Comparison of abdominal adipose tissue versus Body Mass Index (BMI) as a predictor of complications and survival in liver transplantation.

INTRODUCTION: Because of the obesity epidemic, more obese patients are on liver transplant (LT) waiting lists. The diseases associated with obesity may increase complications and limit survival after LT. However, there is no established measure or cut-off point to determine this impact and aid decision making. The aim of the present study is to evaluate obesity in patients undergoing LT via BMI and CT-based measurement of adipose tissue (AAT). These parameters will be used to predict the risk of postoperative complications and 5-year survival. METHODS: A retrospective, single-center study was carried out at a tertiary Spanish hospital, including all patients who received LT between January 2012 and July 2019 (n = 164). The patients were adults who underwent LT using the 'piggyback' technique, preserving the recipient vena cava. Visceral adipose tissue (VAT) and BMI were calculated to examine correlations with postoperative complications and 5-year survival. RESULTS: No significant association was found between postoperative complications by Comprehensive Complication Index, BMI, AAT/height, subcutaneous fat/height and VAT/height. Kaplan-Meier curves for 5-year survival compared LT recipients with BMI < 30.45 vs ≥30.45, with an estimated survival of 58.97 months versus 43.11 months, respectively (P < .001) (Fig. 3) and for LT recipients with an AAT/height <27.35 mm versus ≥27.35 mm, with an estimated survival of 57.69 months versus 46.34 months (P = .001). CONCLUSIONS: This study does not show a higher rate of postoperative complications in obese patients. There is a significantly lower long-term survival in patients with AAT/height ≥27.35 mm and BMI ≥ 30.45. BMI is a valid estimate of obesity and is predictive of survival.

Consensus document from the Spanish Society for Liver Transplantation: enhanced recovery after liver transplantation.

The goal of the Spanish Society for Liver Transplantation (La Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, in November 2022, the 10th Consensus Document Meeting was held, with the participation of experts from the 26 authorized Spanish liver transplantation programs. This edition discusses Enhanced Recovery After Liver Transplantation, dividing needed actions into three periods: preoperative, intraoperative and postoperative. The evaluated evidence and the consensus conclusions for each of these topics are described.

Consensus document from the Spanish Society for Liver Transplantation: Enhanced recovery after liver transplantation. / Documento de consenso de la Sociedad Española de Trasplante Hepático. Recuperación intensificada en trasplante hepático.

The goal of the Spanish Society for Liver Transplantation (Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, in November 2022, the 10th Consensus Document Meeting was held, with the participation of experts from the 26 authorized Spanish liver transplantation programs. This edition discusses enhanced recovery after liver transplantation, dividing needed actions into 3periods: preoperative, intraoperative and postoperative. The evaluated evidence and the consensus conclusions for each of these topics are described.

Optimización de los resultados del programa de bipartición hepática para trasplante split / Liver bipartition program for «SPLIT» transplantation: Optimization results

Introducción: El trasplante hepático (TH) split es un procedimiento extendido por toda Europa. En 2018 en Cataluña, se redefinió la distribución de donantes, siendo candidatos potenciales para split todos aquellos menores de 35 años y se flexibilizó la selección del adulto para el injerto derecho. El objetivo del estudio es evaluar el efecto de estas modificaciones en la utilización de donantes para split, en las listas de espera (LE) y en los resultados de los adultos que recibieron un injerto split. Métodos: Estudio observacional y retrospectivo; dos periodos de recogida de datos «pre» (2013-2017) y «post» (2018-2021). Los resultados de los receptores adultos se analizaron mediante un propensity score matching. Resultados: En el primer periodo fueron registrados tres donantes y se trasplantaron tres pacientes pediátricos y dos adultos; en el periodo post se obtuvieron 24 donantes, realizándose el trasplante en 19 adultos y 24 receptores infantiles. Al comparar las LE se evidenció una disminución significativa tanto en la de adultos (p = 0,0001) como en la infantil (p = 0,0004) y hasta en tres ocasiones no hubo receptores en la LE infantil. No se observaron diferencias significativas en cuanto a morbilidad o mortalidad, ni en la supervivencia global en el grupo de receptores adultos de injertos split. Conclusiones: La flexibilidad en la selección del receptor adulto y la nueva distribución de donantes ayuda a aumentar la tasa de bipartición, permitiendo reducir la LE pediátrica sin afectar los resultados en los trasplantados adultos ni su estancia en LE.(AU)

Introduction: SPLIT liver transplantation is a procedure performed throughout Europe. In 2018 in Catalonia, the distribution of donors was redefined, being potential candidates for SPLIT all those under 35 years and it was made flexible the adult selection for the right graft. The study aim is to evaluate the effect of this modification on the use of SPLIT donors on the adult/pediatric waiting lists, as well as to evaluate the post-transplant results of adults who received a SPLIT donor. Methods: Observational and retrospective study; 2 data collection periods «PRE» (2013–2017) and «POST» (2018–2021). The adults recipients results were analyzed by a propensity score matching. Results: In the first period, three donors were registered and three pediatric patients and two adults received a transplant. In the POST period, 24 donations with liver bipartition were made, performing the transplant in 19 adults and 24 children. When comparing the adults waiting lists, a significant decrease was evidenced, both for adults (p = 0.0001) and on the children's waiting list (p = 0.0004), and up to three times there were no recipients on the pediatric waiting list. No significant differences between hospital morbidity or mortality or overall survival were observed in the group of adult recipients of SPLIT grafts. Conclusions: The flexibility in the selection of the adult recipient and the new distribution of donors makes possible to increase the bipartition rate, reducing the pediatric waiting list without worsening the adults results transplant recipients or their permanence on the waiting list.(AU)

Documento de consenso de la Sociedad Española de Trasplante Hepático. Recuperación intensificada en trasplante hepático / Consensus document from the Spanish Society for Liver Transplantation: Enhanced recovery after liver transplantation

La Sociedad Española de Trasplante Hepático tiene como objetivo la promoción y elaboración de documentos de consenso sobre temas de actualidad en trasplante hepático de abordaje multidisciplinario. Para ello, en noviembre de 2022 se celebró la 10.ª Reunión de Consenso, con la participación de representantes de los 26 programas de trasplante hepático españoles autorizados. En esta edición se abordó la recuperación intensificada tras el trasplante hepático y se dividieron las acciones en 3periodos, preoperatorio, intraoperatorio y postoperatorio. Se exponen a continuación las evidencias evaluadas y las consecuentes recomendaciones consensuadas.(AU)

The goal of the Spanish Society for Liver Transplantation (Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, in November 2022, the 10th Consensus Document Meeting was held, with the participation of experts from the 26 authorized Spanish liver transplantation programs. This edition discusses enhanced recovery after liver transplantation, dividing needed actions into 3periods: preoperative, intraoperative and postoperative. The evaluated evidence and the consensus conclusions for each of these topics are described.(AU)

Gammagrafía de perfusión miocárdica en la evaluación del riesgo cardiovascular en el trasplante hepático de adultos / Myocardial perfusion scintigraphy in the assessment of cardiovascular risk in adult liver transplantation

Introducción El estudio diagnóstico no invasivo del riesgo cardiovascular en pacientes que van a ser llevados a trasplante hepático no es claro especialmente en asintomáticos. Respecto a la gammagrafía de perfusión miocárdica (GPM) se ha pensado que la reserva vasodilatadora deteriorada en estos pacientes puede reducir su rendimiento. El objetivo es valorar el papel de la GPM en la evaluación prequirúrgica de los pacientes que van a ser tratados mediante un trasplante hepático. Material y métodos Estudio retrospectivo, descriptivo y observacional. Se incluyó a todos los pacientes adultos llevados a trasplante hepático entre 2017 y 2021 que tuvieran GPM previa. Se describen los hallazgos de la GPM y se correlacionaron con los hallazgos de angiografía invasiva y con la aparición o no de eventos cardiovasculares peri y postrasplante. Resultados De 188 pacientes trasplantados (edad promedio: 57 años, DE: 12), 178 tenían perfusión miocárdica previa, 82 (46%) pacientes no tenían factores de riesgo cardiovascular y 5 (2,8%) tenían antecedente de enfermedad coronaria. De las GPM, 177 fueron con estrés con dipiridamol realizadas en promedio 10 meses antes del trasplante. Únicamente 17/178 (9,5%) estudios fueron anormales. El seguimiento medio fue de 38 meses (DE: 10). De los pacientes con GPM normal, solo 2 (1,2%) presentaron eventos cardiovasculares, ambos con estudios realizados más de 2años atrás. No hubo muertes de origen cardiovascular. Conclusiones La GPM es una técnica segura y confiable en la valoración cardiovascular en pacientes candidatos a trasplante hepático dada la baja tasa de falsos negativos en el seguimiento (AU)

Introduction The non-invasive diagnostic study of cardiovascular risk in patients who are going to undergo liver transplantation is not clear, especially in asymptomatic patients. Regarding myocardial perfusion scintigraphy (MPS), it has been thought that the impaired vasodilator reserve in these patients may reduce its performance. The objective is to assess the role of the MPS in the pre-surgical evaluation of patients who are going to undergo liver transplantation. Material and methods Retrospective, descriptive and observational study was designed. All adult patients undergoing liver transplantation between 2017 and 2021 who had previous MPS were included. The findings of MPS were described and correlated with the findings of invasive angiography and with the appearance or not of peri- and post-transplant cardiovascular events. Results There were a total of 188 transplanted patients (mean age: 57 years, SD: 12), 178 had previous myocardial perfusion, 82 (46%) patients had no cardiovascular risk factors, and 5 (2.8%) had a history of coronary disease. Of the MPS, 177 were with dipyridamole stress performed on average 10 months before transplantation. Only 17/178 (9.5%) studies were abnormal. The mean follow-up was 38 months (SD: 10). Of the patients with normal MPS, only 2 (1.2%) presented cardiovascular events, both with studies performed more than 2years before the procedure. There were no deaths of cardiovascular origin. Conclusions MPS is a safe and reliable technique for cardiovascular assessment of patients who are candidates for liver transplantation, given the low rate of false negatives during follow-up (AU)

Portosinusoidal vascular disorder: A paradigm shift. / Enfermedad vascular portosinusoidal: un cambio de paradigma.

The term portosinusoidal vascular disorder (PSVD) refers to a clinical-pathological entity that encompasses those patients with intrahepatic vascular damage without cirrhosis at risk of developing severe complications of portal hypertension. Numerous systemic diseases, genetic disorders, and toxic agents have been associated with this pathology, making its diagnosis an important clinical challenge. The recent description of uniform diagnostic criteria and a better understanding of its pathophysiology will allow for better identification of patients, even in early stages of the disease. Although there is currently no effective etiological treatment available, early diagnosis allows for the development of preventive strategies for some severe complications of portal hypertension.

Aplicabilidad del índice de fragilidad hepática en pacientes cirróticos evaluados para trasplante / Applicability of the liver frailty index in cirrhotic patients evaluated for transplantation

Introducción. En las últimas décadas se han desarrollado diferentes scores y modelos para predecir el pronóstico en pacientes con enfermedad hepática crónica avanzada. Los más reconocidos y utilizados son el sistema de estadificación de Child-Pugh (CP) y el score de MELD, pero estos carecen de herramientas para evaluar objetivamente otros factores pronósticos. Por este motivo, se ha incorporado el concepto de fragilidad a la hepatología clínica. El objetivo de este artículo es examinar la aplicabilidad del índice de fragilidad hepática (IFH) en pacientes con cirrosis evaluados para trasplante hepático en Uruguay. Metodología. Estudio observacional, descriptivo y retrospectivo en el Servicio de Enfermedades Hepáticas del Hospital Central de las Fuerzas Armadas (HCFFAA) de enero de 2018 a diciembre de 2021. Resultados. Se evaluaron un total de 78 pacientes, excluyéndose 19 de estos, culminando con una muestra final de 59 pacientes. La edad media fue de 52 años, siendo el 66 % hombres. La principal etiología de la cirrosis fue la alcohólica, y la comorbilidad más frecuente fue el sobrepeso/obesidad (66 %). La media de IFH fue de 4,03 ± 0,45. El 90 % de los pacientes eran prefrágiles, el 10 % frágiles y ningún paciente fue clasificado como no frágil. El 76 % presentaba un estadio avanzado de la enfermedad al momento de la evaluación 42 % CP estadio B, 34 % CP C, 24 % CP A, con una media de MELD-Na de 17,8 ± 7,6. El 17 % tuvo complicaciones infecciosas. La mortalidad global (n=78) fue del 12 %, y la de los pacientes con IFH calculado fue del 22 %. Conclusiones. El cálculo del IFH es realizable en cirróticos como herramienta objetiva que brinda una mirada integral del paciente. A mayor severidad de la cirrosis, mayor es el IFH. Sin embargo, este índice no parece ser un predictor de la eventual realización del trasplante hepático, ni de muerte en lista de espera en nuestros pacientes.

Introduction. In recent decades, several scores and models have been proposed to predict prognosis in patients with advanced chronic liver disease. The most recognized and used are the Child-Pugh (CP) and the Model for End-stage Liver Disease (MELD) scores, but they lack tools to objectively evaluate other prognostic factors. For this reason, the concept of fragility has been incorporated into clinical hepatology. The objective of this study was to evaluate the applicability of the liver frailty index (LFI) in patients with cirrhosis evaluated for liver transplantation in Uruguay. Methodology. Observational, descriptive and retrospective study at the Hospital Central de las Fuerzas Armadas (HCFFAA) Liver Disease Service from January 2018 to December 2021. Results. A total of 78 patients were evaluated, 19 were excluded, culminating in a final sample of 59 patients. The mean age was 52 years, with 66% being men. The main etiology of cirrhosis was alcoholic and the most frequent comorbidity was overweight/obesity (66%). The mean LFI was 4.03 ± 0.45. 90% of patients were pre-fragile, 10% were fragile, and no patient was classified as non-fragile. 76% had an advanced stage of the disease at the time of evaluation: 42% CP stage B, 34% CP C, 24% CP A, with a mean MELD-Na of 17.8 ± 7.6. 17% had infectious complications. Overall mortality (n=78) was 12%, and that of patients with calculated LFI was 22%. Conclusions. The LFI can be calculated in cirrhotic patients, and it is an objective tool that provides a comprehensive view of the patient. LFI depends on the severity of the cirrhosis. However, this index is not a predictor of liver transplantation or death on the waiting list in our patients.

Optimized results of the liver partition program for split-liver transplantation.

INTRODUCTION: Split liver transplantation is a procedure performed throughout Europe. In 2018 in Catalonia, the distribution of donors was redefined, being potential candidates for SPLIT all those under 35-years and it was made flexible the adult selection for the right graft. The study aim is to evaluate the effect of this modifications on the use of Split donors on the adult/pediatric waiting lists, as well as to evaluate the post-transplant results of adults who received a Split donor. METHODS: Observational and retrospective study; 2 data collection periods "PRE" (2013-2017) and "POST" (2018-2021). The adults recipients results were analyzed by a propensity score matching. RESULTS: In the first period 3 donors were registered and 3 pediatric patients and 2 adults recieved a transplant. In the POST period, 24 donations with liver bipartition were made, performing the transplant in 19 adults and 24 childrens. When comparing the adults waiting lists, a significant decrease was evidenced, both for adults (p = 0,0001) and on the children's waiting list (p = 0,0004), and up to 3 times there were no recipients on the pediatric waiting list. No significant differences between hospital morbidity or mortality or overall survival were observed in the group of adult recipients of Split grafts. CONCLUSIONS: The flexibility in the selection of the adult recipient and the new distribution of donors makes possible to increase the bipartition rate, reducing the pediatric waiting list without worsening the adults results transplant recipients or their permanence on the waiting list.

Myocardial perfusion scintigraphy in the assessment of cardiovascular risk in adult liver transplantation.

INTRODUCTION: The non-invasive diagnostic study of cardiovascular risk in patients who are going to undergo liver transplantation is not clear, especially in asymptomatic patients. Regarding myocardial perfusion scintigraphy (MPS), it has been thought that the impaired vasodilator reserve in these patients may reduce its performance. The objective is to assess the role of the MPS in the pre-surgical evaluation of patients who are going to undergo liver transplantation. MATERIAL AND METHODS: Retrospective, descriptive and observational study was designed. All adult patients undergoing liver transplantation between 2017 and 2021 who had previous MPS were included. The findings of MPS were described and correlated with the findings of invasive angiography and with the appearance or not of peri- and post-transplant cardiovascular events. RESULTS: There were a total of 188 transplanted patients (mean age: 57 years, SD: 12), 178 had previous myocardial perfusion, 82 (46%) patients had no cardiovascular risk factors, and 5 (2.8%) had a history of coronary disease. Of the MPS, 177 were with dipyridamole stress performed on average 10 months before transplantation. Only 17/178 (9.5%) studies were abnormal. The mean follow-up was 38 months (SD: 10). Of the patients with normal MPS, only 2 (1.2%) presented cardiovascular events, both with studies performed more than 2 years before the procedure. There were no deaths of cardiovascular origin. CONCLUSIONS: MPS is a safe and reliable technique for cardiovascular assessment of patients who are candidates for liver transplantation, given the low rate of false negatives during follow-up.

Hepatitis C virus-positive donors in HCV-negative recipients in liver transplantation: Is it possible in Mexico?

Hepatitis C virus (HCV) infection is a worldwide public health problem associated with significant morbidity and mortality. In the context of liver transplantation, the demand for organs continues to exceed the supply, prompting the consideration of using organs from HCV-positive donors in HCV-negative recipients. The introduction of direct-acting antivirals (DAAs), which have demonstrated great efficacy in eradicating the virus, has made transplantation of organs from donors with HCV infection possible. The present article provides a brief review of the current evidence on the use of organs from HCV-infected patients.

Posttransplantation diabetes mellitus after liver transplant and the impact of family history of diabetes in a Mexican cohort.

INTRODUCTION AND AIMS: Posttransplantation diabetes mellitus (PTDM) is a serious long-term complication that has a negative impact on graft and patient survival. The purpose of the present study was to describe the incidence of PTDM in a Mexican cohort and evaluate its association with a previous family history of diabetes (FHD). METHODS: A retrospective single-center cohort study was conducted on patients undergoing liver transplantation (LT). The primary outcome was time from LT to PTDM. The diagnosis of PTDM was established using the ADA criteria. A mediation analysis that used adjusted Cox regression models and considered pretransplant prediabetes a mediator was performed, to determine the total effect and direct effect of FHD on PTDM. RESULTS: A total of 152 patients were included, with a median follow-up time of 41 months; 19.2% (n = 29) had pretransplant diabetes. During the follow-up time, 15% of patients developed PTDM (n = 23), with an incidence rate of 4.71 cases/100 person-years. PTDM was significantly higher in patients with FHD, compared with those with no FHD (8.72 cases/100 person-years vs 2.04 cases/100 person-years, respectively; p = 0.001). The adjusted hazard ratio of PTDM for FHD was 4.14 (95% CI 1.60-10.7), p = 0.005) and 3.48 (95% CI 1.35-9.01, p = 0.010), when further controlled for pretransplant prediabetes. CONCLUSION: The occurrence of PTDM was similar to that reported in most international studies. As with type 2 diabetes, family history plays an important role in the development of PTDM, even after accounting for pretransplant prediabetes. Patients with FHD should undergo a stricter metabolic program.

Risk factors of massive blood transfusion in liver transplantation: consequences and a new index for prediction including the donor / Factores de riesgo de transfusión masiva en trasplante hepático: consecuencias y creación de un nuevo índice teniendo en cuenta el tipo de donante

Background: Massive blood transfusion (MBT) is a common occurrence in liver transplant (LT) patients. Recipient-related risk factors include cirrhosis, history of multiple surgeries and suboptimal donors. Despite advances in surgical techniques, anesthetic management and graft preservation have decreased the need for transfusions, this complication has not been completely eliminated. Methods: One thousand four hundred and sixty-nine LT were performed at our institution between May 2003 and December 2020, and data was available regarding transfusion for 1198 of them. We divided the patients into two groups, with regards to transfusion of 6 or more units of packed red blood cells in the first 24 h posttransplant, and we analyzed the differences between the groups. Results: Out of the 1198 patients, 607 (50.7%) met criteria for MBT. Survival was statistically lower at 1, 3, and 5 years when comparing the groups that had MBT to those that did not (92.6%, 85.2% and 79.7%, respectively, in the non MBT group, vs. 78.1%, 71.6% y 66.8%, respectively, in the MBT group). MBT was associated with a 1.5 mortality risk as opposed to non-MBT patients. Logistical regression analysis of our variables yielded the following results for a new model, including serum creatinine (OR 1.97), sodium (OR 1.73), hemoglobin (OR 1.99), platelets (OR 1.37), INR (OR 1.4), uDCD (OR 2.13) and split liver donation. Conclusion: Massive blood transfusion impacts patient survival in a statistically significant way. The most significant risk factors are preoperative hemoglobin, INR and serum creatinine. (AU)

Introducción: La transfusión masiva de hemoderivados (TMH) es un hecho frecuente en el trasplante hepático (TH). A pesar de los avances en la técnica quirúrgica, manejo anestésico y preservación de órganos, la politransfusión no ha desaparecido. Métodos: 1469 TH fueron realizados en nuestro centro entre mayo de 2003 y diciembre de 2020, obteniéndose datos completos de trasfusión de 1198. Dividimos a los pacientes en dos grupos de acuerdo a la necesidad de trasfusión de 6 o más unidades de sangre en las primeras 24 horas después del trasplante, y analizamos las diferencias entre los grupos. Resultados: De los 1198 pacientes, 607 (50.7%) cumplieron criterios de TMH· La supervivencia fue estadísticamente inferior a 1, 3, y 5 años cuando comparamos los grupos en función de TMH o no (92·6%, 85·2% y 79·7%, respectivamente, en el no TMH, vs. 78·1%, 71·6% y 66·8%, respectivamente, en el grupo de TMH). Respecto al análisis de supervivencia, la TMH se asoció a un riesgo 1.5 veces mayor de mortalidad en contra de los pacientes sin TMH· El análisis de regresión logística nos permitió la creación de un nuevo modelo incluyendo creatinina sérica (OR 1.97), sodio (OR 1.73), hemoglobina (OR 1.99), plaquetas (OR 1.37), INR (OR 1.4), uDCD (OR 2.13) y trasplante procedente de split. Conclusión: La transfusión masiva de hemoderivados impacta en la supervivencia del paciente de forma estadísticamente significative. Los factores de riesgo preoperatorios más significativos han sido la hemoglobina, el INR y la creatinine. (AU)

Daño renal asociado al trasplante hepático / Kidney injury associated with liver transplantation

Introducción: El daño renal es frecuente en niños con trasplante hepático (TH), aunque su detección es un desafío. Nuestro objetivo fue evaluar el daño renal agudo (DRA) perioperatorio y analizar la prevalencia de enfermedad renal crónica (ERC) mediante diferentes fórmulas de estimación de la tasa de filtración glomerular (TFG). Métodos: Análisis transversal unicéntrico de una cohorte de niños menores de 18años con TH. Estimamos la TFG utilizando la fórmula Schwartz bedside 2009 basada en la creatinina, Caucasian Asian Pediatric and Adult cohort (CAPA) para cistatinaC y la fórmula combinada de Pottel Full Age Spectrum (FAS). Analizamos la concordancia mediante prueba de Bland Altman y el índice kappa. Medimos la albuminuria, la presión arterial y el volumen urinario por 100ml de filtrado glomerular. Analizamos los factores de riesgo asociados a ERC mediante un análisis univariante y multivariante. Resultados: Se incluyeron 52 pacientes, con una mediana de edad de 9,21años y 5,42años de evolución. Quince (28,8%) tuvieron DRA. Cinco niños (10%) presentaban ERC. El único factor de riesgo asociado fue el fallo hepático agudo en el momento del TH (OR: 8,57, p=0,04). Hubo poca concordancia entre las diferentes fórmulas de estimación. La fórmula de Schwartz clasificó a un paciente con ERC, mientras que Pottel FAS combinada y CAPA clasificaron a cuatro. Hasta el 42% de los niños sin ERC tenían algún marcador de daño renal. Conclusiones: El uso exclusivo de la fórmula Schwartz bedside 2009 para estimar el FG puede limitar el diagnóstico de ERC en niños con TH. La presencia de otros marcadores de daño renal es frecuente y su detección puede prevenir la progresión de la ERC. (AU)

Introduction: Kidney injury associated with paediatric liver transplantation (LT) is common, but its evaluation is challenging. Our aim was to analyse the presence of perioperative acute kidney injury (AKI) and study the prevalence of chronic kidney disease (CKD) using different glomerular filtration rate (GFR) estimation formulas. Methods: We conducted a cross-sectional study in a cohort of children aged less than 18years with a history of LT followed up for 5.42years. We estimated the GFR using the creatinine-based Schwartz bedside formula (2009), the cystatin C-based Caucasian Asian Pediatric and Adult cohort (CAPA) equation and the combined full-age spectrum (FAS) formula as modified by Pottel. We analysed the agreement between them using the Bland-Altman method and the kappa statistic. We measured the albumin level in urine, the urine volume adjusted to 100mL of GFR and blood pressure. We performed univariate and multivariate analyses of the risk factors associated with CKD. Results: The sample included 52 patients with a median age of 9.21years. Fifteen (28.8%) had AKI. Five (10%) had CKD and the only associated risk factor was acute liver failure at the time of LT (odds ratio, 8.57; P=.04). There was poor agreement between the different estimation formulas. One patient was classified as having CKD with the Schwartz formula compared to four patients with the CAPA and the Pottel combined FAS formulas. Up to 42% of children without CKD had some positive marker of kidney injury. Conclusions: The exclusive use of the 2009 Schwartz bedside formula to estimate GFR may lead to underdiagnosis of CKD in children post LT. Other markers of kidney injury are common, and their detection may help prevent the progression of CKD. (AU)

Infecciones bacterianas durante el primer mes post trasplante hepático. Experiencia de 12 años en un único centro. Montevideo-Uruguay

Introducción: Las infecciones bacterianas en trasplante hepático (TH) son una de las principales causas de morbimortalidad. Objetivo: Caracterizar las complicaciones infecciosas bacterianas en el primer mes postrasplante. Pacientes y Métodos: Estudio retrospectivo entre los años 2009-2020. Resultados: 225 pacientes recibieron un TH. 80 (35,5%) desarrollaron al menos un episodio de infección bacteriana en el primer mes postrasplante hepático. Hubo 105 episodios de infección bacteriana con una incidencia de 46,6%. El foco más frecuente fue el abdominal (48,6%) y el microorganismo predominante fue Klebsiella spp. De los 104 aislamientos, el 57,6% presentaron un perfil MDR/XDR. Los pacientes que desarrollaron una complicación infecciosa presentaron menor sobrevida al alta hospitalaria en comparación con los que no la presentaron 87,5 versus 94,5% [OR 4,18 (IC 95%: 1,5-11,6)]. En el análisis multivariado la reintervención quirúrgica precoz [OR 4,286 (IC 95%: 1,911-9,61)], mostró un riesgo significativo de desarrollar una complicación infecciosa bacteriana en el primer mes postrasplante. Conclusiones: Tres de cada 10 pacientes presentaron una infección bacteriana en el primer mes postrasplante con una alta incidencia de bacilos gramnegativos MDR/XDR. Los pacientes que desarrollaron una complicación infecciosa presentaron una menor sobrevida al alta. La reintervención quirúrgica precoz se identificó como un factor predisponente de infección temprana.

Background: Bacterial infections are one of the main causes of morbidity and mortality in liver transplant recipients (LT). Aim: To characterize bacterial infectious complications in the first month an after a liver transplant. Methods: Retrospective analysis of a cohort of liver transplant recipients who presented at least one bacterial infectious complication in the first month after transplant between 2009 and 2020. Results: 225 patients were analyzed. 80 (35.5%) had a least one documented bacterial infection during the first month after transplant. 105 bacterial infections were documented, with an incidence of 46.6%. The most frequent origin was intra-abdominal (48.6%) and the predominant isolated microorganism was Klebsiella spp. Among 104 isolated microorganisms 57.6% showed MDR/XDR profile. Patients who developed a bacterial infectious complication had a shorter overall survival (OS) after discharge from hospital (87.5% vs 94.5%) [OR 4.18 (IC 95%: 1.5-11,6)]. When multivariate analysis of predisposing factors was performed early surgical reoperation was the only variable associated with an increased risk of developing a bacterial complication in the first month [OR 4.286 (IC 95%: 1.911-9.61)]. Conclusions: Three out of 10 patients developed a bacterial infectious complication during the first month after liver transplant with a high incidence of gram-negative bacillus MDR/XDR. Patients who presented infectious complications had a shorter OS after discharge, and early reoperation was identified as a predisposing factor of early infectious complications.

Risk factors of massive blood transfusion in liver transplantation: consequences and a new index for prediction including the donor.

BACKGROUND: Massive blood transfusion (MBT) is a common occurrence in liver transplant (LT) patients. Recipient-related risk factors include cirrhosis, history of multiple surgeries and suboptimal donors. Despite advances in surgical techniques, anesthetic management and graft preservation have decreased the need for transfusions, this complication has not been completely eliminated. METHODS: One thousand four hundred and sixty-nine LT were performed at our institution between May 2003 and December 2020, and data was available regarding transfusion for 1198 of them. We divided the patients into two groups, with regards to transfusion of 6 or more units of packed red blood cells in the first 24 h posttransplant, and we analyzed the differences between the groups. RESULTS: Out of the 1198 patients, 607 (50.7%) met criteria for MBT. Survival was statistically lower at 1, 3, and 5 years when comparing the groups that had MBT to those that did not (92.6%, 85.2% and 79.7%, respectively, in the non MBT group, vs. 78.1%, 71.6% y 66.8%, respectively, in the MBT group). MBT was associated with a 1.5 mortality risk as opposed to non-MBT patients. Logistical regression analysis of our variables yielded the following results for a new model, including serum creatinine (OR 1.97), sodium (OR 1.73), hemoglobin (OR 1.99), platelets (OR 1.37), INR (OR 1.4), uDCD (OR 2.13) and split liver donation. CONCLUSION: Massive blood transfusion impacts patient survival in a statistically significant way. The most significant risk factors are preoperative hemoglobin, INR and serum creatinine.

Sofosbuvir plus glecaprevir/pibrentasvir as salvage therapy after liver transplantation in NS5A inhibitor-experienced patients. A case series.

BACKGROUND: Treatment of chronic hepatitis C virus (HCV) infection with direct-acting antivirals achieves a sustained virologic response rate higher than 95%. However, virologic failure remains a clinical challenge, and data on retreatment are limited, especially in special populations such as liver transplant (LT) recipients. OBJECTIVES: This study evaluated the sofosbuvir plus glecaprevir-pibrentasvir (GLE/PIB) regimen in LT recipients who had failed to a nonstructural protein 5A (NS5A) inhibitor-based regimen. MATERIAL AND METHODS: Retrospective study of 111 liver transplant recipients between January 2018 and December 2020; 18 patients presented with HCV recurrent infection after LT, out of whom three had a history of at least one NS5A inhibitor-based regimen. Salvage therapy with sofosbuvir plus GLE/PIB was started for 12 weeks; baseline characteristics and outcomes were recorded. RESULTS: All three patients (100%) achieved an undetectable HCV viral load 12 weeks after treatment completion. No serious adverse events were observed. CONCLUSION: In our series, sofosbuvir plus GLE/PIB for 12 weeks is an effective and safe salvage therapy after LT in patients previously treated with NS5A inhibitors.

ANTECEDENTES: El tratamiento del virus de la hepatitis C (VHC) crónica con antivirales de acción directa logra tasas de respuesta virológica sostenida superiores a 95 %. Sin embargo, el manejo del fracaso virológico sigue siendo un desafío clínico y la evidencia sobre el retratamiento es limitada, especialmente en poblaciones como los receptores de trasplante hepático (TH). OBJETIVO: Este estudio evaluó el régimen de sofosbuvir más glecaprevir/pibrentasvir (GLE/PIB) en receptores de TH en quienes falló el régimen basado en inhibidores de la proteína no estructural 5A (NS5A). MATERIAL Y MÉTODOS: Estudio retrospectivo de 111 pacientes trasplantados entre enero de 2018 y diciembre de 2020; 18 pacientes presentaron infección recurrente por VHC posterior al TH, tres de ellos tuvieron antecedentes de al menos un régimen basado en inhibidores de NS5A. Se inició terapia de rescate con sofosbuvir más GLE/PIB durante 12 semanas posterior al TH; se registraron las características basales de los pacientes y sus desenlaces. RESULTADOS: En los tres pacientes se logró obtener una carga viral indetectable de VHC a las 12 semanas de finalizar el tratamiento. No se observaron eventos adversos graves. CONCLUSIÓN: En nuestra serie, sofosbuvir más GLE/PIB durante 12 semanas demostró ser una terapia de rescate efectiva y segura posterior al TH en pacientes previamente tratados con inhibidores de NS5A.

“Long-term follow-up of liver transplantation in incidental intrahepatic cholangiocarcinoma and mixed hepatocellular-cholangiocarcinoma” / “Seguimiento a largo plazo del trasplante hepático en el colangiocarcinoma y hepatocolangiocarcinoma mixto incidentales”

Introduction: The standard treatment for intrahepatic cholangiocarcinoma (iCCA) and mixed hepatocellular-cholangiocarcinoma (HCC-CC) is surgical resection, nevertheless, recent studies show adequate survival rates in selected patients with iCCA or HCC-CC undergoing liver transplantation (LT). Methods: A retrospective cohort study was design including all patients undergoing LT at our center between January, 2006 and December, 2019 with incidentally diagnosed iCCA or HCC-CC after pathological examination of the explanted liver (n = 13). Results: There were no iCCA or HCC-CC recurrences during the follow-up, and hence, there were no tumor related deaths. Global and disease-free survival were the same. The 1, 3 and 5-years patient survival were 92.3%, 76.9% and 76.9%, respectively. Survival rates in the “early-stage tumor group” at 1, 3 and 5 years were 100%, 83.3% and 83.3%, respectively, with no significant differences as compared to the “advanced-stage tumors group”. No statistically significant differences in terms of 5-year survival were found when comparing tumor histology (85.7% for iCCA and 66.7% for HCC-CC). Conclusions: These results suggest that LT could be an option in patients with chronic liver disease who develop an iCCA or HCC-CC, even in highly selected advanced tumors, but we must be cautious when analyzing these results because of the small sample size of the series and its retrospective nature. (AU)

Introducción: El tratamiento de elección del colangiocarcinoma intrahepático (iCCA) y el hepato-colangiocarcinoma mixto (HCC-CC) es la resección quirúrgica, sin embargo, estudios recientes han demostrado buenos resultados en pacientes seleccionados sometidos a un trasplante hepático (TH). Métodos: Estudio retrospectivo de una cohorte formada por todos los pacientes que recibieron un TH en nuestro centro entre Enero 2006 y Diciembre 2019 con hallazgo incidental de un iCCA o un HCC-CC durante el estudio histopatológico después del trasplante (n = 13). Resultados: Después de una mediana de seguimiento de 65 meses no hubo ninguna recurrencia tumoral, por lo que la supervivencia global y libre de enfermedad fueron iguales. La supervivencia a 1, 3 y 5 años de la muestra fue del 92.3%, 76.9% y 76.9%, respectivamente. La supervivencia de los pacientes con un ‘early stage’ a 1, 3 y 5 años fue del 100%, 83.3% y 83.3%, respectivamente; sin encontrar diferencias estadísticamente significativas al compararla con la de los pacientes con un ‘advanced stage’. Aunque la supervivencia de los pacientes con iCCA fue mayor que la de los pacientes con HCC-CC (85.7% vs. 66.7% a 5 años, respectivamente), las diferencias no fueron estadísticamente significativas. Conclusiones: El TH podría ser una opción de tratamiento en pacientes con enfermedad hepática terminal que desarrollan un iCCA o un HCC-CC, incluso en estadios avanzados seleccionados, pero estos resultados deben ser analizado con precaución dada la naturaleza retrospectiva del estudio y el escaso tamaño muestral. (AU)

Kidney injury associated with liver transplantation.

INTRODUCTION: Kidney injury associated with paediatric liver transplantation (LT) is common, but its evaluation is challenging. Our aim was to analyse the presence of perioperative acute kidney injury (AKI) and study the prevalence of chronic kidney disease (CKD) using different glomerular filtration rate (GFR) estimation formulas. METHODS: We conducted a cross-sectional study in a cohort of children aged less than 18 years with a history of LT followed up for 5.42 years. We estimated the GFR using the creatinine-based Schwartz bedside formula (2009), the cystatin C-based Caucasian Asian Pediatric and Adult cohort (CAPA) equation and the combined Full-Age Spectrum (FAS) formula as modified by Pottel. We analysed the agreement between them using the Bland-Altman method and the kappa statistic. We measured the albumin level in urine, the urine volume adjusted to 100 mL of GFR and blood pressure. We performed univariate and multivariate analyses of the risk factors associated with CKD. RESULTS: The sample included 52 patients with a median age of 9.21 years. Fifteen (28.8%) had AKI. Five (10%) had CKD and the only associated risk factor was acute liver failure at the time of LT (odds ratio, 8.57; P = 0.04). There was poor agreement between the different estimation formulas. One patient was classified as having CKD with the Schwartz formula compared to four patients with the CAPA and the Pottel combined FAS formulas. Up to 42% of children without CKD had some positive marker of kidney injury. CONCLUSIONS: The exclusive use of the 2009 Schwartz bedside formula to estimate GFR may lead to underdiagnosis of CKD in children post LT. Other markers of kidney injury are common, and their detection may help prevent the progression of CKD.

Sofosbuvir más glecaprevir/pibrentasvir como terapia de rescate postrasplante hepático en pacientes con exposición previa a inhibidores de NS5A. Serie de casos / Sofosbuvir plus glecaprevir/pibrentasvir as salvage therapy after liver transplantation in NS5A inhibitor-experienced patients. A case series

Resumen Antecedentes: El tratamiento de la infección crónica por el virus de la hepatitis C (VHC) con antivirales de acción directa logra tasas de respuesta virológica sostenida superiores a 95 %. Sin embargo, el manejo del fracaso virológico sigue siendo un desafío clínico y la evidencia sobre el retratamiento es limitada, especialmente en poblaciones como los receptores de trasplante hepático (TH). Objetivo: Este estudio evaluó el régimen de sofosbuvir más glecaprevir/pibrentasvir (GLE/PIB) en receptores de TH en quienes falló el régimen basado en inhibidores de la proteína no estructural 5A (NS5A). Material y métodos: Estudio retrospectivo de 111 pacientes trasplantados entre enero de 2018 y diciembre de 2020; 18 pacientes presentaron infección recurrente por VHC posterior al TH, tres de ellos tuvieron antecedentes de al menos un régimen basado en inhibidores de NS5A. Se inició terapia de rescate con sofosbuvir más GLE/PIB durante 12 semanas posterior al TH; se registraron las características basales de los pacientes y sus desenlaces. Resultados: En los tres pacientes se logró obtener una carga viral indetectable de VHC a las 12 semanas de finalizar el tratamiento. No se observaron eventos adversos graves. Conclusión: En nuestra serie, sofosbuvir más GLE/PIB durante 12 semanas demostró ser una terapia de rescate efectiva y segura posterior al TH en pacientes previamente tratados con inhibidores de NS5A.

Abstract Background: Treatment of chronic hepatitis C virus (HCV) infection with direct-acting antivirals achieves a sustained virologic response rates higher than 95%. However, virologic failure remains a clinical challenge, and data on retreatment are limited, especially in special populations such as liver transplant (LT) recipients. Objective: This study evaluated the sofosbuvir plus glecaprevir-pibrentasvir (GLE/PIB) regimen in LT recipients who had failed to a nonstructural protein 5A (NS5A) inhibitor-based regimen. Material and methods: Retrospective study of 111 liver transplant recipients between January 2018 and December 2020; 18 patients presented with HCV recurrent infection after LT, out of whom three had a history of at least one NS5A inhibitor-based regimen. Salvage therapy with sofosbuvir plus GLE/PIB was started for 12 weeks; baseline characteristics and outcomes were recorded. Results: All three patients (100%) achieved an undetectable HCV viral load 12 weeks after treatment completion. No serious adverse events were observed. Conclusion: In our series, sofosbuvir plus GLE/PIB for 12 weeks is an effective and safe salvage therapy after LT in patients previously treated with NS5A inhibitors.