Prospective analysis between the therapy of immunosuppressive medication and allogeneic microchimerism after liver transplantation.

After liver transplantation, migration of donor-derived hematopoietic cells to recipient can be detected in peripheral blood. This state is termed microchimerism. The aim of this study was to investigate prospectively the presence of allogeneic microchimerism, the occurrence of acute cellular rejection and the level of immunosuppression in transplanted patients. Microchimerism occurrence between 10 days and 12 months after liver transplantation was analyzed in 47 patients aged between 15 and 65 by a two-stage nested PCR/SSP technique to detect donor MHC HLA-DR gene specifically. A pre-transplant blood sample was collected from each patient to serve as individual negative control. Microchimerism was demonstrated in 32 (68%) of the 47 patients; of these, only 10 patients (31.2%) presented rejection. Early microchimerism was observed in 25 patients (78.12%) and late microchimerism in 7 patients (21.8%). Among the patients with microchimerism, 14 were given CyA and 18 were given FK506. In the group without microchimerism, 12 patients were given CyA and 03 were given FK506. There was a significant association between the presence of microchimerism and the absence of rejection (p=0.02) and also between microchimerism and the type of immunosuppression used. Our data indicate that microchimerism and probably differentiation of donor-derived leukocytes can have relevant immunologic effects both in terms of sensitization of recipient and in terms of immunomodulation toward tolerance induction.

Recurrent hepatitis C treatment with direct acting antivirals - a real life study at a Brazilian liver transplant center.

Recurrent hepatitis C (HCV) after liver transplantation (LT) is an important cause of morbidity and mortality. Antiviral treatment is recommended to avoid unfavorable outcomes. Direct-acting antivirals (DAA) have transformed HCV treatment, with higher efficacy and fewer side-effects than interferon-based therapies traditionally used. To evaluate DAA treatment outcomes at a Brazilian transplant unit, data of patients who finished HCV treatment at the Liver Transplant Unit of the University of Campinas were analyzed. Treatment consisted of sofosbuvir, daclatasvir, and ribavirin, for 12 or 24 weeks, according to the national guidelines. Fifty-five patients completed antiviral treatment and 54 had HCV-viral load results available. The majority of patients were male (78%), 58 years old on average, 65% had hepatocellular carcinoma (HCC) before LT, and 67% were interferon treatment-experienced. Most patients had HCV genotype 1 (65%), 35% had genotype 3, and started treatment on an average of 38 months after LT (range: 2-228). Fifty-eight percent were treated for 12 weeks and 42% for 24 weeks, using a mean dose of ribavirin of 10.1 mg/kg (4.2-16.1). There were no treatment interruptions due to serious side effects. The sustained virological response rate was 98%. Only one patient relapsed, a genotype 3 cirrhotic treated for 12 weeks. The average follow-up after starting antivirals was 20 months. There were no recurrences of HCC, but there was one rejection episode and one cirrhosis decompensation episode, both 12 weeks after treatment. DAA treatment is safe and effective in the post-LT setting and was not associated to HCC recurrence in the cohort studied.

Case Reports and Literature Review About Family Autonomy in the Process of Donation of Organs and Gametes: An Ethical and Legal Analysis.

The recovery or collection of postmortem semen raises relevant ethical and social concerns. In this study we report 2 cases witnessed by the authors in an organ procurement organization in Brazil. The patients had a diagnosis of brain death, were organ donors, and had no consent for the use of postmortem sperm. In Brazil, the diagnosis of brain death has been clearly established since 1997, with the most recent update in 2017, but has not considered the possibility of the collection of sperm or eggs from the donor. A review of the world literature has been carried out, as well as current legislation in different countries, including Brazil, with special interest in the impact on the autonomy of the deceased (informed consent or not), the wife, the generation of the child and their rights, and the ethical role of the physician.

Profile of cadaveric liver donors of the OPO-UNICAMP From 2002 to 2006.

INTRODUCTION: Four decades after the first successful liver transplantation, the organ donation shortage challenges the scientific community to create various new strategies. OBJECTIVES: We sought to analyze the profile of registered cadaveric liver donors for an Organ Procurement Organization (OPO) during the period of 2002 through 2006. METHODS: This retrospective analysis of 122 deceased donors in the OPO-Unicamp corresponded to the period of 2002 through 2006. RESULTS: Men were identified as 57.14% of donors and the overall average age was 32.88 years with 16.53% over 50 years of age. Analyzing the causes of brain death, cerebral trauma (CET) was responsible for 46.22% and cerebral vascular accidents, 33.61%. The percentage of use of vasoactive drugs was 88.43%. Observing the donors' backgrounds, we observed that 11.90% had alcoholism, 1.23% drug addiction and 27.78% infection. We verified cardiac arrest in 9.43%. In accordance with the expanded criteria of donation, 89.26% of donors fulfilled some of the criteria: 73.55%, one criterion; 14.05%, two; 1.65%, three; and no donor fulfilled 4 or 5. CONCLUSION: The donor profile in our unit is a young man with CET and who fulfills at least one expanded donation criterion. Finally, to increase the number of donors, the use of vasoactive drugs (89.26%), cardiopulmonary resuscitation (9.43%), and infection (27.78%) were not considered reasons to discard the liver.

Intraoperative massive transfusion decreases survival after liver transplantation.

Patients undergoing liver transplantation often experience coagulopathy and massive intraoperative blood loss that can lead to morbidity and reduced survival. The aim of this study was to verify the survival rate and discover predictive factors for death among liver transplant patients who received massive intraoperative blood transfusions. This cohort study was based on prospective data collected retrospectively from January 2004 to July 2006. The 232 patients were distributed according to their blood requirements, (namely, more or less than 6 units), including red blood cell saver. The statistical analyses were performed using Student t test, Cox hazard regression, and the Kaplan-Meier method (log-rank test). The massively transfused cohort displayed higher Child-Pugh classifications (10.2 vs 9.6; P = .03); model for end-stage liver disease (MELD) scores (19 vs 17; P = .02); recipient weights (75.4 vs 71 kg; P = .03); as well as warm ischemia times (70.7 vs 56.4 minutes; P < .001) and surgery times (584.6 vs 503.4 minutes; P < .05). The proportional hazard (Cox) regression analysis showed that the risk of death increased 2.1% for each unit of donor sodium and 1.6% for each additional year of donors age over 50. The survival rates at 6, 12, 60, and 120 months for > or = 6 vs <6 U of blood transfusion of 63.8% vs 83.3%; 53.9% vs 76.3%; 40% vs 60%; 34.5% vs 49.2%. In conclusion, we observed that patients receiving over 6 red blood cell units intraoperatively displayed reduced survival. Predictive factors for this risk factor were high donor level of sodium and of age.

Elderly donors for HCV(+) versus non-HCV recipients: patient survival following liver transplantation.

INTRODUCTION: Chronic liver failure due to hepatitis C virus (HCV)-related cirrhosis is the leading indication for liver transplantation. Inferior long-term results have been reported for liver transplantation in HCV(+) patients, especially when marginal donor livers are utilized. AIM: The aim of this study was to analyze retrospectively the outcome of liver transplantation patients from elderly donors in the case of HCV(+) versus non-HCV recipients. METHODS: Among 330 liver transplantations performed from January 1994 to December 2006, we selected 244 excluding acute hepatic failure, children, and retransplants. Among these patients we analyzed 232 subjects who underwent the piggyback technique. Donor risk index (DRI) as described by Feng et al was applied using 1.7 as a cutoff value. We used Kaplan-Meier survival and Cox hazard regression analyses. We studied 14 donor variables using descriptive statistical tests. RESULTS: There were 148 (63.8%) HCV(+) recipients and 84 (36.2%) non-HCV liver transplant recipients. Among HCV(+) recipients, 130/148 (87.8%) patients received livers, from donors less than 50 years old, and 18/148 (12.2%), over 50 years. The descriptive statistics of patient categorical variables are shown in Table 1, and continuous variables in Table 2. The cumulative proportional survival curves are shown in Figs 1 and 2. Mortality predictive factors in HCV(+) liver transplant recipients with donor age > 50 years old as determined by Cox hazard regression showed that death risk was increased with hazard ratios for warm ischemia = 1.01 (P = .001); for red blood cell intraoperative requirements = 2.63 (P = .003); for Child-Turcotte-Pugh classification points = 2.25 (P = .04), and for DRI > 1.7 = 2.19 (P = .03). In conclusion, advancing donor age, as well as the use of nonideal donors, intraoperative bleeding, and prolonged warm ischemia, had an adverse influence on patient survival for HCV(+) recipients.

Expanded Milan criteria on pathological examination after liver transplantation: analysis of preoperative data.

BACKGROUND: We sought to evaluate the accuracy of imaging techniques related to the Milan criteria (MC) compared with the explant histology and the survival of these patients. METHODS: Between 1997 and 2006, we selected 45 cirrhotic patients with hepatocellular carcinoma distributed into two groups according to explant histology: MC and Expanded Milan Criteria (EMC). Age, gender, preoperative imaging (ultrasound [US] and/or computed tomography [CT]), maximal tumor dimension, number of tumors, explanted histology, histology degree, alpha-fetoprotein (AFP) level and vascular invasion were compared among the patients to evaluate the value of these prognostic factors for survival after liver transplantation. RESULTS: By histology 42.2% explants were identified as EMC. The mean AFP level was 204.5 ng/mL. Vascular invasion was detected in 31.5% of explants and 68.4% showed incidental tumors. The survival rates after 10 years were 47.4% whereas MC patients showed 57.77%. The mean AFP level among MC patients was 150.2 ng/mL with vascular invasion detected in 7.7% of explants, and 47.4% with incidental tumors. The overall sensitivity of the imaging techniques was 83.3% for CT and 75% for US. The specificity was 96% for CT and 80.1% for US. CONCLUSION: Scan examinations in the preoperative evaluation underestimated about 42.2% of tumors. Those patients had vascular invasion but the survival after 10 years was similar between the ECM and MC groups.

Ischemia With Preconditioning in Wistar Rats Maintains Mitochondrial Respiration, Even With Mild Hepatocellular Disturbance.

INTRODUCTION: In hepatectomy or liver transplantation, preconditioning is a procedure indicated to protect the organ from ischemia-reperfusion injury (I-R). OBJECTIVE: Evaluate the effect of preconditioning after hepatic I-R in Wistar rats, through mitochondrial respiration, liver histology, and profile. METHOD: Twenty male Wistar rats, weighing on average 307.1 g, were anesthetized with sodium thiopental (25 mg/kg) intravenously and xylazine hydrochloride (30 mg/kg) intramuscularly. The animals were divided into 2 groups: the preconditioning group (PCG), which contained 10 animals, and the hepatic pedicle was isolated and submitted to clamping with microvascular clamp (10 minutes of ischemia and 10 minutes of reperfusion, followed by 30 minutes of ischemia and 30 minutes of reperfusion); and the simulated operation group (SOG), which contained 10 animals submitted to manipulation of the hepatic pedicle and observation for the same length of time, with blood collected for transaminase dosage measurements, and liver biopsy for evaluation of mitochondrial respiration and histologic liver analysis and after sacrificed under anesthesia. The project was approved by the Ethics Committee on Animal Experimentation CEEA/UNICAMP under protocol number 3905-1. RESULT: The PCG mitochondria showed the same respiration level as the SOG, when stimulated with the addition of adenosine diphosphate or carbonyl cyanide p-trifluoromethoxyphenylhydrazone. In the respiratory control ratio and resting of velocity of respiration the groups behaved in a similar way. The PCG presented high aspartate and alanine transaminases (P < .03) and about 60% of sinusoidal congestion and venous congestion in the histologic analysis when compared with SOG. CONCLUSION: We found that ischemia with preconditioning in Wistar rats can lead to mild histologic and biochemical dysfunction without leading to impairment of mitochondrial respiration.

Clinical impact of culture-positive preservation fluid on solid organ transplantation: A systematic review and meta-analysis.

Contamination of the preservation fluid (PF) used for donated organs is a potential source of post-transplant infection. However, the information on this issue is scarce. We therefore conducted a systematic review and meta-analysis to assess the incidence of culture-positive PF and its impact on solid organ transplant (SOT) recipients. Seventeen studies were identified and included. The overall incidence of culture-positive PF was 37% (95% CI: 27% to 49%), and the incidence of PF-related infections among SOT recipients with PF cultures that grew pathogenic microorganisms was 10% (95% CI: 7% to 15%). There were differences in the rates of infections due to pathogenic microorganisms between SOT recipients who received pre-emptive treatment and those who did not, but without statistical significance. The mortality rate among SOT recipients with PF-related infection was 35% (95% CI: 21% to 53%). In conclusion, although contamination of the PF of donated organs is frequent, the incidence of PF-related infection is relatively low. A closely clinical and microbiologic monitoring of the SOT recipient in case of culture-positive PF, regardless of the type of microorganism isolated might be do in order to establish a prompt diagnosis of PF-related infection.

Model for End-Stage Liver Disease Score Before Hepatic Transplantation and Root Mean Square of the Diaphragmatic Domes Affect Postoperative Extubation Time.

INTRODUCTION: The liver transplantation procedure, in addition to its prolonged surgical time, also predisposes to complications such as changes in respiratory mechanics, lung volumes, and gas exchange. OBJECTIVE: This study aims to verify if clinical factors related to the recipient, namely immediate pretransplant Model for End-Stage Liver Disease (MELD) score, surgical time, and root square metric (RMS) of the diaphragmatic domes, affect the extubation time after liver transplantation. METHOD: A prospective study, with a sample collected for convenience, gathered age (years), sex (male or female), MELD score immediately prior to transplantation (without the addition of special situation scores), and surgical time and time for extubation (in minutes). The latter were obtained from the physiotherapy team records, and surface electromyography was performed within 30 minutes after elective extubation, by a single researcher, with supplemental oxygen support, maintaining SpO2 ≥ 95% and following protocol of positioning and acquisition of electromyographic signals based on the study of Oliveira et al (2012). RESULTS: For the 21 patients studied, the RMS of the left dome showed a moderate-intensity correlation (-0.56) with the time of extubation, and linear multiple regression model the left dome (P = .013) and preoperative MELD score (P = .048) showed significant correlation with extubation time. CONCLUSION: The preoperative MELD score and the RMS values of the left dome significantly correlate with the time for patient extubation after liver transplantation, showing the effect of previously acquired muscle weakness and preoperative MELD score on postoperative outcome.

Clinical Profile of Patients With Diabetes Mellitus and Liver Transplantation: Results After a Multidisciplinary Team Intervention.

BACKGROUND: Over the years, survival after liver transplantation has increased and metabolic complications are becoming more common, contributing to patients' morbidity and mortality. The objectives of this study were to describe a population of patients with hepatic transplantation and diabetes mellitus (DM), evaluate the frequency of metabolic complications, and assess the impact of a multidisciplinary team on DM management. MATERIALS AND METHODS: This was a retrospective study involving interview and medical record analysis of 46 consecutive patients followed at the diabetes mellitus and liver transplantation unit of a tertiary university hospital, all evaluated by a multidisciplinary team. RESULTS: Of all patients, 76.1% were men, with a median age 60 years old (interquartile range: 56 to 65 years) and liver transplantation time of 5 years (interquartile range: 0.6-9 years). Hypertension, hypercholesterolemia, hypertriglyceridemia, alcoholism, and smoking were present in 47.8%, 34.8%, 23.9%, 34.8%, and 30.4% of the patients, respectively. The most frequent immunosuppressant in use was tacrolimus (71.1%). Regarding nutritional status, 37.9% of patients were classified as overweight according to body mass index, and 41.2% were considered overweight according to the triceps skin fold. The median glycosylated hemoglobin and weight before and after intervention of the multidisciplinary team in all 46 patients were, respectively, 7.6% (5.7% to 8.8%) versus 6.5% (5.7% to 7.7%); P = .022 and 70.5 kg (64.7 to 82.0 kg) versus 71.6 kg (65.0 to 85.0 kg); P = .18. CONCLUSIONS: Hypertension and dyslipidemia were common in transplanted patients with DM. Intervention of the multidisciplinary team resulted in a significant improvement in glycosylated hemoglobin without significant weight gain.

Frequency of Thyroid Dysfunction in Patients With Diabetes Mellitus Before and After Liver Transplantation.

BACKGROUND: There is mutual influence between the liver and thyroid hormone metabolism. Patients with diabetes mellitus (DM) also have an increased prevalence of thyroid disorders (TDs). The objectives of this study were to evaluate the frequency of TD before and after liver transplantation (LT) in a population of patients with DM as a whole and when categorized by sex. MATERIALS AND METHODS: This was a retrospective study involving interview and medical record analysis of 46 consecutive patients followed at the diabetes mellitus and liver transplantation unit of a tertiary university hospital. RESULTS: Of all patients, 76.1% were men with a median age of 60 years old (interquartile range: 56 to 65 years) and time since LT of 5 years (range, 0.6 to 9 years). Hypertension, hypercholesterolemia, hypertriglyceridemia, alcoholism, and smoking were present in 47.8%, 34.8%, 23.9%, 34.8%, and 30.4% of the patients, respectively. The most frequent immunosuppressant in use was tacrolimus (71.1%). TD was present in 4.3% and 13% before and after LT, respectively (P = .058). In women and men, these frequencies were 9.1% and 18.2% (P = .563), and 2.9% and 11.8% (P = .045), respectively. CONCLUSIONS: Frequency of TD was high both before and after LT. After transplantation, prevalence of TD increased in men and differences between males and females almost disappeared. Further studies are needed to assess if screening for TD before and after LT in patients with DM might be beneficial, especially in men.

Survival analysis of obese patients undergoing liver transplantation.

INTRODUCTION: The influence of preoperative obesity in liver transplanted patients remains undetermined. OBJECTIVE: To analyze the survival of obese patients undergoing liver transplantation. METHODS: We calculated the body mass index (BMI; kg/m2) of 244 liver transplantation patients. All transplantations were performed from September 1991 to December 2006. The patients were divided according to the BMI values: nonobese (NO) patients (BMI<30) and obese (O) patients (BMI>30). Pre- and postoperative data were used. The following statistical tests were employed: Student's t test, Kaplan-Meier survival, and Cox-Mantel tests. RESULTS: Group O was composed of 38 individuals (15.3%) with BMI of 33.1, and the BMI of NO was 24. Group O showed an average age of 50.1 years and group NO, 45.5 years (P<.05). Group O postoperative creatinine was higher (P=.001). Both groups had similar MELD scores with an average of 17.5+/-5.9. According to the Child-Pugh classification, group NO included 140 (69.6%) B and 61 (30.3%) C patients; group O, 8 (21%) B and 30 (79%) C patients. There were no significant differences between the groups when comparing cold and warm ischemia times, surgical times, intensive care stay, or blood requirements. The actuarial survivals after 1 and 5 years were 61.3% and 51% for group O and 68% and 47% for NO group (P>.05). A Cox proportional hazard analysis showed that the survival time in this study was related to red blood cell transfusions, recipient sodium, MELD score, donor sodium, and age. Recipient age was a main factor in multiple regression analysis for obese patients in this study. CONCLUSION: There was no significant difference between O and NO for the 1-year and long-term survivals, but older patients displayed lower survival times.

Hepatic Artery Thrombosis After Liver Transplantation: Five-Year Experience at the State University of Campinas.

BACKGROUND: Hepatic artery thrombosis (HAT) is reported in 4%-15% of orthotopic liver transplants. Risk factors include technical error in the anastomosis, vascular anatomic variation, and high microvascular resistance. The aim of this study was to verify the incidence of HAT, early or late, and possible risk factors. METHODS: This was a retrospective study from January 2007 to December 2012 at the State University of Campinas. Variables analyzed were age, sex, cold and warm ischemia times, underlying disease, presence of hepatocellular carcinoma, Model for End-Stage Liver Disease (MELD) score, arterial anatomic variation in the graft, cytomegalovirus (CMV) infection, rejection, biliary complications, retransplantation rate, and survival. RESULTS: The incidence of HAT was 21/263, or 7.9%. Pure average MELD score was 22 ± 7.4. There was vascular anatomic variation in the graft in 14.2% of cases, in the majority (66.6%) a right hepatic artery from the superior mesenteric artery, and 4.76% of patients had CMV infection and acute cellular rejection (1 case each). There were biliary complications in 38% of patients, 13.3% of cases in patients with early HAT, and 100% of patients with late HAT (P = .002). Body mass index in late HAT was higher (P = .01). CONCLUSIONS: Late HAT was related to a significant increase in biliary complications (stenosis), and the survival rate was similar at 5 years.

Later Evaluation of Ischemia and Reperfusion by the Pringle Maneuver in Wistar Rats, Demonstrating That Hepatic Lesions Can Be Reversible.

OBJECTIVE: There has been much research on hepatic ischemia and reperfusion by means of short or longer interruption of the portal triad. The aim of this work was to evaluate the mitochondrial respiratory activity and liver histology at 2 different times after the Pringle maneuver. METHODS: Twenty-eight male Wistar rats, weighing ∼308 g, with histologic and mitochondrial study: immediate ischemic group (IIG; 40 minutes; 9 animals) and late ischemic group (LIG; 28 days; 9 animals). The rats were anesthetized and underwent a U-incision in the abdomen. In a simulated operation, manipulation of the hepatic pedicle was performed (5 animals immediate [ISG] and 5 late [LSG]). The hepatic pedicle was clamped for 20 minutes of ischemia foloowed by 20 minutes of reperfusion. The animals were killed under anesthesia. RESULTS: Mitochondria when stimulated by adenosine diphosphate or carbonylcyanide p-trifluoromethoxyphenylhydrazone had a significant respiratory reduction (P < .001). The respiratory control ratio in the LIG was altered (P < .02) compared with IIG. In the resting state, there was no change in the velocity of respiration between ischemic groups. Histopathologic findings showed 55.5% sinusoidal dilatation in IIG and 66.6% in LIG; 77.7% ballooning in IIG and 55.5% in LIG; and 11.1% focal necrosis in both IIG and LIG. CONCLUSIONS: The oxidative phosphorylation system recovered with improvement in mitochondrial respiration; however, morphologic recovery was associated with the type and intensity of injury.

Survival benefits of interferon-based therapy in patients with recurrent hepatitis C after orthotopic liver transplantation.

Recurrent hepatitis C after orthotopic liver transplantation (OLT) is universal and can lead to graft failure and, consequently, reduced survival. Hepatitis C treatment can be used to prevent these detrimental outcomes. The aim of this study was to describe rates of hepatitis C recurrence and sustained virological response (SVR) to interferon-based treatment after OLT and its relationship to survival and progression of liver disease through retrospective analysis of medical records of 127 patients who underwent OLT due to cirrhosis or hepatocellular carcinoma secondary to chronic hepatitis C between January 2002 and December 2013. Fifty-six patients were diagnosed with recurrent disease, 42 started interferon-based therapy and 37 completed treatment. Demographic, treatment- and outcome-related variables were compared between SVR and non-responders (non-SVR). There was an overall 54.1% SVR rate with interferon-based therapies. SVR was associated with longer follow-up after treatment (median 66.5 vs 37 months for non-SVR, P=0.03) and after OLT (median 105 vs 72 months, P=0.074), and lower rates of disease progression (15 vs 64.7%, P=0.0028) and death (5 vs 35.3%, P=0.033). Regardless of the result of therapy (SVR or non-SVR), there was a significant difference between treated and untreated patients regarding the occurrence of death (P<0.001) and months of survival (P<0.001). Even with suboptimal interferon-based therapies (compared to the new direct-acting antivirals) there is a 54.1% SVR rate to treatment. SVR is associated with improved survival and reduced risks of clinical decompensation, loss of the liver graft and death.

Association Safety of Liver Preservation Solutions at the State University of Campinas From 2010 to 2014.

The probable reason for mixing solutions during the harvesting procedure is due to the presence of multiple transplant teams that have their own solution usage tradition. Despite numerous studies comparing the efficacy of different preservation solutions, there is no study addressing the associating solution and if there is any impact on liver graft and patient survival. The aim was to evaluate the effect of the association of preservation solutions during the harvesting procedure on liver transplantation outcomes, especially in relation to the degree of preservation injury in the postreperfusion period and patient survival. We analyzed 206 transplants that were distributed as follows: when there was association (89/206 = 43.2%) and when there was no association (117/206 = 56.8%). There was a statistically significant difference in relation to the degree of preservation injury correlated to cold ischemia time (P = .009, odds ratio 1.992; 95% confidence interval 1.185-3.347). Severe harvesting (grades III and IV) was 71.8% when the solution was not associated (P = .008). There was no difference regarding patient survival either. We found that the association of liver preservation solutions has no impact on patient survival, so it can be done safely. The best survival rate was associated with minimal harvesting.

Diaphragm Muscle Surface Electromyography in Patients Submitted to Liver Transplant and Eligible for Extubation.

INTRODUCTION: Liver disease induces many organic and metabolic changes, leading to malnutrition and weight and muscular function loss. Surface electromyography is an easily applicable, noninvasive study, through which the magnitudes of the peaks on the charts depict voluntary muscle activity. AIM: To evaluate the diaphragmatic surface electromyography of postoperative liver transplantation subjects. METHODS: Subjects were patients who underwent liver transplantation and extubation in the Clinical Hospital of State University of Campinas. Electromyography data were collected with support pressure of ≤10 cm H2O, Glasgow Coma Scale = 11, and minimum dosages of vasoactive drugs, and data were collected again 30 minutes after extubation. Signal collection was performed with sEMG System Brazil SAS1000V3 electromyograph and electrode stickers. Statistical analysis was performed using R software. RESULTS: The average time of surgery was 345.36 ± 125.62 minutes. Time from spontaneous mode until extubation was 417.14 ± 362.97 minutes. The RMS (root mean square) values of the right and left domes in spontaneous mode with minimal ventilation parameters were 26.68 ± 10.92 and 26.55 ± 10.53, respectively, and the RMS values after extubation were 31.93 ± 18.69 to 34.62 ± 13.55, for right and left domes. The last calculated pretransplant Model for End-stage Liver Disease score averaged 19.64 ± 8.41. CONCLUSION: There were significant differences between the RMS of the diaphragm domes under mechanical ventilation and after extubation, showing lower effectiveness of the diaphragm muscle against resistance, without the aid of positive pressure and the existing overload of the left dome.

Immunomodulation, Acute Renal Failure, and Complications of Basiliximab Use After Liver Transplantation: Analysis of 114 Patients and Literature Review.

Basiliximab is considered to be effective in preventing cellular rejection (CR) in solid organ transplantation and is commonly used for renal transplants. The aim of this study was describe the population of patients undergoing orthotopic liver transplantation (LT) receiving basiliximab in the period 2012-2016 in the liver transplant service at the State University of Campinas, São Paulo, Brazil. We analyzed 114 patients who underwent LT and received basiliximab; 83 (72.8%) were male and 31 (27.2%) female, with an overall mean age of 54.3 years. Immunosuppression was performed with corticosteroids during anesthetic induction, and postoperatively with tacrolimus in 85.5%, sodium mycophenolate in 81.7%, cyclosporine in 12.7%, and everolimus in 15.5% of patients. CR was observed in 25.43% of patients, confirmed by biopsy in 15 patients: 50% acute CR, 21.42% late acute CR, and 28.57% chronic CR. Thus, the data are consistent with the literature regarding the benefit of using basiliximab as induction therapy while reducing the incidence of CR after LT, but on univariate analysis to evaluate factors associated with the occurrence of CR, the analyzed variables did not present statistical significance. There was acute renal failure (ARF) in 46.84% of patients and hemodialysis was performed in 20% of cases. In a previous series in our service, there was an ARF rate of 50%, so the incidence reduction of ARF after basiliximab use was 3.16%. Moreover, there was 6.95% hepatic artery thrombosis, 2.6% portal vein thrombosis, 2.6% biliary fistulas, 17.4% pneumonia, and 3.4% sepsis, which did not differ from the literature or from our earlier study without the use of basiliximab, suggesting the safety of this medication. In conclusion, in this series, basiliximab influenced the decrease of the CR incidence with no proven benefit on improvement in the ARF.

Immunoexpression of Heat Shock Protein 70, Glypican 3, Glutamine Synthetase, and Beta-Catenin in Hepatocellular Carcinoma After Liver Transplantation: Association Between Positive Glypican 3 and Beta-Catenin With the Presence of Larger Nodules.

BACKGROUND: Hepatocellular carcinoma (HCC) is the 6th leading cause of cancer worldwide. Its recurrence ranges from 6% to 26%. In the literature, many factors are associated with higher risk of recurrence, without a clear definition of the best method that could predict this highly lethal event. OBJECTIVE: The aim of this study was to evaluate the immunoexpression of immunohistochemical markers: HSP70, glypican 3, glutamine synthetase, and beta-catenin, as well as studying their association with tumor characteristics and prognosis of patients undergoing liver transplantation for HCC. METHODS: We studied 90 patients who underwent liver transplantation from 1998 to 2012. Afterwards we evaluated factors related to survival, tumor recurrence, and the correlation of expression of the immunohistochemical markers. RESULTS: Immunohistochemical marker glutamine synthetase showed a positive trend toward better survival. HSP70-positive patients had a higher prevalence of histologic grade III. Patients with positive glypican 3 showed larger lesions and a higher number with AFP >200 ng/mL. Patients with positive beta-catenin showed larger nodules and more with histologic grade III. The association between beta-catenin and glypican 3 showed positive association with larger nodules. CONCLUSIONS: Most of the markers studied had a correlation with at least one of the variables studied, confirming our hypothesis that these markers can indeed assist in assessing the prognosis of patients undergoing liver transplantation for HCC.