Management of liver transplantation waiting list for decompensated cirrhosis in a Spanish tertiary hospital: differences between hepatitis C virus recipients and other etiologies.

BACKGROUND: Decompensated cirrhosis due to hepatitis C virus (HCV) is one of the main indications for liver transplantation (LT) in Spain. Recurrence of HCV after LT is the main cause of graft loss and death in HCV-positive recipients. Advanced donor age determines a more aggressive recurrence of HCV and a shorter survival. In this setting, in our liver unit, grafts from younger donors are allocated to HCV-positive recipients. The aim of this study was a comparative analysis of allocation of grafts in HCV-positive recipients versus other etiologies and the impact on waiting list time, Model for End-Stage Liver Disease (MELD) score progression until LT, need of admission in a hospital, survival until LT. METHODS: This was a retrospective study from the cohort of patients included in the waiting list for LT owing to decompensated cirrhosis in the Hospital Gregorio Marañón from January 2008 to June 2013. RESULTS: A total of 91 patients were included; 63 patients (69.23%) received LT; 19 (20.88%) retired from the waiting list: 6 because of improvement, 11 (12.08%) because of death. In both groups, the age of recipients was similar (HCV 52 y vs other 53 y; P = .549). HCV patients were included in the waiting list with lower MELD score than other etiologies (HCV 16.1 vs other 19.4; P = .010); nevertheless, MELD score was similar at the time of LT in both groups (HCV 18.9 vs other 19.4; P = .675). Time on waiting list was significantly longer in HCV patients (198 d vs 86 d; P = .002) and they were admitted in hospital more days (30 d vs 12 d; P = .03). Donor age in the HCV group was significantly lower (64.3 y vs 54.7 y; P = .006). The intention-to-treat survival analysis did not show differences between the groups (log rank = 0.504). CONCLUSIONS: HCV patients with decompensated cirrhosis receive grafts from younger donors. HCV patients remain waiting longer for an optimal organ and suffer MELD deterioration and more days admitted in hospital. These differences in allocation of grafts did not affect final survival. In our experience, designating younger organs to HCV-positive patients does not penalize neither HCV recipients nor recipients with other etiologies.

Pancreatitis aguda como presentación de una panarteritis nodular asociada a hepatitis C: reactivación tuberculosa por triple terapia inmunosupresora / Acute pancreatitis as a presentation of panarteritis nodosa associated with hepatitis C: tuberculous reactivation due to triple immunosuppressive therapy

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[Massive abdominal vein thrombosis with acute liver failure and toxic megacolon as onset of ulcerative colitis]. / Trombosis venosa masiva abdominal con insuficiencia hepática aguda y megacolon tóxico como presentación de colitis ulcerosa.

The prevalence of systemic thromboembolic complications is higher in patients with inflammatory bowel disease than in the general population. This hypercoagulable state is due to an increased production of procoagulant substances proportionally related to the inflammatory activity of the disease, although recent reports have focused on the presence of inherited thrombophilic disorders in this entity. We present the case of a 32-year-old woman with no relevant medical history who presented with massive abdominal vein thrombosis, including suprahepatic, portal, splenic and superior mesenteric veins, and secondary acute liver failure in her first ulcerative colitis flare and who later developed toxic megacolon requiring emergency total colectomy despite steroids and cyclosporine. Anticoagulant therapy achieved complete resolution of suprahepatic thrombosis and partial resolution in the splenic and superior mesenteric veins, with final cavernous transformation of the portal vein.

Trombosis venosa masiva abdominal con insuficiencia hepática aguda y megacolon tóxico como presentación de colitis ulcerosa / Massive abdominal vein thrombosis with acute liver failure and toxic megacolon as onset of ulcerative colitis

Los pacientes con enfermedad inflamatoria intestinal (EII) presentan una prevalencia superior de complicaciones tromboembólicas sistémicas que la población general. Este estado de hipercoagulabilidad se debe a una producción excesiva de sustancias procoagulantes relacionada proporcionalmente con la actividad de la enfermedad, aunque ciertas publicaciones recientes han revelado un número creciente de mutaciones genéticas predisponentes a la trombofilia en estos enfermos. Se presenta el caso de una mujer de 32 años, sin antecedentes patológicos de interés, en la que su primer brote de EII se presentó clínicamente como una trombosis venosa masiva abdominal (que afectaba a las venas suprahepáticas, porta, esplénica y mesentérica superior), con una insuficiencia hepática aguda y el desarrollo posterior de un megacolon tóxico, a pesar de la administración de esteroides y ciclosporina, por lo que se realizó a la paciente una colectomía total urgente. La anticoagulación consiguió la resolución completa de la trombosis de las venas suprahepáticas y parcial de la esplénica y mesentérica superior, con transformación cavernomatosa de la porta

The prevalence of systemic thromboembolic complications is higher in patients with inflammatory bowel disease than in the general population. This hypercoagulable state is due to an increased production of procoagulant substances proportionally related to the inflammatory activity of the disease, although recent reports have focused on the presence of inherited thrombophilic disorders in this entity. We present the case of a 32-year-old woman with no relevant medical history who presented with massive abdominal vein thrombosis, including suprahepatic, portal, splenic and superior mesenteric veins, and secondary acute liver failure in her first ulcerative colitis flare and who later developed toxic megacolon requiring emergency total colectomy despite steroids and cyclosporine. Anticoagulant therapy achieved complete resolution of suprahepatic thrombosis and partial resolution in the splenic and superior mesenteric veins, with final cavernous transformation of the portal vein

Sistemas de soporte hepático artificial: estado actual del tratamiento con diálisis de albúmina (MARS) / Artificial liver support systems: update on albumin dialysis (MARS)

La mortalidad de los pacientes con insuficiencia hepática sigue siendo inaceptablemente elevada. La insuficiencia hepática crónica agudizada tiene casi tan mal pronóstico como el fallo hepático agudo, de forma que es fundamental el desarrollo de sistemas que permitan el soporte de la función hepática, bien hasta el trasplante hepático o bien hasta la recuperación de la situación presente antes del daño agudo. La diálisis de albúmina es un sistema de soporte hepático artificial que permite la detoxificación de sustancias ligadas a la albúmina y de sustancias hidrosolubles, con lo que mantiene la homeostasis del paciente. La experiencia clínica actual todavía es limitada, si bien se ha demostrado que presenta efectos beneficiosos sobre parámetros clínicos, analíticos y hemodinámicos. El desarrollo de este sistema en un futuro pasa por la realización de estudios controlados multicéntricos que evalúen su efecto sobre la supervivencia en distintas afecciones

Mortality among patients with liver insufficiency continues to be unacceptably high. The prognosis of patients with acute episodes of chronic liver insufficiency is almost as poor as that of patients with acute liver failure. Therefore, systems that support liver function, either until liver transplantation can be performed or until resolution of the situation before acute injury occurs, are essential. Albumin dialysis is a system of artificial liver support that allows detoxification of albumin-related and hydrosoluble substances, thus maintaining the patient's homeostasis. Current clinical experience of this therapy is still limited, although beneficial effects on clinical, laboratory and hemodynamic parameters have been demonstrated. Multicenter, controlled trials to evaluate the effect of this therapy on survival in distinct diseases are

[Artificial liver support systems: update on albumin dialysis (MARS)]. / Sistemas de soporte hepático artificial: estado actual del tratamiento con diálisis de albúmina (MARS).

Mortality among patients with liver insufficiency continues to be unacceptably high. The prognosis of patients with acute episodes of chronic liver insufficiency is almost as poor as that of patients with acute liver failure. Therefore, systems that support liver function, either until liver transplantation can be performed or until resolution of the situation before acute injury occurs, are essential. Albumin dialysis is a system of artificial liver support that allows detoxification of albumin-related and hydrosoluble substances, thus maintaining the patient's homeostasis. Current clinical experience of this therapy is still limited, although beneficial effects on clinical, laboratory and hemodynamic parameters have been demonstrated. Multicenter, controlled trials to evaluate the effect of this therapy on survival in distinct diseases are needed.

Indicaciones y posibilidades terapéuticas de la diálisis de albúmina (MARS) / Indications and therapeutic possibilities of albumin dyalisis (MARS)

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[Indications and therapeutic possibilities of albumin dialysis (MARS)].

Despite remarkable medical advances during the last few years, liver failure--both acute and chronic--still results in high mortality. Since liver transplant programs were developed to improve survival in numerous hepatic end-stage disorders, fewer than 15% of patients with liver failure do actually receive a transplantation, be it because of the presence of procedural contraindications (toxic habits, age, concurrent disease), or of clinical conditions that may render surgery more difficult or worsen transplant prognosis. All these circumstances encouraged the development of alternative procedures to increase liver graft availability, as is the case of liver partition techniques and living-donor transplantation. On the other hand, organ scarcity for transplantation during the 1960s encouraged the parallel development of liver support systems in an attempt to reduce mortality and to improve patient survival while waiting for a transplant. Such systems attempt to replace a number of synthesis and detoxification functions for the damaged liver parenchyma. During the past few years both bioartificial systems--also referred to as "bioartificial livers"--based on bioreactors containing functionally active living hepatocytes, and extracorporeal liver detoxification systems have been developed. The latter type includes the so-called MARS (molecular adsorbent recirculating system) system, which combines albumin-bound molecule clearance and novel dialysis membrane biocompatibility.