Trasplante de páncreas-riñón simultáneo. Experiencia del Hospital Doce de Octubre / Simultaneous pancreas-kidney transplantation. Experience of the Doce de Octubre Hospital

Introducción: El trasplante de páncreas-riñón simultáneo constituye el tratamiento de elección en la diabetes tipo 1 o tipo 2 con fallo renal terminal o preterminal (diálisis o prediálisis), por ser la única terapia que consigue el estado euglucémico (insulino-independiente) en el paciente diabético. Métodos: Estudio retrospectivo y descriptivo de una serie de 175 pacientes trasplantados de páncreas-riñón simultáneo entre marzo de 1995 y abril de 2016. Se analizan las características de los donantes y receptores, variables perioperatorias e inmunosupresión, morbimortalidad postrasplante, supervivencia del paciente e injerto y factores de riesgo de supervivencia del paciente e injerto. Resultados: La mediana de edad de los donantes fue de 28 años y la media de los receptores, de 38,8 ± 7,3años, siendo 103 hombres y 72 mujeres. La derivación duodeno-entérica se realizó en 113 casos y la duodeno-vesical, en 62. Las tasas de complicaciones postrasplante fueron las siguientes: infección global (70,3%), pancreatitis del injerto (26,3%), hemorragia intraabdominal (17,7%), trombosis del injerto (12,6%) y rechazo pancreático global (10,9%). Las causas de mortalidad fueron fundamentalmente cardiovasculares e infecciosas. La supervivencia del paciente a 1, 3 y 5 años fue del 95,4, del 93 y del 92,4%, respectivamente, mientras que la del injerto correspondió al 81,6, al 77,9 y al 72,3%, respectivamente, durante el mismo periodo. Conclusiones: En nuestra experiencia de 20 años de trasplante pancreático-renal simultáneo las tasas de morbilidad y supervivencia del paciente y del injerto a 5 años son similares a las referidas en los registros internacionales de trasplante pancreático (AU)

Introduction: Simultaneous pancreas-kidney transplantation (SPKT) constitutes the therapy of choice for diabetes type 1 or type 2 associated with end-stage renal disease, because is the only proven method to restore normo-glicemic control in the diabetic patient. Methods: Retrospective and descriptive study of a series of 175 patients who underwent SPKT from March 1995 to April 2016. We analyze donor and recipient characteristics, perioperative variables and immunosuppression, post-transplant morbi-mortality, patient and graft survival, and risk factors related with patient and graft survival. Results: Median age of the donors was 28 years and mean age of recipients was 38.8 ± 7.3 years, being 103 males and 72 females. Enteric drainage of the exocrine pancreas was performed in 113 patients and bladder drainage in 62. Regarding post-transplant complications, the overall rate of infections was 70.3%; graft pancreatitis 26.3%; intraabdominal bleeding 17.7%; graft thrombosis 12.6%; and overall pancreas graft rejection 10.9%. The causes of mortality were mainly cardiovascular and infectious complications. Patient survival at 1, 3 and 5-year were 95.4%, 93% and 92.4%, respectively, and pancreas graft survival at 1, 3 and 5-year were 81.6%, 77.9% y 72.3%, respectively. Conclusions: In our 20-year experience of simultaneous pancreas-kidney transplantation, the morbidity rate, and 5-year patient and pancreas graft survivals were similar to those previously reported from the international pancreas transplant registries (AU)

Simultaneous pancreas-kidney transplantation. Experience of the Doce de Octubre Hospital. / Trasplante de páncreas-riñón simultáneo. Experiencia del Hospital Doce de Octubre.

INTRODUCTION: Simultaneous pancreas-kidney transplantation (SPKT) constitutes the therapy of choice for diabetes type1 or type2 associated with end-stage renal disease, because is the only proven method to restore normo-glicemic control in the diabetic patient. METHODS: Retrospective and descriptive study of a series of 175 patients who underwent SPKT from March 1995 to April 2016. We analyze donor and recipient characteristics, perioperative variables and immunosuppression, post-transplant morbi-mortality, patient and graft survival, and risk factors related with patient and graft survival. RESULTS: Median age of the donors was 28years and mean age of recipients was 38.8±7.3years, being 103 males and 72 females. Enteric drainage of the exocrine pancreas was performed in 113 patients and bladder drainage in 62. Regarding post-transplant complications, the overall rate of infections was 70.3%; graft pancreatitis 26.3%; intraabdominal bleeding 17.7%; graft thrombosis 12.6%; and overall pancreas graft rejection 10.9%. The causes of mortality were mainly cardiovascular and infectious complications. Patient survival at 1, 3 and 5-year were 95.4%, 93% and 92.4%, respectively, and pancreas graft survival at 1, 3 and 5-year were 81.6%, 77.9% y 72.3%, respectively. CONCLUSIONS: In our 20-year experience of simultaneous pancreas-kidney transplantation, the morbidity rate, and 5-year patient and pancreas graft survivals were similar to those previously reported from the international pancreas transplant registries.

El trasplante de hígado en adulto, procedente de donante vivo. Una opción valida / Liver transplantation in adult, from living donor. A valid option

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Liver Transplantation for Hepatic Trauma: A Study From the European Liver Transplant Registry.

BACKGROUND: Liver transplantation is the most extreme form of surgical management of patients with hepatic trauma, with very limited literature data supporting its use. The aim of this study was to assess the results of liver transplantation for hepatic trauma. METHODS: This retrospective analysis based on European Liver Transplant Registry comprised data of 73 recipients of liver transplantation for hepatic trauma performed in 37 centers in the period between 1987 and 2013. Mortality and graft loss rates at 90 days were set as primary and secondary outcome measures, respectively. RESULTS: Mortality and graft loss rates at 90 days were 42.5% and 46.6%, respectively. Regarding general variables, cross-clamping without extracorporeal veno-venous bypass was the only independent risk factor for both mortality (P = 0.031) and graft loss (P = 0.034). Regarding more detailed factors, grade of liver trauma exceeding IV increased the risk of mortality (P = 0.005) and graft loss (P = 0.018). Moreover, a tendency above the level of significance was observed for the negative impact of injury severity score (ISS) on mortality (P = 0.071). The optimal cut-off for ISS was 33, with sensitivity of 60.0%, specificity of 80.0%, positive predictive value of 75.0%, and negative predictive value of 66.7%. CONCLUSIONS: Liver transplantation seems to be justified in selected patients with otherwise fatal severe liver injuries, particularly in whom cross-clamping without extracorporeal bypass can be omitted. The ISS cutoff less than 33 may be useful in the selection process.

Trasplante hepático y cardiaco simultáneo en pacientes con polineuropatía amiloidótica familiar / Simultaneous liver and heart transplantation in patients with familial amyloid polyneuropathy

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Trasplante hepático como tratamiento de la polineuropatía amiloidótica familiar en pacientes mayores de 60 años / Liver transplantation as treatment of familial amyloid polyneuropathy in patients older than 60 years

Fundamento y objetivo: La polineuropatía amiloidótica familiar (PAF) constituye el tipo más prevalente de amiloidosis sistémica hereditaria. Es una enfermedad autosómica dominante que se caracteriza por el depósito de una variante anómala de la transtiretina. Tiene una distribución mundial, con zonas endémicas localizadas en Portugal, Suecia y Japón. En España hay un foco endémico, localizado en Mallorca. El trasplante hepático es la única opción curativa para los pacientes con PAF. El objetivo de este estudio fue describir las características clínicas y demográficas de los pacientes trasplantados con diagnóstico de PAF. Material y método: Se evaluaron 6 pacientes trasplantados por PAF entre abril de 1986 y diciembre de 2012. Resultados: La edad media fue de 57,7 + 16 años, los pacientes de origen español eran mayores de 60 años. Todos los pacientes presentaban síntomas progresivos en forma de polineuropatía mixta. En 2 pacientes se realizó un doble trasplante hepatocardiaco secuencial, efectuándose en primer lugar el trasplante hepático. La supervivencia del paciente y del injerto fue del 80% a los uno, 3 y 5 años. Conclusiones: El único tratamiento etiológico eficaz para la PAF es el trasplante hepático. Una detección temprana es la clave para el tratamiento y el control, evitándose el daño orgánico irreversible (AU)

Background and objective: Familial amyloid polyneuropathy (FAP) is the most prevalent type of hereditary systemic amyloidosis. It is an autosomal dominant disease characterized by the deposition of an abnormal variant transthyretin. It has a worldwide distribution, with localized endemic areas in Portugal, Sweden and Japan. In Spain there is an endemic focus, located in Mallorca. Liver transplantation is the only curative option for patients with FAP. The aim of this study was to describe the clinical and demographic characteristics of patients transplanted with a diagnosis of PAF. Material and method: Six patients with PAF underwent liver transplantation between April 1986 and December 2012. Results: The mean age was 57.7 + 16 years, patients of Spanish origin were older than 60 years. All patients had progressive symptoms as mixed polyneuropathy. In 2 patients, combined heart-liver transplants sequentially were performed. Patient survival and graft was 80% at one, 3 and 5 years. Conclusions: The only effective treatment for etiologic PAF is liver transplantation. Early detection is the key to the treatment and control, avoiding the irreversible organ damage (AU)

[Liver transplantation as treatment of familial amyloid polyneuropathy in patients older than 60 years]. / Trasplante hepático como tratamiento de la polineuropatía amiloidótica familiar en pacientes mayores de 60 años.

BACKGROUND AND OBJECTIVE: Familial amyloid polyneuropathy (FAP) is the most prevalent type of hereditary systemic amyloidosis. It is an autosomal dominant disease characterized by the deposition of an abnormal variant transthyretin. It has a worldwide distribution, with localized endemic areas in Portugal, Sweden and Japan. In Spain there is an endemic focus, located in Mallorca. Liver transplantation is the only curative option for patients with FAP. The aim of this study was to describe the clinical and demographic characteristics of patients transplanted with a diagnosis of PAF. MATERIAL AND METHOD: Six patients with PAF underwent liver transplantation between April 1986 and December 2012. RESULTS: The mean age was 57.7+16 years, patients of Spanish origin were older than 60 years. All patients had progressive symptoms as mixed polyneuropathy. In 2 patients, combined heart-liver transplants sequentially were performed. Patient survival and graft was 80% at one, 3 and 5 years. CONCLUSIONS: The only effective treatment for etiologic PAF is liver transplantation. Early detection is the key to the treatment and control, avoiding the irreversible organ damage.

Using old liver grafts for liver transplantation: where are the limits?

The scarcity of ideal liver grafts for orthotopic liver transplantation (OLT) has led transplant teams to investigate other sources of grafts in order to augment the donor liver pool. One way to get more liver grafts is to use marginal donors, a not well-defined group which includes mainly donors > 60 years, donors with hypernatremia or macrosteatosis > 30%, donors with hepatitis C virus or hepatitis B virus positive serologies, cold ischemia time > 12 h, non-heart-beating donors, and grafts from split-livers or living-related donations. Perhaps the most practical and frequent measure to increase the liver pool, and thus to reduce waiting list mortality, is to use older livers. In the past years the results of OLT with old livers have improved, mainly due to better selection and maintenance of donors, improvements in surgical techniques in donors and recipients, and intra- and post-OLT management. At the present time, sexagenarian livers are generally accepted, but there still exists some controversy regarding the use of septuagenarian and octogenarian liver grafts. The aim of this paper is to briefly review the aging process of the liver and reported experiences using old livers for OLT. Fundamentally, the series of septuagenarian and octogenarian livers will be addressed to see if there is a limit to using these aged grafts.

Trasplante hepático con injerto procedente de donación después de muerte cardiocirculatoria controlada. Situación actual / Liver transplant with donated graft after controlled cardiac death. Current situation

La presión en lista de espera de trasplante hepático obliga a la exploración de nuevas fuentes de donación, siendo la utilización de injertos procedentes de donantes después de muerte cardiocirculatoria una de las que reúnen un potencial más prometedor e interesante. Inicialmente, este recurso ha sido utilizado en España a través de la llamada categoría II de Maastricht, previamente denominada asistolia no controlada tipo II . Diferentes motivos han conducido a reconsiderar la donación después de la llamada muerte cardiocirculatoria controlada en el territorio nacional. El fenómeno distintivo en este tipo de donación es el estrés isquémico al que se exponen los órganos del donante con sus importantes implicaciones sobre los resultados. Los aspectos particulares de esta modalidad de trasplante hepático son el objeto de este trabajo (AU)

An increasing pressure on the liver transplant waiting list, forces us to explore new sources, in order to expand the donor pool. One of the most interesting and with a promising potential, is donation after cardiac death (DCD). Initially, this activity has developed in Spain by means of the Maastricht type II donation in the uncontrolled setting. For different reasons, donation after controlled cardiac death has been reconsidered in our country. The most outstanding circumstance involved in DCD donation is a potential ischemic stress, that could cause severe liver graft cell damage, resulting in an adverse effect on liver transplant results, in terms of complications and outcomes. The complex and particular issues related to DCD Donation will be discussed in this review (AU)

[Liver transplant with donated graft after controlled cardiac death. Current situation]. / Trasplante hepático con injerto procedente de donación después de muerte cardiocirculatoria controlada. Situación actual.

An increasing pressure on the liver transplant waiting list, forces us to explore new sources, in order to expand the donor pool. One of the most interesting and with a promising potential, is donation after cardiac death (DCD). Initially, this activity has developed in Spain by means of the Maastricht type II donation in the uncontrolled setting. For different reasons, donation after controlled cardiac death has been reconsidered in our country. The most outstanding circumstance involved in DCD donation is a potential ischemic stress, that could cause severe liver graft cell damage, resulting in an adverse effect on liver transplant results, in terms of complications and outcomes. The complex and particular issues related to DCD Donation will be discussed in this review.

Long-term results using old liver grafts for transplantation: sexagenerian versus liver donors older than 70 years.

BACKGROUND: The most practical measure to augment the available number of liver grafts and thus reduce waiting list mortality is to increase the donor age limit. We hypothesized that with careful selection of old liver donors without age limit it should be possible to obtain good patient and graft survival. METHODS: The present study comprises 351 adults who underwent liver transplantation. They were divided into three groups according to the age of the liver donors: group 1: 226 recipients of donors <60 years; group 2: 75 recipients of donors between 60 and 70 years; and group 3: 50 recipients of donors >70 years. A comparative study among the groups was performed. RESULTS: Patient survival rates at 1, 3, and 5 years were, respectively, 81.0, 76.1, and 71.1 % in group 1; 83.8, 74, and 72.2 % in group 2; and 76, 70.0, and 62.9 % in group 3 (P = NS). Graft survival at 1, 3, and 5 years was, respectively, 74.8, 69.0, and 64.1 % in group 1; 82.7, 71.4, and 69.6 % in group 2; and 71.4, 64.8, and 58.3 % in group 3 (P = NS). We analyzed the use of older grafts in recipients with HCV cirrhosis and did not find significant differences in patient and graft survival at 1, 3, and 5 years. In multivariate analysis increased donor body mass index and decreased recipient albumin were associated with lower patient and graft survival. CONCLUSIONS: Because patient and graft survival rates are not affected by donor age, well-selected older donor livers can be safely used if they show good function and preharvesting conditions.

Age-related differences in hepatic ischemia/reperfusion: gene activation, liver injury, and protective effect of melatonin.

BACKGROUND: Ischemia/reperfusion (I/R) causes functional and structural damage to liver cells, this being more pronounced with increasing age of the tissue. Melatonin is a pineal indole that has been shown to play an important role as a free radical scavenger and anti-inflammatory molecule. MATERIAL AND METHODS: The age-dependent responses to I/R were compared in 2-mo-old and 14-mo-old male Wistar rats. After 35 min of hepatic ischemia followed by 36 h of reperfusion, rats were sacrificed. Sham-operated control rats underwent the same protocol without real vascular occlusion. Animals were intraperitoneally injected with 10 mg/kg melatonin 24 h before the operation, at the time of surgery, and 12 and 24 h after it. The tissues were submitted to histopathologic evaluation. The levels of ALT and AST were analyzed in plasma. The expression of TNF-α, IL-1ß, IL-10, MCP-1, IFN-γ, iNOS, eNOS, Bad, Bax, Bcl2, AIF, PCNA, and NFKB1 genes were detected by RT-PCR in hepatic tissue. RESULTS: I/R was associated with significant increases in the expression of pro-inflammatory and pro-apoptotic genes in liver. Older rats submitted to I/R were found to respond with increased liver damage as compared with young rats, with serum ALT and AST levels significantly higher than in young animals. Mature rats also showed more evident increases in expression of pro-inflammatory cytokines (IL-1ß, MCP-1, and IFN-γ) as well as a decrease in the mRNA expression of IL-10 as compared with young animals. Pro-apoptotic genes (Bax, Bad, and AIF) were significantly enhanced in liver after I/R, without differences between young and mature animals. However, the expression of Bcl2 gene did not show any change. Melatonin treatment was able to lower the expression of pro-inflammatory cytokines and pro-apoptotic genes and to improve liver function, as indicated by normalization of plasma AST and ALT levels and by reduction of necrosis and microsteatosis areas. CONCLUSIONS: Melatonin treatment was able to reduce the I/R-stimulated pro-inflammatory and pro-apoptotic genes in the rat liver. Since older animals showed a more marked increase in inflammation and in liver injury, the treatment was more effective in those subjects.

The influence of immunosuppression switching in liver function in adult hepatic transplantation.

We evaluate the 5-year results of a single-centre prospective randomized trial that compared cyclosporine microemulsion (CyA-me) in triple therapy (plus steroids and azathioprine) and Tacrolimus (Tac) in double therapy (plus steroids) for primary immunosuppression. One hundred adult patients undergoing liver transplantation were randomized to receive Tac (n=51) or CyA-me (n=49). Ten patients in group A, and thirty-one patients in group B had their main immunosuppressive agent switched. The switch was much more frequent from CyA-me to Tac (n=31; 62.3%), mainly because of lack of efficacy (n=12; 38.7%). Six of 10 patients were shifted from Tac to CyA-me for side effects. The clinical course of the majority of patients converted from CyA-me to Tac improved clearly after conversion. Donor age and acute rejection (number, severity and rejection free days) had a significative association with lack of efficacy in group B. In these series, the conversion to Tac from CyA-me could be accomplished safely, with an excellent long-term outcome.

Primary retroperitoneal liposarcoma: clinical and histological analysis of ten cases

El liposarcoma retroperitoneal constituye una neoplasia infrecuente y localmente agresiva. Realizamos un análisis retrospectivo de los 10 pacientes (6 varones; edad media: 63,2±11años) con diagnóstico histológico de liposarcoma retroperitoneal atendidos en nuestra institución entre 1999–2007. La presencia de una masa abdominal palpable constituyó la forma de presentación más frecuente. Todos los pacientes fueron sometidos a resección quirúrgica, obteniéndose en cuatro casos márgenes negativos. El análisis histológico reveló lo siguientes subtipos: bien diferenciado (6 casos), desdiferenciado (dos casos), pleomórfico (un caso) y mixoide/células redondas (un caso). En cinco casos fue necesaria la resección concomitante de órganos adyacentes. La mitad de los pacientes presentaron recurrencia tumoral, fundamentalmente limitada al retroperitoneo o a la cavidad abdominal. La supervivencia media libre de recurrencia fue de 43,3 meses (IC 95%: 25,7–60,8), con una probabilidad de supervivencia global a los 3 y 5 años del 79 y 61%. Los pacientes sometidos a resección quirúrgica completa con márgenes negativos presentaron una tendencia hacia una mayor supervivencia libre de recurrencia (62,9 vs. 29,3 meses; p=0.06) (AU)

Retroperitoneal liposarcoma constitutes an uncommon and locally aggressive malignancy. We performed a retrospective analysis of 10 patients (6 males; mean age: 63.2±11 years) with histologically proven retroperitoneal liposarcoma seen at our institution between 1999 and 2007. Presence of a palpable abdominal mass was the main symptom at diagnosis. All patients underwent complete surgical resection. Negative microscopic margin was achieved in four cases. Histological analysis revealed the following subtypes: well-differentiated (6 cases), dedifferentiated (two cases), pleomorphic, and myxoid/round cell (one case each). Concomitant resection of adjacent organs was needed in five cases. Half of the patients developed tumor recurrence, mainly limited to the retroperitoneum or abdominal cavity. The mean recurrence-free survival was 43.3 months (95%CI: 25.7–60.8), with 3- and 5-year overall survival rates of 79% and 61%, respectively. Patients undergoing complete resection with clear margins showed a near-significant trend toward increased recurrence-free survival (62.9 vs. 29.3 months; P=0.06) (AU)

Primary retroperitoneal liposarcoma: clinical and histological analysis of ten cases.

Retroperitoneal liposarcoma constitutes an uncommon and locally aggressive malignancy. We performed a retrospective analysis of 10 patients (6 males; mean age: 63.2+/-11 years) with histologically proven retroperitoneal liposarcoma seen at our institution between 1999 and 2007. Presence of a palpable abdominal mass was the main symptom at diagnosis. All patients underwent complete surgical resection. Negative microscopic margin was achieved in four cases. Histological analysis revealed the following subtypes: well-differentiated (6 cases), dedifferentiated (two cases), pleomorphic, and myxoid/round cell (one case each). Concomitant resection of adjacent organs was needed in five cases. Half of the patients developed tumor recurrence, mainly limited to the retroperitoneum or abdominal cavity. The mean recurrence-free survival was 43.3 months (95%CI: 25.7-60.8), with 3- and 5-year overall survival rates of 79% and 61%, respectively. Patients undergoing complete resection with clear margins showed a near-significant trend toward increased recurrence-free survival (62.9 vs. 29.3 months; P=0.06).

Selección del donante de hígado mayor de 70 años / No disponible

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