Molecular Adsorbent Recirculating System Support Followed by Liver Transplantation for Multiorgan Failure From Heatstroke.

BACKGROUND: Exertional heatstroke is an extremely rare cause of fulminant hepatic failure. Maximal supportive care has failed to provide adequate survival in earlier studies. This is particularly true in cases accompanied by multiorgan failure. METHODS AND MATERIALS: Our prospectively collected transplant database was retrospectively reviewed to identify patients undergoing liver transplantation for heatstroke between January 1, 2012, and December 31, 2016. We report 3 consecutive cases of male patients with fulminant hepatic failure from exertional heatstroke. RESULTS: All patients developed multiorgan failure and required intubation, vasopressor support, and renal replacement therapy. All patients were listed urgently for liver transplantation and were supported with the molecular adsorbent recirculating system while awaiting transplantation. All patients underwent liver transplantation alone and are alive and well, with recovered renal function, normal liver allograft function, and no chronic sequelae of their multiorgan failure at more than one year. CONCLUSION: Extreme heatstroke leading to whole-body organ dysfunction and fulminant liver failure is a complex entity that may benefit from therapy using the Molecular Adsorbent Recirculating System while waiting for liver transplantation as a component of a multidisciplinary, multiorgan system approach.

Substance Use and Psychosocial Functioning in a Sample of Liver Transplant Recipients with Alcohol-Related Liver Disease.

Despite the frequency of liver transplantation in alcoholic recipients, the burden of co-occurring psychosocial comorbidities remains poorly defined. METHODS: A survey study was conducted to examine demographic, substance use, mental health, and social support variables among liver transplant (LT) recipients with alcoholic liver disease (ALD) (LT-ALD: n  = 67). Survey completers (n = 67) were compared to a sample of liver transplant recipients without ALD (LT: n = 134). RESULTS: Survey participants (n  = 67) were predominately male, in their mid-fifties, and were retired or on disability. Alcohol consumption during the 6 months prior to transplant was reported by more than a third of participants. Alcohol consumption post-transplant was reported by 21.2% of respondents, with 4.5% of participants reporting "at-risk" levels of post-transplant alcohol use. Illicit drug use prior to transplant was reported by nearly half of participants (47.8%), and 16.4% reported illicit drug use post-transplant. Approximately half of the sample reported a history of cigarette smoking, and one-third of respondents (29.2%) reported current cigarette smoking. Participants frequently endorsed mental health symptoms consistent with moderate to severe depression (22.4%) and anxiety (17.9%). CONCLUSIONS: Despite relatively low rates of problematic alcohol use post-transplant, there is a significant burden of disability, substance use, and psychiatric symptomatology in this population.

Intraoperative Continuous Veno-Venous Hemofiltration Facilitates Surgery in Liver Transplant Patients With Acute Renal Failure.

INTRODUCTION: We have aggressively used continuous veno-venous hemofiltration (CVVH) on high model for end-stage liver disease (MELD) score liver transplant patients with acute kidney injury and hypothesized that the addition of intraoperative CVVH therapy would improve overall outcomes. METHODS: We performed a retrospective review of all adult, single organ, liver transplant recipients requiring preoperative renal replacement therapy between January 1, 2011 and June 1, 2013. Intraoperative and perioperative records and laboratory values were collected and used to create a database of these patients. Patients were grouped according to whether or not they underwent CVVH at the time of liver transplantation. RESULTS: Twenty-one patients with new-onset renal failure requiring preoperative renal replacement therapy received a liver transplant alone. Fourteen received intraoperative CVVH and 7 patients did not. The average MELD score was similar between groups (34 for intraoperative CVVH vs 35; P = .8). Preoperative sodium and potassium were higher for the group receiving intraoperative CVVH, but still fell within normal ranges. Preoperative lactate levels were higher in the group that received intraoperative CVVH (4.7 vs 2.0 mmol/L; P = .01). Intraoperative CVVH did not decrease intraoperative transfusion requirements or intensive care unit (ICU) and hospital lengths of stay. Differences in reoperative rates did not reach statistical significance. All patients were weaned off renal replacement therapy. One-year patient survival rate was 86% for intraoperative CVVH versus 71% without. CONCLUSION: The judicious use of intraoperative CVVH therapy may permit patients with increasing severity of illness to achieve outcomes comparable with less ill patients.

Efficiency of the LigaSure vessel sealing system for recipient hepatectomy in liver transplantation.

BACKGROUND: Although the LigaSure device is widely used, its use in liver transplantation, where compounding factors of portal hypertension, coagulopathy, and thrombocytopenia exist, is poorly described. METHODS: From October 1, 2011, to December 31, 2011, 6 patients underwent liver transplantation with recipient hepatectomy utilizing the LigaSure device. Outcomes using the device were compared with 6 contemporaneous patients in whom the device was not used. RESULTS: Patient demographics, preoperative laboratory values, and Model for End-Stage Liver Disease scores were not different. Recipient hepatectomy was performed, on average, 43 minutes faster using the LigaSure device (P = .02). Although total operative time and intraoperative blood product usage were lower when the LigaSure was used, these differences did not attain statistical significance. Duration of stay and recipient readmission rates were similar. CONCLUSIONS: LigaSure vessel sealing is an efficient method for recipient hepatectomy in liver transplantation. Vessel sealing of caval, portal, and other structures can be safely performed in the setting of end-stage liver disease.

Induction of transplantation tolerance with a short course of tacrolimus (FK506): I. Rapid and stable tolerance to two-haplotype fully mhc-mismatched kidney allografts in miniature swine.

BACKGROUND: Inbred miniature swine provide a large animal model in which the effects of selective major histocompatibility complex (MHC) matching can be reproducibly studied. We have previously demonstrated that although a 12-day course of cyclosporine uniformly induces tolerance to class I-mismatched renal allografts, it does not induce tolerance across full MHC barriers. In this study, we assessed whether and at what dose tacrolimus might permit allografts to induce tolerance across different MHC barriers. METHODS: Recipients of MHC disparate renal allografts were treated with a 12-day course of tacrolimus by continuous intravenous infusion. Groups were divided as follows: (1) class I-mismatched kidneys with 0.3 mg/kg/day tacrolimus (n=3); (2) fully MHC-mismatched kidneys with 0.3 mg/kg/day tacrolimus (n=2); and (3) fully MHC-mismatched kidneys with 0.12-0.16 mg/kg/day tacrolimus (n=4). RESULTS: In groups 1 and 2, recipients with tacrolimus levels of 45-80 ng/ml accepted renal allografts long-term with stable renal function. Donor-specific hyporesponsiveness was demonstrated by cell-mediated lymphocytotoxicity and mixed lymphocyte response, and subsequent donor-matched grafts were also accepted, without further immunosuppression (n=4), confirming systemic tolerance. In group 3, recipients that achieved tacrolimus levels of 35 ng/ml (n=2) accepted their grafts without chronic changes, whereas recipients with levels of 20-26 ng/ml (n=2) developed chronic allograft glomerulopathy, suggesting 35 ng/ml as the threshold blood level for tolerance induction. In vitro assays demonstrated that peripheral blood lymphocytes from tolerant animals produced inhibitory cytokines, suggesting the involvement of regulatory mechanisms. CONCLUSIONS: To our knowledge, this study represents the first demonstration of the induction of transplant tolerance across a two-haplotype full MHC barrier with a short course of immunosuppression in a large animal model. These studies may also have clinical applicability, because the time course required to induce tolerance was sufficiently short that the high drug levels required might be expected to be tolerated clinically with only transient toxicity.

Experiencia del Servicio de Ginecología del Hospital Italiano en el tratamiento combinado del estadio III del cáncer de mama / Experience of the Gynaecology Department of the Italian Hospital in the combined treatment of breast cancer stage III

La finalidad de esta publicación es mostrar la experiencia del Servicio de Ginecología del Hospital Italiano, con el tratamiento combinado (quimioterapia de inducción o neoadyuvante, cirugía, radioterapia y quimioterapia de consolidación) en el carcinoma de mama localmente avanzado no inflamatorio. El esquema terapéutico consistió básicamente en 3 ciclos de inducción seguidos por mastectomía o radioterapia, en una secuencia acorde con la factibilidad quirúrgica obtenida; y posteriormente 6 ciclos de QT de consolidación. El grupo en estudio incluye 95 pacientes, con un seguimiento promedio de 47 meses (12-144). Se halló un 46,15 por ciento de respuestas a la quimioterapia de inducción. La sobrevida global actuarial y la sobrevida libre de enfermedad a 5 y 10 años fue de 58,66 por ciento y 42,94 por ciento, 40,83 por ciento y 34,02 por ciento respectivamente. Se observó una diferencia sustancial en la sobrevida libre de enfermedad de acuerdo a la respuesta a la quimioterapia de inducción (RC+RP: 56,84 por ciento; RP+NR: 14,52 por ciento) y al estadio (IIIa: 77,14 por ciento; IIIb: 34,14 por ciento). La tasa de recurrencias locorregionales fue de 11,57 por ciento, la cual sufrió modificaciones en relación al estadio, al estado de la axila y respuesta a la quimioterapia de inducción. El análisis comparativo de los grupos "tratamiento combinado" versus "local + sistémico" (control histórico), reveló una sobrevida similar para ambos; sin embargo se observó una mayor tasa de recurrencias locales en este último (23,7 por ciento). Finalmente las pacientes sometidas a una cirugía conservadora (15) exhibieron una sobrevida global de 5 años de 69 por ciento; sólo una recidivó localmente (6,6 por ciento). Actualmente, se dispone de evidencia indirecta contundente de que el tratamiento combinado aumentó la sobrevida y el control local en relación a los tratamientos locorregionales exclusivos. Sin embargo, la mortalidad en el estadio III de cáncer de mama continúa siendo elevada.

Experiencia del Servicio de Ginecología del Hospital Italiano en el tratamiento combinado del estadio III del cáncer de mama / Experience of the Gynaecology Department of the Italian Hospital in the combined treatment of breast cancer stage III

La finalidad de esta publicación es mostrar la experiencia del Servicio de Ginecología del Hospital Italiano, con el tratamiento combinado (quimioterapia de inducción o neoadyuvante, cirugía, radioterapia y quimioterapia de consolidación) en el carcinoma de mama localmente avanzado no inflamatorio. El esquema terapéutico consistió básicamente en 3 ciclos de inducción seguidos por mastectomía o radioterapia, en una secuencia acorde con la factibilidad quirúrgica obtenida; y posteriormente 6 ciclos de QT de consolidación. El grupo en estudio incluye 95 pacientes, con un seguimiento promedio de 47 meses (12-144). Se halló un 46,15 por ciento de respuestas a la quimioterapia de inducción. La sobrevida global actuarial y la sobrevida libre de enfermedad a 5 y 10 años fue de 58,66 por ciento y 42,94 por ciento, 40,83 por ciento y 34,02 por ciento respectivamente. Se observó una diferencia sustancial en la sobrevida libre de enfermedad de acuerdo a la respuesta a la quimioterapia de inducción (RC+RP: 56,84 por ciento; RP+NR: 14,52 por ciento) y al estadio (IIIa: 77,14 por ciento; IIIb: 34,14 por ciento). La tasa de recurrencias locorregionales fue de 11,57 por ciento, la cual sufrió modificaciones en relación al estadio, al estado de la axila y respuesta a la quimioterapia de inducción. El análisis comparativo de los grupos "tratamiento combinado" versus "local + sistémico" (control histórico), reveló una sobrevida similar para ambos; sin embargo se observó una mayor tasa de recurrencias locales en este último (23,7 por ciento). Finalmente las pacientes sometidas a una cirugía conservadora (15) exhibieron una sobrevida global de 5 años de 69 por ciento; sólo una recidivó localmente (6,6 por ciento). Actualmente, se dispone de evidencia indirecta contundente de que el tratamiento combinado aumentó la sobrevida y el control local en relación a los tratamientos locorregionales exclusivos. Sin embargo, la mortalidad en el estadio III de cáncer de mama continúa siendo elevada. (AU)