Hepatocellular Carcinoma in Ceará: Epidemiology and Treatment in a Reference Liver Transplant Center in Northeast Brazil.

Hepatocellular carcinoma remains a significant worldwide malignancy and an important cause of cancer-related death. The incidence is increasing globally. In Latin America, there is no consistent data on the epidemiology of hepatocellular carcinoma. However, Brazil is considered a country with an intermediate incidence of this liver neoplasm. In the state of Ceará, situated in the northeast region of Brazil, there are no consistent clinical and epidemiologic data on the actual incidence and the treatment of hepatocellular carcinoma. The purpose of this article is to describe epidemiologic characteristics and treatment forms of patients with hepatocellular carcinoma who were treated in a Liver Transplant Center. A retrospective observational study was conducted using the database from the register of 299 patients with hepatocellular carcinoma between June 2004 and February 2022. Only patients born in Ceará were included. Therefore, most patients were eligible, based on the Milan Criteria, to undergo liver transplantation with a Model End Stage Liver Disease score of 12.48 ± 4.66 points, and the waiting list time was approximately 7 months with 8.7% hepatocellular carcinoma recurrence after liver transplant. A total of 38.5 % of cases were outside the Milan criteria at the time of cancer diagnosis, and transarterial chemoembolization was the main treatment choice. In conclusion, the diagnosis of hepatocellular carcinoma in Ceará mainly occurs in male patients with hepatitis C or alcoholism, with a mean age of 61.55 years and a previous diagnosis of liver disease. Liver transplantation was the best curative therapeutic form in patients with cirrhosis and hepatocellular carcinoma in Ceará, where a significant number of patients were diagnosed with intermediate and advanced-stage hepatocellular carcinoma, so public health policies are important for the screening and monitoring of liver disease.

Chikungunya Infection in Solid Organ Transplant Recipients.

BACKGROUND: Chikungunya virus (CHIKV) is an emerging mosquito-borne disease that causes acute febrile polyarthralgia and arthritis. CHIKV has spread rapidly to the Americas and, in Brazil, autochthonous cases are increasingly been reported. Solid organ transplant (SOT) recipients who travel to or live in CHIKV endemic areas are under high risk of acquiring the disease. Few data exist regarding the clinical characteristics of CHIKV infections in this population. We report the first case series of CHIKV infection in SOT recipients. METHODS: We retrospectively evaluated 13 cases of CHIKV infection in SOT recipients between January 2016 and December 2016 confirmed by laboratory tests and transplanted in the Renal and Liver Transplant Units of Walter Cantídio University Hospital from Federal University of Ceará. RESULTS: Positive CHIKV serology (enzyme-linked immunosorbent assay immunoglobulin M) was found in all patients (9 kidney and 4 liver transplant recipients). All of these patients had been living in endemic areas for dengue and CHIKV in the past months before the illness. The mean time between transplantation and CHIKV infection was of 7.2 years. Fever presented in 11 (84.6%) patients and 5 (38.5%) presented with a maculopapular rash. All cases had joint symptoms: 11 (84.6%) with symmetrical and peripheral polyarthralgia/polyarthritis and 2 (15.3%) with monoarthralgia/monoarthritis. Six (46%) patients had a joint complaint that lasted 3 months. Two patients had concomitant positive dengue serology (enzyme-linked immunosorbent assay immunoglobulin M). There were no cases of complications or deaths. CONCLUSION: SOT with CHIKV infection seems to have a clinical presentation and evolution similar to those seen in the general population, with no apparent damage to the graft.

L-Alanyl-Glutamine Attenuates Oxidative Stress in Liver Transplantation Patients.

BACKGROUND: Ischemia/reperfusion injury during liver transplantation can cause severe damage to the graft. The objective of this randomized, double-blind study was to evaluate the possible protective effects of L-alanyl-glutamine on the liver graft. METHODS: The sample included 33 patients from a liver transplantation service in Northeastern Brazil. Before cold ischemia, the patients received 50 g of L-alanyl-glutamine (treatment group) or saline (control group) through the portal vein. The graft was biopsied at the time of recovery, at the beginning of warm ischemia, and at the end of transplantation to determine malondialdehyde (MDA), heat-shock protein (Hsp)70, nuclear factor kappa-beta (NFkB), superoxide dismutase (SOD), and reduced glutathione (GSH) levels. RESULTS: The blood parameters were similar in the two groups. In the treatment group, MDA did not increase at the beginning of cold ischemia and decreased at the end of transplantation. This phenomenon was not observed in the control group. GSH, SOD, Hsp70, and NFkB levels were similar in the two groups. CONCLUSIONS: Our findings suggest that preconditioning with L-alanyl-glutamine attenuates the effects of ischemia/reperfusion-related oxidative stress and reduces lipid peroxidation in the grafts of liver transplantation patients.

Ten-year experience with liver transplantation for hepatocellular carcinoma in a Federal University Hospital in the Northeast of Brazil.

Hepatocellular carcinoma (HCC) is the most frequent and important primary liver tumor, with annual worldwide incidence of over 1 million cases, accounting for at least 500,000 deaths per year. The majority of cases of HCC occur in the setting of liver cirrhosis. In this retrospective, descriptive, and analytical study, between May 2002 and April 2012, 664 liver transplantations (LT) were conducted at a Federal University Hospital in the Northeast of Brazil, among which 140 LT were performed in patients with HCC. The tumor was more frequent in men with an average age of 56 years and infected with hepatitis C virus, many with a history of alcohol abuse. Alpha-fetoprotein was not useful in the diagnosis, and imaging methods have failed to diagnose the nodules in 19 patients (13.6%). Transarterial chemoembolization was the most-used bridging therapy to inhibit tumor growth for patients with HCC eligible for transplantation. The implementation of the Model for End Stage Liver Disease score in 2006 brought benefits to these patients. The rate of HCC recurrence after LT was 8.57% and occurred more often in the first 2 years after transplantation, with the liver graft being the most common site. Significant risk factors for recurrence were a long time on the LT waiting list, number of liver nodules over 3.5, and the presence of vascular invasion. In conclusion, LT for HCC leads to excellent long-term survival, with relatively few patients dying from tumor recurrence.

Orthotopic liver transplantation for hepatocellular carcinoma: one center's experience in the Northeast of Brazil.

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world and the third leading cause of cancer-related death. In this study, we sought to assess the outcome of patients with HCC who underwent orthotopic liver transplantation (OLT) in a center in the northeast of Brazil. Between May 2002 and July 2008, 294 OLTs were performed at our center. In 45 patients, HCC was confirmed by histological examination of the explant. Patients were predominantly men of ages ranging from 14-67 years. Hepatitis C virus was involved in 55.4% of the cases. Alpha fetoprotein (AFP) levels were normal in 65.2% of the patients and surpassed 100 ng/mL in only 10.4%. The median waiting time on the list was 10 months. Seventeen patients (37.7%) presented a solitary nodule, 19 (42.2%) had 2 or 3 nodules, and 9 patients (20%) had more than 3 nodules. The maximal diameter of the largest tumor was <3 cm in 26 patients (57.7%) and exceeded 5 cm in 6 patients (13.3%). Ten tumors were well differentiated, 32 were moderately differentiated, and 3 were poorly differentiated. Eleven tumors showed microvascular invasion. There have been 4 tumor recurrences. There was an association between microvascular invasion and tumor recurrence with a statistically significant relative risk. In conclusion, OLT is an excellent option for patients with HCC. The recurrence rate was low (<10%). However, we believe that more prospective studies are needed about OLT beyond the Milan criteria because our study suggested that microvascular invasion may be more important than tumor size or number.

Continuous versus interrupted suture for hepatic artery anastomosis in liver transplantation: differences in the incidence of hepatic artery thrombosis.

BACKGROUND: Hepatic artery thrombosis (HAT) is a serious complication after orthotopic liver transplantation (OLT) and remains a significant cause of graft loss. HAT following OLT has been reported in 3% to 9% of patients. Among the surgical factors considered to be associated with HAT, arterial reconstruction might be the most important. The goal of this study was to compare the incidence of HAT between interrupted suture (IS) and continuous suture (CS) techniques during hepatic artery reconstruction in liver transplantation. METHODS: We performed a retrospective analysis of 200 consecutive liver transplantations occurring between May 2002 and December 2006, including medical records for: age, gender, cold ischemic time, warm ischemic time, type and number of arterial anastomosis. Hepatic artery anastomoses were performed using a 7-0 prolene with a running CS in the first 105 patients (CS group), and with an IS in the last 95 patients (IS group). RESULTS: Statistical analysis of age, gender, cold and warm ischemia time, and number of hepatic artery anastomoses was not different between the CS and IS groups. Eleven episodes of HAT were identified in the CS group (10%) and two episodes (2%) in the IS cohort, a significant difference (P = .0173). CONCLUSIONS: Our results suggested that IS might be a better choice for hepatic artery anastomosis with a lower incidence of HAT.

A new biliodigestive anastomosis technique after hepatic artery thrombosis as bridge to liver retransplantation: a case presentation.

Arterial complications after liver transplantation are frequent. Hepatic artery thrombosis (HAT) is usually associated with biliary complications. Herein we have reported a case of a patient who was admitted for jaundice, itch, and elevated aspartate aminotransferase and alanine aminotransferase levels at 6 weeks after liver transplantation. HAT associated with a biloma was diagnosed and an urgent operation performed requiring a new biliodigestive anastomosis technique. Fourteen months after the first transplant, the patient was retransplanted. The operation performed may be an alternative to treat biliary complications due to late HAT.

Domino liver transplantation with double piggyback: is this the best technique? A case report.

Sequential or domino liver transplantation is a well-established procedure for patients with familial amyloidotic polyneuropathy (FAP). Donation for domino liver transplantation imposed the resection of the inferior vena cava along with the liver, requiring complete suprarenal vena cava clamping and usually the use of venovenous bypass. We describe a successful case in which it was possible to perform the FAP hepatectomy by the piggyback technique.

Evaluation of hepatic function after orthotopic liver transplantation: a comparative study using Belzer and Collins solutions.

Belzer and Collins are solutions used in liver transplantation. The purpose of this study was to compare liver function after utilization of two different schemes of graft preservation using both solutions. Between December 2004 and September 2005, 43 liver transplantations were performed. Twenty-three of these used 2 L of Collins solution and 2 L of Belzer solution as the preservation solution. The others used three L of Collins and 1 L of Belzer solution as the preservation solution. The cold ischemia time of both groups was similar. We analyzed liver function using the serum ALT, AST, bilirubin and international normalized ratio. On the first day after the transplantation, the level of international normalized ratio of the group of patients that used 1 L of Belzer was significantly higher than the other group (P<.05). The levels of ALT, AST, and bilirubin were not different on day 7 after transplantation. We concluded that using only 1 L of Belzer solution is as efficient with the advantage that it is less expensive.