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1.
Antimicrob Agents Chemother ; 68(3): e0127923, 2024 Mar 06.
Artículo en Inglés | MEDLINE | ID: mdl-38299818

RESUMEN

Invasive primary Candida surgical site infections (IP-SSIs) are a common complication of liver transplantation, and targeted antifungal prophylaxis is an efficient strategy to limit their occurrence. We performed a retrospective single-center cohort study among adult single liver transplant recipients at Duke University Hospital in the period between 1 January 2015 and 31 December 2020. The study aimed to determine the rate of Candida IP-SSI according to the peri-transplant antifungal prophylaxis received. Of 470 adult single liver transplant recipients, 53 (11.3%) received micafungin prophylaxis, 100 (21.3%) received fluconazole prophylaxis, and 317 (67.4%) did not receive systemic antifungal prophylaxis in the peri-transplant period. Ten Candida IP-SSIs occurred among 5 of 53 (9.4%) micafungin recipients, 1 of 100 (1.0%) fluconazole recipients, and 4 of 317 (1.3%) recipients who did not receive antifungal prophylaxis. Our study highlights the limitations of antifungal prophylaxis in preventing invasive Candida IP-SSI after liver transplant surgery. We hypothesize that pathogen, host, and pharmacokinetic-related factors contributed to the occurrence of Candida IP-SSI despite antifungal prophylaxis. Our study reinforces the need for a risk-based, multi-pronged approach to fungal prevention, including targeted antifungal administration in patients with risks for invasive candidiasis and close monitoring, especially among patients with surgically complex procedures, with timely control of surgical leaks.


Asunto(s)
Candidiasis Invasiva , Candidiasis , Trasplante de Hígado , Adulto , Humanos , Antifúngicos/uso terapéutico , Fluconazol/uso terapéutico , Trasplante de Hígado/efectos adversos , Micafungina/uso terapéutico , Estudios Retrospectivos , Estudios de Cohortes , Infección de la Herida Quirúrgica/prevención & control , Infección de la Herida Quirúrgica/tratamiento farmacológico , Candidiasis Invasiva/tratamiento farmacológico , Candidiasis Invasiva/prevención & control , Candida
2.
Transplant Proc ; 51(3): 665-675, 2019 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-30979449

RESUMEN

BACKGROUND: Live donor kidney transplantation (LDKT) is underutilized by patients with end-stage kidney disease due to knowledge, communication, and logistical barriers. MATERIAL AND METHODS: The Talking About Live Kidney Donation Social Worker Intervention (TALK-SWI) is a previously validated intervention demonstrated to improve patients' access to and pursuit of LDKT through in-person delivery of education and social support. To help overcome logistical barriers to LDKT, we adapted TALK-SWI into a telehealth intervention employing digital (ie, tablet, smartphone) and telephone technologies. We studied the usability and acceptability of both the mobile device and telephone counseling portions of the intervention among people with kidney disease. For the digital portion, we assessed critical (ie, inability to complete a task) and non-critical (ie, ability to complete a task utilizing an alternative method) errors participants encountered when using the program and their preferences regarding digital materials. Simultaneously, we assessed participants' satisfaction with telephone-adapted counseling compared to the original, in-person counseling. RESULTS: The 15 participants testing the digital technology made 25 critical errors and 29 non-critical errors, while they easily completed 156 tasks (out of 210). A majority of participants (73%) preferred the tablet/smart phone education application over traditional materials, and most (80%) indicated they would be more likely to utilize the mobile platform over traditional materials. Participants testing the telephone-adapted (n = 45) and in-person (n = 125) social worker counseling all reported high satisfaction with the intervention. CONCLUSION: We successfully adapted a validated educational and behavioral intervention to improve access to LDKT into a usable and acceptable telehealth intervention.


Asunto(s)
Trasplante de Riñón/educación , Donadores Vivos/educación , Donadores Vivos/provisión & distribución , Educación del Paciente como Asunto/métodos , Telemedicina/métodos , Computadoras de Mano , Consejo/métodos , Femenino , Humanos , Trasplante de Riñón/psicología , Donadores Vivos/psicología , Masculino , Persona de Mediana Edad , Teléfono Inteligente , Telemedicina/instrumentación
3.
Am J Transplant ; 17(12): 3123-3130, 2017 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-28613436

RESUMEN

Incompatible living donor kidney transplantation (ILDKT) has been established as an effective option for end-stage renal disease patients with willing but HLA-incompatible living donors, reducing mortality and improving quality of life. Depending on antibody titer, ILDKT can require highly resource-intensive procedures, including intravenous immunoglobulin, plasma exchange, and/or cell-depleting antibody treatment, as well as protocol biopsies and donor-specific antibody testing. This study sought to compare the cost and Medicare reimbursement, exclusive of organ acquisition payment, for ILDKT (n = 926) with varying antibody titers to matched compatible transplants (n = 2762) performed between 2002 and 2011. Data were assembled from a national cohort study of ILDKT and a unique data set linking hospital cost accounting data and Medicare claims. ILDKT was more expensive than matched compatible transplantation, ranging from 20% higher adjusted costs for positive on Luminex assay but negative flow cytometric crossmatch, 26% higher for positive flow cytometric crossmatch but negative cytotoxic crossmatch, and 39% higher for positive cytotoxic crossmatch (p < 0.0001 for all). ILDKT was associated with longer median length of stay (12.9 vs. 7.8 days), higher Medicare payments ($91 330 vs. $63 782 p < 0.0001), and greater outlier payments. In conclusion, ILDKT increases the cost of and payments for kidney transplantation.


Asunto(s)
Incompatibilidad de Grupos Sanguíneos/economía , Rechazo de Injerto/economía , Prueba de Histocompatibilidad/economía , Fallo Renal Crónico/cirugía , Trasplante de Riñón/economía , Donadores Vivos , Complicaciones Posoperatorias/economía , Estudios de Casos y Controles , Femenino , Estudios de Seguimiento , Tasa de Filtración Glomerular , Rechazo de Injerto/epidemiología , Supervivencia de Injerto , Humanos , Pruebas de Función Renal , Masculino , Persona de Mediana Edad , Pronóstico , Calidad de Vida , Estudios Retrospectivos , Factores de Riesgo
5.
Am J Transplant ; 14(7): 1573-80, 2014 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-24913913

RESUMEN

Incompatible live donor kidney transplantation (ILDKT) offers a survival advantage over dialysis to patients with anti-HLA donor-specific antibody (DSA). Program-specific reports (PSRs) fail to account for ILDKT, placing this practice at regulatory risk. We collected DSA data, categorized as positive Luminex, negative flow crossmatch (PLNF) (n = 185), positive flow, negative cytotoxic crossmatch (PFNC) (n = 536) or positive cytotoxic crossmatch (PCC) (n = 304), from 22 centers. We tested associations between DSA, graft loss and mortality after adjusting for PSR model factors, using 9669 compatible patients as a comparison. PLNF patients had similar graft loss; however, PFNC (adjusted hazard ratio [aHR] = 1.64, 95% confidence interval [CI]: 1.15-2.23, p = 0.007) and PCC (aHR = 5.01, 95% CI: 3.71-6.77, p < 0.001) were associated with increased graft loss in the first year. PLNF patients had similar mortality; however, PFNC (aHR = 2.04; 95% CI: 1.28-3.26; p = 0.003) and PCC (aHR = 4.59; 95% CI: 2.98-7.07; p < 0.001) were associated with increased mortality. We simulated Centers for Medicare & Medicaid Services flagging to examine ILDKT's effect on the risk of being flagged. Compared to equal-quality centers performing no ILDKT, centers performing 5%, 10% or 20% PFNC had a 1.19-, 1.33- and 1.73-fold higher odds of being flagged. Centers performing 5%, 10% or 20% PCC had a 2.22-, 4.09- and 10.72-fold higher odds. Failure to account for ILDKT's increased risk places centers providing this life-saving treatment in jeopardy of regulatory intervention.


Asunto(s)
Anticuerpos/inmunología , Incompatibilidad de Grupos Sanguíneos/epidemiología , Rechazo de Injerto/etiología , Antígenos HLA/inmunología , Trasplante de Riñón/legislación & jurisprudencia , Trasplante de Riñón/estadística & datos numéricos , Donadores Vivos/provisión & distribución , Adulto , Incompatibilidad de Grupos Sanguíneos/diagnóstico , Incompatibilidad de Grupos Sanguíneos/inmunología , Femenino , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Incidencia , Fallo Renal Crónico/mortalidad , Fallo Renal Crónico/cirugía , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pronóstico , Factores de Riesgo , Tasa de Supervivencia
6.
Pediatr Transplant ; 18(2): E57-63, 2014 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-24438382

RESUMEN

The most common identifiable causes of acute liver failure in pediatric patients are infection, drug toxicity, metabolic disease, and autoimmune processes. In many cases, the etiology of acute liver failure cannot be determined. Acute leukemia is an extremely rare cause of acute liver failure, and liver transplantation has traditionally been contraindicated in this setting. We report a case of acute liver failure in a previously healthy 15-yr-old male from pre-B-cell acute lymphoblastic leukemia. He underwent liver transplantation before the diagnosis was established, and has subsequently received chemotherapy for pre-B-cell acute lymphoblastic leukemia. He is currently alive 31 months post-transplantation. The published literature describing acute lymphoblastic leukemia as a cause of acute liver failure is reviewed.


Asunto(s)
Leucemia de Células B/complicaciones , Leucemia de Células B/terapia , Fallo Hepático Agudo/complicaciones , Fallo Hepático Agudo/cirugía , Trasplante de Hígado , Leucemia-Linfoma Linfoblástico de Células Precursoras/complicaciones , Leucemia-Linfoma Linfoblástico de Células Precursoras/terapia , Adolescente , Biopsia , Humanos , Inmunosupresores/uso terapéutico , Hígado/patología , Pruebas de Función Hepática , Masculino , Donantes de Tejidos , Resultado del Tratamiento
7.
Am J Transplant ; 13(3): 808-10, 2013 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-23331705

RESUMEN

Posterior reversible encephalopathy syndrome (PRES) is a small vessel microangiopathy of the cerebral vasculature that occurs in 0.5-5% of solid organ transplant recipients, most commonly associated with tacrolimus (Tac). Clinical manifestations include hypertension and neurologic symptoms. We report an adult multivisceral transplant recipient who experienced recurrent PRES initially associated with Tac and subsequently with sirolimus. A 49-year-old woman with short bowel syndrome underwent multivisceral transplantation due to total parenteral nutrition-related liver disease. She was initially maintained on Tac, mycophenalate mofetil (MMF) and prednisone. Three months after transplantation, she developed renal dysfunction, leading to a reduction in Tac and the addition of sirolimus. Eight months after transplantation, she developed PRES. Tac was discontinued and PRES resolved. Sirolimus was increased to maintain trough levels of 12-15 ng/mL. Fourteen months after transplant, she experienced recurrent PRES which resolved after discontinuing sirolimus. Currently 3 years posttransplant, she is maintained on cyclosporine, MMF and prednisone with no PRES recurrence. In addition to calcineurin inhibitors, sirolimus may also be associated with PRES after solid organ transplantation. Ours is the first report of sirolimus-associated PRES in the setting of multivisceral transplantation. Identifying a safe alternative immunosuppression regimen was challenging but ultimately successful.


Asunto(s)
Rechazo de Injerto/tratamiento farmacológico , Hepatopatías/cirugía , Trasplante de Hígado/efectos adversos , Síndrome de Leucoencefalopatía Posterior/inducido químicamente , Complicaciones Posoperatorias/prevención & control , Sirolimus/efectos adversos , Tacrolimus/efectos adversos , Femenino , Rechazo de Injerto/inducido químicamente , Humanos , Inmunosupresores/efectos adversos , Persona de Mediana Edad , Síndrome de Leucoencefalopatía Posterior/tratamiento farmacológico , Pronóstico , Recurrencia
8.
Am J Transplant ; 12(8): 2242-6, 2012 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-22594310

RESUMEN

Restoring abdominal wall cover and contour in children undergoing bowel and multivisceral transplantation is often challenging due to discrepancy in size between donor and recipient, poor musculature related to birth defects and loss of abdominal wall integrity from multiple surgeries. A recent innovation is the use of vascularized posterior rectus sheath to enable closure of abdomen. We describe the application of this technique in two pediatric multivisceral transplant recipients--one to buttress a lax abdominal wall in a 22-month-old child with megacystis microcolon intestinal hypoperistalsis syndrome and another to accommodate transplanted viscera in a 10-month child with short bowel secondary to gastoschisis and loss of domain. This is the first successful report of this procedure with long-term survival. The procedure has potential application to facilitate difficult abdominal closure in both adults and pediatric liver and multivisceral transplantation.


Asunto(s)
Anomalías Múltiples/cirugía , Seudoobstrucción Intestinal/cirugía , Trasplante de Órganos , Colon/anomalías , Colon/cirugía , Femenino , Humanos , Lactante , Masculino , Trasplante Homólogo , Vejiga Urinaria/anomalías , Vejiga Urinaria/cirugía
11.
Am J Transplant ; 9(9): 1988-2003, 2009 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-19563332

RESUMEN

No official document has been published for primary care physicians regarding the management of liver transplant patients. With no official source of reference, primary care physicians often question their care of these patients. The following guidelines have been approved by the American Society of Transplantation and represent the position of the association. The data presented are based on formal review and analysis of published literature in the field and the clinical experience of the authors. These guidelines address drug interactions and side effects of immunosuppressive agents, allograft dysfunction, renal dysfunction, metabolic disorders, preventive medicine, malignancies, disability and productivity in the workforce, issues specific to pregnancy and sexual function, and pediatric patient concerns. These guidelines are intended to provide a bridge between transplant centers and primary care physicians in the long-term management of the liver transplant patient.


Asunto(s)
Inmunosupresores/uso terapéutico , Trasplante de Hígado/métodos , Cuidados Posoperatorios , Atención Primaria de Salud/métodos , Atención Primaria de Salud/normas , Adulto , Niño , Rechazo de Injerto , Humanos , Terapia de Inmunosupresión , Enfermedades Renales/patología , Enfermedades Renales/terapia , Hepatopatías/patología , Hepatopatías/terapia , Recurrencia , Factores de Tiempo , Resultado del Tratamiento
12.
Am J Transplant ; 6(6): 1422-9, 2006 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-16686766

RESUMEN

Inflammatory bowel disease (IBD) is associated with primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH) and can recur or develop de novo after orthotopic liver transplantation (OLT). The aim of this study was to investigate the incidence and severity of IBD after liver transplantation and to perform a multivariate analysis for possible risk factors. In this retrospective study, 91 patients transplanted for PSC or AIH, without prior colectomy, were included. Sixty patients were transplanted for PSC, 31 for AIH. IBD activity before and after OLT and other possible risk factors were analysed in a multivariate model. Forty-nine patients (54%) had IBD before OLT. Forty patients (44%) had active IBD after transplantation: recurrence in 32 and de novo in 8. Cumulative risk for IBD after OLT was 15, 39 and 54% after 1, 5 and 10 years, respectively. In 59% of patients with IBD prior to OLT the disease was more active after transplantation. Risk factors for recurrent disease were: symptoms at time of OLT, short interval of IBD before OLT and use of tacrolimus. 5-aminosalicylates were protective. A cytomegalovirus positive donor/negative recipient combination increased the risk for de novo IBD.


Asunto(s)
Colangitis Esclerosante/cirugía , Hepatitis Autoinmune/cirugía , Enfermedades Inflamatorias del Intestino/epidemiología , Trasplante de Hígado/efectos adversos , Adulto , Colangitis Esclerosante/complicaciones , Infecciones por Citomegalovirus/epidemiología , Estudios de Seguimiento , Hepatitis Autoinmune/complicaciones , Humanos , Inmunosupresores/efectos adversos , Enfermedades Inflamatorias del Intestino/etiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Donantes de Tejidos
15.
J Pediatr Surg ; 37(2): 151-4, 2002 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-11819189

RESUMEN

BACKGROUND/PURPOSE: The aim of this study was to determine causes of late graft loss and long-term outcome after isolated intestinal transplantation in children at a single center. METHODS: All children who underwent primary isolated intestinal transplantation at our center with a minimum follow-up of 1 year were the subject of this retrospective study. RESULTS: Twenty-eight children underwent primary isolated intestinal transplantation. Median graft survival was 705 days (range, 0 to 2,630 days) and median patient survival was 1,006 days (range, 0 to 2,630 days). There were 6 deaths and 15 graft losses (including the 6 nonsurvivors). Seven of the losses occurred 6 or more months after transplant. Of these, 2 losses occurred because of death of the recipients of sepsis; both recipients had functioning grafts. The 5 remaining late graft losses occurred because of acute rejection in 2 patients, chronic rejection in 2 (1 with concomitant acute rejection) and a diffuse stricturing process without the histologic hallmarks of chronic rejection in the fifth. All late survivors with intact grafts are off total parenteral nutrition (TPN). CONCLUSIONS: Late graft loss remains a concern in a small percentage of patients after isolated intestinal transplantation. Nutritional autonomy from TPN is possible in the majority of these children after transplantation.


Asunto(s)
Rechazo de Injerto , Supervivencia de Injerto , Intestinos/trasplante , Factores de Edad , Niño , Preescolar , Ciclosporina/administración & dosificación , Estudios de Seguimiento , Humanos , Inmunosupresores/administración & dosificación , Lactante , Enfermedades Intestinales/etiología , Enfermedades Intestinales/mortalidad , Enfermedades Intestinales/cirugía , Intestino Delgado/trasplante , Nutrición Parenteral Total/efectos adversos , Estudios Retrospectivos , Tasa de Supervivencia , Tacrolimus/administración & dosificación , Trasplante Homólogo , Resultado del Tratamiento
16.
Transplantation ; 72(11): 1846-8, 2001 Dec 15.
Artículo en Inglés | MEDLINE | ID: mdl-11740401

RESUMEN

The most common application of small bowel transplantation is for the patient with parenteral nutrition-induced liver failure. In this setting, the small intestine is transplanted simultaneously with the liver. We identified three technical problems that we believe contributed to complications in our first eight patients. First, pancreaticoduodenectomy was challenging in the infant donor. Second, the bowel graft was prone to volvulus around the skeletonized donor portal vein. Third, in the pediatric recipient, use of the donor bowel for Roux-en-Y biliary reconstruction was associated with biliary leaks in the early postoperative period. Our surgical technique of liver/small bowel (L/SB) transplantation has evolved since our early experience in 1990. Modifications in the L/SB operation, reported briefly in 1996 and 1997, have led to easier graft preparation and have reduced the incidence of technical complications.


Asunto(s)
Intestino Delgado/trasplante , Trasplante de Hígado/métodos , Humanos , Métodos
17.
Transplantation ; 71(7): 892-5, 2001 Apr 15.
Artículo en Inglés | MEDLINE | ID: mdl-11349722

RESUMEN

BACKGROUND: Lipoatrophic diabetes is an insulin resistance syndrome characterized by the complete or partial lack of adipose tissue and disturbances in lipid and glucose metabolism. Nonalcoholic steatohepatitis (NASH) is a well-described change in liver pathology consisting of steatosis, hepatitis, and fibrosis that can be associated with lipoatrophic diabetes. RESULTS: This article describes the first reported case of lipoatrophic diabetes with NASH leading to liver failure and liver transplantation. Before transplantation, the patient required 600-700 U of insulin/day. After transplantation, a dramatic decline in her insulin requirements was observed, despite corticosteroids. Eighteen months after transplantation, her glycemic control worsened, and she developed recurrent NASH on serial liver biopsies. CONCLUSIONS: NASH associated with lipoatrophic diabetes can recur after liver transplantation, and in this case, was accompanied by increased insulin requirements. These results suggest that the development of NASH itself may contribute to the insulin resistance observed in lipoatrophic diabetes.


Asunto(s)
Diabetes Mellitus Lipoatrófica/etiología , Hígado Graso/complicaciones , Hepatitis/complicaciones , Fallo Hepático/etiología , Fallo Hepático/cirugía , Trasplante de Hígado , Adulto , Diabetes Mellitus Lipoatrófica/fisiopatología , Femenino , Humanos , Resistencia a la Insulina , Hígado/patología , Cirrosis Hepática/etiología , Cirrosis Hepática/patología , Recurrencia
18.
Transplantation ; 71(8): 1058-60, 2001 Apr 27.
Artículo en Inglés | MEDLINE | ID: mdl-11374402

RESUMEN

INTRODUCTION: The enterocyte-specific protein, intestinal fatty acid binding protein (I-FABP), is detectable in serum only after intestinal injury. Previous studies in animals suggest that I-FABP might be a useful marker of intestinal allograft rejection. MATERIALS AND METHODS: I-FABP was repetitively measured in nine intestinal transplant recipients and correlated with findings of surveillance endoscopy. RESULTS: Average interval between I-FABP determination and biopsy was 3.4 days (SD=4.2 days). Average number of rejection episodes per patient totalled 1.6+/-1.2. General linear modeling demonstrated no tendency for increases in serum FABP to precede histologic graft rejection (P=0.263). Restriction of the analysis to I-FABP determinations 1 day before or on the day of biopsy failed to affect these results. Minor increases in I-FABP were often associated with histologically normal grafts, whereas rejection often occurred when I-FABP was not detectable. DISCUSSION: Serum I-FABP levels do not predict clinical intestinal allograft rejection.


Asunto(s)
Proteínas Portadoras/sangre , Rechazo de Injerto/diagnóstico , Intestinos/trasplante , Proteínas de Neoplasias , Trasplante Homólogo/fisiología , Proteínas Supresoras de Tumor , Adulto , Biomarcadores/sangre , Biomarcadores/orina , Proteínas Portadoras/orina , Niño , Preescolar , Proteína de Unión a los Ácidos Grasos 7 , Proteínas de Unión a Ácidos Grasos , Ácidos Grasos/metabolismo , Rechazo de Injerto/sangre , Rechazo de Injerto/patología , Humanos , Intestinos/patología , Monitoreo Fisiológico/métodos , Reproducibilidad de los Resultados , Trasplante Homólogo/patología
19.
Transplantation ; 70(10): 1472-8, 2000 Nov 27.
Artículo en Inglés | MEDLINE | ID: mdl-11118093

RESUMEN

BACKGROUND: Patients with fulminant hepatic failure (FHF) often die awaiting liver transplantation. Extracorporeal liver perfusion (ECLP) has been proposed as a method of "bridging" such patients to transplantation. We report the largest experience to date of ECLP using human and porcine livers in patients with acute liver failure. METHODS: Patients with FHF unlikely to survive without liver transplantation were identified. ECLP was performed with human or porcine livers. Patients underwent continuous perfusion until liver transplantation or withdrawal of support. Two perfusion circuits were used: direct perfusion of patient blood through the extracorporeal liver and indirect perfusion with a plasma filter between the patient and the liver. FINDINGS: Fourteen patients were treated with 16 livers in 18 perfusion circuits. Nine patients were successfully "bridged" to transplantation. ECLP stabilized intracranial pressure (ICP) and cerebral perfusion pressure (CPP). Arterial ammonia levels fell from a median of 146 to 83 micromol/liter within 12 hr and this reduction was maintained at least 48 hr. Pig and human ECLP lowered ammonia levels equally. Serum bilirubin levels also fell from a median of 385 to 198 micromol/liter over the first 12 hr but the response was not sustained as well with porcine livers. There was no immunological benefit to using the the filtered perfusion circuit. INTERPRETATION: These data demonstrate that ECLP is safe and can provide metabolic support for comatose patients with fulminant hepatic failure for up to 5 days. While labor and resource intensive, this technology is available to centers caring for patients with acute liver failure and deserves wider evaluation and application.


Asunto(s)
Circulación Extracorporea/métodos , Fallo Hepático Agudo/cirugía , Trasplante de Hígado , Perfusión/métodos , Adolescente , Adulto , Amoníaco/sangre , Animales , Anticuerpos Antiidiotipos/metabolismo , Biopsia , Niño , Endotelio Vascular/metabolismo , Encefalopatía Hepática/cirugía , Humanos , Hígado/patología , Trasplante de Hígado/mortalidad , Trasplante de Hígado/patología , Tasa de Supervivencia , Porcinos , Trasplante Heterólogo
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