Understanding the Elevated Lethality of COVID-19 in Liver Transplant Recipients: Does Immunosuppression Management Matter? Results from a Brazilian Multicentric Historical Cohort.

BACKGROUND: Infections by SARS-CoV-2 in liver transplant recipients (LT) patients are of particular concern, notably due to perceived added risks related to immunosuppression and comorbidity burden. Current literature on this topic often relies on small, non-standardized, and geographically limited studies. This manuscript describes COVID-19 presentations and causes for elevated mortality in a large cohort of LT recipients. METHODS: This study was designed as a multicentric historical cohort, including LT recipient patients with COVID-19 in 25 study centers, with the primary endpoint being COVID-related death. We also collected demographic, clinical, and laboratory data regarding presentation and disease progression. RESULTS: Two hundred and thirty-four cases were included. The study population was predominantly male and White and had a median age of 60 years. The median time from transplantation was 2.6 years (IQR 1-6). Most patients had at least one comorbidity (189, 80.8%). Patient age (P = .04), dyspnea (P < .001), intensive care unit admission (P < .001), and mechanical ventilation (P < .001) were associated with increased mortality. Modifications of immunosuppressive therapy (P < .001), specifically the suspension of tacrolimus, maintained significance in multivariable analysis. CONCLUSIONS: Attention to risk factors and the individualization of patient care, especially regarding immunosuppression management, is crucial for delivering more precise interventions to these individuals.

Preoperative Alpha-Fetoprotein and Radiological Total Tumor Diameter as Predictors of Hepatocellular Carcinoma Recurrence After Liver Transplantation.

BACKGROUND: Liver transplantation is a unique treatment opportunity for patients with chronic liver disease and hepatocellular carcinoma (HCC). Selection of HCC patients for transplantation was revolutionized by Milan-based criteria, but tumor recurrence and shortage of organs are still a major concern. Nowadays, additional preoperative tumor parameters can help to refine the graft allocation process. The objective of this study was to evaluate the prognostic value and cut-off points of pretransplant serum alpha-fetoprotein (AFP) levels and radiological tumor parameters on liver transplantation outcomes. METHODS: This is a single-team retrospective cohort of 162 consecutive deceased donor liver transplants (DDLT) with pathologically confirmed HCC. Pretransplant serum AFP levels and radiological tumor parameters were retrieved from a preoperative follow-up. Receiver-operating characteristics (ROC) curves were used to evaluate cut-off points for each outcome. Multivariate Cox regression model was used to assess the predictors of HCC relapse and recipient mortality. RESULTS: Twelve recipients (7.4%) had HCC recurrence after transplantation, with median survival time of 5.8 months. Pretransplant AFP ≥30 ng/mL (hazard ratio [HR]: 13.84, P = .003) and radiological total tumor diameter (TTD) ≥5 cm (HR: 12.89, P = .005) were independent predictors for HCC relapse. Moreover, pretransplant AFP ≥150 ng/mL was independently associated with recipient mortality (HR: 4.45, P = .003). CONCLUSIONS: Pretransplant AFP levels and radiological TTD were independently associated with HCC relapse and recipient mortality after DDLT, with different cut-off points predicting different outcomes. These findings may contribute to improving decision-making in the context of liver transplantation for HCC patients.

Incidental Finding of Multiple Synchronous Neoplasms in Explanted Liver After Transplantation: A Case Report.

Liver transplantation is the only potentially curative treatment for patients with end-stage liver disease. After the procedure, histopathologic analysis of the liver explant may reveal neoplasms that were not previously diagnosed in preoperative imaging examinations. This incidental finding of primary liver neoplasms in the explant is not an uncommon situation in liver transplant, and hepatocarcinomas and cholangiocarcinomas are the types of tumors most frequently encountered in this scenario. These are the most common primary neoplasms of the liver, and liver transplantation is often a curative treatment for these types of tumors when they are in their earlier stages. In contrast, liver plasmacytoma is a rare type of plasma cell neoplasm, consisting of a single mass of monoclonal plasma cells, which is treated primarily by radiotherapy and is seldom encountered in the setting of liver transplant. We report the case of a patient who underwent liver transplantation for the treatment of cryptogenic cirrhosis, with no preoperative diagnosis of liver tumors. Analysis of the liver explant revealed the presence of three synchronous neoplasms with different histologic origins: a 27-mm hepatocellular carcinoma, a 17-mm intrahepatic cholangiocarcinoma, and a 25-mm solitary hepatic plasmacytoma. The patient received no further adjuvant treatment and remained well and with no signs of disease recurrence over an observation period of 44 months. We found no previous report in the literature of the synchronous presence of these three types of liver neoplasms.

Progressive Familial Intrahepatic Cholestasis Type 2 and Recurrence After Liver Transplantation: A Case Report.

Progressive familial intrahepatic cholestasis type 2 (PFIC2) is a rare autosomal recessive disorder caused by mutations in the ABCB11 gene. Clinical manifestations include cholestasis with low γ-glutamyltransferase (GGT), hepatosplenomegaly, and severe pruritus. Liver transplantation is required for individuals with progressive liver disease or failure of the bypass procedure and has been considered curative. However, in the case of PFIC2, although bile salt excretory pump (BSEP) deficiency is a liver-specific condition rather than a systemic disease, evidence of recurrent BSEP disease has been shown in a small proportion of allografts. We describe an unusual case of a 21-year-old individual with PFIC2 and evidence of recurrent BSEP disease after liver transplantation, with clinical and laboratory improvement after pulse therapy with methylprednisolone for 3 days and adjustment of oral immunosuppression. This case report highlights the recurrence of PFIC2 in patients post liver transplant. It also emphasizes the importance of clinical suspicion, which should be considered in cases of posttransplant cholestasis in PFIC2 patients, especially those with low γ-glutamyltransferase (GGT) and without signs of acute graft rejection. Having knowledge of the condition favors a targeted diagnostic approach and contributes to early therapeutic management and a higher success rate.

Liver Transplantation After Acute Portal Vein Thrombosis: Case Report.

BACKGROUND: Portal vein thrombosis is a relatively frequent complication in patients with liver cirrhosis. Its detection and management are essential to avoid worsening portal hypertension or liver function complications. This complication can also negatively impact or even preclude liver transplant. CASE PRESENTATION: We report the case of a patient who presented with acute portal vein thrombosis, which allowed the diagnosis of liver cirrhosis and hepatocarcinoma within the Milan criteria. Chemical thrombolysis was performed with a mechanical aspiration of the thrombus, and in a second moment, the patient was submitted to a liver transplant. CONCLUSIONS: Advances in the therapeutic approach to portal vein thrombosis and surgical techniques have allowed the condition to no longer be an absolute contraindication to liver transplantation. Diagnosis in the acute phase is associated with greater therapeutic success, aiming to avoid the extension of thrombosis and achieve portal vein recanalization.

DOES THE ASSOCIATION OF TACROLIMUS AND MYCOPHENOLATE MOFETIL CHANGE THE HEALING OF THE ABDOMINAL WALL? STUDY IN RATS SUBMITTED TO ISCHEMIA AND KIDNEY REPERFUSION.

BACKGROUND: Tacrolimus and mycophenolate mofetil are immunosuppressive agents widely used on the postoperative period of the transplants. AIM: To evaluate the influence of the association of them on the abdominal wall healing in rats. METHODS: Thirty-six Wistar rats were randomly assigned in three groups of 12. On the early postoperative period, four of the control group and three of the experimental groups died. The three groups were nominated as follow: control group (GC, n=8); group I (GI, n=11, standard operation, mycophenolate mofetil and tacrolimus); group II (GII, n=10, standard operation, mycophenolate mofetil and tacrolimus). The standard operation consisted of right total nephrectomy and 20 min ischemia of the left kidney followed by reperfusion. Both NaCl 0.9% and the immunosuppressive agents were administered starting on the first postoperative day and continuing daily until the day of death on the 14th day. On the day of their deaths, two strips of the anterior abdominal wall were collected and submitted to breaking strength measurement and histological examination. RESULTS: There were no significant differences in wound infection rates (p=0,175), in the breaking strength measurement and in the histological examination among the three groups. CONCLUSION: The combination of the immunosuppressive agents used in the study associated with renal ischemia and reperfusion does not interfere in the abdominal wall healing of rats.

500 Consecutive Liver Transplants: The Outcomes of a New Transplantation Program in the Middle West of Brazil.

INTRODUCTION: Liver transplantation is the standard treatment for end-stage liver disease. Brazil holds the third highest number of liver transplants performed per year, but center maldistribution results in high discrepancies in accessing this treatment. In 2012, an interstate partnership successfully implemented a new liver transplantation program in the middle west of Brazil. Here, we report the results of the first 500 liver transplants performed in this new program and discuss the impacts of a new transplant center in regional transplantation dynamics. METHODS: We reviewed data from the first 500 consecutive deceased donor liver transplants performed in the new program during an 8-year period. We analyzed data on patients' clinical and demographic profiles, postoperative outcomes, and graft and recipient survival rates. Univariate survival analysis was conducted using log-rank tests to compare the groups. RESULTS: Almost half (48%) of the procured organs and 40% of the recipients transplanted in our center were from outside our state. Recipient 30-day mortality was 9%. Overall recipient survival at 1 year and 5 years was 85% and 80%, respectively. Mortality was significantly associated with higher Model for End-Stage Liver Disease (P < .001) but not with the presence of hepatocellular carcinoma (P = .795). DISCUSSION: The new transplantation program treated patients from different regions of Brazil and became the reference center in liver transplantation for the middle west region. Despite the recent implementation, our outcomes are comparable to experienced centers around the world. This model can inspire the creation of new transplantation programs aiming to democratize access to liver transplantation nationwide.

Electrical stunning in South American catfish (Rhamdia quelen) using direct current waveform: welfare and meat quality / Insensibilização elétrica em Jundiá (Rhamdia quelen) usando corrente direta: bem-estar e qualidade da carne

In Brazil, humane slaughter regulation is in use since 2000; however it is not applied to fish. This paper studied parameters for electrical stunning using direct current waveform in South American catfish (Rhamdia quelen) and its subsequent effects on muscular pH and rigor mortis. Seventy fish were allocated into two groups. In group 125, fish were stunned using 125 Volts (V), 30 Hz, duty cycle of 90% and 1.3 Amp (A) applied for 30 s; in group 400, fish were stunned with 400 V, 30 Hz, duty cycle of 27%, 0.9 A, for 30 s. Unconsciousness time was determined through behavioural assessment. After slaughter, ten fish from each group were refrigerated for both measurements muscular pH and rigor mortis index (RMI) at 0, 3, 6, 24, 72 and 120 h. In 125, 14.4% (5/35) of fish were not effectively stunned, in contrast with 400 in which 100% of fish (35/35) were effectively stunned. The unconsciousness duration was higher in 400 group (87.7±16.1 s) in contrast with group 125 (66.6 ± 16.1 s). Until 6 h post mortem ninety percent of fish reached maximum rigor mortis (RMI=100%).(AU)

No Brasil, a normativa de abate humanitário está em vigência desde 2000, no entanto tal norma não contempla peixes. O objetivo deste trabalho foi estudar os parâmetros para insensibilização elétrica em Jundiá (Rhamdia quelen) e seus efeitos sobre o pH muscular e o rigor mortis. Setenta peixes foram alocados em dois grupos. No grupo 125, os peixes foram insensibilizados usando 125 Volts (V), 30 Hz, duty cycle of 90% e 1.3 Amp (A) durante 30 s; no grupo 400, os peixes foram insensibilizados com 400 V, 30 Hz, duty cycle of 27%, 0.9 A, durante 30 s. O tempo de inconsciência foi determinado por avaliação comportamental. Após o abate, 10 peixes de cada grupo foram refrigerados para mensurações de pH muscular e o índice rigor mortis (RMI) às 0, 3, 6, 24, 72 e 120 h. No grupo 125, 14.4% (5/35) dos peixes não foram efetivamente insensibilizados, em contraste com o grupo 400, em que 100% dos peixes (35/35) foram efetivamente insensibilizados. A duração da inconsciência foi significativamente maior no tratamento 400, igual a 87.7 ± 16.1 s em relação aos 66.6 ± 16.1 s no 125. Noventa por cento dos peixes atingiram o máximo rigor mortis (RMI=100%) dentro das 6 h pós-abate. A insensibilização elétrica em Jundiá parece ser possível usando parâmetros do grupo 400, devido à duração de inconsciência maior que 60 s.(AU)

Electrical stunning in South American catfish (Rhamdia quelen) using direct current waveform: welfare and meat quality / Insensibilização elétrica em Jundiá (Rhamdia quelen) usando corrente direta: bem-estar e qualidade da carne

In Brazil, humane slaughter regulation is in use since 2000; however it is not applied to fish. This paper studied parameters for electrical stunning using direct current waveform in South American catfish (Rhamdia quelen) and its subsequent effects on muscular pH and rigor mortis. Seventy fish were allocated into two groups. In group 125, fish were stunned using 125 Volts (V), 30 Hz, duty cycle of 90% and 1.3 Amp (A) applied for 30 s; in group 400, fish were stunned with 400 V, 30 Hz, duty cycle of 27%, 0.9 A, for 30 s. Unconsciousness time was determined through behavioural assessment. After slaughter, ten fish from each group were refrigerated for both measurements muscular pH and rigor mortis index (RMI) at 0, 3, 6, 24, 72 and 120 h. In 125, 14.4% (5/35) of fish were not effectively stunned, in contrast with 400 in which 100% of fish (35/35) were effectively stunned. The unconsciousness duration was higher in 400 group (87.7±16.1 s) in contrast with group 125 (66.6 ± 16.1 s). Until 6 h post mortem ninety percent of fish reached maximum rigor mortis (RMI=100%).

No Brasil, a normativa de abate humanitário está em vigência desde 2000, no entanto tal norma não contempla peixes. O objetivo deste trabalho foi estudar os parâmetros para insensibilização elétrica em Jundiá (Rhamdia quelen) e seus efeitos sobre o pH muscular e o rigor mortis. Setenta peixes foram alocados em dois grupos. No grupo 125, os peixes foram insensibilizados usando 125 Volts (V), 30 Hz, duty cycle of 90% e 1.3 Amp (A) durante 30 s; no grupo 400, os peixes foram insensibilizados com 400 V, 30 Hz, duty cycle of 27%, 0.9 A, durante 30 s. O tempo de inconsciência foi determinado por avaliação comportamental. Após o abate, 10 peixes de cada grupo foram refrigerados para mensurações de pH muscular e o índice rigor mortis (RMI) às 0, 3, 6, 24, 72 e 120 h. No grupo 125, 14.4% (5/35) dos peixes não foram efetivamente insensibilizados, em contraste com o grupo 400, em que 100% dos peixes (35/35) foram efetivamente insensibilizados. A duração da inconsciência foi significativamente maior no tratamento 400, igual a 87.7 ± 16.1 s em relação aos 66.6 ± 16.1 s no 125. Noventa por cento dos peixes atingiram o máximo rigor mortis (RMI=100%) dentro das 6 h pós-abate. A insensibilização elétrica em Jundiá parece ser possível usando parâmetros do grupo 400, devido à duração de inconsciência maior que 60 s.

Electrical stunning in South American catfish (Rhamdia quelen) using direct current waveform: welfare and meat quality / Insensibilização elétrica em Jundiá (Rhamdia quelen) usando corrente direta: bem-estar e qualidade da carne

ABSTRACT: In Brazil, humane slaughter regulation is in use since 2000; however it is not applied to fish. This paper studied parameters for electrical stunning using direct current waveform in South American catfish (Rhamdia quelen) and its subsequent effects on muscular pH and rigor mortis. Seventy fish were allocated into two groups. In group 125, fish were stunned using 125 Volts (V), 30 Hz, duty cycle of 90% and 1.3 Amp (A) applied for 30 s; in group 400, fish were stunned with 400 V, 30 Hz, duty cycle of 27%, 0.9 A, for 30 s. Unconsciousness time was determined through behavioural assessment. After slaughter, ten fish from each group were refrigerated for both measurements muscular pH and rigor mortis index (RMI) at 0, 3, 6, 24, 72 and 120 h. In 125, 14.4% (5/35) of fish were not effectively stunned, in contrast with 400 in which 100% of fish (35/35) were effectively stunned. The unconsciousness duration was higher in 400 group (87.7±16.1 s) in contrast with group 125 (66.6 ± 16.1 s). Until 6 h post mortem ninety percent of fish reached maximum rigor mortis (RMI=100%).

RESUMO: No Brasil, a normativa de abate humanitário está em vigência desde 2000, no entanto tal norma não contempla peixes. O objetivo deste trabalho foi estudar os parâmetros para insensibilização elétrica em Jundiá (Rhamdia quelen) e seus efeitos sobre o pH muscular e o rigor mortis. Setenta peixes foram alocados em dois grupos. No grupo 125, os peixes foram insensibilizados usando 125 Volts (V), 30 Hz, duty cycle of 90% e 1.3 Amp (A) durante 30 s; no grupo 400, os peixes foram insensibilizados com 400 V, 30 Hz, duty cycle of 27%, 0.9 A, durante 30 s. O tempo de inconsciência foi determinado por avaliação comportamental. Após o abate, 10 peixes de cada grupo foram refrigerados para mensurações de pH muscular e o índice rigor mortis (RMI) às 0, 3, 6, 24, 72 e 120 h. No grupo 125, 14.4% (5/35) dos peixes não foram efetivamente insensibilizados, em contraste com o grupo 400, em que 100% dos peixes (35/35) foram efetivamente insensibilizados. A duração da inconsciência foi significativamente maior no tratamento 400, igual a 87.7 ± 16.1 s em relação aos 66.6 ± 16.1 s no 125. Noventa por cento dos peixes atingiram o máximo rigor mortis (RMI=100%) dentro das 6 h pós-abate. A insensibilização elétrica em Jundiá parece ser possível usando parâmetros do grupo 400, devido à duração de inconsciência maior que 60 s.

Combined Liver and Kidney Transplant in Acute Intermittent Porphyria: A Case Report.

BACKGROUND Acute intermittent porphyria is an inherited disease caused by a defect in heme biosynthesis, with accumulation of neurotoxic metabolites leading to acute neurovisceral symptoms. Some patients develop long-term neurological and renal damage after the acute episodes, many of them requiring hemodialysis. Since heme production in the human body occurs predominantly in the bone marrow and liver, liver transplantation has been shown to significantly reduce the production of neurotoxic metabolites, effectively controlling the disease. Patients with severe acute intermittent porphyria who have chronic kidney failure may benefit from combined kidney and liver transplant. Only 2 uses of this approach have been previously reported in the literature. CASE REPORT We report here the case of a 19-year-old male patient who received a combined liver and kidney transplant for the treatment of acute intermittent porphyria. He presented the first symptoms of the disease 4 years before the procedure, with abdominal pain and significant neurological impairment, with weakness requiring prolonged mechanical ventilation. He also had chronic kidney failure secondary to the porphyria. A combined liver and kidney transplant was performed, with no intraoperative complications. The explanted liver showed light siderosis, as well as portal and perisinusoidal fibrosis at microscopy. At 3.5 years of follow-up, he remains clinically well, with normal hepatic and renal function, had had no further acute porphyria episodes, and shows progressive neurological recovery. CONCLUSIONS This case demonstrates that combined liver and kidney transplant can be a curative treatment for patients with severe acute intermittent porphyria associated with end-stage renal failure. The patient shows satisfactory long-term function of both grafts, with no clinical or biochemical signs of porphyria recurrence.

Transmission of cryptococcosis by liver transplantation: A case report and review of literature.

BACKGROUND: Cryptococcosis is a fungal infection caused by the yeast-like encapsulated basidiomycetous fungus of the Cryptococcus neoformans (C. neoformans) species complex. These fungi are ubiquitous in soil and bird droppings, and infection by them is an important global health concern, particularly in immunosuppressed patients, such as organ transplant recipients and those infected by the human immunodeficiency virus. The fungus usually enters the body through the respiratory tract, but extremely rare cases of infection acquired by transplantation of solid organs have been reported. CASE SUMMARY: We report a case of disseminated cryptococcosis in a liver transplant recipient, diagnosed 2 wk after the procedure. The patient initially presented with fever, hyponatremia and elevated transaminase levels, manifesting intense headache after a few days. Blood cultures were positive for C. neoformans. Liver biopsy showed numerous fungal elements surrounded by gelatinous matrix and sparse granulomatous formations. Magnetic resonance imaging of the brain showed multiple small lesions with low signal in T2, peripheric enhancement and edematous halo, diffuse through the parenchyma but more concentrated in the subcortical regions. Treatment with amphotericin B for 3 wk, followed by maintenance therapy with fluconazole, led to complete resolution of the symptoms. The recipients of both kidneys from the same donor also developed disseminated cryptococcosis, confirming the transplant as the source of infection. The organ donor lived in a rural area, surrounded by tropical rainforest, and had negative blood cultures prior to organ procurement. CONCLUSION: This case highlights the risk of transmission of fungal diseases, specifically of C. neoformans, through liver graft during liver transplantation.

Does the association of tacrolimus and mycophenolate mofetil change the healing of the abdominal wall? study in rats submitted to ischemia and kidney reperfusion / A associação de tacrolimus e micofenolato mofetil altera a cicatrização da parede abdominal? estudo em ratos submetidos à isquemia e reperfusão renal

ABSTRACT Background: Tacrolimus and mycophenolate mofetil are immunosuppressive agents widely used on the postoperative period of the transplants. Aim: To evaluate the influence of the association of them on the abdominal wall healing in rats. Methods: Thirty-six Wistar rats were randomly assigned in three groups of 12. On the early postoperative period, four of the control group and three of the experimental groups died. The three groups were nominated as follow: control group (GC, n=8); group I (GI, n=11, standard operation, mycophenolate mofetil and tacrolimus); group II (GII, n=10, standard operation, mycophenolate mofetil and tacrolimus). The standard operation consisted of right total nephrectomy and 20 min ischemia of the left kidney followed by reperfusion. Both NaCl 0.9% and the immunosuppressive agents were administered starting on the first postoperative day and continuing daily until the day of death on the 14th day. On the day of their deaths, two strips of the anterior abdominal wall were collected and submitted to breaking strength measurement and histological examination. Results: There were no significant differences in wound infection rates (p=0,175), in the breaking strength measurement and in the histological examination among the three groups. Conclusion: The combination of the immunosuppressive agents used in the study associated with renal ischemia and reperfusion does not interfere in the abdominal wall healing of rats.

RESUMO Racional: O tacrolimus e o micofenolato mofetil são imunossupressores amplamente utilizados no pós-operatório dos transplantes de órgãos. Objetivo: Avaliar os efeitos deles sobre a cicatrização da parede abdominal em ratos. Métodos: Foram utilizados 36 ratos Wistar, distribuídos aleatoriamente em três grupos de 12. No pós-operatório imediato, quatro do grupo controle e três do grupo experimentação morreram. Os três grupos receberam as seguintes denominações: grupo controle (GC, n=8); grupo I (GI, n=11, operação-padrão, micofenolato mofetil e tacrolimus); grupo II (GII, n=10, operação-padrão, micofenolato mofetil e tacrolimus). A operação-padrão consistiu de nefrectomia total à direita, isquemia durante 20 min seguida de reperfusão do rim esquerdo. Solução de NaCl 0,9% e micofenolato mofetil + tracolimus foram administradas a partir do 1° dia do pós-operatório e mantidas até o dia do sacrifício dos animais, no 14° dia. Na data do sacrifício, foram retirados dois fragmentos da parede abdominal para análise da resistência à ruptura e exame histológico. Resultados: Não houve diferença estatisticamente significativa no índice de infecção de ferida operatória (p=0,175), nos valores de resistência de ruptura e nos achados histopatológicos entre os três grupos de animais. Conclusão: Os esquemas de imunossupressão empregados associados ao fenômeno da isquemia-reperfusão renal não induzem fraqueza significativa da cicatriz da parede abdominal em ratos no 14° dia de pós-operatório.

Leukocytoclastic vasculitis caused by hepatitis C virus in a liver transplant recipient: A case report.

BACKGROUND: Infection by the hepatitis C virus (HCV) is currently considered to be a global health issue, with a high worldwide prevalence and causing chronic disease in afflicted individuals. The disease largely involves the liver but it can affect other organs, including the skin. While leukocytoclastic vasculitis has been reported as one of the dermatologic manifestations of HCV infection, there are no reports of this condition as the first symptom of HCV recurrence after liver transplantation. CASE SUMMARY: We report here a case of leukocytoclastic vasculitis in a liver transplant recipient on maintenance immunosuppression. The condition presented as a palpable purpura in both lower extremities. Blood and urine cultures were negative and all biochemical tests were normal, excepting evidence of anemia and hypocomplementemia. Imaging examination by computed tomography showed a small volume of ascites, diffuse thickening of bowel walls, and a small bilateral pleural effusion. Skin biopsy showed leukocytoclasia and fibrinoid necrosis. Liver biopsy was suggestive of HCV recurrence in the graft, and HCV polymerase chain reaction yielded 11460 copies/mL and identified the genotype as 1A. Treatment of the virus with a 12-wk direct-acting antiviral regimen of ribavirin, sofosbuvir and daclatasvir led to regression of the symptoms within the first 10 d and subsequent complete resolution of the symptoms. CONCLUSION: This case highlights the difficulties of diagnosing skin lesions caused by HCV infection in immunosuppressed patients.

Use of extracorporeal membrane oxygenation for treating acute cardiomyopathy after liver transplantation: a case report. / Uso de oxigenação por membrana extracorpórea para tratamento de miocardiopatia aguda após transplante hepático: relato de caso.

We report the case of a female patient, 58 years of age, without known heart disease, who underwent liver transplantation without complications. On the second postoperative day, the patient developed cardiogenic shock secondary to stress-induced cardiomyopathy (Takotsubo-like syndrome). The patient was successfully managed with veno-arterial peripheral extracorporeal membrane oxygenation for 6 days, with complete recovery of cardiac function and of the hepatic graft. Coronary syndrome and acute myocarditis were excluded as the causes of the shock. The use of extracorporeal membrane oxygenation in this scenario is possible and safe, considering its specialized protocols and treatment.

Reportamos o caso de paciente do sexo feminino, 58 anos, sem doença cardíaca conhecida, submetida a transplante hepático sem intercorrências. No segundo dia do pós-operatório desenvolveu choque cardiogênico secundário à miocardiopatia induzida pelo estresse (síndrome de Takotsubo-like). A paciente foi manejada com sucesso com oxigenação por membrana extracorpórea venoarterial periférica, por 6 dias, com recuperação completa da função cardíaca, bem como do enxerto hepático. Síndrome coronariana e miocardite aguda foram excluídas como causas do choque. O uso de oxigenação por membrana extracorpórea neste cenário é possível e seguro, considerando protocolos e tratamento especializado neste tipo de suporte.

Uso de oxigenação por membrana extracorpórea para tratamento de miocardiopatia aguda após transplante hepático: relato de caso / Use of extracorporeal membrane oxygenation for treating acute cardiomyopathy after liver transplantation: a case report

RESUMO Reportamos o caso de paciente do sexo feminino, 58 anos, sem doença cardíaca conhecida, submetida a transplante hepático sem intercorrências. No segundo dia do pós-operatório desenvolveu choque cardiogênico secundário à miocardiopatia induzida pelo estresse (síndrome de Takotsubo-like). A paciente foi manejada com sucesso com oxigenação por membrana extracorpórea venoarterial periférica, por 6 dias, com recuperação completa da função cardíaca, bem como do enxerto hepático. Síndrome coronariana e miocardite aguda foram excluídas como causas do choque. O uso de oxigenação por membrana extracorpórea neste cenário é possível e seguro, considerando protocolos e tratamento especializado neste tipo de suporte.

ABSTRACT We report the case of a female patient, 58 years of age, without known heart disease, who underwent liver transplantation without complications. On the second postoperative day, the patient developed cardiogenic shock secondary to stress-induced cardiomyopathy (Takotsubo-like syndrome). The patient was successfully managed with veno-arterial peripheral extracorporeal membrane oxygenation for 6 days, with complete recovery of cardiac function and of the hepatic graft. Coronary syndrome and acute myocarditis were excluded as the causes of the shock. The use of extracorporeal membrane oxygenation in this scenario is possible and safe, considering its specialized protocols and treatment.

Feed management of pacu juveniles cultivated in net cages / Manejo alimentar de juvenis de pacu criados em tanques rede

The aim of this work was to evaluate the feed management (feed percentage and feeding frequency) of pacu (Piaractus mesopotamicus) juveniles bred in net cages. To evaluate the feed percentage 2,000 juveniles (12.12±0.51 g) were randomly distributed in 20 cages of 1 m3 (0.8 m3 of useful volume). The fish were fed four times a day (8:00 a.m.; 11:00 a.m.; 2:00 p.m.; and 5:00 p.m.) with 4, 7, 10, 13, and 16% of feed. To evaluate feeding frequency, another 2,000 juveniles (9.56±0.56 g) were randomly distributed in 20 cages of 0.8 m3 of useful volume. The fish were fed one, two, three and four times a day. Due to the feed percentage, significant effects (P0.05) by the feeding frequency. Considering the weight gain and apparent feed conversion of pacu juveniles cultivated in net cages, 8% of feed is recommended regardless of the feeding frequency adopted.

O objetivo do presente trabalho foi avaliar o manejo alimentar (porcentagem de arraçoamento e frequência alimentar) de juvenis de pacu (Piractus mesopotamicus) criados em tanques rede. Para avaliar a porcentagem de arraçoamento foram utilizados 2.000 juvenis (12,12±0,51 g), distribuídos em 20 tanques rede de 0,8 m3 de volume útil, alimentados quatro vezes ao dia (8, 11, 14 e 17 horas), com 4, 7, 10, 13 e 16% de arraçoamento. Para avaliar a frequência alimentar, foram utilizados 2.000 juvenis (9,56±0,56 g), distribuídos em 20 tanques rede com 0,8 m3 de volume útil, alimentados uma, duas, três e quatro vezes ao dia. Observou-se efeito significativo (P0,05) da frequência alimentar sobre os parâmetros zootécnicos, composição centesimal e bioquímicos do sangue. Considerando o ganho de peso e conversão alimentar aparente de juvenis de pacu criados em tanques rede, recomenda-se 8% de arraçoamento, independentemente da frequência alimentar adotada.

Feed management of pacu juveniles cultivated in net cages / Manejo alimentar de juvenis de pacu criados em tanques rede

The aim of this work was to evaluate the feed management (feed percentage and feeding frequency) of pacu (Piaractus mesopotamicus) juveniles bred in net cages. To evaluate the feed percentage 2,000 juveniles (12.12±0.51 g) were randomly distributed in 20 cages of 1 m3 (0.8 m3 of useful volume). The fish were fed four times a day (8:00 a.m.; 11:00 a.m.; 2:00 p.m.; and 5:00 p.m.) with 4, 7, 10, 13, and 16% of feed. To evaluate feeding frequency, another 2,000 juveniles (9.56±0.56 g) were randomly distributed in 20 cages of 0.8 m3 of useful volume. The fish were fed one, two, three and four times a day. Due to the feed percentage, significant effects (P<0.05) were observed for the parameters of weight gain, final length, final biomass, specific growth rate, and apparent feed conversion. The performance parameters, centesimal composition, and blood biochemistry were not influenced (P>0.05) by the feeding frequency. Considering the weight gain and apparent feed conversion of pacu juveniles cultivated in net cages, 8% of feed is recommended regardless of the feeding frequency adopted.(AU)

O objetivo do presente trabalho foi avaliar o manejo alimentar (porcentagem de arraçoamento e frequência alimentar) de juvenis de pacu (Piractus mesopotamicus) criados em tanques rede. Para avaliar a porcentagem de arraçoamento foram utilizados 2.000 juvenis (12,12±0,51 g), distribuídos em 20 tanques rede de 0,8 m3 de volume útil, alimentados quatro vezes ao dia (8, 11, 14 e 17 horas), com 4, 7, 10, 13 e 16% de arraçoamento. Para avaliar a frequência alimentar, foram utilizados 2.000 juvenis (9,56±0,56 g), distribuídos em 20 tanques rede com 0,8 m3 de volume útil, alimentados uma, duas, três e quatro vezes ao dia. Observou-se efeito significativo (P<0,05) para os parâmetros de ganho de peso, comprimento final, biomassa final, e conversão alimentar aparente, em função do percentual de arraçoamento. Não foram observadas influências (P>0,05) da frequência alimentar sobre os parâmetros zootécnicos, composição centesimal e bioquímicos do sangue. Considerando o ganho de peso e conversão alimentar aparente de juvenis de pacu criados em tanques rede, recomenda-se 8% de arraçoamento, independentemente da frequência alimentar adotada.(AU)

Quantificação de alumínio inorgânico em suplementos minerais para bovinos comercializados no estado de São Paulo / Inorganic aluminum measurement in mineral supplements for cattle commercialized in São Paulo state

Realizou-se pesquisa quantificando o elemento alumínio em diferentes formulações minerais mais comercializadas no Estado de São Paulo. O metal pesado foi determinado pela técnica de espectrofotometria de absorção atômica. Em 18 amostras somente 09 tiveram valores inferiores aos 1000 ppm, recomendado como máximo valor aceitável. Os números oscilaram entre 293 e 2.930 ppm, com o maior resultado sendo encontrado numa amostra de sal mineral no município de Taciba. Os resultados demonstram a necessidade do monitoramento e fiscalização junto aos fabricantes, pois algumas misturas minerais podem ser eminentemente perigosas, possibilitando efeitos cumulativos tóxicos de alumínio inorgânico aos bovinos.

The authors carried out research quantifying the aluminum element in different mineral formulations most commercialized in São Paulo. The heavy metal was determined by the technique of atomic absorption spectrophotometry. From 18 samples only 09 samples had values lower than 1000 ppm , recommended a maximum acceptable value . The numbers ranged between 293 and 2,930 ppm , with the highest value being found in a mineral salt sample in the city of Taciba . The results demonstrate the need for monitoring and supervision with manufacturers , as some mineral mixtures can be highly dangerous , allowing toxic cumulative effects of inorganic aluminum to cattle.

Quantificação de alumínio inorgânico em suplementos minerais para bovinos comercializados no estado de São Paulo / Inorganic aluminum measurement in mineral supplements for cattle commercialized in São Paulo state

Realizou-se pesquisa quantificando o elemento alumínio em diferentes formulações minerais mais comercializadas no Estado de São Paulo. O metal pesado foi determinado pela técnica de espectrofotometria de absorção atômica. Em 18 amostras somente 09 tiveram valores inferiores aos 1000 ppm, recomendado como máximo valor aceitável. Os números oscilaram entre 293 e 2.930 ppm, com o maior resultado sendo encontrado numa amostra de sal mineral no município de Taciba. Os resultados demonstram a necessidade do monitoramento e fiscalização junto aos fabricantes, pois algumas misturas minerais podem ser eminentemente perigosas, possibilitando efeitos cumulativos tóxicos de alumínio inorgânico aos bovinos. (AU)

The authors carried out research quantifying the aluminum element in different mineral formulations most commercialized in São Paulo. The heavy metal was determined by the technique of atomic absorption spectrophotometry. From 18 samples only 09 samples had values lower than 1000 ppm , recommended a maximum acceptable value . The numbers ranged between 293 and 2,930 ppm , with the highest value being found in a mineral salt sample in the city of Taciba . The results demonstrate the need for monitoring and supervision with manufacturers , as some mineral mixtures can be highly dangerous , allowing toxic cumulative effects of inorganic aluminum to cattle. (AU)