Análisis del sistema de alistamiento y priorización para trasplante hepático de adultos en Chile

Background: In Chile, organ allocation for liver transplantation (LT) in adults is prioritized according to the MELD-Na score. Exceptions such as Hepatocellular Carcinoma (HCC) and other non-HCC exceptions receive a score called Operational MELD score. Aim: To evaluate the effectiveness of the MELD-Na score and the operational MELD score as a prioritization system for LT in Chile. Material and Methods: Retrospective analysis of the waiting list (WL) of adult candidates (≥ 15 years) for elective LT in Chile from 2011 to 2017. The probability of leaving the WL, defined by death or contraindication for LT was compared in three groups: 1) Cirrhotic patients prioritized according to their real MELD-Na score (CPM), 2) HCC and 3) other non-HCC exceptions. Results: We analyzed 730 candidates for LT, with a median age of 57 years, 431 (56%) were men. In the study period, 352 LT were performed (48%). The annual exit rate was significantly higher in the CPM group (45.5%) compared to HCC (33.1%) and non-HCC (29.3%), (p < 0.001). Post LT survival was 86% at 1 year and 85% at 5 years, without significant differences between groups. In the CPM group, post-transplant survival was significantly lower (p < 0.05) in patients with MELD-Na ≥ 30 at transplant (81% per year) compared to patients with patients with MELD-Na < 30 (91% per year). Conclusions: MELD-Na score can discriminate very well patients who have a higher risk of death in the short and medium term. However, the assignment of operational scores for situations of exception produces inequities in the allocation of organs for LT and must therefore be carefully adjusted.

[Analysis of the organ allocation system for liver transplantation in Chile]. / Análisis del sistema de alistamiento y priorización para trasplante hepático de adultos en Chile.

BACKGROUND: In Chile, organ allocation for liver transplantation (LT) in adults is prioritized according to the MELD-Na score. Exceptions such as Hepatocellular Carcinoma (HCC) and other non-HCC exceptions receive a score called Operational MELD score. AIM: To evaluate the effectiveness of the MELD-Na score and the operational MELD score as a prioritization system for LT in Chile. MATERIAL AND METHODS: Retrospective analysis of the waiting list (WL) of adult candidates (≥ 15 years) for elective LT in Chile from 2011 to 2017. The probability of leaving the WL, defined by death or contraindication for LT was compared in three groups: 1) Cirrhotic patients prioritized according to their real MELD-Na score (CPM), 2) HCC and 3) other non-HCC exceptions. RESULTS: We analyzed 730 candidates for LT, with a median age of 57 years, 431 (56%) were men. In the study period, 352 LT were performed (48%). The annual exit rate was significantly higher in the CPM group (45.5%) compared to HCC (33.1%) and non-HCC (29.3%), (p < 0.001). Post LT survival was 86% at 1 year and 85% at 5 years, without significant differences between groups. In the CPM group, post-transplant survival was significantly lower (p < 0.05) in patients with MELD-Na ≥ 30 at transplant (81% per year) compared to patients with patients with MELD-Na < 30 (91% per year). CONCLUSIONS: MELD-Na score can discriminate very well patients who have a higher risk of death in the short and medium term. However, the assignment of operational scores for situations of exception produces inequities in the allocation of organs for LT and must therefore be carefully adjusted.

Prioritization for liver transplantation using the MELD score in Chile: Inequities generated by MELD exceptions.: A collaboration between the Chilean Liver Transplant Programs, the Public Health Institute and the National Transplant Coordinator.

INTRODUCTION AND AIM: The MELD score has been established as an efficient and rigorous prioritization system for liver transplant (LT). Our study aimed to evaluate the effectiveness of the MELD score as a system for prioritization for LT, in terms of decreasing the dropout rate in the waiting list and maintaining an adequate survival post-LT in Chile. MATERIALS AND METHODS: We analyzed the Chilean Public Health Institute liver transplant registry of candidates listed from October 15th 2011 to December 31st 2014. We included adult candidates (>15 years old) listed for elective cadaveric LT with a MELD score of 15 or higher. Statistical analysis included survival curves (Kaplan-Meier), log-rank statistics and multivariate logistic regression. RESULTS: 420 candidates were analyzed. Mean age was 53.6±11.8 years, and 244 were men (58%). Causes of LT included: Liver cirrhosis without exceptions (HC) 177 (66.4%); hepatocellular carcinoma (HCC) 111 (26.4%); cirrhosis with non-HCC exceptions 102 (24.3%) and non-cirrhotic candidates 30 (7.2%). LT rate was 43.2%. The dropout rate was 37.6% at 1-year. Even though the LT rate was higher, the annual dropout rate was significantly higher in cirrhotic candidates (without exceptions) compared with cirrhotics with HCC, and non-HCC exceptions plus non-cirrhotic candidates (47.9%; 37.2% and 24.2%, respectively, with p=0.004). Post-LT survival was 84% per year, with no significant differences between the three groups (p=0.95). CONCLUSION: Prioritization for LT using the MELD score system has not decreased the dropout rate in Chile (persistent low donor's rate). Exceptions generate inequities in dropout rate, disadvantaging patients without exceptions.

Post-transplant lymphoproliferative disorder in adult liver transplant recipients: a South American multicenter experience.

Post-transplant lymphoproliferative disorder (PTLD) is a major and potentially life-threatening complication after solid-organ transplantation. The aim of this study was to describe the disease characteristics, clinical practices, and survival related to PTLD in adult orthotopic liver transplant (OLT) recipients in South America. We conducted a survey at four different transplant groups from Argentina, Brazil, and Chile. Among 1621 OLT recipients, 27 developed PTLD (1.7%); the mean age at diagnosis was 53.7 (± 14) yr with a mean time of 39.7 (± 35.2) months from OLT to PTLD diagnosis. Initial therapy included reduction in immunosuppression alone in 23.1% of the patients. Either rituximab or chemotherapy was employed as initial or second-line therapy in 76.9% of the patients. PTLD location was frequently extranodal (80.7%) and mostly involving the transplanted liver (59.3%). The overall survival at one and five yr post-PTLD diagnosis was 53.8% and 46.2%, respectively. Significant univariate risk factors for post-PTLD mortality included lactate dehydrogenase ≥ 250 U/L (HR 9.66, p = 0.02), stage III/IV PTLD (HR 5.34, p = 0.004), and HCV infection (HR 7.68, p = 0.01). In conclusion, PTLD in OLT adult recipients is predominantly extranodal, and although mortality is high, long-term survival is possible.

[Clinical presentation of hydatid disease during 15 years: a case series from Santiago, Chile]. / Quince años de experiencia clínica con hidatidosis.

INTRODUCTION: Hydatidosis is a neglected parasitic disease that is endemic in Chile. We present the clinical experience of a single center in Santiago from 1996 to 2010. METHODS: Cases were identified using hospital's database. Clinical and pathological features, treatment and outcomes were retrospectively analyzed. RESULTS: In total, 23 patients were identified requiring 30 surgical interventions. Median age was 40 years old (range 5 to 73), and 76.5% visited or resided in regions of known endemicity in Chile. Abdominal cysts were predominant (78.3%), and most patients were symptomatic (73.9%). Elimination of cyst material by cough was reported in 42.9% of patients with symptomatic thoracic cysts. Eosinophilia was present in 41.2% of patients, and 57.1% had positive serology for hydatidosis. All patients underwent surgical treatment, in 60.9% in combination with albendazole treatment. While the majority of liver cysts (88.9%) were treated by complete cyst resection, lung cysts (83.3%) were predominantly treated by cyst resection plus capitonnage. Pathological examination revealed fertile cysts in 24%. Postsurgical morbidity was frequent (37.9%), and 13.3% of the series required readmission for this cause. Near 25% of patients remained in hospital > 14 days, a feature associated with fever during admission (p < 0.05). No recurrence was reported in the fraction of patients that were followed-up for 2 years or more. CONCLUSIONS: Our analysis of 23 cases demonstrates that patients were mainly adults suffering from abdominal cysts. Most patients were successfully treated by surgery with or without antiparasitic drugs but complications leading to prolonged hospital stays and readmissions were not infrequent.

Quince años de experiencia clínica con hidatidosis / Clinical presentation of hydatid disease during 15 years: a case series from Santiago, Chile

Introduction: Hydatidosis is a neglected parasitic disease that is endemic in Chile. We present the clinical experience of a single center in Santiago from 1996 to 2010. Methods: Cases were identified using hospital's database. Clinical and pathological features, treatment and outcomes were retrospectively analyzed. Results: In total, 23 patients were identified requiring 30 surgical interventions. Median age was 40 years old (range 5 to 73), and 76.5% visited or resided in regions of known endemicity in Chile. Abdominal cysts were predominant (78.3%), and most patients were symptomatic (73.9%). Elimination of cyst material by cough was reported in 42.9% of patients with symptomatic thoracic cysts. Eosinophilia was present in 41.2% of patients, and 57.1% had positive serology for hydatidosis. Aill patients underwent surgical treatment, in 60.9% in combination with albendazole treatment. While the majority of liver cysts (88.9%) were treated by complete cyst resection, lung cysts (83.3%) were predominantly treated by cyst resection plus capitonnage. Pathological examination revealed fertile cysts in 24%. Postsurgical morbidity was frequent (37.9%), and 13.3% of the series required readmission for this cause. Near 25% of patients remained in hospital > 14 days, a feature associated with fever during admission (p < 0.05). No recurrence was reported in the fraction of patients that were followed-up for 2 years or more. Conclusions: Our analysis of 23 cases demonstrates that patients were mainly adults suffering from abdominal cysts. Most patients were successfully treated by surgery with or without antiparasitic drugs but complications leading to prolonged hospital stays and readmissions were not infrequent.

Introducción: La hidatidosis es una enfermedad endémica en Chile. Se presenta la experiencia clínica de un hospital en Santiago, desde 1996 al 2010. Métodos: Los casos fueron identificados usando las bases de datos institucionales y se analizaron las características clínicas y patológicas, el tratamiento y la evolución en forma retrospectiva. Resultados: Se identificaron 23 pacientes intervenidos en 30 oportunidades. La mediana de edad fue de 40 años (rango 5 a 73) y 76,5% visitó o residía en zonas endémicas en Chile. Los quistes abdominales fueron predominantes (78,3%) y la mayor parte de los pacientes eran sintomáticos (73,9%). Un 42,9% de aquellos con quistes sintomáticos torácicos reportó eliminación de vesículas con la tos. Un 41,2% presentó eosinofilia y 57,1% tuvo serología positiva para hidatidosis. Todos los pacientes fueron tratados quirúrgicamente, en 60,9% en combinación con albendazol. La mayoría de los quistes hepáticos fueron tratados con cirugía radical (88,9%) y los pulmonares predominantemente con quistostomía y capitonaje (83,3%). Un 24% de los quistes eran fértiles. La morbilidad post-quirúrgica fue frecuente (37,9%) y 13,3% de la serie requirió reingresos por esta causa. Cerca de 25% de los pacientes estuvo hospitalizado por más de 14 días, un fenómeno asociado con la presencia de fiebre por complicación séptica al ingreso (p < 0,05). No se registraron recurrencias en la fracción de pacientes seguidos por más de dos años. Conclusiones: La hidatidosis afecta principalmente a adultos en su cavidad abdominal. Aunque los pacientes fueron tratados exitosamente con cirugía, las complicaciones, estadías prolongadas y reingresos por esta causa no fueron infrecuentes.

[General considerations, indications and contraindications for liver transplantation in Chile: a multicenter consensus development document]. / Trasplante hepático en Chile: Aspectos generales, indicaciones y contraindicaciones (Documento de consenso).

Liver transplantation is an excellent therapeutic option for terminal liver disease. During the last decades the results of liver transplantation have improved significantly with a patient survival rate of nearly 90% at one year and 80% at 5 years of follow-up. The main indications for liver transplantation include: end-stage liver disease associated to cirrhosis, acute liver failure, and hepatic tumors (mainly hepatocarcinoma). The absolute contraindications for a transplant are less frequent than in the past, and include: severe co-morbidity (cardiac or pulmonary), sepsis, advanced HIV disease and extra-hepatic malignancy. This document presents a Consensus of the main groups performing liver transplantation in Chile, about its indications and contraindications. It also reviews general aspects of liver transplantation, including the selection and referral of liver transplant candidates, allocation of organs and the evaluation of severity of liver disease.

Trasplante hepático en Chile: Aspectos generales, indicaciones y contraindicaciones (Documento de consenso) / General considerations, indications and contraindications for liver transplantation in Chile: A multicenter consensus development document

Liver transplantation is an excellent therapeutic option for terminal liver disease. During the last decades the results of liver transplantation have improved significantly with a patient survival rate of nearly 90 percent at one year and 80 percent at 5 years of follow-up. The main indications for liver transplantation include: end-stage liver disease associated to cirrhosis, acute liver failure, and hepatic tumors (mainly hepatocarcinoma). The absolute contraindications for a transplant are less frequent than in the past, and include: severe co-morbidity (cardiac or pulmonary), sepsis, advanced HIV disease and extra-hepatic malignancy. This document presents a Consensus of the main groups performing liver transplantation in Chile, about its indications and contraindications. It also reviews general aspects of liver transplantation, including the selection and referral of liver transplant candidates, allocation of organs and the evaluation of severity of liver disease.

[Sirolimus for rescue of recurrent acute rejection and diabetes mellitus after liver transplantation: report of one case]. / Rescate con Sirolimus por rechazo agudo recurrente y diabetes mellitus en trasplante hepático. Caso clínico pediátrico.

Sirolimus (SRL) is a new immunosuppressive drug approved for renal transplantation, but is being used increasingly in orthotopic liver transplantation (OLT). Compared with the calcineurin inhibitors, SRL has different mechanisms of action and side effects profile. Thus, this drug offers significant potential advantages over other immunosuppressive agents. SRL does not cause glucose intolerance, hypertension or renal failure, but it may cause dyslipidemia, hepatic artery thrombosis, thrombocytopenia, anemia, leukopenia, oral mucosa ulcers, edema, arthralgias and wound complications. SRL inhibits the signal of interleukin 2 at a post-receptor level, inhibiting lymphocyte proliferation and fibroblast proliferation. It also has antineoplastic and antifungal effects. We report a 10 years old girl who underwent OLT, experiencing a biopsy-proven recurrent acute rejection (AR) in spite of using three immunosuppressive agents (tacrolimus, mofetil micofenolate and steroids). She developed diabetes mellitus as a consequence of the immunosuppressive therapy. She was rescued with SRL, not experiencing AR again. Mofetil micofenolate, steroids and insulin could be discontinued and tacrolimus doses were reduced, without experiencing severe complications. SRL is a new and safe immunosuppressive agent for rescue in patients with OLT and recurrent AR.

[Combined liver-kidney transplantation: report of a case]. / Trasplante combinado hepato-renal: a propósito de un caso.

End stage renal disease is not an absolute contraindication for liver transplantation (LT) in patients with end stage liver disease. Actuarial patient and graft survival are comparable for children and adults who undergo LT alone and liver-kidney transplantation (LKT). The most common indications for LKT are the primary hyperoxaluria type I (PH1) and the liver and renal polycystic disease. We report a 12 years old boy with congenital hepatic fibrosis with severe portal hypertension, encephalopathy and polycystic kidney disease with end stage renal disease on dialysis that underwent LKT. During the second postoperative week, he had a biopsy-proven acute liver and renal rejection, that had a good response to corticosteroids. Thirty days after surgery, the liver biopsy was without rejection. No other complications were observed.

[Liver transplantation in adults: a caseload from Clínica Alemana de Santiago, Chile]. / Trasplante hepático en adultos: casuística de Clínica Alemana de Santiago.

BACKGROUND: The success of orthotopic liver transplantation (OLT) has resulted in its widespread use for different liver diseases. AIM: To report our 8 years experience with adult OLT at Clinica Alemana de Santiago. PATIENTS AND METHODS: In all transplantations done at the center, we recorded patient's overall data and survival, postoperative medical and surgical complications and causes of death. RESULTS: Between November 1993 and September 2001, 51 consecutive OLT were performed in 44 patients (22 females, median age 45 years old). Thirty eight patients presented with chronic and 6 with acute or sub-acute liver failure. Cryptogenic cirrhosis and hepatitis C infection were the most common causes for OLT. Postoperative bleeding and extrahepatic biliary complications were seen in 17.6 and 21.5% of cases respectively. Acute rejection, bacterial infections, CMV infection or disease and post OLT hemodialysis were the most common medical complications (51, 31, 19.6 and 19.6% of cases respectively). The overall 1 and 5 years survival rates were 80% and 73% respectively. Considering exclusively the last 22 OLT performed since January 1999, the 1 year survival rate has improved to 91%. CONCLUSIONS: Liver transplantation in Chile provides a good long term survival with acceptable morbidity, due to a multidisciplinary approach management. The survival rates have improved over the last few years probably due to better surgical techniques, ICU care and immunosuppression. These overall results are comparable with those from other Centers in developed countries.

Colecistectomía laparoscópica en colecistitis aguda / Laparoscopic cholecistectomy in acute cholecistitis

Se comunica nuestra experiencia en el tratamiento quirúrgico de la colecistitis aguda por vía laparoscópica. Se operó a 82 pacientes, pudiendo completarse el procedimiento laparoscópico en 72 de ellos. Se utilizó tanto la técnica francesa como la americana. El tiempo operatorio fue de 90,4 minutos. La estadía hospitalaria postoperatoria fue de 2,87 días. Cuatro pacientes presentaron complicaciones quirúrgicas y 11 complicaciones médicas. Fallece 1 paciente el día 18 postoperatorio por una embolia pulmonar masiva. Los resultados sugieren que esta técnica es una alternativa válida y segura para el tratamiento de la colecistitis aguda

Cáncer primitivo del duodeno / Duodenal primitive cancer

El cáncer primitivo del duodeno (CPD) es raro, y en nuestro Hospital representa el 0,008% de las biopsias. En el período 1945-90, descartando los tumores de la ampolla de Vater, hallamos catorce casos: ocho adenocarcinomas (ADC), cinco linfomas y un histiocitoma maligno. Los ADC generalmente son periampulares; los otros dos tumores son infraampulares. La sintomatología más frecuente fue dolor, obstrucción duodenal y compromiso del estado general, de comienzo insidioso. El dolor abdominal predominó en los pacientes con ADC y la diarrea, en los enfermos con linfomas. El diagnóstico, por lo general es tardío, cuando el tumor está avanzado. El diagnóstico etiológico se hizo principalmente por biopsia endoscópica (12 casos), y quirúrgica, sólo en 2 casos. La radiología con medio de contraste y el TAC abdominal son técnicas complementarias y permiten conocer la extensión de la lesión. El tratamiento de los adenocarcinomas es quirúrgico: pancreatoduodenectomía en las formas localizadas; cirugía derivativa paliativa en las formas avanzadas, que son las más frecuentes. En los linfomas, la quimioterapia es el tratamiento de elección, además de cirugía resectiva para los casos localizados. En el seguimiento hallamos sólo un paciente vivo, que corresponde a una enferma con linfoma no Hodgkin, sometida a cirugía resectiva y quimioterapia, 52 meses antes. La mayor sobrevida alcanzada en nuestra serie, fue de 13 años, y corresponde a una paciente con ADC sometida a pancreatoduodenectomía radical. La sobrevida promedio de los pacientes con linfomas que han fallecido, es superior a la de aquellos con adenocarcinomas (39 meses vs. 27 meses)