RESUMEN
Neurological complications (NCs) can frequently and significantly affect morbidity and mortality of liver transplant (LT) recipients. We analysed incidence, risk factors, outcome and impact of the immunosuppressive therapy on NC development after LT. We analysed 478 LT in 440 patients, and 93 (19.5%) were followed by NCs. The average LOS was longer in patients experiencing NCs. The 1-, 3- and 5-year graft survival and patient survival were similar in patients with or without a NC. Multivariate analysis showed the following as independent risk factors for NC: a MELD score ≥20 (OR = 1.934, CI = 1.186-3.153) and an immunosuppressive regimen based on calcineurin inhibitors (CNIs) (OR = 1.669, CI = 1.009-2.760). Among patients receiving an everolimus-based immunosuppression, the 7.1% developed NCs, vs. the 16.9% in those receiving a CNI (P = 0.039). There was a 1-, 3- and 5-year NC-free survival of 81.7%, 81.1% and 77.7% in patients receiving a CNI-based regimen and 95.1%, 93.6% and 92.7% in those not receiving a CNI-based regimen (P < 0.001). In patients undergoing a LT and presenting with nonmodifiable risk factors for developing NCs, an immunosuppressive regimen based on CNIs is likely to result in a higher rate of NCs compared to mTOR inhibitors.
Asunto(s)
Inhibidores de la Calcineurina/efectos adversos , Everolimus/efectos adversos , Terapia de Inmunosupresión/efectos adversos , Inmunosupresores/efectos adversos , Trasplante de Hígado , Enfermedades del Sistema Nervioso/inmunología , Complicaciones Posoperatorias/inmunología , Adulto , Anciano , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Enfermedades del Sistema Nervioso/epidemiología , Enfermedades del Sistema Nervioso/etiología , Evaluación de Resultado en la Atención de Salud , Complicaciones Posoperatorias/epidemiología , Prevalencia , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND & AIMS: The model for end-stage liver disease (MELD) is used for organ allocation in liver transplantation (LT), but its prognostic performance is less accurate in patients with low score. We assess the outcome of patients with MELD < 18 awaiting LT, finding prognostic variables to identify a high dropout risk. METHODS: Training set consisted of 277 patients and validation cohort of 292 patients. Competing risk regression analysis, taking into account LT, was used for univariate/multivariate analysis. RESULTS: Ascites, sodium, bilirubin, albumin and glomerular filtration rate were independently associated with a 12-month dropout risk in the training set. Combining these five prognostic parameters, we calculated a new score named liver-renal-risk (LIRER). In the validation set, the 12-month LIRER concordance index showed a discrimination power [0.798, 95% confidence interval (95% CI) 0.793-0.803] better than MELD (0.582, 95% CI 0.575-0.588), Child-Turcotte-Pugh (0.687, 95% CI 0.681-0.693), MELD-sodium (0.721, 95% CI 0.715-0.727) and MELD-ascites-sodium (0.729, 95% CI 0.724-0.735), with a remarkable calibration (Hosmer-Lemeshow test: P = 0.91; R(2) = 0.911). Considering all study patients, the risk of wait list dropout increased with the rise in LIRER. The survival benefit analysis comparing the wait list dropout risk with the mortality of the 216 transplanted patients with same LIRER showed an important benefit for LT in patients with LIRER > 15.9. CONCLUSIONS: In patients with low MELD (<18), combination of ascites, sodium, albumin, bilirubin and renal function in a new score (LIRER) discriminates patients at high risk of medium-term adverse outcome from those in whom LT may be safely deferred.
Asunto(s)
Enfermedad Hepática en Estado Terminal/cirugía , Cirrosis Hepática/complicaciones , Trasplante de Hígado/normas , Modelos Teóricos , Medición de Riesgo/métodos , Índice de Severidad de la Enfermedad , Ascitis/patología , Bilirrubina/sangre , Estudios de Cohortes , Enfermedad Hepática en Estado Terminal/etiología , Tasa de Filtración Glomerular/fisiología , Humanos , Trasplante de Hígado/métodos , Valor Predictivo de las Pruebas , Pronóstico , Análisis de Regresión , Albúmina Sérica , Sodio/sangre , Listas de EsperaRESUMEN
BACKGROUND & AIMS: Salvage liver transplantation (SLT) is an attractive sequential strategy which combines liver resection (LR) for hepatocellular carcinoma (HCC), followed by liver transplant (LT) in the event of HCC recurrence or progressive liver deterioration. To compare the long-term results of SLT with primary liver transplant (PLT). METHODS: Between 2000 and 2011, 125 patients (72 transplantable) underwent LR and 226 underwent LT in our unit. The outcome of SLT was analysed in a two-step fashion: firstly, SLT (n = 28) was compared with PLT (n = 198), secondly an intention-to-treat analysis was performed on all transplantable HCC patients who underwent LR (LRT group = 72) compared to PLT (n = 198). RESULTS: The five-year overall survival (OS) was 65.4% vs. 49.2% (P = 0.63), and disease-free survival (DFS) was 89.7% vs. 80.6% (P = 0.31) for PLT and SLT respectively. Predictive factors for DFS after LT included HCC total diameter [hazard ratio (HR) 1.29 P = 0.003], alpha-foetoprotein (HR 1.002 P < 0.001) and number of HCC nodules (HR 1.317 P = 0.035), whereas viral hepatitis C positivity (HR 1.911 P = 0.03) and outside Up-to-seven criteria (HR 2.652 P < 0.001) were negative independent prediction factors of OS. Intention-to-treat analysis showed that OS at 5 years was improved in PLT vs. LRT (LRT n = 72 including SLT plus LR group) and was 69.4% vs. 42.2% (P < 0.004), with an additional increase in DFS (89.2% vs. 54.5% respectively P < 0.001). CONCLUSION: Salvage liver transplantation is a safe treatment strategy, as it does not impair long-term survival. At intention-to-treat analysis, PLT showed improved survival compared with LRT.
Asunto(s)
Carcinoma Hepatocelular/cirugía , Hepatectomía , Neoplasias Hepáticas/cirugía , Trasplante de Hígado , Terapia Recuperativa , Anciano , Anciano de 80 o más Años , Carcinoma Hepatocelular/metabolismo , Carcinoma Hepatocelular/mortalidad , Progresión de la Enfermedad , Supervivencia sin Enfermedad , Estudios de Factibilidad , Femenino , Hepatectomía/efectos adversos , Hepatectomía/mortalidad , Humanos , Análisis de Intención de Tratar , Italia , Estimación de Kaplan-Meier , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/patología , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/mortalidad , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia , Modelos de Riesgos Proporcionales , Reoperación , Factores de Riesgo , Terapia Recuperativa/efectos adversos , Terapia Recuperativa/mortalidad , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: To generate a robust predictive model of Early (3 months) Graft Loss after liver transplantation, we used a Bayesian approach to combine evidence from a prospective European cohort (Liver-Match) and the United Network for Organ Sharing registry. METHODS: Liver-Match included 1480 consecutive primary liver transplants performed from 2007 to 2009 and the United Network for Organ Sharing a time-matched series of 9740 transplants. There were 173 and 706 Early Graft Loss, respectively. Multivariate analysis identified as significant predictors of Early Graft Loss: donor age, donation after cardiac death, cold ischaemia time, donor body mass index and height, recipient creatinine, bilirubin, disease aetiology, prior upper abdominal surgery and portal thrombosis. RESULTS: A Bayesian Cox model was fitted to Liver-Match data using the United Network for Organ Sharing findings as prior information, allowing to generate an Early Graft Loss-Donor Risk Index and an Early Graft Loss-Recipient Risk Index. A Donor-Recipient Allocation Model, obtained by adding Early Graft Loss-Donor Risk Index to Early Graft Loss-Recipient Risk Index, was then validated in a distinct United Network for Organ Sharing (year 2010) cohort including 2964 transplants. Donor-Recipient Allocation Model updating using the independent Turin Transplant Centre dataset, allowed to predict Early Graft Loss with good accuracy (c-statistic: 0.76). CONCLUSION: Donor-Recipient Allocation Model allows a reliable donor and recipient-based Early Graft Loss prediction. The Bayesian approach permits to adapt the original Donor-Recipient Allocation Model by incorporating evidence from other cohorts, resulting in significantly improved predictive capability.
Asunto(s)
Enfermedad Hepática en Estado Terminal/cirugía , Supervivencia de Injerto , Trasplante de Hígado/estadística & datos numéricos , Medición de Riesgo , Donantes de Tejidos/estadística & datos numéricos , Adulto , Factores de Edad , Anciano , Teorema de Bayes , Índice de Masa Corporal , Estudios de Cohortes , Isquemia Fría/estadística & datos numéricos , Funcionamiento Retardado del Injerto/epidemiología , Femenino , Rechazo de Injerto/epidemiología , Humanos , Italia/epidemiología , Masculino , Persona de Mediana Edad , Análisis Multivariante , Disfunción Primaria del Injerto/epidemiología , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Prognostic factors for hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) are still a matter of debate. The absence of viable tumor in the native liver, due to effectiveness of pre-LT locoregional treatment or liver resection, is an intriguing prognostic factor that had never been evaluated. METHODS: Between November 2000 and December 2011, 210 LTs were performed in patients with evidence of HCC and cirrhosis. RESULTS: Fifty-three (25.2%) patients did not show any evidence of active residual HCC in the native liver (Group NVH), whereas 157 (74.8%) patients showed viable HCC (Group VH). All patients in Group NVH were treated before LT with a multimodal approach combining transarterial chemoembolization, liver resection, radiofrequency ablation, percutaneous ethanol injection, or sorafenib, whereas, in Group VH, 110 of the 157 (70.1%) patients received bridging therapy (P<0.001). HCC recurrence occurred in none of the patients in Group NVH (0%) and in 25 (15.9%) patients in Group VH (P=0.003). Liver resection was the most effective treatment in obtaining absence of HCC on liver explantation. The results of multivariate analysis showed that existence of pathologic HCC findings outside of the University of California-San Francisco criteria (P=0.001; odds ratio, 4; confidence interval, 1.7-9.2) and the presence of viable HCC (P=0.003; odds ratio, 5.9; confidence interval, 1.5-17.6) were independently associated with HCC recurrence. CONCLUSIONS: The histologic absence of viable HCC in the native liver after LT and morphologic criteria, due to the high effectiveness of pre-LT bridging treatments, is a highly positive prognostic factor against HCC recurrence after LT.
Asunto(s)
Carcinoma Hepatocelular/cirugía , Neoplasias Hepáticas/cirugía , Trasplante de Hígado , Recurrencia Local de Neoplasia/prevención & control , Adulto , Anciano , Carcinoma Hepatocelular/mortalidad , Carcinoma Hepatocelular/patología , Femenino , Humanos , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/patología , Masculino , Persona de Mediana Edad , Análisis MultivarianteRESUMEN
BACKGROUND: The aim of our work is to assess the clinical outcomes of liver transplantation (LT) for hepatocellular carcinoma (HCC) in HIV-coinfected patients. This is a multicenter study involving three Italian transplant centers in northern Italy: University of Modena, University of Bologna, and University of Udine. PATIENTS AND METHODS: We compared 30 HIV-positive patients affected by HCC who underwent LT with 125 HIV-uninfected patients who received the same treatment from September 2004 to June 2009. At listing, there were no differences between HIV-infected and -uninfected patients regarding HCC features. Patients outside the University of California, San Francisco criteria (UCSF) were considered eligible for LT if a down-staging program permitted a reduction of tumor burden. RESULTS: HIV-infected patients were younger, they were more frequently anti-HCV positive, and a higher number of HIV-infected patients presented a coinfection HBV-HCV. Pre-LT treatments (liver resection and or locoregional treatments) were similar between the two groups. Histological characteristics of the tumor were similar in patients with and without HIV infection. No differences were observed in terms of overall survival and HCC recurrence rates. CONCLUSION: LT for HCC is a feasible procedure and the presence of HIV does not particularly affect the post-LT outcome.
Asunto(s)
Carcinoma Hepatocelular/terapia , Infecciones por VIH/terapia , Neoplasias Hepáticas/terapia , Trasplante de Hígado , Adulto , Anciano , Carcinoma Hepatocelular/complicaciones , Carcinoma Hepatocelular/patología , Carcinoma Hepatocelular/virología , Femenino , Estudios de Seguimiento , Infecciones por VIH/complicaciones , Infecciones por VIH/patología , Infecciones por VIH/virología , VIH-1/patogenicidad , Humanos , Italia , Neoplasias Hepáticas/complicaciones , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/virología , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/patología , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
The benefits of calcineurin inhibitor (CNI)-sparing regimens on renal function following liver transplantation (LT) have been demonstrated in clinical studies. This observational study assessed the real-life effects of mycophenolate mofetil (MMF) introduction in LT patients. Four hundred and ninety-seven patients in whom MMF was introduced according to local standards or clinical considerations were entered. Patients were grouped by time between transplantation and start of MMF (start of study): Group A (n = 263): ≤6 d; Group B (n = 64): >6 d to ≤1 month; Group C (n = 74): >1 month to ≤1 yr; and Group D (n = 96): >1 yr. CNI sparing occurred in all groups, particularly in Groups C and D. Mean MMF doses at 12 months were 1202.7, 1363.5, 1504.7, and 1578.1 mg/d, respectively, in Groups A-D. At introduction of MMF, median glomerular filtration rate was 73.3, 81.7, 62.7, and 53.7 mL/min/1.73 m(2) in Groups A-D. At 12 months, this decreased to 66 mL/min/1.73 m(2) in Groups A and B, remained stable in Group C, and increased in Group D (64.8 mL/min/1.73 m(2) ). Serious adverse drug reactions were lowest in Group D. In conclusion, MMF with a subsequent decrease in CNI was well tolerated and improved renal function even years after transplantation. A more forceful MMF dosing strategy with greater CNI sparing may further improve renal function.
Asunto(s)
Rechazo de Injerto/prevención & control , Inmunosupresores/uso terapéutico , Hepatopatías/cirugía , Ácido Micofenólico/análogos & derivados , Femenino , Tasa de Filtración Glomerular , Humanos , Trasplante de Hígado , Masculino , Persona de Mediana Edad , Ácido Micofenólico/uso terapéutico , Pronóstico , Factores de RiesgoRESUMEN
BACKGROUND: The caudate lobe, because of its location and its highly unpredictable vascular anatomy, is one of the most surgical challenging segment of the liver. Hepatocellular carcinoma (HCC) of the caudate lobe in cirrhotic patients is not easily amenable to surgical resection. In order to treat HCC and to down-stage these patients within accepted criteria for liver transplantation (LT), laparoscopic radiofrequency ablation (RFA) can be performed. SUBJECTS AND RESULTS: We present three cases of laparoscopic RFA for caudate lobe HCC. All three patients were successfully treated with laparoscopic RFA. The computed tomography scans 1 month postsurgery revealed complete necrosis of the lesion. No postoperative complications occurred, and all patients had a short postoperative stay. All three patients underwent, thereafter, LT from a deceased donor. CONCLUSIONS: Laparoscopic RFA is the treatment of choice in patients with HCC who could be scheduled for LT. Furthermore, a laparoscopic technique with an accurate ultrasound examination of liver parenchyma can allow for a complete exclusion of hepatic lesions undetectable at the preoperative imaging and provides the minimal onset of adhesions, both approaches that are extremely useful in patients undergoing liver transplantation.
Asunto(s)
Carcinoma Hepatocelular/cirugía , Ablación por Catéter/métodos , Laparoscopía/métodos , Neoplasias Hepáticas/cirugía , Trasplante de Hígado/métodos , Carcinoma Hepatocelular/diagnóstico por imagen , Humanos , Hígado/cirugía , Neoplasias Hepáticas/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
This study reports one case of primary inferior vena cava (IVC) leiomyosarcoma. A 67-year-old woman was referred to the authors' clinic for evaluation. She presented complaining of epigastric and right upper abdominal quadrant pain. Contrast-enhanced abdominal computed tomography scan revealed a 5.2 × 6.4 cm heterogeneously enhancing mass involving the anteromedial aspect of the IVC, below the renal vein (segment I), deforming the duodenum. There was a partial intraluminal extension in the IVC. Laparotomic resection was performed, with total en bloc excision of the lower IVC tumor. The caval continuity was restored with concomitant interposition of a banked depopulated vena cava homograft. Histological findings showed leiomyosarcoma originating from IVC. The postoperative course was uneventful: Neither recurrence nor metastasis was evident at 4 years postsurgery.
Asunto(s)
Leiomiosarcoma/cirugía , Neoplasias Vasculares/cirugía , Vena Cava Inferior , Anciano , Medios de Contraste , Femenino , Humanos , Leiomiosarcoma/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Neoplasias Vasculares/diagnóstico por imagen , Grado de Desobstrucción VascularAsunto(s)
Bencenosulfonatos/uso terapéutico , Carcinoma Hepatocelular/terapia , Trasplante de Hígado , Terapia Neoadyuvante , Piridinas/uso terapéutico , Sirolimus/uso terapéutico , Adulto , Antineoplásicos/uso terapéutico , Terapia Combinada , Hepacivirus , Hepatitis C/diagnóstico , Hepatitis C/tratamiento farmacológico , Hepatitis C/virología , Humanos , Inmunosupresores/uso terapéutico , Cirrosis Hepática/diagnóstico , Cirrosis Hepática/tratamiento farmacológico , Cirrosis Hepática/virología , Masculino , Niacinamida/análogos & derivados , Compuestos de Fenilurea , Sorafenib , Resultado del TratamientoRESUMEN
BACKGROUND: The Liver Match is an observational cohort study that prospectively enrolled liver transplantations performed at 20 out of 21 Italian Transplant Centres between June 2007 and May 2009. Aim of the study is to investigate the impact of donor/recipient matching on outcomes. In this report we describe the study methodology and provide a cross-sectional description of donor and recipient characteristics and of graft allocation. METHODS: Adult primary transplants performed with deceased heart-beating donors were included. Relevant information on donors and recipients, organ procurement and allocation were prospectively entered in an ad hoc database within the National Transplant Centre web-based Network. Data were blindly analysed by an independent Biostatistical Board. RESULTS: The study enrolled 1530 donor/recipient matches. Median donor age was 56 years. Female donors (n = 681, median 58, range 12-92 years) were older than males (n = 849, median 53, range 2-97 years, p < 0.0001). Donors older than 60 years were 42.2%, including 4.2% octogenarians. Brain death was due to non-traumatic causes in 1126 (73.6%) cases. Half of the donor population was overweight, 10.1% was obese and 7.6% diabetic. Hepatitis B core antibody (HBcAb) was present in 245 (16.0%) donors. The median Donor Risk Index (DRI) was 1.57 (>1.7 in 35.8%). The median cold ischaemia time was 7.3h (≥ 10 in 10.6%). Median age of recipients was 54 years, and 77.7% were males. Hepatocellular carcinoma (HCC) was the most frequent indication overall (44.4%), being a coindication in roughly 1/3 of cases, followed by viral cirrhosis without HCC (28.2%) and alcoholic cirrhosis without HCC (10.2%). Hepatitis C virus infection (with or without HCC) was the most frequent etiologic factor (45.9% of the whole population and 71.4% of viral-related cirrhosis), yet hepatitis B virus infection accounted for 28.6% of viral-related cirrhosis, and HBcAb positivity was found in 49.7% of recipients. The median Model for End Stage Liver Disease (MELD) at transplant was 12 in patients with HCC and 18 in those without. Multivariate analysis showed a slight but significant inverse association between DRI and MELD at transplant. CONCLUSIONS: The deceased donor population in Italy has a high-risk profile compared to other countries, mainly due to older donor age. Almost half of the grafts are transplanted in recipients with HCC. Higher risk donors tend to be preferentially allocated to recipients with HCC, who are usually less ill and older. No other relevant allocation strategy is currently adopted at national level.
Asunto(s)
Trasplante de Hígado , Selección de Paciente , Donantes de Tejidos , Obtención de Tejidos y Órganos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Femenino , Fibrosis/cirugía , Supervivencia de Injerto , Prueba de Histocompatibilidad , Humanos , Italia , Neoplasias Hepáticas/cirugía , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del Tratamiento , Listas de EsperaRESUMEN
BACKGROUND AND OBJECTIVE: Despite clinical and laboratory evidence of perioperative hypercoagulability, alterations in haemostasis after potentially haemorrhagic oncologic surgery are difficult to predict. This study aims to evaluate the entity, the extent and the duration of perioperative coagulative alterations following pancreas and liver oncologic surgery, by the use of both routine tests and thromboelastogram (TEG). METHODS: Fifty-six patients undergoing liver (n = 38) and pancreatic (n = 18) surgery were studied. The coagulation profile was evaluated by platelet count, prothrombin time-international normalized ratio, activated partial thromboplastin time, antithrombin III and TEG at the beginning, at the end of the operation and on postoperative days 1, 3, 5 and 10. RESULTS: All preoperative coagulative screening and TEG traces were normal before incision. In the postoperative period of the liver and pancreas groups, despite an increase in prothrombin time-international normalized ratio, a reduction in antithrombin III and platelet count and normal activated partial thromboplastin time and fibrinogen, TEG evidenced a normocoagulability in the liver group, with a major tendency towards hypocoagulability in the pancreas group, as evidenced by a transient increase in R-time and K-time between postoperative days 1 and 3. During the study period, four cases of pulmonary embolism, resolved with heparin infusion, were recorded, in the absence of laboratory and thromboelastographic evidence of hypercoagulability. CONCLUSION: Despite laboratory tests evidencing hypocoagulability in both groups, TEG traces showed a normocoagulability in liver resections, whereas a transient thromboelastographic hypocoagulability was evident in patients undergoing pancreas surgery. The discrepancy between laboratory values and thromboelastographic variables was even more evident in patients undergoing major liver resections compared with minor ones. Our study supports the role of thromboelastography, despite its limitations, as a valuable tool for the evaluation of the perioperative whole coagulation process and hypercoagulability changes and to increase patient safety through better management of antithrombotic therapy.
Asunto(s)
Coagulación Sanguínea , Hepatectomía , Neoplasias Hepáticas/cirugía , Pancreatectomía , Neoplasias Pancreáticas/cirugía , Tromboelastografía , Trombofilia/diagnóstico , Anciano , Antitrombina III/metabolismo , Coagulación Sanguínea/efectos de los fármacos , Femenino , Fibrinolíticos/uso terapéutico , Hepatectomía/efectos adversos , Humanos , Relación Normalizada Internacional , Neoplasias Hepáticas/sangre , Masculino , Persona de Mediana Edad , Pancreatectomía/efectos adversos , Neoplasias Pancreáticas/sangre , Tiempo de Tromboplastina Parcial , Atención Perioperativa , Recuento de Plaquetas , Valor Predictivo de las Pruebas , Cuidados Preoperatorios , Estudios Prospectivos , Tiempo de Protrombina , Reproducibilidad de los Resultados , Trombofilia/sangre , Trombofilia/etiología , Trombofilia/prevención & control , Factores de TiempoRESUMEN
Biliary tract complications after liver transplantation represent a source of morbidity and mortality. Performing an analysis to evaluate whether HIV infection and its related comorbidities, such as HIV-related cholangiopathy, could be an unknown risk factor for biliary stricture, we found that HIV-positivity could lead to greater susceptibility to biliary damage. The pathogenesis of the damage seems to involve the pretransplant immunological status and the number and type of posttransplant infections, although further studies are needed.
Asunto(s)
Infecciones por VIH/inmunología , Hepatitis B/inmunología , Trasplante de Hígado/inmunología , Adulto , Infecciones por VIH/complicaciones , Infecciones por VIH/mortalidad , Hepatitis B/mortalidad , Humanos , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/mortalidad , Masculino , Complicaciones Posoperatorias/mortalidad , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
Temporary portocaval shunt and total hepatectomy is a technique used in the presence of toxic liver syndrome because of fulminant hepatic failure, hepatic trauma, primary non-function (PNF), and eclampsia. We performed this technique on four patients. An indication for anhepatic state was severe hemodynamic instability in three of them. Etiologies of these three patients were as follows: PNF after liver transplantation, ischemic hepatitis after right hepatic artery embolization, and massive reperfusion syndrome during a liver transplantation. In the fourth patient, during the liver transplantation when hepatic artery was ligated, a kidney carcinoma in the donor graft was discovered. We decided to complete the hepatectomy and to construct a temporary portocaval shunt. Mean anhepatic phases were 19 h and 15 min. All patients survived the two-stage liver transplantation procedure without major complications. Our cases demonstrated that temporary portocaval shunt while awaiting urgent liver transplantation could be an effective "bridge" in selected patients who develop toxic liver syndrome; however, a short time between portocaval shunt and transplantation and careful intensive care managements are mandatory.
Asunto(s)
Hepatectomía , Hepatopatías/cirugía , Trasplante de Hígado/métodos , Derivación Portocava Quirúrgica/métodos , Adulto , Femenino , Humanos , Hepatopatías/etiología , Hepatopatías/patología , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Immunocompromised persons infected with Mycobacterium tuberculosis (MTB) have increased risk of tuberculosis (TB) reactivation, but their management is hampered by the occurrence of false-negative results of the tuberculin skin test (TST). The T-cell interferon (IFN)-gamma release blood assays T-SPOT.TB (TS.TB) [Oxford Immunotec; Abingdon, UK] and QuantiFERON-TB Gold In-Tube (QFT-IT) [Cellestis Ltd; Carnegie, VIC, Australia] might improve diagnostic accuracy for latent TB infection (LTBI) in high-risk persons, although their performance in different groups of immunocompromised patients is largely unknown. METHODS AND RESULTS: Over a 1-year period, we prospectively enrolled patients in three different immunosuppressed groups, as follows: 120 liver transplantation candidates (LTCs); 116 chronically HIV-infected persons; and 95 patients with hematologic malignancies (HMs). TST, TS.TB, and QFT-IT were simultaneously performed, their results were compared, and intertest agreement was evaluated. Overall, TST provided fewer positive results (10.9%) than TS.TB (18.4%; p < 0.001) and QFT-IT (15.1%; p = 0.033). Significantly fewer HIV-infected individuals had at least one positive test (9.5%) compared with LTCs (35.8%; p < 0.001) and patients with HMs (29.5%; p < 0.001). Diagnostic agreement between tests was moderate (kappa = 0.40 to 0.65) and decreased in the HIV-infected group when the results of the TS.TB were compared with either TST (kappa = 0.16) or QFT-IT (kappa = 0.19). Indeterminate blood test results due to low positive control values were significantly more frequent with QFT-IT (7.2%) than with TS.TB (0.6%; p < 0.001). CONCLUSIONS: Blood tests identified significantly more patients as being infected with MTB than TST, although diagnostic agreement varied across groups. Based on these results, we recommend tailoring application of the new blood IFN-gamma assays for LTBI in different high-risk groups and advise caution in their current use in immunosuppressed patients.
Asunto(s)
Huésped Inmunocomprometido , Prueba de Tuberculina/métodos , Tuberculosis/diagnóstico , Latencia del Virus , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Infecciones por VIH/inmunología , Infecciones por VIH/microbiología , Neoplasias Hematológicas/inmunología , Neoplasias Hematológicas/microbiología , Humanos , Fallo Hepático/inmunología , Fallo Hepático/microbiología , Trasplante de Hígado/inmunología , Masculino , Persona de Mediana Edad , Mycobacterium tuberculosis/fisiología , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Tuberculosis/complicaciones , Tuberculosis/inmunología , Adulto JovenRESUMEN
BACKGROUND: Patients undergoing liver transplantation for hepatocellular carcinoma within the Milan criteria (single tumour =5 cm in size or =3 tumours each =3 cm in size, and no macrovascular invasion) have an excellent outcome. However, survival for patients with cancers that exceed these criteria remains unpredictable and access to transplantation is a balance of maximising patients' chances of cure and organ availability. The aim of this study was to explore the survival of patients with tumours that exceed the Milan criteria, to assess whether the criteria could be less restrictive, enabling more patients to qualify as transplant candidates, and to derive a prognostic model based on objective tumour characteristics, to see whether the Milan criteria could be expanded. METHODS: Data on patients who underwent transplantation for hepatocellular carcinoma despite exceeding Milan criteria at different centres were recorded via a web-based survey completed by specialists from each centre. The survival of these patients was correlated retrospectively with the size of the largest tumour nodule, number of nodules, and presence or absence of microvascular invasion detected at pathology. Contoured multivariable regression Cox models produced survival estimates by means of different combinations of the covariates. The primary aim of this study was to derive a prognostic model of overall survival based on tumour characteristics, according to the main parameters used in the Tumour Node Metastasis classification. The secondary aim was the identification of a subgroup of patients with hepatocellular carcinoma exceeding the Milan criteria, who achieved a 5-year overall survival of at least 70%-ie, similar to the outcome expected for patients who meet the Milan criteria. FINDINGS: Over a 10-month period, between June 25, 2006, and April 3, 2007, data for 1556 patients who underwent transplantation for hepatocellular carcinoma were entered on the database by 36 centres. 1112 patients had hepatocellular carcinoma exceeding Milan criteria and 444 patients had hepatocellular carcinoma shown not to exceed Milan criteria at post-transplant pathology review. In the group of patients with hepatocellular carcinomas exceeding the criteria, the median size of the largest nodule was 40 mm (range 4-200) and the median number of nodules was four (1-20). 454 of 1112 patients (41%) had microvascular invasion and, for those transplanted outside the Milan criteria, 5-year overall survival was 53.6% (95% CI 50.1-57.0), compared with 73.3% (68.2-77.7) for those that met the criteria. Hazard ratios (HR) associated with increasing values of size and number were 1.34 (1.25-1.44) and 1.51 (1.21-1.88), respectively. The effect was linear for size, whereas for number of tumours, the effect tended to plateau above three tumours. The effect of tumour size and number on survival was mediated by recurrence (b=0.08, SE=0.12, p=0.476). The presence of microvascular invasion doubled HRs in all scenarios. The 283 patients without microvascular invasion, but who fell within the Up-to-seven criteria (hepatocellular carcinomas with seven as the sum of the size of the largest tumour [in cm] and the number of tumours) achieved a 5-year overall survival of 71.2% (64.3-77.0). INTERPRETATION: More patients with hepatocellular carcinoma could be candidates for transplantation if the current dual (yes/no) approach to candidacy, based on the strict Milan criteria, were replaced with a more precise estimation of survival contouring individual tumour characteristics and use of the up-to-seven criteria.
Asunto(s)
Carcinoma Hepatocelular/cirugía , Neoplasias Hepáticas/cirugía , Trasplante de Hígado , Adolescente , Adulto , Anciano , Carcinoma Hepatocelular/mortalidad , Niño , Humanos , Neoplasias Hepáticas/mortalidad , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
INTRODUCTION: Among the adverse effects of different calcineurin inhibitors (CIs), nephrotoxicity is the most common (incidence: 18.1% at 13 y from liver transplantation) and depends on a variable degree of tubular-interstitial injury accompanied by focal glomerular sclerosis. A new immunosuppressive drug was introduced in solid organ transplant management, Sirolimus (SRL). It is a nonnephrotoxic immunosuppressor. METHODS: Twenty-six patients who developed nephrotoxicity owing to CIs, showing an increment of serum creatinine levels (>1.8 mg/dL) were switched to SRL monotherapy, initially at a dosage between 3 and 5 mg/d, and subsequently adapted to achieve trough level between 8 to 10 ng/mL. RESULTS: Patients were followed-up for a mean period of 40.3 months (range, 8.4 to 76.7) from liver transplantation. Mean follow-up after switch was 27.5 months (range, 2 to 71.2). Immunosuppression therapy was converted after a mean period of 12.8 months (range, 0.2 to 43.4). Serum creatinine, urea, and estimated glomerular filtration rate were significantly improved. DISCUSSION: Patients developing renal dysfunction after liver transplantation may be successfully treated by conversion from CI to SRL. Hypertriglyceridemia and hypercholesterolemia represent the principal side effects from SRL, but are treatable. Furthermore, SRL can significantly improve glucose tolerance.