The role of HBIG in real life for patients undergoing liver transplantation due to HDV-related cirrhosis.

Recommended post-liver transplant (LT) prophylaxis in patients with hepatitis delta includes a nucleos(t)ide analogue (NA) and anti-hepatitis B immunoglobulin (HBIG) indefinitely. We analysed the use of HBIG in real-life clinical practice and its impact on HBV/HDV recurrence in 174 HDV-related LT patients from 10 Spanish liver transplant centres (1988-2018). Median post-LT follow-up was 7.8 (2.3-15.1) years and patient survival at 5 years was 90%. Most patients (97%) received HBIG in the immediate post-LT, but only 42% were on HBIG at the last control. Among those discontinuing HBIG, the median time on treatment was 18 (7-52) months. Post-LT HBsAg+ was detected in 16 (9%) patients and HBV-DNA in 12 (7%). Despite HBsAg positivity, HDV recurrence was reported only in three patients (1.7%), all of whom were not receiving NA and had discontinued HBIG. Our data suggest that a finite HBIG prophylaxis in HDV-LT is feasible, especially if high-barrier NAs are used.

Improvement of quality of care provided to outpatients with hepatic cirrhosis after an educational intervention.

OBJECTIVE: A set of indicators has been reported to measure the quality of care for cirrhotic patients, and previously published studies report variable adherence rates to these indicators. This study aimed to assess the quality of care provided to cirrhotic outpatients before and after an educational intervention by determining its impact on adherence to quality indicators. METHODS: We conducted a quasi-experimental, cross-sectional study including 324 cirrhotic patients seen in 2017 and 2019 at a tertiary teaching hospital in Spain. Quality indicators were assessed in five domains: documentation of cirrhosis etiology, disease severity assessment, hepatocellular carcinoma (HCC) screening, variceal bleeding prophylaxis, and vaccination. After identifying areas for improvement, an educational intervention was implemented. A second evaluation was performed after the intervention to assess changes in adherence rates. RESULTS: Before the intervention, adherence rates were excellent (>90%) for indicators related to variceal bleeding prophylaxis and documentation of cirrhosis etiology, acceptable (60-80%) for HCC screening and disease severity assessment, and poor (<50%) for vaccinations. After the educational intervention, there was a statistically significant improvement in adherence rates for eight indicators related to HCC screening (70-90%), disease severity assessment (90%), variceal bleeding prophylaxis (>90%), and vaccinations (60-90%). CONCLUSION: Our study demonstrates a significant improvement in the quality of care provided to cirrhotic outpatients after an educational intervention. The findings highlight the importance of targeted educational interventions to enhance adherence to quality indicators in the management of cirrhosis.

¿Está justificado el retrasplante hepático en la era actual? / Is Liver Retransplantation Justified in the Current Era?

Introducción: El retrasplante hepático (ReTH) es una indicación de TH controvertida. Nuestro objetivo fue determinar la tasa de ReTH y las indicaciones, morbilidad, mortalidad posoperatoria y supervivencia actuarial del paciente retrasplantado en nuestra serie. Métodos: Estudio retrospectivo de una serie prospectiva de 1.645 pacientes trasplantados entre 1984 y 2018. Se analizan los resultados según el tipo de ReTH (precoz vs. tardío), periodo de estudio e indicaciones. Resultados: Hemos realizado 150 ReTH en 140 pacientes. La tasa de ReTH fue de 9%. El 30% (45) de los ReTH fueron precoces, siendo tardíos el otro 70% (105). Las causas más frecuentes fueron: colangitis isquémica (27%), trombosis de la arteria hepática (19%), fallo primario del injerto (15%) y recidiva de la cirrosis por virus de la hepatitis C (VHC) (15%). La duración de la cirugía (395 vs. 270 min; p = 0,001), tiempo de isquemia (435 vs. 390 min; p = 0,005) y necesidad transfusional (8 vs. 5 CH; p = 0,034) fue mayor en los casos de ReTH tardío, mientras que la mortalidad posoperatoria (10 vs. 20%; p = 0,01) fue mejor en los casos de ReTH tardío. La supervivencia actuarial a uno y cinco años fue de 71% y 58%, respectivamente, con una mejoría significativa en la última década (80% y 64%). Por otra parte, la supervivencia en los casos de ReTH por colangitis isquémica es superior que otras indicaciones (78 vs. 51%; p = 0,02). Conclusiones: El retrasplante es complejo y está asociado a una elevada morbimortalidad. Sin embargo, los resultados han mejorado en los últimos años por lo que su indicación está justificada. (AU)

Introduction: Liver retransplantation (LRT) is a controversial indication. Our aim was to evaluate the rate of LRT at our institution, and to analyze its indications and short- and long-term results. Methods: We conducted a retrospective study of a prospectively collected database, including 1645 LT from 1984 to 2018. Results have been analyzed depending on type of LRT (early vs late), study period and indications. Results: We performed 150 LRT in 140 patients. The LRT rate was 9%. Of these, 45 LRT were early (30%), and the other 70% were late LRT. The main indications were: ischemic cholangitis (27%), arterial thrombosis (19%), primary non-function (15%), and HCV recurrence (15%). Mean surgery duration (395 vs. 270 min; P = .001), cold ischemia time (435 vs. 390 min; P = .005) and transfused units required (8 vs. 5 RBC; P = .034) were higher in cases of late LRT. Postoperative mortality (10 vs. 20%; P = .01) was better in cases of late LRT. One- and 5-year actuarial survival rates were 71% and 58%, respectively, which were significantly better during the last decade (80% and 64%). Five-year actuarial survival for ischemic cholangitis is better than other indications, such as recurrence of HCV (78 vs. 51%; P = .02). Conclusions: Liver retransplantation is complex and associated with high morbidity and mortality. However, indications and long-term results have improved during recent years. Therefore, LRT is justified. (AU)

Carcinoma hepatocelular en paciente con síndrome de Budd-Chiari por membrana en la vena cava inferior. Posibilidad de resección tras tratamiento angio-radiológico del síndrome de Budd-Chiari / Hepatocelular carcinoma in a patient with Budd-Chiari syndrome caused by an inferior vena cava membrane. Possibility of resection after angio-radiological treatment of Budd-Chiari syndrome

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Resultados del trasplante hepático con donantes de más de 70 años / Outcomes of liver transplant with donors over 70 years of age

La escasez de órganos para trasplante ha hecho aumentar progresivamente la aceptación de donantes con criterios marginales, como la edad. MÉTODOS: Se ha realizado un análisis comparativo de la evolución postrasplante dependiendo de la edad de los donantes (grupo I: edad inferior a 70 años [n = 474] vs. grupo II: edad superior a 70 años [n = 105]), a lo largo de un periodo de 10 años. RESULTADOS: No había diferencias significativas entre ambos grupos en días de UCI, sexo, peso y requerimientos de fármacos vasoactivos. El grupo I presentó parada cardiaca de forma más frecuente (GI: 14 vs. GII: 3%; p = 0,005). No hubo diferencias en la disfunción primaria (GI: 6 vs. GII: 7,7%; p = 0,71), estancia en UCI (GI: 2,7 ± 2 vs. GII: 3,3 ± 3,8 días; p = 0,46) y hospitalaria (GI: 13,5 ± 10 vs. GII: 15,5 ± 11; p = 0,1), ni mortalidad hospitalaria (GI: 5,3 vs. GII: 5,8%; p = 0,66). Tras una mediana de seguimiento de 42 meses, tampoco se encontraron diferencias en la incidencia de complicaciones biliares (GI: 17 vs. GII: 20%; p = 0,40) ni vasculares (GI: 11 vs. GII: 9%; p = 0,69). La supervivencia actuarial a 5 años fue similar entre ambos grupos de estudio (GI: 70 vs. GII: 76%; p = 0,54). CONCLUSIONES: En nuestra experiencia, la utilización de injertos de donantes mayores de 70 años, si se evitan factores de riesgo adicionales (tiempo de isquemia, esteatosis, hipernatremia), no empeora los resultados del trasplante hepático a corto ni a largo plazo

Organ shortage has forced transplant teams to progressively expand the acceptance of marginal donors. METHODS: We performed a comparative analysis of the post-transplant evolution depending on donor age (group I: less than 70 years old (n = 474) vs. group II: 70 or more years old [n = 105]) over a 10 year period (2002-2011). RESULTS: Donors over 70 years old were similar to donors less than 70 years old in terms of ICU stay, gender, weight, laboratory results, and use of vasoactive drugs. However, the younger donor group presented with cardiac arrest more often (GI: 14 vs. GII: 3%, P=.005). There were no differences in initial poor function (GI: 6% vs. GII: 7,7%; P=.71), ICU stay (GI: 2.7 ± 2 vs. GII: 3.3 ± 3.8, P=.46), hospital stay (GI: 13.5 ± 10 vs. GII: 15.5 ± 11, P=.1), or hospital mortality (GI: 5.3 vs. GII: 5.8%, P=.66) between receptors of more or less than 70 year old grafts. After a median follow up of 32 months, no differences were found in the incidence of biliary tract complications (GI: 17 vs. GII: 20%, P=.4) or vascular complications (GI: 11 vs. GII: 9%, P=.69). The actuarial 5 year survival was similar for both study groups (GI: 70 vs. GII: 76%, P=.54). CONCLUSIONS: In our experience, the use of grafts from donors older than 70 years, when other risk factors are avoided (cold ischemia, steatosis, sodium levels), does not worsen the results of liver transplantation on the short or long term

Endoscopic radiofrequency ablation for APC refractory gastric antral vascular ectasia using the HALO90 system in a kidney transplant candidate

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Detección precoz, prevención y manejo de la insuficiencia renal en el trasplante hepático / Early detection, prevention and management of renal failure in liver transplantation

La insuficiencia renal es una complicación frecuente de la población con trasplante hepático que se asocia con una elevada morbimortalidad. Se han descrito múltiples factores de riesgo para el desarrollo de insuficiencia renal postrasplante hepático en los periodos pre y postrasplante hepático, así como en el propio momento del trasplante. Para reducir el impacto de la insuficiencia renal postrasplante hepático es necesaria una actitud activa para la identificación de los pacientes con factores de riesgo, la implementación de estrategias preventivas y la detección precoz del deterioro de la función renal. Tomando como base las evidencias publicadas y la experiencia clínica, el presente documento incluye recomendaciones para la monitorización de la función renal en los pacientes con trasplante hepático, la prevención y el manejo de la insuficiencia renal postrasplante hepático, y la derivación al nefrólogo. Asimismo, se actualizan las pautas inmunosupresoras probadas para la prevención o el control del deterioro de la función renal tras el trasplante hepático

Renal failure is a frequent complication in liver transplant recipients and is associated with increased morbidity and mortality. A variety of risk factors for the development of renal failure in the pre- and post-transplantation periods have been described, as well as at the time of surgery. To reduce the negative impact of renal failure in this population, an active approach is required for the identification of those patients with risk factors, the implementation of preventive strategies, and the early detection of progressive deterioration of renal function. Based on published evidence and on clinical experience, this document presents a series of recommendations on monitoring RF in LT recipients, as well as on the prevention and management of acute and chronic renal failure after LT and referral of these patients to the nephrologist. In addition, this document also provides an update of the various immunosuppressive regimens tested in this population for the prevention and control of post-transplantation deterioration of renal function

Trasplante cardiaco y hepático secuencial por polineuropatía amiloidótica familiar / Sequential heart and liver transplantation for familial amyloid polyneuropathy

Fundamento y objetivo: El trasplante hepatocardíaco combinado por polineuropatía amiloidótica familiar (PAF) es el tratamiento de elección para los pacientes con cardiomiopatía asociada a PAF. Sin embargo, hay aspectos controvertidos, como la realización de los 2 trasplantes de forma simultánea o secuencial y la posibilidad de trasplante dominó en esta situación. La mayor parte de los casos publicados se han realizado de forma simultánea, requiriendo generalmente el uso de bypass venovenoso y sin utilizarse en muchos casos el hígado del paciente con PAF como injerto para un trasplante dominó. Pacientes y método: Presentamos 3 casos de trasplante secuencial cardíaco y hepático por PAF realizados en nuestro centro. Ninguno de los 3 casos presentó complicaciones intraoperatorias ni posoperatorias destacables. Resultados: Se discuten los 3 casos y la literatura médica, haciendo especial énfasis en las indicaciones del trasplante secuencial en esta situación, del trasplante dominó y el papel de la elastografía hepática en este contexto. Conclusión: En nuestra experiencia, el trasplante cardíaco y hepático realizado de forma consecutiva a un paciente con PAF es posible y seguro. Permite mantener la hemodinámica y el uso del hígado del paciente con PAF como injerto dominó, hecho fundamental, dada la escasez de injertos (AU)

Background and objective: Combined heart and liver transplantation for familial amyloid polyneuropathy (FAP) is currently the best treatment for patients with cardiomyopathy related to FAP. However, its optimal timing and the possibility of domino liver transplantation in this setting remain under discussion. Most such cases in the medical literature have been performed simultaneously, although many of them have required the use of veno-venous bypass and the majority have not used the liver as a graft for domino liver transplantation. Patients and method: We report 3 cases of non-Val30Met mutation that underwent sequential heart and domino liver transplantation at our institution. Results: We describe the 3 cases and the medical literature, with special attention to the reason for sequential heart and liver transplantation, the role of transient elastography in this setting, and the feasibility of domino liver transplantation. Conclusion: In our experience, combined heart and liver transplantation is a feasible but challenging procedure for patients with FAP. Performing the procedure sequentially rather than simultaneously seems safer and easier, both technically and hemodynamically. More importantly, such an approach allows the use of livers from FAP patients as grafts for domino liver transplantation (AU)

Complicaciones biliares tras el trasplante hepático / Biliary complications after liver transplant

Las complicaciones biliares postrasplante hepático han sido desde los incios de su historia tema de gran interés por su elevada incidencia, y su influencia en la morbi mortalidad. La fístula biliar es actualmente infrecuente, y su manejo sencillo. La estenosis anastomótica mantiene una incidencia del 10-15%. Si bien se considera que el tratamiento de elección actual es mediante CPRE, el tratamiento quirúrgico (hepaticoyeyunostomía) sigue teniendo un papel relevante. Las estenosis no-anastomóticas tienen una incidencia del 5-10%, se relacionan con factores isquémicos o inmunológicos y su tratamiento habitualmente es el retrasplante. La coledocolitiasis tiene una incidencia del 5-10%, siendo el tratamiento de elección la CPRE. Sin embargo, el tratamiento de las complicaciones biliares, deberá ser individualizado. Deberemos tener en cuenta el momento del diagnóstico, la función hepática, el estado general del paciente, y la disponibilidad y experiencia del equipo en las diferentes opciones terapéuticas (AU)

There have been biliary complications since the beginning of liver transplants, and is a topic of great interest due to its high incidence, as well as their influence on morbidity and mortality. The biliary fistula is currently uncommon and its management is straightforward. Anastomotic stenosis continues to have an incidence of 10-15%. Although the current treatment of choice is endoscopic retrograde cholangiopancreatography (ERCP), surgical treatment (hepatico-jejunostomy) continues to have an important role. Non-anastomotic stenosis has an incidence of 5-10%, and is associated with ischaemic or immunological factors, and usually involves a re-transplant. Choledocholithiasis has an incidence of 5-10%, with the treatment of choice being ERCP. However the treatment of biliary complications should be individualised. We must take into account, liver function, the general health status of the patient, and the availability and experience of the team in the different therapeutic options (AU)

Papel de la cirugía en el manejo de las complicaciones biliares tras el trasplante hepático / Role of surgery in the management of biliary complications after liver transplantation

Resumen El manejo de las complicaciones biliares (CB) postrasplante hepático ha evolucionado en los últimos años. Resumen Los objetivos de este estudio fueron, analizar la incidencia y el manejo de las CB en nuestro centro en 1.000 transplantes hepáticos; y estudiar específicamente el manejo de las estenosis anastomóticas (EA). Resultados la incidencia de CB fue del 23%. Se dieron 76 casos de fístula biliar, 106 casos de estenosis anastomóticas, 46 casos de estenosis no-anastomóticas, 42 coledocolitiasis y 19 otras complicaciones. Resultados De los 106 casos de estenosis anastomóticas, se indicó tratamiento radiológico (CPRE o CTPH) en 62 casos. En 38 casos (33%), la estenosis anastomótica se resolvió mediante tratamiento quirúrgico, en 18 tras previo tratamiento radiológico. La morbilidad y mortalidad relacionada con el tratamiento radiológico de las CB fue discretamente superior (morbilidad: Quir: 4 (18%) vs Radiol: 20 (32%); p=0,2 y mortalidad: Quir: 0% vs Radiol: 8 (11%); p=0,23).Resultados De los 46 pacientes con estenosis no anastomóticas, 29 (63%) fueron tratados mediante retrasplante. Conclusión El tratamiento quirúrgico tiene un papel relevante en el manejo de las CB postrasplante hepático, y es el tratamiento de elección en algunos casos de estenosis anastomóticas. El retrasplante, sin manipulación previa, es el tratamiento de elección en los pacientes con estenosis no anastomóticas (AU)

Abstract Management of biliary tract complications (BTC) after liver transplantation (LT) has progressed in recent years. The aims of this study were, to analyse the incidence and management in our institution of BTC after 1000LT; and to study the management of patients with anastomotic strictures (AS). Results The incidence of BTC was 23%. There were 76 cases of bile leak, 106 cases of anastomotic strictures, 46 non-anastomotic strictures, 42 choledocolithiasis and 19 other complications. Results Among 106 cases of anastomotic strictures, radiological treatment, either PTC or ERCP, was initially indicated in 62. The AS of 38 patients (33%) were resolved with surgical treatment, 18 of them after a previous attempt at radiological treatment. Patients who were treated initially by radiologically required more procedures. Morbidity and mortality related to BTC were slightly higher in the group of patients treated by radiology (morbidity: surgical: 4 (18%) vs. radiological: 20 (32%); p=0.2 and mortality: surgical: 0% vs. radiological: 8 (11%); p=0.23).Results Among 46 patients with non-anastomotic strictures, 29 were resolved with retransplantation (63%). Conclusions Surgery has a significant role in the management of BTC, and is the treatment of choice in some cases of anastomotic strictures. Retransplantation may be the preferred option in patients with non-anastomotic strictures (AU)