Understanding the Elevated Lethality of COVID-19 in Liver Transplant Recipients: Does Immunosuppression Management Matter? Results from a Brazilian Multicentric Historical Cohort.

BACKGROUND: Infections by SARS-CoV-2 in liver transplant recipients (LT) patients are of particular concern, notably due to perceived added risks related to immunosuppression and comorbidity burden. Current literature on this topic often relies on small, non-standardized, and geographically limited studies. This manuscript describes COVID-19 presentations and causes for elevated mortality in a large cohort of LT recipients. METHODS: This study was designed as a multicentric historical cohort, including LT recipient patients with COVID-19 in 25 study centers, with the primary endpoint being COVID-related death. We also collected demographic, clinical, and laboratory data regarding presentation and disease progression. RESULTS: Two hundred and thirty-four cases were included. The study population was predominantly male and White and had a median age of 60 years. The median time from transplantation was 2.6 years (IQR 1-6). Most patients had at least one comorbidity (189, 80.8%). Patient age (P = .04), dyspnea (P < .001), intensive care unit admission (P < .001), and mechanical ventilation (P < .001) were associated with increased mortality. Modifications of immunosuppressive therapy (P < .001), specifically the suspension of tacrolimus, maintained significance in multivariable analysis. CONCLUSIONS: Attention to risk factors and the individualization of patient care, especially regarding immunosuppression management, is crucial for delivering more precise interventions to these individuals.

Outcomes after pancreas retransplantation: is the juice worth the squeeze?

PURPOSE OF REVIEW: Pancreas retransplantations are rarely carried out, and their outcomes are still debatable because of a lack of studies and clinical series on this issue. RECENT FINDINGS: In general, pancreas retransplantations achieve similar or even higher patient survival than primary transplantations; however, it should be noted that this finding may be biased, as only healthier patients are selected for retransplantation. Graft survival in retransplantations is usually lower than that in primary transplantation, but this comparison may also be biased, as most retransplantations are solitary pancreas transplantations (which are known to have lower graft survival), whereas primary transplantations are mostly simultaneous kidney-pancreas transplantations. Technical loss is similar between primary pancreas transplantations and pancreas retransplantations, but the occurrence of surgical complications is greater in the latter. SUMMARY: This review summarizes the literature on pancreas retransplantations, comparing them with primary transplantations, and demonstrates that in selected patients in experienced centres, retransplantation can be a valid and effective option for returning the patient to an insulin-free state.

Renal autotransplantation to treat renal artery aneurysm: case report / Autotransplante renal para tratamento de aneurisma de artéria renal: relato de caso

CONTEXT: Renal artery aneurysm (RAA) is uncommon and usually asymptomatic, but complications like rupture or thromboembolism of the aneurysm can occur, with consequent renal infarction. Most of the clinical findings are found incidentally through imaging examinations, in investigating other diseases. Renal autotransplantation (RAT) is an alternative treatment for complex RAA, with satisfactory results described in the literature. CASE REPORT: The patient was a 48-year-old man with a history of systemic arterial hypertension, thrombocytopenia and advanced hepatosplenic schistosomiasis. He complained of right lumbar pain, which was investigated through imaging examinations (computed tomography and angiotomography). These revealed right RAA of 2.5 cm in diameter. Evaluation by the vascular surgery team found that this was untreatable using endovascular methods. The treatment performed was open right nephrectomy with kidney preservation in solution, followed by aneurysmectomy, suturing of the injured artery and kidney reimplantation in the right iliac fossa with anastomosis of the iliac vessels and ureter. The durations of the surgery and kidney ischemia were 385 and 140 minutes, respectively. The patient was discharged on the 20th postoperative day, with creatinine concentration of 1.4 mg/dL, urea 41 mg/dL, urine volume 1400 mL/24 h and ascites treated with diuretics. CONCLUSION: RAT is indicated basically in three situations: extracorporeal reconstruction of complex aneurysms of the renal pedicle, extensive ureteral injury, and conservative kidney cancer surgery in patients with a single kidney. This study presents a case of a patient with advanced liver disease and RAA that was untreatable using endovascular methods and was successfully treated using RAT. .

CONTEXTO: O aneurisma de artéria renal (AAR) é incomum e, em geral, assintomático, mas podem ocorrer complicações como rotura ou embolia de trombos do aneurisma com consequente infarto renal. A maioria dos achados clínicos é encontrada acidentalmente por exames de imagem na investigação de outras doenças. O autotransplante renal (ATR) constitui-se em alternativa de tratamento de AAR com resultados satisfatórios descritos na literatura. RELATO DE CASO: Paciente masculino, 48 anos, com histórico de hipertensão arterial sistêmica, plaquetopenia e esquistossomose hepatoesplênica avançada. Referia dor lombar direita que após exames de imagem (tomografia computadorizada e angiotomografia) revelou AAR direita com 2,5 cm de diâmetro não tratável por via endovascular após avaliação da equipe de cirurgia vascular. O tratamento realizado foi uma nefrectomia aberta direita com preservação renal em solução, seguida de aneurismectomia, sutura da artéria lesada e reimplante do rim na fossa ilíaca direita com anastomoses dos vasos ilíacos e do ureter. O tempo cirúrgico e de isquemia renal foram de 385 e 140 minutos, respectivamente. Recebeu alta hospitalar no vigésimo dia do pós-operatório, com concentrações de creatinina de 1,4 mg/dL, ureia de 41 mg/dL, volume urinário de 1400 mL/24 h e ascite tratada com diuréticos. CONCLUSÃO: O ATR está indicado basicamente em três casos: reconstrução extracorpórea de aneurismas complexos do pedículo renal, lesão ureteral extensa e cirurgia conservadora de câncer renal em pacientes com único rim. Este estudo apresenta caso de paciente com doença hepática avançada e AAR intratável por método endovascular e tratado com sucesso por ATR. .

Renal autotransplantation to treat renal artery aneurysm: case report.

CONTEXT: Renal artery aneurysm (RAA) is uncommon and usually asymptomatic, but complications like rupture or thromboembolism of the aneurysm can occur, with consequent renal infarction. Most of the clinical findings are found incidentally through imaging examinations, in investigating other diseases. Renal autotransplantation (RAT) is an alternative treatment for complex RAA, with satisfactory results described in the literature. CASE REPORT: The patient was a 48-year-old man with a history of systemic arterial hypertension, thrombocytopenia and advanced hepatosplenic schistosomiasis. He complained of right lumbar pain, which was investigated through imaging examinations (computed tomography and angiotomography). These revealed right RAA of 2.5 cm in diameter. Evaluation by the vascular surgery team found that this was untreatable using endovascular methods. The treatment performed was open right nephrectomy with kidney preservation in solution, followed by aneurysmectomy, suturing of the injured artery and kidney reimplantation in the right iliac fossa with anastomosis of the iliac vessels and ureter. The durations of the surgery and kidney ischemia were 385 and 140 minutes, respectively. The patient was discharged on the 20th postoperative day, with creatinine concentration of 1.4 mg/dL, urea 41 mg/dL, urine volume 1400 mL/24 h and ascites treated with diuretics. CONCLUSION: RAT is indicated basically in three situations: extracorporeal reconstruction of complex aneurysms of the renal pedicle, extensive ureteral injury, and conservative kidney cancer surgery in patients with a single kidney. This study presents a case of a patient with advanced liver disease and RAA that was untreatable using endovascular methods and was successfully treated using RAT.

Experience with 53 portal-duodenal drained solitary pancreas transplants.

Systemic-enteric drainage is currently the most common technique for pancreas transplantation (PT). A novel alternative technique, portal-duodenal drainage (PDD), has potential physiological benefits and provides improved monitoring of the pancreatic graft. The current study describes 53 solitary PT procedures (43 pancreas after kidney and 10 pancreas transplant alone) using the PDD technique over the last three yr. This method resulted in one-yr patient survival at 96% and 83% graft survival. There were five cases (9.4%) of thrombosis, in which transplantectomy and two-layer closure of the native duodenum were performed. No fistulas were observed. Here, we demonstrate that the PDD technique in PT was as safe and effective as current techniques in clinical use.

Liver transplantation for neotropical polycystic echinococcosis caused by Echinococcus vogeli: a case report.

Neotropical polycystic echinococcosis (NPE) is a parasitic disease caused by cestodes of Echinococcus vogeli. This parasite grows most commonly in the liver, where it produces multiples cysts that cause hepatic and vessel necrosis, infects the biliary ducts, and disseminates into the peritoneal cavity, spreading to other abdominal and thoracic organs. In cases of disseminated disease in the liver and involvement of biliary ducts or portal system, liver transplantation may be a favorable option. We present a report of the first case of liver transplantation for the treatment of advanced liver NPE caused by E. vogeli.

Liver transplantation for neotropical polycystic echinococcosis caused by Echinococcus vogeli: a case report

Neotropical polycystic echinococcosis (NPE) is a parasitic disease caused by cestodes of Echinococcus vogeli. This parasite grows most commonly in the liver, where it produces multiples cysts that cause hepatic and vessel necrosis, infects the biliary ducts, and disseminates into the peritoneal cavity, spreading to other abdominal and thoracic organs. In cases of disseminated disease in the liver and involvement of biliary ducts or portal system, liver transplantation may be a favorable option. We present a report of the first case of liver transplantation for the treatment of advanced liver NPE caused by E. vogeli.

Over 500 pancreas transplants by a single team in São Paulo, Brazil.

Pancreas transplantation (PT) remains a developing practice in Latin America. From 1996 to 2009, 506 PTs were performed by our team in the following categories: simultaneous pancreas-kidney (SPK), simultaneous deceased donor pancreas and living-donor kidney (SPLK), pancreas after kidney (PAK), and pancreas transplant alone (PTA). Enteric drainage was preferred for SPK and bladder drainage for solitary PT or SPLK. Immunosuppression was with tacrolimus, mycophenolate mofetil, and steroids, and anti-lymphocytic drugs were used to induce solitary PT and SPLK. The series includes 254 SPK, 60 SPLK, 94 PAK, and 98 PTA. The one-yr patient survivals were 82% for SPK, 90% for SPLK, 95% for PTA, and 93% for PAK. The one-yr pancreas graft survivals were 70% for SPK, 86% for SPLK, 86% for PAK, and 77% for PTA. The one-yr kidney graft survivals were 77.5% for SPK and 89% for SPLK. This represents the largest reported PT series in Latin America. Results comparable to those of developed countries were achieved, with the exception of the SPK category. This has led our program to prioritize solitary PT and SPLK.

Expanding postmortem donor pool using steatotic liver grafts: a new look.

BACKGROUND: Clinical demand for liver transplant steadily grows while organs offer has reached a plateau years ago. To expand the donor liver pool, various options have been considered including acceptance of suboptimal donors and steatotic grafts, with a risk of poorer outcomes. The latter risk and its relation to the grade of liver graft steatosis have been studied in this prospective clinical study. METHODS: One hundred eighteen consecutive liver transplantation (115 patients) performed between May 2002 and March 2008 were prospectively analyzed. According to the grade of steatosis on a 2 hr postreperfusion biopsy, four groups were considered: absence (<5%) (n=34), mild (<30%) (n=40), moderate (30%-60%) (n=23), or severe steatosis (> or = 60%) (n=21). Donors and recipients demographic data, and patients and grafts survival rates were compared among the four groups. RESULTS: Eighty-four (71%) grafts presented some degree of steatosis (macrosteatosis: 19.5%, microsteatosis: 47%, mix type: 33.5%). Patient and graft survival were significant lower in the "severe steatosis" group, as a whole. Grafts with less than 30% predominant macro-, or microsteatosis also had poorer outcomes with lower patient and graft survival rates. CONCLUSION: Steatotic liver grafts were used on a large scale (71%) in this clinical series. The analysis confirms that using grafts with moderate (>30%) and severe steatosis (>60%) have a negative impact on outcomes. The authors conclude that using these grafts allow a significant increase in organ offer that counterbalances the negative outcome for patients who are not offered a transplant, and this supports the need for further clinical research.

Derivação esplenorrenal distal com a interposição de enxerto de veia mesentérica inferior: Relato de caso / Use of inferior mesenteric vein as an interposition graft for distal renal shunt: case report

Hemorragia digestiva alta por ruptura de varizes esofágicas é uma gravecomplicação da hipertensão portal em pacientes cirróticos. Quando osangramento está associado à trombose venosa portal, os procedimentosendoscópicos ou anastomose (shunt) portossistêmica intra-hepáticatransjugular (TIPS) são difíceis e menos eficientes. Nesta situação, aanastomose esplenorrenal distal é uma boa alternativa. O objetivo é discutiruma anastomose esplenorrenal distal com a utilização de enxerto autólogode veia mesentérica inferior. Relatamos o caso de um paciente do sexomasculino, 52 anos, portador de cirrose hepática alcoólica e trombosede veia porta. Evoluiu com nove episódios de hemorragia digestiva alta,apesar do tratamento endoscópico. Como sua função hepática permaneciaboa, a anastomose esplenorrenal distal foi considerada a melhor opção terapêutica. Foi realizada uma anastomose esplenorrenal distal, cominterposição de enxerto autólogo de veia mesentérica inferior, em virtudede eventos inesperados durante a dissecção da veia esplênica. Nãoocorreram complicações pós-operatórias.

Upper digestive bleeding due to rupture of esophageal varices is asevere complication of portal hypertension in cirrhotic patients. Whenit is associated with portal vein thrombosis, transjugular intrahepaticportosystemic shunt or endoscopic procedures are difficult and lesseffective. In this situation, splenorenal shunt is a good alternative.The aim was to discuss a distal splenorenal shunt with autologousinferior mesenteric vein graft. We report a case of a male patient, 52years old, suffering from alcoholic hepatic cirrhosis and portal veinthrombosis. He had nine episodes of upper digestive bleeding, in spiteof endoscopic treatment. His hepatic function remained good and distalsplenorenal shunt was chosen as the best therapeutic option. Theinferior mesenteric vein was used as an interposition graft for distalrenal shunt due to unexpected events during splenic vein dissection.Postoperative recovery went uneventfully.

Retransplante de pâncreas solitário: Estudo de 22 casos / Solitary pancreas retransplant: Study of 22 cases

O objetivo deste trabalho foi apresentar a experiência dos autores com retransplante de pâncreas em pacientes previamente submetidos a transplantesimultâneo de pâncreas-rim, transplante de pâncreas após rim, e transplante de pâncreas isolado. Entre janeiro/1996 adezembro/2005 foram realizados 330 transplantes de pâncreas, sendo 308 transplantes primários e 22 (6%) retransplantes de pâncreas solitário. Foram analisados: a idade dos pacientes; o tempo médio decorrido entre o 1º e o 2º transplantes; as causasde perda do primeiro enxerto; as características técnicas do transplante e do retransplante e os critérios de seleção dos doadores para a captação de pâncreas para o retransplante.Resultados: A idade média dos pacientes foi de 34,3 anos e o tempo médio decorrido entre os transplantes foi de 19,3 meses. As causas de perda do primeiro enxerto pancreático foram:trombose venosa em 8 (35%), arterial em 5 (23%), rejeição crônicaem 4 (18%), lesão de isquemia reperfusão em 2, pancreatite derefluxo em 1, não função primária em 1 e sepse em 1 caso. Em 16 (72%) casos, o segundo transplante foi realizado na mesma fossa ilíaca do anterior. A drenagem venosa foi realizada na veia ilíaca em 16 (72%), veia cava inferior em 5 (22%) e veia porta em 1 caso.A drenagem foi exócrina vesical em 18 (82%) e entérica em 4 (18%) casos. O esquema de imunossupressão foi quádruplo seqüencial em todos os casos, com uso de antilinfocítico, tacrolimus, micofenolato mofetil e esteróides. Houve apenas um óbito devido a sepse, com sobrevidas em 1 ano de paciente eenxerto de 95% e 85%, respectivamente. Não houve risco adicional quando a retirada do enxerto primário foi feita no momento doretransplante. O retransplante de pâncreas foi tecnicamente possível em todos os casos e propiciou resultadossemelhantes ao transplante primário de pâncreas.

Worth continuing doing ex situ liver graft splitting? A single-center analysis.

Grafts for split liver transplantation can be prepared in situ during the retrieval operation, or ex situ on the back table. The in situ technique has theoretical advantages because it minimizes the cold ischemic time and allows excellent hemostasis at the cut surface. However, in situ liver division prolongs the retrieval procedure, may precipitate hemodynamic instability in the donor, and may cause logistical difficulties for some centers. This report is a single-center analysis comparing results of ex situ liver division (group I: 1992-97; and group II: 1998-2001) before and after a new protocol for liver graft division was introduced in our center. Eighty-nine split liver transplants (SLT) were reviewed retrospectively. Vascular complications were less common in group II (3.3% vs. 20%; p = 0.04), and 1-year graft survival increased from 59% to 78% (p = 0.03). Since 1998, 1-year graft survival of SLT has been similar to that of conventional liver graft transplantation in our center (78% and 74%, respectively). In conclusion, good results can be achieved from splitting livers ex situ and this procedure should be considered when the in situ technique is not feasible.

Ex situ preparation of left split-liver grafts with left vascular pedicle only: is it safe? A comparative single-center study.

The procurement of left-lateral-segment grafts from living donors for transplantation in children is performed by retaining only the left branches of the artery and veins. New techniques and the implementation of microsurgery in the transplant operation made this procedure a successful approach. However, controversy persists about using such an approach for division of liver grafts from cadaveric donors, and many teams prefer retaining the main arterial trunk with the left split graft, with or without the main portal vein trunk. Since 1998, in our center, when a donor-liver graft is divided we prefer retaining the main vessels with the right split graft if graft vascular anatomy is favorable. After 1998, 40 liver grafts from cadaveric donors were divided, and all divisions were performed ex situ. This experience was retrospectively reviewed to compare the outcome of left split grafts prepared for implantation with the left vasculature only (group A), or with the main arterial supply (group B). A single vascular complication occurred (one hepatic artery thrombosis in group B). Three patients died (one in group A and two in group B) and three other grafts were lost (one in group A and two in group B). One-year and 3-year graft survival rates were 94% and 86% in group A, and 83% and 83% in group B, respectively (not significantly [NS] different). We conclude that left split grafts can be safely transplanted with the left vascular supply only, provided that division is guided by careful anatomical evaluation and that vascular reconstructions are adequate.

Hepatic vein reconstruction in ex situ split-liver transplantation.

BACKGROUND: Anatomy of the left hepatic vein (LHV) was studied in a series of 53 consecutive cadaveric liver grafts that were divided for transplantation. METHODS: All divisions were performed ex situ and provided a left split graft with only the LHV as the hepatic outflow. The anatomy was categorized into three types: (A) single LHV trunk, (B) two veins closely merging toward the median hepatic vein, or (C) a double outflow. RESULTS: Direct implantation of the graft was performed in type A and was possible in type B after simple plasty of the ostia to create a single orifice. In type C, a venous jump graft could be interposed at bench work to allow direct anastomosis into the recipient. There were no related complications, except one type A case with late outflow obstruction. CONCLUSION: Liver division can be performed safely in liver grafts with variant LHV anatomy, if appropriate techniques for reconstruction are used. Also ex situ liver division has the advantage of allowing a detailed anatomic evaluation before dividing LHV: reconstruction can be performed ex situ, allowing a single-step direct anastomosis in the recipient, thus shortening suturing time.

Adesäo à terapêutica de reposiçäo hormonal no climatério: experiência no ambulatório de menopausa - UNICAMP / Compliance with hormonal replacement therapy in climateric women: experience of menopause clinic - UNICAMP

A adesao à TRH é um ponto crucial no tratamento de mulheres pós-menopausadas e climatéricas, já que os efeitos benéficos dos hormônios podem ser afetados ou mesmo perdidos se as mulheres nao mantiverem o tratamento. Apesar da relevância do assunto, poucas avaliaçoes têm sido realizadas neste sentido. O objetivo deste estudo foi avaliar o esquema de reposiçao hormonal e a adesao ao tratamento, no Ambulatório de Menopausa do CAISM/UNICAMP. Foi avaliado, retrospectivamente, o comportamento de 127 pacientes desta clínica diante da TRH durante o ano de 1992. A média etária das pacientes foi de 5O,6 anos (+ 7,4). O regime de reposiçao hormonal mais utilizado foi a associaçao de estrogênios e progestogênios de forma cíclica. A adesao à TRH nao foi afetada pelo tipo de esquema utilizado e foi considerada alta (86 por cento), talvez devido à assistência multiprofissional e à seleçao das pacientes, uma vez que, de 224 pacientes admitidas no Ambulatório, somente 127 (56,7 por cento) receberam TRH.