Effectiveness and safety of once-daily tacrolimus formulations in de novo liver transplant recipients: The PRETHI study.

Data comparing long-term effectiveness and safety of once-daily tacrolimus formulations in de novo liver transplantation are scarce. We compared the effectiveness, pharmacokinetic profile, and safety of LCPT (Envarsus) and PR-Tac (Advagraf) for up to 12 months post-transplant. Adult de novo liver transplant recipients who started IR-Tac (Prograf) and were converted to LCPT or PR-Tac 3-5 days post-transplant were included. Data from 163 patients were analyzed, 87 treated with LCPT and 76 with PR-Tac. The incidence of treatment failure was 30.5% in the LCPT group versus 23.0% in the PR-Tac group (p = .291). Biopsy-proven acute rejection (BPAR) was reported in 26.8% of patients in the LCPT group and 17.6% in the PR-Tac group (p = .166). Graft loss was experienced in one patient (1.2%) in the LCPT group and three patients (4.1%) in the PR-Tac group (p = .346). Death was registered in three patients (3.7%) in the LCPT group and three patients (4.1%) in the PR-Tac group (p > .999). Patients in the LCPT group showed 45.7% higher relative bioavailability (Cmin /total daily dose [TDD]; p < .01) with similar Cmin and 33.3% lower TDD versus PR-Tac (p < .01). The evolution of renal function, safety profile, and the incidence of post-transplant renal failure, dyslipidemia, obesity, hypertension, and diabetes mellitus were similar in patients treated with LCPT and PR-Tac. In de novo liver transplant patients, LCPT and PR-Tac showed comparable effectiveness with higher relative bioavailability, similar Cmin and lower TDD in the LCPT group. Renal function, safety, and post-transplant complications were comparable in LCPT and PR-Tac groups.

Pancreatic encephalopathy, a little known complication of acute pancreatitis.

A 62-year-old male presented with severe post-endoscopic retrograde cholangiopancreatography (post-ERCP) acute pancreatitis. He required admission to the Intensive Care Unit (ICU) twice due to respiratory and renal failure and neurological deterioration. On the hospitalization ward, he presented a fluctuating alteration of the level of consciousness, with bradypsychia, disorientation and somnolence, which persisted after hemodynamic, metabolic and renal stabilization. A brain magnetic resonance imaging (MRI) was performed showing focal lesions due to small vessel disease, some with cavitations due to necrosis, and mild to moderate subcortical atrophy. A diagnosis of pancreatic encephalopathy was made given the clinical and radiological findings. The patient recovered full cognitive capacity after one week with adequate nutrition supported by protein supplementation.

Paroxysmal nocturnal hemoglobinuria and liver transplantation, a new paradigm.

Paroxysmal nocturnal hemoglobinuria (PNH) is a type of hemolytic anemia acquired by the PIG-A gene mutation. This causes a deficiency of a complement regulatory protein, CD59, which results in hemolysis, hemoglobinuria and thrombosis (due to the release of procoagulant factors). Budd-Chiari syndrome is characteristic in these patients and has classically been considered as a contraindication for liver transplantation (LT) due to post-transplant recurrence. Since the approval of eculizumab for the treatment of PHN, disease control is possible and therefore the post-transplant recurrence of thrombotic phenomena involving the liver is avoided.

Hemorrhagic complications following paracentesis.

Paracentesis is a common and well accepted technique for its diagnostic-therapeutic profitability. This procedure is considered rapid, minimally invasive and safe, but we must not forget that it can lead to severe complications. In this letter we present two patients with hemorrhagic complications following paracentesis. Both cases were treated by percutaneous transarterial embolization. Likewise, in the absence of consensus on the prevention of complications and on their optimal management, we make some recommendations.

Segmental arterial mediolysis in splanchnic arteries: an uncommon cause of abdominal pain.

Segmental arterial mediolysis is an uncommon arterial disease that primarily involves splanchnic arteries; abdominal pain is the most common clinical manifestation. We report the case of a 53-year-old male with postprandial diffuse abdominal pain of one month's standing. Physical examination was uneventful, and laboratory tests revealed no abnormal findings. Abdominopelvic CT/Angio-CT showed an increased caliber of the superior mesenteric artery resulting from eccentric circumferential wall thickening. The patent lumen had a segment with fusiform aneurysmal dilatation, 7 x 26 mm long. These vascular changes extended along a number of distal jejunal branches, which also presented complete lumen obliteration. Abdominal arteries were free from signs of arteriosclerotic disease. Findings were consistent with segmental arterial mediolysis.

Fungal cholangitis of the hepatobiliary tract: a case report.

We report the case of a 52-year-old male diagnosed with primary sclerosing colangitis, mainly of the extrahepatic bile duct, with a long evolution. After liver transplantation, the explanted liver showed necrosis of the bile duct wall, with fungal structures inside the bile duct that was compatible with Candida. The patient was treated with mesalazine and ursodeoxycholic acid and does not have a stent in the bile duct.

Liver transplantation in patients with type IIIa glycogen storage disease, cirrhosis and hepatocellular carcinoma.

Type III glycogen storage disease (GSD-III) is an autosomal recessive disorder due to the deficiency of the glycogen debrancher enzyme. 80% of the patients have hepatic and muscular involvement (IIIa), compared to 15% with only liver involvement (IIIb). As the life expectancy improves in these patients, the possible liver complications are better understood.

Protecting renal function: a relevant decision for liver transplantation.

Advances in surgical technique, as well as in medical management and immunosuppression (IS), have represented a significant improvement in the survival of patients undergoing liver transplantation (LT), with 1-year, 5-year, and 10-year survival rates of 86%, 73%, and 62%, respectively, according to the Spanish liver transplant registry.

Hepatic encephalopathy secondary to a splenorenal shunt that manifested a long time after a liver transplantation.

Splenorenal shunts are a rare cause of hyperammonemia and hepatic encephalopathy in the absence of cirrhosis. We report the case of a woman, who presented hepatic encephalopathy, with a normal functioning graft, after 14 years of liver transplantation, confirmed by liver biopsy.

Recommendations of everolimus use in liver transplant. / Recomendaciones de uso de everolimus en el trasplante hepático.

Mammalian target of rapamycin (mTOR) inhibitors, everolimus (EVL) and sirolimus are immunosuppressive agents with a minor nephrotoxic effect, limited to the development of proteinuria in some cases. The combination of EVL and low-dose tacrolimus has proven to be as safe and effective as standard therapy with tacrolimus for the prevention of acute cellular rejection. Early initiation of EVL-based immunosuppressive regimens with reduced exposure to calcineurin inhibitors has been shown to significantly improve renal function of LT recipients during induction and maintenance phases, with comparable efficacy and safety profiles. In patients with established kidney failure, initiating EVL may enable clinicians to reduce calcineurin inhibitors exposure, thereby contributing to the improved renal function of these patients. Although there is not sufficient evidence to recommend their use to prevent the recurrence of hepatocellular carcinoma and the progression of de novo tumours, they are used in this context in routine clinical practice.

Hepatoportal sclerosis clinical different evolutionary stages: presentation of 3 cases and literature review.

Hepatoportal sclerosis (HPS) is characterized by presinusoidal intrahepatic portal hypertension associated with splenomegaly and anemia in patients with non-cirrhotic liver. Liver biopsy is essential, especially to rule out other processes. Being a disease of unknown etiology, the majority of cases have been described in eastern countries. However, it may be an underdiagnosed disease in the West. Symptoms are related to portal hypertension and the clinical spectrum is wide, ranging from anemia with normal liver function tests to bleeding due to esophageal varices. Treatment is directed to the complications and the prognosis is better than in patients with cirrhosis.We report three cases of HPS presenting at different clinical stages and the findings of liver biopsies, the clinical outcomes and a review of scientific literature.

Positron emission tomography/computed tomography in patients with hepatocellular carcinoma undergoing liver transplantation. Useful, necessary or irrelevant?

Hepatocellular Carcinoma (HCC) is an aggressive tumor entity, with the only curative options being surgical resection or orthotopic liver transplantation (OLT). The presence of one single tumor nodule of less than 5 centimeters diameter or a maximum of 3 nodules, with the largest of these not exceeding 3 centimeters (Milan criteria) constitute the clinical situation in which the best results for OLT in patients with HCC have been achieved. The survival of patients fulfilling the Milan criteria after transplantation is comparable to patients with similar tumor stages without cirrhosis, undergoing hepatic resection. The application of PET in oncology has become increasingly common in the last decade as it is a non-invasive tool that also gathers information about the degree of the biological aggressiveness of the tumor. The objective of this study was to perform a review of the literature, identifying the strengths and weaknesses of the PET as a prognostic tool in patients with HCC after OLT.