Intra-abdominal hypertension, fluid balance, and adverse outcomes after orthotopic liver transplantation.

BACKGROUND: Intra-abdominal hypertension (IAH) is frequently encountered in critically ill surgical patients. We aimed to evaluate the incidence of IAH after orthotopic liver transplant (OLT) and its impact on organ function, hospital length-of-stay (LOS), and death. METHODS: This prospective, observational, cohort study evaluated consecutive adult patients admitted in the ICU after undergoing OLT. Intra-abdominal pressure (IAP) was measured every 4-6 h for 3 days. Worsening IAP was defined as a gradual increase in IAP over a period of time. Daily fluid balance was the daily sum of all intakes minus the output. RESULTS: IAH was observed in 48% of the patients within the first 3 days after ICU admission, while ACS was diagnosed in 15%. Patients with IAH had a higher positive fluid balance at day 1 (1764 mL [812-2733 mL] vs. 1301 mL [241-1904 mL], p = 0.025). Worsening IAH was associated with fewer days free of organ dysfunction. IAH within 72 h after ICU admission was independently associated with a composite outcome of death or a longer ICU LOS (odds ratio 2.9; CI 95% 1.02-8.25, p = 0.043). CONCLUSION: After OLT, nearly half of the patients presented IAH, that was associated with unfavorable outcomes.

Impact of Brazilian expanded criteria for liver transplantation in patients with hepatocellular carcinoma: a multicenter study.

INTRODUCTION AND OBJECTIVES: Hepatocellular carcinoma (HCC) is one of the main indications for orthotopic liver transplantation (OLT). In Brazil, selection criteria for HCC is an expanded version of the Milan Criteria (MC), the so-called "Brazilian Milan Criteria" (BMC). Our aims were to evaluate post-OLT outcomes in patients with HCC and analyze the BMC performance. MATERIALS AND METHODS: We conducted a multicenter, retrospective cohort study, analyzing medical records of 1,059 liver transplant recipients with HCC. Tumor was staged according to MC and BMC and correlated with overall survival (OS) and disease-free survival (DFS). We compared the ability of MC and BMC to predict OS and DFS using Delta C-statistic. RESULTS: Post-OLT OS were 63% in five years and HCC recurrence was observed in 8% of patients. At diagnosis, 85% of patients were within MC. Patients within MC at diagnosis and in the explant showed a higher OS and DFS than patients outside MC and within BMC and patients outside both criteria (p < 0.001). Patients outside MC in the explant had an increased risk of tumor recurrence (HR: 3.78; p < 0.001) and poor survival (HR:1.77; p = 0.003). The BMC presented a lower performance than MC in properly classifying patients regarding recurrence risk. CONCLUSIONS: In a large Brazilian cohort of HCC patients submitted to liver transplantation, we observed satisfactory overall survival and recurrence rates. However, patients transplanted within the Brazilian expanded criteria had lower OS and DFS when compared to patients within MC, which may generate future discussions regarding the criteria currently used.

Hepatocellular carcinoma recurrence after liver transplantation in a Brazilian multicenter study: clinical profile and prognostic factors of survival.

BACKGROUND: Liver transplantation (LT) is the treatment of choice for patients with unresectable early hepatocellular carcinoma (HCC). Post-LT HCC recurrence rates range from 8 to 20% and still impact on overall survival (OS). The aim of our study was to evaluate the impact of HCC recurrence on post-LT survival and analyze prognostic factors among those patients with recurrence. PATIENTS AND METHODS: We carried out a national, multicenter, retrospective cohort study in Brazil. Medical records of 1119 LT recipients with HCC were collected. Data from patients with post-LT HCC recurrence were analyzed and correlated with post-relapse survival. RESULTS: OS of the 1119 patients included in the study was 63% over 5 years. Post-LT HCC recurrence occurred in 86 (8%) patients. The mean time to recurrence was 12 months. Sites of recurrence were extrahepatic in 55%, hepatic in 27%, and both hepatic and extrahepatic in 18%. Recurrence treatment was performed in 50 (64%) cases, mostly with sorafenib. Post-relapse survival rates were 34% at 1 year and 13% at 5 years. Univariable analysis identified α-fetoprotein more than 1000 ng/ml at relapse, recurrence treatment, extrahepatic location, and time to recurrence more than 2 years as prognostic factors. In multivariable analysis, recurrence treatment, extrahepatic location, and time to recurrence more than 2 years were independent predictors of better survival. CONCLUSION: In a large Brazilian cohort of LT recipients with HCC, post-LT HCC recurrence occurred in 8% and impacted significantly on the OS. Patients with early recurrence presented a worse prognosis. However, treatment of recurrence improved outcomes, highlighting the importance of early diagnosis.

Pseudo-aneurisma de artéria hepática comum direita em mulher jovem com Lupus Eritematoso Sistêmico / Pseudoaneurysm of the right common hepatic artery in a young woman with SystemicLupus Erythematosus

Aneurismas de artéria hepática comum são lesões vasculares raras e representam a segunda incidência deaneurismas de artérias viscerais. As principais etiologias são: aterosclerose (32%) e trauma (22%). Outrascausas menos comuns são vasculites, procedimentos diagnósticos e terapêuticos percutâneos e complicação anastomótica de transplante de fígado. O diagnóstico de aneurisma intra-hepático é difícil antes de suaruptura, o qual está associado a uma mortalidade superior a 20% dos casos. Este artigo relata a história de uma paciente do sexo feminino, de 26 anos, portadora de Lupus Eritematoso Sistêmico (LES) que apresentavahá 2 meses dor tipo cólica na parte superior do abdome com irradiação para dorso. O diagnóstico de pseudo-aneurisma de artéria hepática comum foi feito após investigação da dor abdominal com métodos de imagem.Para aneurisma intra-hepático, o tratamento de escolha é a embolização, e este procedimento tem aumentado a sobrevida desses pacientes. Em alguns casos de aneurismas proximais, torna-se necessária a ressecção do fígado ou mesmo de transplante hepático.

Hepatic artery aneurysms are rare vascular lesions and represent a second incidence of aneurysms ofvisceral arteries. The main etiologies are atherosclerosis (32%) and trauma (22%). Other less common causesinclude vasculitis, diagnostic procedures, percutaneous therapies and as an anastomotic complication ofliver transplantation. Diagnosis of an intra-hepatic aneurysm before its rupture is difficult; ruptures areassociated to mortality in more that 20% of the cases. This work reports the case of a 26-year-old femalepatient with systemic lupus erythematosus who presented with a colic-type pain in the upper abdomen withirradiation to the back for two months. The diagnosis of hepatic artery pseudoaneurysm was made after animaging investigation of the abdominal pain. The first-line treatment for intra-hepatic aneurysms is embolization,which improves the patients’ survival rate. In some cases of proximal aneurysms, resection of the liver oreven liver transplantation is required.

As Organizações de Procura de Órgãos (OPOs) são efetivas? Análise de sete anos de atividade de uma OPO brasileira / Are the Organ Procurement Organizations (OPO) effective? A sevenyear

Introdução: A falta de órgãos humanos é o princial fator que limita o aumento do número dos transplantes (Tx) no Brasil. O governo do estado implantou as Organizações de Procura de Órgãos (OPOs) para aumentar a oferta de órgãos para Tx, entretanto ainda são escassos os relatos que demonstram a efetividade dessas OPOs. Objetivo: Esse trabalho teve o objetivo de analisar a evolução de uma OPO regional (OPO-SJRP) e avaliar seu desempenho em 7 anos (1997 a 2003). Casuística e método: Foram analisadas retrospectivamente as causas de não-efetivação das doações de MO / C e 1781 notificações de potenciais doadores (PD), sendo n= 1323 para córneas (C) e 458 para múltiplos órgãos (MO), que resultaram em 745 doadores de C e 166 de MO. Resultados: A análise mostrou redução de 25% nas notificações de PD. Entretanto, ocorreu aumento dos doadores efetivos de MO de 5 pmp/ano para 19 pmp/ano e nos de C de 36 pmp/ano para 63 pmp/ano. Na OPOSJRP as causas de não-efetivação das doações de MO foram principalmente a recusa familiar (RF) (20%) e a contra-indicação médica (CIM) (38%). Para as doações de C, a RF ocorreu em 35% e a CIM em 13%. A OPOSJRP apresenta taxas médias anuais de notificação para MO e de doação efetiva de 34 pmp e 12 pmp respectivamente, maiores que as demais OPOs do estado. Conclusão: A OPO-SJRP aumentou significativamente nos últimos 7 anos o número de doadores efetivos para transplantes de MO e de C e possui taxas de notificação e de doação pmp/ano similares ou maiores do que às das outras OPOs do Estado de S. Paulo

Linfoma de tecido linfático associado a mucosa MALT, primário de fígado, com infiltraçäo de vesícula biliar e medula óssea / Mucosa associated lymphatic tissue lymphoma, MALT, primarily from the liver, with infiltration of gall bladder and bone marrow

Linfomas hepáticos primários do fígado säo raros. Linfomas indolentes de expressäo B do tipo tecido linfático associado a mucosa säo ainda mais raros e inusitados, estando descritos na literatura somente quatro casos. Os autores apresentam neste relato um caso de paciente do sexo feminino, com 73 anos de idade com queixas dolorosas e sintomatologia de comprometimento biliar. O diagnóstico de linfoma do tecido linfático associado a mucosa (MALT) foi realizado acidentalmente pelo encontro de anormalidades hepáticas no momento do ato cirúrgico. O aspecto hepático era micronodular com a presença de lesäo ulcerada, que biopsiadas revelaram o diagnóstico. O estadiamento da moléstia comprovou infiltraçäo da medula óssea pelo linfoma, dado este infrequente, e a endoscopia digestiva alta foi normal, näo revelando comprometimento deste aparelho, dado comum e mais freqüente deste tipo de linfoma.