Management of liver transplantation waiting list for decompensated cirrhosis in a Spanish tertiary hospital: differences between hepatitis C virus recipients and other etiologies.

BACKGROUND: Decompensated cirrhosis due to hepatitis C virus (HCV) is one of the main indications for liver transplantation (LT) in Spain. Recurrence of HCV after LT is the main cause of graft loss and death in HCV-positive recipients. Advanced donor age determines a more aggressive recurrence of HCV and a shorter survival. In this setting, in our liver unit, grafts from younger donors are allocated to HCV-positive recipients. The aim of this study was a comparative analysis of allocation of grafts in HCV-positive recipients versus other etiologies and the impact on waiting list time, Model for End-Stage Liver Disease (MELD) score progression until LT, need of admission in a hospital, survival until LT. METHODS: This was a retrospective study from the cohort of patients included in the waiting list for LT owing to decompensated cirrhosis in the Hospital Gregorio Marañón from January 2008 to June 2013. RESULTS: A total of 91 patients were included; 63 patients (69.23%) received LT; 19 (20.88%) retired from the waiting list: 6 because of improvement, 11 (12.08%) because of death. In both groups, the age of recipients was similar (HCV 52 y vs other 53 y; P = .549). HCV patients were included in the waiting list with lower MELD score than other etiologies (HCV 16.1 vs other 19.4; P = .010); nevertheless, MELD score was similar at the time of LT in both groups (HCV 18.9 vs other 19.4; P = .675). Time on waiting list was significantly longer in HCV patients (198 d vs 86 d; P = .002) and they were admitted in hospital more days (30 d vs 12 d; P = .03). Donor age in the HCV group was significantly lower (64.3 y vs 54.7 y; P = .006). The intention-to-treat survival analysis did not show differences between the groups (log rank = 0.504). CONCLUSIONS: HCV patients with decompensated cirrhosis receive grafts from younger donors. HCV patients remain waiting longer for an optimal organ and suffer MELD deterioration and more days admitted in hospital. These differences in allocation of grafts did not affect final survival. In our experience, designating younger organs to HCV-positive patients does not penalize neither HCV recipients nor recipients with other etiologies.

[Expert recommendations for the diagnosis and treatment of chronic hepatitis C infection in the prison setting]. / Recomendaciones de expertos sobre el diagnóstico y tratamiento de la hepatitis C crónica en el medio penitenciario.

The prevalence of HCV infection in Spanish prisons is very high (38.5%). The characteristics of the infected patients, particularly the high rate of HIV coinfection, makes it very likely that the morbidity and mortality produced by serious liver disease secondary to this infection will increase considerably in the coming years. A group of Spanish experts with experience in patients who are inmates has been invited to establish a series of recommendations for the diagnosis and treatment of chronic hepatitis C infection in Spanish prisons.

Tumoral response factors after radiofrequency ablation of hepatocellular carcinoma in cirrhotic liver.

OBJECTIVE: Hepatocellular carcinoma (HCC) ablation by radiofrequency (RFA) is a novel technique with a great variety of methods whose efficacy and predictive factors have not been completely studied. Some of the main predictive factors in this type of treatment are analyzed in the present study. PATIENTS AND METHODS: Ninety-three patients with hepatocellular carcinoma over cirrhosis, and with no indication for surgical resection were treated by RFA. Two different types of electrodes were used for RFA (refrigerated-"Cool-Tip" and perfusion with saline solution, the approach was percutaneous, by laparoscopy or laparotomy. RESULTS: Overall survival at 1, 2 and 3 years was 88, 81, and 76%, with a free-disease survival (FDS) of 66, 31 and 17%, respectively. For tumors less than 3 cm, FDS at 1,2 and 3 years was 74, 44 and 30%, while for more than 3 cm in size FDS was 55, 12 and 0% (p = 0.02). FDS for HCC with one nodule was 70, 36 and 22%, and for more than one nodule it decreased to 50, 17 and 0% at 1, 2 and 3 years, respectively (p = 0.07). Surprisingly, the method employed for RFA has a main influence in FDS, with 0% at 3 years for perfusion electrodes and 26% for cool-tip electrodes at the same period. CONCLUSIONS: In this series, overall survival at three years was relatively high; however, tumoral size, number of nodules and RFS method were independent variables associated with disease-free survival.

[Massive abdominal vein thrombosis with acute liver failure and toxic megacolon as onset of ulcerative colitis]. / Trombosis venosa masiva abdominal con insuficiencia hepática aguda y megacolon tóxico como presentación de colitis ulcerosa.

The prevalence of systemic thromboembolic complications is higher in patients with inflammatory bowel disease than in the general population. This hypercoagulable state is due to an increased production of procoagulant substances proportionally related to the inflammatory activity of the disease, although recent reports have focused on the presence of inherited thrombophilic disorders in this entity. We present the case of a 32-year-old woman with no relevant medical history who presented with massive abdominal vein thrombosis, including suprahepatic, portal, splenic and superior mesenteric veins, and secondary acute liver failure in her first ulcerative colitis flare and who later developed toxic megacolon requiring emergency total colectomy despite steroids and cyclosporine. Anticoagulant therapy achieved complete resolution of suprahepatic thrombosis and partial resolution in the splenic and superior mesenteric veins, with final cavernous transformation of the portal vein.

[Hepatoportal sclerosis and liver angiosarcoma: an infrequent association with a possible common etiology]. / Esclerosis hepatoportal y angiosarcoma hepático: una asociación infrecuente y una posible etiología común.

Hepatoportal sclerosis is characterized by fibrosis of the intima of the portal vein and its branches leading to the development of presinusoidal portal hypertension. We describe the case of a 58-year-old woman with idiopathic hepatoportal sclerosis, who was admitted to our service due to impairment of liver function, with rapid clinical worsening and finally the development of multiorgan failure. Autopsy showed a diffuse liver angiosarcoma with splenic metastases. The patient had no history of domestic or occupational exposure to substances involved in the development of hepatoportal sclerosis or liver angiosarcoma. The development of liver angiosarcoma in a patient with hepatoportal sclerosis is exceptional, even though both diseases may have a common etiology.

Rheumatologic and autoimmune manifestations in patients with chronic hepatitis C virus infection.

Hepatitis C virus (HCV) has been associated with several autoimmune and rheumatologic disorders. The aim of this study was to determine the incidence of these abnormalities in patients with chronic HCV. We studied 56 patients, 29 of whom (52%) had biochemical abnormalities that suggested immunological disorders. Cryoglobulinemia was detected in nine patients (22%), antinuclear antibodies in eleven (20%), rheumatoid factor in seven (19.27%) and hypocomplementemia in fourteen (29.16%). The most common clinical manifestations were: arthralgias (52%), myalgias (16%), xerostomia (28.5%) and xerophthalmia (14%). These results indicate the existence of a relationship between HCV and rheumatologic disorders. We conclude that HCV may play a role in the pathogenesis of these autoimmune phenomena, but more studies are required to define the extent of this role.

[Aneurysms of the splenic artery in patients with liver transplantation]. / Aneurismas de la arteria esplénica en pacientes con trasplante hepático.

Splenic artery aneurysms (SAA) are not uncommon in patients with hepatic transplant (HT). Three in 150 transplanted patients in our institutions were diagnosed with SAA and two of them had a spontaneous rupture. In two patients embolization with interventionist radiology was performed with excellent results. SAA should be investigated before and after HT and be treated with embolization as soon as possible because of the high risk of rupture.

[Arterial revascularization of liver graft with PTFE vascular prosthesis]. / Revascularización arterial de injerto hepático con prótesis vascular de PTFE.

When the hepatic artery is not available in liver transplantation because of its bad quality or low flow, arterial grafts from the donor have to be used to obtain arterial blood flow from the aorta. The case of use of a vascular PTFE prosthesis when no vascular grafts were available is presented, with good outcome 6 months after transplantation.

[Ischemic hepatitis following liver biopsy in a patient with transplanted liver]. / Hepatitis isquémica tras biopsia hepática en paciente transplantada hepática.

We report a case of ischemic hepatitis following a percutaneous liver biopsy in a 51 year old female patient, who had had an orthotopic liver transplant 6 months before. The angiographic study demonstrated a marked stenosis in the hepatic artery at the anastomosis site and a small arterioportal fistula. We suggest that the percutaneous liver biopsy was partially responsible for the ischemic hepatitis, due to the development of a small arterioportal fistula in a previously damaged vascular area with hepatic artery stenosis.

[The response to hepatitis B vaccine prior to orthotopic liver transplantation]. / Respuesta a la vacuna de la hepatitis B previa al trasplante hepático ortotópico.

UNLABELLED: HBV hepatitis is a severe complication of orthotopic liver transplantation (OLT) due to the immunosuppression therapy. OBJECTIVES: The aim of this study is to evaluate the efficacy of the active HBV immunization on these patients before OLT. PATIENTS AND METHODS: This was a prospective trial, with 34 patients (20 M and 14 F), that received a double dose (40 micrograms) of HBV surface proteic Ag, on the 0th, 30th and 60th days of the study and posterior control of anti-HBs levels. If there wasn't a response, they received two more doses on the 90th and 120th days. RESULTS: There was a seroconversion in 22 patients (64.7%). Chronic alcoholism determined a lower rate of response than other etiologies (p < 0.05); this was the same in HCV chronic liver disease (p < 0.01). During their follow up, two patients had acute HBV hepatitis: one of them presented a negative response from the beginning, and in the other, anti-HBs developed transiently, when the HBV markers appeared. CONCLUSIONS: Previous HBV active immunization in OLT patients with double dose in a quick sequence, determined a positive response in a high number of patients with a higher rate of seroconversion than in other studies. The response was not so high in patients with chronic alcoholism or HVC chronic liver disease. We conclude that HVB vaccination should be done in these patients.

[The liver transplant program of the Hospital General Universitario Gregorio Marañón: an analysis of the first 100 patients]. / Programa de trasplante hepático del Hospital General Universitario Gregorio Marañón: análisis de los 100 primeros pacientes.

During a 3-year period between 1990 and 1993, 100 patients received orthotopic liver transplantation at the "Gregorio Marañón" University General Hospital. The mean age of the patients was relatively high (46.9 +/- 10 years), with an important number of cirrhotic patients (91%). The rate of primary liver failure was relatively low (4.5% of transplantations) although 12 cases with more than 55 years were included in the present series. Eleven retransplantations were performed, 8 for early failure of the graft and 3 for chronic failure. Postoperative complications of the graft were vascular in 9 cases, biliary in 17 cases, and acute rejection (cellular) in 70 patients, although only 50 of these patients required treatment with steroid boluses. Infections were diagnosed in 60 cases with 80% of major infections, 6 of them caused by Aspergillus fumigatus that were lethal in all the cases. Postoperative survival was 82%, 72%, 69% and 69% at 1 month, 6 months, 1 year and 2 years respectively.

[Mixed cryoglobulinemia associated with hepatitis C virus]. / Crioglobulinemia mixta asociada al virus de la hepatitis C.

We report six cases of essential mixed cryoglobulinemia associated with chronic liver disease and positive HCV markers, who showed several acute symptoms of vasculitis, arthralgias, neuropathy and glomerulonephritis. The presence in the serum and cryoprecipitates of anti HCV antibodies detected by the second-generation ELISA (ELISA 2) and the of HCV RNA by PCR in the serum in all six cases, suggest an important role for this virus in the pathogenesis of mixed cryoglobulinemia.

[Resection of recurrent hepatocarcinoma on a transplanted liver]. / Resección de hepatocarcinoma recidivante sobre hígado trasplantado.

Recurrence of hepatocellular carcinoma is rarely treated by surgical resection and has not been reported in the main series of liver transplantation. In this paper we present the case of a patient transplanted for hepatocellular carcinoma on cirrhosis who developed a tumoral recurrence in the transplanted liver four months later. The new tumor was removed by hepatectomy and the patient is free of tumor 24 months after resection. Surgical resection should be considered a treatment of tumoral recurrence after liver transplantation as is done after hepatectomy.

[Hepatic angiosarcoma with splenic metastasis]. / Angiosarcoma hepático con metástasis esplénica.

Angiosarcoma of the liver is an extremely rare tumor with a rapidly fatal course. This report describes the case of a 52-year-old male with an hepatic angiosarcoma not related to any known carcinogen. The hepatosplenic metastases and the brief clinical course, did not let us to complete diagnostic and therapeutic strategies.

[Transjugular hepatic biopsy. Apropos the first 100 cases and a review of the literature]. / Biopsia hepática transyugular: a propósito de los cien primeros casos y revisión de la literatura.

Under certain conditions a percutaneous liver biopsy cannot be carried out. In many of these patients transjugular liver biopsy is the correct option. We present our first hundred biopsies: in 92 cases a liver specimen was obtained; in 80 cases (87%) the tissue specimen allowed the histopathologic diagnosis; in five cases perforation of the hepatic capsule was observed, without producing hemoperitoneum. The mortality in our series was nil. In our experience and the revision of the literature, we consider that transvenous (transjugular) needle biopsy is an efficient and reliable procedure.

[The Budd-Chiari syndrome as the first manifestation of polycythemia vera]. / Síndrome de Budd-Chiari como primera manifestación de policitemia vera.

The case of a 57-year-old male diagnosed as having Budd-Chiari syndrome secondary to a polycythemia vera, which produced a thrombosis of the suprahepatic veins as a first manifestation, is presented. The rarity of this clinical case and the rapidly lethal evolution of the patient, confirms the bad prognosis of this association.