Favorable Long-term Outcome in Patients Submitted to Liver Transplantation After Downstaging of Hepatocellular Carcinoma According to a Brazilian Selection Protocol.

BACKGROUND: In October 2008, the Brazilian Ministry of Health authorized listing of downstaged hepatocellular carcinoma (HCC) for liver transplantation, according to a standardized protocol. The aim of this study was to compare the outcome of patients submitted to liver transplantation after downstaging of HCC with the results other standard indications in Brazil. METHODS: We conducted a retrospective analysis of 2,667 adult 1st elective deceased-donor liver transplantations registered at the database of the Transplant Notification Center of the São Paulo State Health Secretariat. These cases are classified into 3 groups: "cirrhosis," including 1,709 patients transplanted because of end-stage liver disease; "Milan-HCC," including 873 HCC patients initially meeting the Milan criteria; and "downstaging" group, including 85 HCC patients submitted to tumor downstaging to the Milan criteria before liver transplantation. RESULTS: One-, 3-, 5-, and 6-year patients survivals were, respectively, 82.7%, 72.0%, 66.1%, and 66.1%, in the "downstaging" group and 76.7%, 68.4%, 63.9%, and 63.5% in the "Milan-HCC" group (P = .483). At the same time intervals, patient survivals were 67.8%, 62.9%, 60.9%, and 60.2% in the "cirrhosis" group. These probabilities were significantly lower than those of both "downstaging" (P = .047) and "Milan-HCC" (P = .001) groups. CONCLUSIONS: Patients submitted to liver transplantation after downstaging of HCC, according to a Brazilian selection protocol, present long-term outcomes similar to HCC patients initially within the Milan criteria and better survival than recipients with end-stage liver disease.

Donor risk index does not predict graft survival after pancreas transplantation in Brazil.

BACKGROUND: Pancreas donor risk index (DRI) was developed by using large multicenter American data to predict the risk of adverse outcomes in pancreas transplantation based on donor and technical/logistical characteristics. AIM: The goal of this study was to evaluate the usefulness of the DRI in predicting graft survival in a Brazilian population of pancreas transplant recipients. METHOD: We conducted a retrospective analysis of the 570 procedures performed by the same surgical team between 1996 and 2011. Because of the lack of sufficient data for the calculation of DRI values, only 154 cases were studied (27%), of which 105 underwent simultaneous pancreas-kidney transplantation, 33 underwent pancreas after kidney transplantation, and 16 underwent pancreas transplantation alone. Donor cause of death was classified as cerebrovascular accident (CVA) and non-CVA. Graft origin was divided into three groups: local, if the graft was obtained in the metropolitan area of the city of São Paulo; regional, if collected in other cities of the state of São Paulo; and national, if obtained outside the state. RESULTS: Logistic regression analysis did not find a statistically significant association between DRI values and 1-year graft survival (odds ratio = 0.676; 95% confidence interval 0.152 to 3.014; P = .60). One-year graft survival calculated by the Kaplan-Meier method was 89.8% in transplants with DRI ≤ 1, 77.9% in those with 1 < DRI < 1.5, and 93.3% in those with DRI ≥ 1.5 (P = .106). CONCLUSION: The pancreas DRI model did not prove effective in predicting pancreas graft survival in a Brazilian sample of recipients.

Comparative morphometric analysis of 5 interpositional arterial autograft options for adult living donor liver transplantation.

UNLABELLED: In living donor liver transplantation, the right-sided graft presents thin and short vessels, bringing forward a more difficult anastomosis. In these cases, an interpositional arterial autograft can be used to favor the performance of the arterial anastomosis, making the procedure easier and avoiding surgical complications. OBJECTIVE: We compared the inferior mesenteric artery (IMA), the splenic artery (SA), the inferior epigastric artery (IEA), the descending branch of the lateral circumflex femoral artery (LCFA), and the proper hepatic artery (PHA) as options for interpositional autograft in living donor liver transplantation. METHOD: Segments of at least 3 cm of all 5 arteries were harvested from 16 fresh adult cadavers from both genders through standardized dissection. The analyzed measures were proximal and distal diameter and length. The proximal diameter of the RHA and the distal diameter of the SA, IMA, IEA and the LCFA were compared to the distal diameter of the RHA. The proximal and distal diameters of the SA, IEA and LCFA were compared to study caliber gain of each artery. RESULTS: All arteries except the IMA showed statistical significant difference in relation to the RHA in terms of diameter. Regarding caliber gain, the arteries demonstrated statistical significant difference. All the harvested arteries except PHA were 3 cm in length. CONCLUSION: The IMA demonstrated the best compatibility with the RHA in terms of diameter and showed sufficient length to be employed as interpositional graft. The PHA, the SA, the IEA and the LCFA presented statistically significant different diameters when compared to the RHA. Among these vessels, only the PHA did not show sufficient mean length.

Consequences of the implementation of the Model for End-stage Liver Disease system for liver allocation in Brazil.

BACKGROUND: In July 2006, the system for liver allocation in Brazil started to rely on the Model for End-stage Liver Disease (MELD) scale, replacing the previous chronological criteria. Under the new system, the score for listing pediatric patients is obtained by multiplication of the calculated PELD score by 3. The current criteria also features extra points for diseases such as hepatocellular carcinoma (HCC). This study sought to analyze the consequences of implementation of the MELD system on waiting list mortality, posttransplant survival rates and characteristics of the transplanted patients. METHODS: We retrospectively studied data from the State Health Secretariat of São Paulo, regarding all patients registered on the waiting list for liver transplantation in the State of São Paulo, in two periods: July 2005 to July 2006 (pre-MELD era) and July 2006 to July 2010 (MELD era). Patient survival rates calculated using the Kaplan-Meier method were compared by the log-rank test. P values <.05 were considered statistically relevant. RESULTS: After implementation of the MELD, waiting list registrations decreased by 39.8%; the percentage of transplants in HCC recipients increased from 2.4% to 23.7%; pediatric transplants increased from 6.5% to 9.3%; deaths on the list fell from 599 in the pre-MELD era to 359 in the last year analyzed; recipients with higher MELD displayed significantly lower posttransplant survival rates; HCC patients, better survival after transplantation (P = .002); No difference was observed comparing survival rates between pre-MELD and MELD eras (P = 474) or between adults and children (P = .867). CONCLUSION: Under the MELD system for liver allocation in Brazil, there was a reduction in waiting list mortality and an increased number of transplantations in pediatric and HCC recipients. Survival rates of patients with higher MELD score were inferior. However, this result was offset by the greater survival in HCC recipients, with no difference in patient survival rates between the pre-MELD and MELD eras.

Leprosy in transplant recipients: report of a case after liver transplantation and review of the literature.

Leprosy still is an important public health problem in several parts of the world including Brazil. Unlike the diseases caused by other mycobacteria, the incidence and clinical presentation of leprosy seems little affected in immunosuppressed patients. We report the first case, to our knowledge, of a liver transplant patient who developed multi-bacillary leprosy. The patient presented with papules and infiltrated plaques with loss of sensation suggestive of leprosy 3.5 years after living-related liver transplantation for autoimmune hepatitis. A skin biopsy showing non-caseating macrophagic granulomas, neuritis, and intact acid-fast bacilli on Fite-Faraco stain, confirmed the diagnosis of borderline lepromatous leprosy. The donor of the liver did not show any evidence of leprosy. During follow-up, the patient presented 2 episodes of upgrading leprosy type I reactions, 1 mild before leprosy treatment, and 1 moderate 3 months after receiving standard multi-drug treatment (rifampicin, clofazimine, and dapsone). These reactions were accompanied by increase in liver function tests, especially of canalicular enzymes. This reaction occurred despite the patient's triple immunosuppression regimen. The moderate reaction was successfully treated with further immunosuppression (prednisone, 0.5 mg/kg). Currently, the patient is asymptomatic, off leprosy medication, with routine liver transplant follow-up. The dilemmas in diagnosis and management of such a case are discussed and the literature on leprosy in transplant recipients is reviewed.

Força muscular e mortalidade na lista de espera de transplante de fígado / Muscle strength and mortality while on a liver transplant waiting list

OBJETIVO: Avaliar a força de músculos respiratórios e de mão em pacientes na lista de espera para o transplante de fígado e associá-los a mortalidade. MATERIAIS E MÉTODOS: Foram estudados retrospectivamente 132 pacientes submetidos à avaliação fisioterapêutica de rotina e que esperavam o transplante de fígado. A força dos músculos ventilatórios foi avaliada por meio das pressões inspiratória e expiratória máximas e a força do membro superior por meio de dinamometria. Os pacientes foram divididos em dois grupos: grupo A, com 51 pacientes (14 mulheres, 50,1±12,3 anos) que morreram enquanto estavam na lista de espera e grupo B, com 81 pacientes (31 mulheres, 45,0±3,8 anos) que sobreviveram até o transplante de fígado. Foi utilizado o teste de t de Student com nível de significância de 5 por cento. RESULTADOS: Os valores médios da pressão inspiratória máxima (PImax) dos grupos A e B foram 65,7±28,0 e 77,5±33,8mmHg (p=0,04), respectivamente, e as pressões expiratórias máximas foram 72,9±32,9 e 84,4±33,1mmHg (p=0,07), respectivamente. Os valores médios da força da mão esquerda dos grupos A e B foram 18,5±8,1 e 21,5±10,5kgf (p=0,08), respectivamente, e da força da mão direita foram 20,2±9,7 e 23,5±12,5kgf (p=0,10), respectivamente. CONCLUSÕES: A PImax é menor nos pacientes que morreram enquanto aguardavam o transplante. No mesmo grupo, foi observado que a pressão expiratória máxima e a força da mão direita e esquerda foram menores, apesar de não apresentarem diferenças estatisticamente significante.

OBJECTIVE: To evaluate respiratory muscle strength and hand strength in patients on a liver transplant waiting list and to associate these with mortality. METHODS: one hundred and thirty-two patients who underwent routine physical therapy evaluation while waiting for liver transplantation were studied retrospectively. Respiratory muscle strength was assessed by measuring the maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP), and upper-limb strength was evaluated by dynamometry. The patients were divided into two groups: group A, consisting of 51 patients (14 females, 50.1±12.3 years) who died while on the waiting list; and group B, consisting of 81 patients (31 females, 45.0±3.8 years) who survived until the time of liver transplant. Student's t test was used with a 5 percent significance level. RESULTS: The mean MIP values for groups A and B were 65.7±28.0 and 77.5±33.8mmHg (p=0.04), respectively, and the mean MEP values were 72.9±32.9 and 84.4±33.1mmHg (p=0.07), respectively. The mean values for left-hand strength in groups A and B were 18.5±8.1 and 21.5±10.5kgf (p=0.08), and the mean values for right-hand strength were 20.2±9.7 and 23.5±12.5kgf (p=0.10), respectively. CONCLUSIONS: MIP was lower in the patients who died while waiting for liver transplantation. In the same group, it was observed that the MEP values and right and left-hand strength were numerically lower, although they did not reach statistically significant differences.

Twenty years of liver transplantation in Brazil.

This paper summarizes the 20 years of liver transplantation in Brazil, in the context of the Western world scenario. More than 5000 liver transplantations have been performed in the country since September 1, 1985. The living-donor liver transplantation, one of the landmarks in liver transplantation, was first described by our team in 1989. Brazil is the seventh country in number of liver transplants in the Western world and the first in Latin America. Almost 1000 procedures were performed in 2004, 19% of them involving living donors.

Subcapsular hematoma of the graft after liver transplantation.

Subcapsular hematoma of the graft is an underreported complication of liver transplantation (LT). Among 408 LT performed from September 1, 1985, to September 1, 2000, eight patients developed a subcapsular hematoma within 30 days after LT (8/408 = 2.0%). Among the six early cases observed, five required further surgical approaches due to hematoma progression, rupture, and hemorrhage. One patient underwent liver retransplantation due to uncontrollable hepatic hemorrhage. The two more recent cases were successfully treated by early opening of the Glisson's capsule with hemostasis of the hepatic raw bleeding surface. The five patients who developed acute renal failure required dialysis. Three patients died during hospitalization. Among the survivors, two were discharged on the postoperative (PO) day 15; the others on PO day 37, 38, and 56. In conclusion, subcapsular hematoma of the graft is a potentially serious complication of LT that may produce severe hemorrhage, shock, and in extreme cases, graft loss or even death. The severity of the complication is related to the extension of the decapsulated area of the graft. An early surgical approach with intentional opening of the hematoma before progression of the lesion seems to facilitate hemostasis and improve results.