Model for end-stage liver disease-based allocation system for liver transplantation in Argentina: does it work outside the United States?

BACKGROUND: In July 2005, Argentina was the first country after the United States to adopt the MELD system. The purpose of the present study was to analyse the impact of this new system on the adult liver waiting list (WL). METHODS: Between 2005 and 2009, 1773 adult patients were listed for liver transplantation: 150 emergencies and 1623 electives. Elective patients were categorized using the MELD system. A prospective database was used to analyse mortality and probability to be transplanted (PTBT) on the WL. RESULTS: The waiting time increased inversely with the MELD score and PTBT positively correlated with MELD score. With scores >/= 18 the PTBT remained over 50%. However, the largest MELD subgroup with <10 points (n = 433) had the lower PTBT (3%). In contrast, patients with T(2) hepatocellular carcinoma benefited excessively with the highest PTBT (84.2%) and the lowest mortality rate (5.4%). The WL mortality increased after MELD adoption (10% vs. 14.8% vs. P < 0.01). Patients with <10 MELD points had >fourfold probability of dying on the WL than PTBT (14.3% vs. 3%; P < 0.0001). CONCLUSIONS: After MELD implementation, WL mortality increased and most patients who died had a low MELD score. A comprehensive revision of the MELD system must be performed to include cultural and socio-economical variables that could affect each country individually.

Combined cardiohepatic transplantation due to severe heterozygous familiar hypercholesteremia type II: first case in Argentina--a case report.

Heterozygous familial hypercholesteremia type II is a recessive autonomic disease with a population incidence

Trasplante hepático en pacientes con trombosis portal: manejo intraoperatorio y resultados / Hepàtico transplant in patients with thrombosis vestibule: intraoperating handling and results

Antedecentes: La trombosis de la vena porta (TVP) es una complicación del paciente cirrótico que previamente era considerada una contraindicación para el trasplante hepático. Objetivos: Describir los resultados y evolución alejada de una serie consecutiva de trasplantes hepáticos realizados en pacientes portadores de TVP y analizarlos comparativamente con pacientes trasplantados sin TVP. Lugar de aplicación: Programa de trasplante hepático de una hospital público. Diseño: Retrospectivo, longitudinal, descriptivo. Material y Método: Entre julio de 1995 y junio del 2006, se realizaron 26 trasplantes hepáticos en pacientes con TVP (8,7%). Se analizaron factores de riesgo para TVP, variables del trasplante y del postrasplante. Se realizó un análisis comparativo con 273 pacientes trasplantados sin TVP. Resultados: 53,8% varones, edad 40,7 años. La TVP fue un hallazgo intraoperatorio en el 65%. Etiologías: cirrosis postnecróticas 73%, hepatopatías colestáticas 23% y fibrosis hepática congénita 4%. El 61,5% Child-Pugh C. Se realizó trombectomia en 21 pacientes con TVP Grados I, II y IV e injerto mesentérico portal extra-anatómico en 5 pacientes con TVP Grado III. La morbilidad fue del 57,7% la recurrencia de la TVP de 7,7% y la mortalidad durante la internación 26,9%. El trasplante en TVP presentó un incremento en el requerimiento de hemoderivados y en el índice de reoperaciones. La supervivencia al año fue 59,6% 75,2% para el Grado I y 44,8% para el Grado 2, 3 y 4. Conclusiones: La TVP no es contraindicación para el trasplante, su variedad más frecuente es el grado 1 y la técnica más empleada es trombectomía. El trasplante en pacientes con TVP demostró mayor requerimiento de hemoderivados, incidencia de complicaciones y de retrombosis portal y se asoció a una menor supervivencia en TVP grados 2, 3 y 4.

Liver resection for non-colorectal, non-neuroendocrine metastases: analysis of a multicenter study from Argentina.

BACKGROUND AND AIM: Resection of colorectal liver metastases has become a standard of care, although the value of this procedure in non-colorectal non-neuroendocrine (NCRNNE) metastases remains controversial and is still a matter of debate. The aim of the study was to determine the utility of liver resection in the long-term outcome of patients with NCRNNE metastases. MATERIAL AND METHODS: The records of 106 patients who underwent liver resection for NCRNNE metastases in the period 1989 to 2006 at 5 HPB Centers in Argentina were analyzed. Patient demographics, tumor characteristics, type of resection, long-term outcome and prognostic factors were analyzed. Depending on primary tumor sites, a comparative analysis of survival was performed. RESULTS: Mean age was 54 (17-76). Hepatic metastases were solitary in 62.3% and unilateral in 85.6%. Primary tumor sites: Urogenital (37.7%), sarcomas (21.7%), breast (17.9%), gastrointestinal (6.6%), melanoma (5.7%), and others (10.4%). Fifty-one major hepatectomies and 55 minor resections were performed. Twenty patients underwent synchronous resections. An R0 resection could be achieved in 89.6%. Perioperative mortality was 1.8%. Overall, 1-year, 3-year, and 5-year survival rates were 67%, 34%, and 19%, respectively. Survival was significantly longer for metastases of urogenital (p=0.0001) and breast (p=0.003) origin. Curative resections (p=0.04) and metachronous disease (p=0.0001) were predictors of better survival. CONCLUSIONS: Liver resection is an effective treatment for NCRNNE liver metastases; it gives satisfactory long-term survival especially in metachronous disease, in patients with metastases from urogenital and breast tumors and when R0 procedures can be performed.

Liver transplantation in adult patients with portal vein thrombosis: risk factors, management and outcome.

BACKGROUND: Portal vein thrombosis (PVT) is a well recognized complication of patients with end-stage cirrhosis and its incidence ranges from 2 to 26%. The aim of this study was to analyze the results and long-term follow-up of a consecutive series of liver transplants performed in patients with PVT and compare them with patients transplanted without PVT. PATIENTS AND METHODS: Between July 1995 and June 2006, 26 liver transplants were performed in patients with PVT (8.7%). Risk factors and variables associated with the transplant and the post-transplant period were analyzed. A comparative analysis with 273 patients transplanted without PVT was performed. RESULTS: The patients comprised 53.8% males, average age 40, 7 years. PVT was detected during surgery in 65%. Indications for transplantation were: post-necrotic cirrhosis 73%, cholestatic liver diseases 23%, and congenital liver fibrosis 4%. Child-Pugh C: 61.5%. Techniques were trombectomy in 21 patients with PVT grades I, II, IV, and extra-anatomical mesenteric graft in 5 with grade III. Morbidity was 57.7%, recurrence of PVT was 7.7%, and in-hospital mortality was 26.9%. Greater operative time, transfusion requirements, and re-operations were found in PVT patients. One-year survival was 59.6%: 75.2% for grade 1 and 44.8% for grades 2, 3, and 4. DISCUSSION: The study demonstrated a PVT prevalence of 8.7%, a higher incidence of partial thrombosis (grade 1), and successful management of PVT grade 4 with thrombectomy. Liver transplant in PVT patients was associated with an increased operative time, transfusion requirements, re-interventions, and lower survival rate according to PVT extension.

Nitric oxide in liver transplantation.

Liver transplantation is the only therapeutic option for patients with end-stage liver disease. Nitric oxide, a free radical produced from L-arginine, a potent vasodilator, also inhibits platelet adhesion and aggregation, reduces adhesion of leukocytes to the endothelium and suppresses proliferation of vascular smooth muscle cells. The inducible form of the nitric oxide synthase may generate large quantities of nitric oxide, and may be induced by the action of cytokines and lipopolysaccharides. Nitric oxide can be released from the hepatic vascular endothelium, platelets and Kupffer cells as a response to ischemia-reperfusion injury and circulatory shock. We analyzed the relationships between the levels of nitric oxide, hepatic enzymes and other clinical parameters (glucose, total proteins, total bilirubin, creatinine, albumin) obtained in serum samples before liver transplantation and every 48 h till day 15 in 15 patients aged 40 +/- 13 years. Aspartate aminotransferase and alanine aminotransferase levels changed from high at the beginning, to almost normal at the end of the study, cholinesterase levels remained decreased throughout the study and nitric oxide remained high, never reaching normal values.

Liver transplantation in transthyretin familial amyloid polyneuropathy: first report from Argentina.

This is the first report from Argentina of liver transplantation in patients with transthyretin related familial amyloidotic polyneuropathy. The aims of the study were to analyze the clinical characteristics of this new focus and evaluate the postoperative complications and long term follow up. Five of ten patients evaluated underwent liver transplantation. During the waiting period the polyneuropathy disability score in each patient progressed one or two stages. Pretransplant modified body mass index was 723. The procedure was done with full size grafts in four cases and a split right graft in one. All patients presented postoperative complications related to disease: severe edema of the legs, recurrent choledochal lithiasis, postoperative hernia, necrotizing fasciitis and ischemic rectosigmoidal perforation. Assessment of three patients after 20 months of transplantation showed improvement in somatic and mental symptoms. No improvement was noted in cardiac denervation and gastric stasis. Liver transplantation is a rational therapeutic option for transthyretin familial amyloidotic polyneuropathy in Argentina and should be indicated in earlier stages of the symptomatic disease to reduce the postoperative morbidity and mortality. Family studies and follow up of asymptomatic carriers will define the epidemiological behavior in this country and facilitate early therapeutic intervention.

Impact of age and amyloidosis on thiol conjugation of transthyretin in hereditary transthyretin amyloidosis.

Variant forms and post-translational modifications of transthyretin (TTR) can be identified by electrospray ionisation mass spectrometry (ESI-MS). The aim of the present study was to investigate thiol conjugation of transthyretin and it's relation to age and symptomatic amyloid disease in different populations of variant TTR carriers. Plasma samples from 70 individuals from Denmark, Argentina, Sweden and Japan, with 2 different TTR mutations were analysed. The percentage cysteine (Cys) conjugated wild and variant TTR were calculated from the corresponding peaks of the spectra, and multiple regression analysis was employed to disclose relationships between age, symptomatic amyloid disease and origin. Age, origin and presence of symptomatic disease, were found to be independent factors related to transthyretin conjugation. A higher percentage of conjugated to unconjugated TTR was disclosed in symptomatic, but not in asymptomatic carriers. In summary: Thiol conjugation of TTR is dependent on age and presence of symptomatic amyloid disease. Furthermore, it varies between different populations. Variant TTR is more susceptible to thiol conjugation than the wild type. Post-translational factors may be related to amyloid formation and/or toxicity.

Variant transthyretin (TTR) amyloidosis in Argentina. Detection of the trait by electrospray ionization mass spectrometry of lyophilized TTR immunoprecipitate.

We have developed a quick and reliable diagnostic method for detecting variant forms of transthyretin (TTR); namely, centrifugal concentration followed by electrospray ionization mass spectrometry (ESI-MS). Argentinian patients from three families with neuropathic amyloidosis and their relatives were screened for mutated TTR by ESI-MS. In order to facilitate transportation, we investigated the impact storage had on lyophilized anti-TTR-antibody precipitates' mass spectra. For this investigation, plasma samples from three Swedish patients with known TTR amyloidosis were analysed. We detected identical, additional peaks corresponding to a variant form of TTR in 10 members of the families, and also in a lyophilized sample sent unfrozen by mail from Argentina. All except one symptomatic subject had additional peaks, the exception having undergone a liver transplantation for the disease. All patients were early onset cases, i.e. below 35 years of age, and family history suggests an aggressive, rapidly progressing disease. Lyophilized anti-TTR-antibody precipitates stored at room temperature for 1 week exhibited only minor differences compared with plasma samples stored at -70 degrees C. In a new Argentinian study on familial amyloidotic polyneuropathy, the variant TTR was quickly identified and typed by ESI-MS. To facilitate transportation, dry-frozen samples can be used and the quality of the spectra is similar to that of samples stored at -70 degrees C.

Valor de la punción biopsia dirigida en la estadificación del carcinoma colo-rectal / Value of the biopsy puncture for colorectal carcinoma stage

Objetivo: Analizar retrospectivamente los resultados que se obtuvieron con la punción guiada por Tomografía Computada en pacientes con metástasis de carcinoma colorrectal. Diseño: Análisis retrospectivo de una serie de punciones guiadas por Tomografía Computada. Lugar de realización: Servicio de Cirugía General, Hospital Español de Buenos Aires. Pacientes y métodos: de 131 punciones biopsias abdominales realizadas entre enero de 1992 y junio de 1996 se realizaron 21 punciones efectuadas en 20 pacientes con metástasis de carcinoma colorrectal. La edad promedio fue de 66 años. Se utilizó un Tomógrafo Computado Philips Tomoscán 60 y un Tomógrafo helicoidal Toshiba Xvision. El procedimiento fue realizado con anestesia local y agujas modelo Turner con calibres variables según la lesión entre 19 y 23 Gauge. En todos los casos se realizó control tomográfico post-punción. En todos los casos se realizó análisis citológico del material intraprocedimiento. Resultados: En el 100 por ciento de los casos sólo fue necesario realizar una sola muestra. No se registraron complicaciones relacionadas con el método. En el 90 por ciento de los pacientes la punción decidió terapéutica oncológica concreta. La sensibilidad general en todas las localizaciones fue del 85 por ciento. La especificidad y el valor predictivo positivo fueron del 100 por ciento siendo los resultados comparables con otras series más numerosas. Conclusión: La punción aspiración con agujas finas guiadas por Tomografía Computada resulta un método seguro y útil, participando en forma decisiva en la toma de decisiones terapéuticas en aquellos pacientes con lesiones secundarias de carcinoma colorrectal.

Valor de la punción biopsia dirigida en la estadificación del carcinoma colo-rectal / Value of the biopsy puncture for colorectal carcinoma stage

Objetivo: Analizar retrospectivamente los resultados que se obtuvieron con la punción guiada por Tomografía Computada en pacientes con metástasis de carcinoma colorrectal. Diseño: Análisis retrospectivo de una serie de punciones guiadas por Tomografía Computada. Lugar de realización: Servicio de Cirugía General, Hospital Español de Buenos Aires. Pacientes y métodos: de 131 punciones biopsias abdominales realizadas entre enero de 1992 y junio de 1996 se realizaron 21 punciones efectuadas en 20 pacientes con metástasis de carcinoma colorrectal. La edad promedio fue de 66 años. Se utilizó un Tomógrafo Computado Philips Tomoscán 60 y un Tomógrafo helicoidal Toshiba Xvision. El procedimiento fue realizado con anestesia local y agujas modelo Turner con calibres variables según la lesión entre 19 y 23 Gauge. En todos los casos se realizó control tomográfico post-punción. En todos los casos se realizó análisis citológico del material intraprocedimiento. Resultados: En el 100 por ciento de los casos sólo fue necesario realizar una sola muestra. No se registraron complicaciones relacionadas con el método. En el 90 por ciento de los pacientes la punción decidió terapéutica oncológica concreta. La sensibilidad general en todas las localizaciones fue del 85 por ciento. La especificidad y el valor predictivo positivo fueron del 100 por ciento siendo los resultados comparables con otras series más numerosas. Conclusión: La punción aspiración con agujas finas guiadas por Tomografía Computada resulta un método seguro y útil, participando en forma decisiva en la toma de decisiones terapéuticas en aquellos pacientes con lesiones secundarias de carcinoma colorrectal. (AU)