venous stenosis in PTFE dialysis grafts. Swedberg et al cytokines (bFGF, PDGF, and VEGF), and angiogenesis within demonstrated that smooth muscle cells and extracellular the neointima and adventitia are likely to contribute to the matrix (ECM) proteins are important components of pathogenesis of VNH in PTFE dialysis grafts. Interventions this lesion [9], while Rekhter et al have shown that there aimed at these specific mediators and processes may be successis a significant amount of angiogenesis within these speciful in reducing the very significant human and economic costs mens [10]. of vascular access dysfunction. Recent studies in a variety of experimental arterial models of endothelial and smooth muscle injury have suggested that macrophages, endothelial cells, and smooth

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External Beam Radiation Therapy for PTFE Dialysis Grafts: A Pilot Study

Journal of Vascular Access, Jan 23, 2012

Purpose: The aim of this study was to identify the effects of external beam radiation on PTFE dia... more Purpose: The aim of this study was to identify the effects of external beam radiation on PTFE dialysis graft dysfunction. Methods: Seven patients who underwent PTFE dialysis graft angioplasty were randomized to receive either two 8 Gy doses of external beam radiation or no radiation. The primary endpoint was time to graft thrombosis with a secondary endpoint of time to first intervention. Results: There was no statistically significant difference between the two groups in either of the endpoints, although grafts in the radiation group had a shorter time to thrombosis or intervention. Conclusions: Our results demonstrate technical feasibility for use of external beam radiation in the setting of dialysis vascular access graft dysfunction. Larger randomized studies are required to identify whether there is a clinical benefit from this intervention.

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External beam radiation reduces venous neointimal hyperplasia in PTFE dialysis grafts

Current Surgery, Nov 1, 2000

The selectin-mediated interaction between neutrophils and activated endothelial cells may be crit... more The selectin-mediated interaction between neutrophils and activated endothelial cells may be critical in the development of ischemia/reperfusion injury associated with cardiac surgery. Antineutrophil therapies have been shown to effectively limit ischemia/reperfusion injury, but limit overall immune function. Objective: We examined the effect of localized antibody (Ab) therapy-anti-E-/L-selectin mAb (EL-246)-on neutrophil infiltration into transplanted hearts. Methods: Twelve ovine cervical heterotopic heart transplants were performed. Five minutes prior to allograft reperfusion, the left and right coronary arteries were perfused with EL-246 (treated; n ϭ 6), EL-81 (nonblocking E-selectin control Ab; n ϭ 2), or saline (control; n ϭ 4). After 24 hours of reperfusion, peripheral blood samples were collected for leukocyte (white blood cell) and neutrophil (PMN) quantification, and the animals were sacrificed. Myocardial neutrophils were quantified (PMNs/hpf) with a monoclonal antimyeloperoxidase antibody using computerized image analysis. The Student t test was used for statistical analysis. Results: EL-246 effectively reduced PMN infiltration; the 3.2 Ϯ 0.5 PMNs/ hpf in treated endocardial specimens were significantly less than the 6.5 Ϯ 1.3 PMNs in control endocardium (p ϭ 0.0095). Despite the presumed effects of surgical manipulation, a similar decrease was seen in epicardial specimens: 3.7 Ϯ 0.6 PMNs/hpf (treated) versus 6.8 Ϯ 1.6 PMNs/hpf (control; p ϭ 0.04). Antibody administration did not affect peripheral white blood cells or PMNs. Conclusions: Localized intracoronary treatment is an effective route for immunomodulatory therapy delivery. Intracoronary EL-246 effectively inhibits neutrophil infiltration into cardiac allografts, without decreasing peripheral immune cells. Decreasing myocardial neutrophil infiltration may minimize ischemia/reperfusion injury after cardiac surgery.

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Solutions for Hemodialysis Vascular access Dysfunction: Thinking out of the Box!!

Journal of Vascular Access, 2005

Solutions for hemodialysis vascular access dysfunction: Thinking out of the box!!

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Oral Arginine Improves Blood Pressure in Renal Transplant and Hemodialysis Patients

Journal of Parenteral and Enteral Nutrition, 2001

Hypertension in kidney transplant (KT) patients may result from attenuated whole-body nitric oxid... more Hypertension in kidney transplant (KT) patients may result from attenuated whole-body nitric oxide (NO) content and abnormal NO-mediated vasodilation. Increasing NO bioavailability with L-arginine (ARG) could theoretically restore the NO-mediated vasodilatory response and lower blood pressure. In a prospective pilot study, 6 normotensive volunteers and 10 KT patients received oral supplements of ARG (9.0 g/d) for 9 days, then 18.0 g/d for 9 more days. Six hemodialysis (HD) and 4 peritoneal dialysis patients received the same dose for 14 days. Five KT patients received 30 mL/d of canola oil (CanO) in addition to ARG. Systolic (SBP) and diastolic (DBP) blood pressure, creatinine clearance (CCr), and serum creatinine (Cr) were measured at baseline, day 9, and day 18. In a subsequent study, 20 hypertensive KT patients with stable but abnormal renal function were randomized in a crossover study to start ARG-only or ARG+CanO supplements for two 2-month periods with an intervening month of no supplementation. SBP, DBP, CCr, and Cr were measured monthly for 7 months. In the pilot study, ARG reduced the SBP in HD patients from 171.5 +/- 7.5 mmHg (baseline) to 142.8 +/- 8.3 mmHg (p = .028). In the crossover study, SBP was reduced from baseline (155.9 +/- 5.0 mmHg), after the first 2 months (143.2 +/- 3.2 mmHg; p = .03) and subsequent 2 months (143.3 +/- 2.5 mmHg; p = .014) of supplementation. DBP was also reduced after supplementation in both studies. CanO had no effect on blood pressure. Renal function did not change. Oral preparations of ARG (+/-CanO) were well tolerated for up to 60 consecutive days and had favorable effects on SBP and DBP in hypertensive KT and HD patients.

Time to Abolish Metrics That Sustain Systemic Racism in Kidney Allocation

JAMA, Mar 21, 2023

Inequitiesinhealthcarearemagnifiedinkidneytransplantation because of the gross imbalance between ... more Inequitiesinhealthcarearemagnifiedinkidneytransplantation because of the gross imbalance between the need and supply of donated kidneys. Currently, nearly 90 000 patientshavebeenwait-listedfortransplantintheUS.Black patients are less likely to be referred for transplant, to complete the candidate evaluation, to be wait-listed, and to receive a transplant compared with White patients. Efforts to eliminate structural determinants of racism in the transplantsystemareessentialtominimizethesedisparities.The Kidney Donor Profile Index (KDPI) is a metric used to allocatedeceaseddonorkidneys,whichbydesigndowngrades the perceived quality of kidneys donated by Black donors. This Viewpoint asserts that the KDPI in its current form is not fit to guide kidney allocation because it devalues organ donation by Black donors based on a weak association between donor race and kidney transplant failure. This association is confounded by unmeasured differences in social determinantsofhealthbetweenthemainlyBlackrecipients of Black donor kidneys and the mainly White recipients of non-Black donor kidneys. The KDPI was developed to predict the transplant survivalofdeceaseddonorkidneys. 1 Thecontinuousscorewas basedon10variables,includingdonorrace.Despitelimited predictive performance, the score was incorporated into

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Continuous Improvement in Solid Organ Transplantation in Infants and Children

Solid Organ Transplantation in Infants and Children, 2018

Burnett Kelly

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