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2.
Lancet Gastroenterol Hepatol ; 5(11): 1008-1016, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32866433

RESUMO

BACKGROUND: Despite concerns that patients with liver transplants might be at increased risk of adverse outcomes from COVID-19 because of coexisting comorbidities and use of immunosuppressants, the effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on this patient group remains unclear. We aimed to assess the clinical outcomes in these patients. METHODS: In this multicentre cohort study, we collected data on patients with laboratory-confirmed SARS-CoV-2 infection, who were older than 18 years, who had previously received a liver transplant, and for whom data had been submitted by clinicians to one of two international registries (COVID-Hep and SECURE-Cirrhosis) at the end of the patient's disease course. Patients without a known hospitalisation status or mortality outcome were excluded. For comparison, data from a contemporaneous cohort of consecutive patients with SARS-CoV-2 infection who had not received a liver transplant were collected from the electronic patient records of the Oxford University Hospitals National Health Service Foundation Trust. We compared the cohorts with regard to several outcomes (including death, hospitalisation, intensive care unit [ICU] admission, requirement for intensive care, and need for invasive ventilation). A propensity score-matched analysis was done to test for an association between liver transplant and death. FINDINGS: Between March 25 and June 26, 2020, data were collected for 151 adult liver transplant recipients from 18 countries (median age 60 years [IQR 47-66], 102 [68%] men, 49 [32%] women) and 627 patients who had not undergone liver transplantation (median age 73 years [44-84], 329 [52%] men, 298 [48%] women). The groups did not differ with regard to the proportion of patients hospitalised (124 [82%] patients in the liver transplant cohort vs 474 [76%] in the comparison cohort, p=0·106), or who required intensive care (47 [31%] vs 185 [30%], p=0·837). However, ICU admission (43 [28%] vs 52 [8%], p<0·0001) and invasive ventilation (30 [20%] vs 32 [5%], p<0·0001) were more frequent in the liver transplant cohort. 28 (19%) patients in the liver transplant cohort died, compared with 167 (27%) in the comparison cohort (p=0·046). In the propensity score-matched analysis (adjusting for age, sex, creatinine concentration, obesity, hypertension, diabetes, and ethnicity), liver transplantation did not significantly increase the risk of death in patients with SARS-CoV-2 infection (absolute risk difference 1·4% [95% CI -7·7 to 10·4]). Multivariable logistic regression analysis showed that age (odds ratio 1·06 [95% CI 1·01 to 1·11] per 1 year increase), serum creatinine concentration (1·57 [1·05 to 2·36] per 1 mg/dL increase), and non-liver cancer (18·30 [1·96 to 170·75]) were associated with death among liver transplant recipients. INTERPRETATION: Liver transplantation was not independently associated with death, whereas increased age and presence of comorbidities were. Factors other than transplantation should be preferentially considered in relation to physical distancing and provision of medical care for patients with liver transplants during the COVID-19 pandemic. FUNDING: European Association for the Study of the Liver, US National Institutes of Health, UK National Institute for Health Research.


Assuntos
Infecções por Coronavirus , Unidades de Terapia Intensiva/estatística & dados numéricos , Transplante de Fígado , Pandemias , Pneumonia Viral , Betacoronavirus/isolamento & purificação , Estudos de Coortes , Comorbidade , Infecções por Coronavirus/sangue , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Creatinina/análise , Doença Hepática Terminal/cirurgia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Transplante de Fígado/métodos , Transplante de Fígado/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Pneumonia Viral/sangue , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Sistema de Registros/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Fatores de Risco , Análise de Sobrevida
3.
Intern Emerg Med ; 15(8): 1507-1515, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32979193

RESUMO

Transplant programs have been severely disrupted by the COVID-19 pandemic. Italy was one of the first countries with the highest number of deaths in the world due to SARS-CoV-2. Here we propose a management model for the reorganization of liver transplant (LT) activities and policies in a local intensive care unit (ICU) assigned to liver transplantation affected by restrictions on mobility and availability of donors and recipients as well as health personnel and beds. We describe the solutions implemented to continue transplantation activities throughout a given pandemic: management of donors and recipients' LT program, ICU rearrangement, healthcare personnel training and monitoring to minimize mortality rates of patients on the waiting list. Transplantation activities from February 22, 2020, the data of first known COVID-19 case in Italy's Emilia Romagna region to June 30, 2020, were compared with the corresponding period in 2019. During the 2020 study period, 38 LTs were performed, whereas 41 were performed in 2019. Patients transplanted during the COVID-19 pandemic had higher MELD and MELD-Na scores, cold ischaemia times, and hospitalization rates (p < 0.05); accordingly, they spent fewer days on the waitlist and had a lower prevalence of hepatocellular carcinoma (p < 0.05). No differences were found in the provenance area, additional MELD scores, age of donors and recipients, BMI, re-transplant rates, and post-transplant mortality. No transplanted patients contracted COVID-19, although five healthcare workers did. Ultimately, our policy allowed us to continue the ICU's operations by prioritizing patients hospitalized with higher MELD without any case of transplant infection due to COVID-19.


Assuntos
Cuidados Críticos/métodos , Transplante de Fígado/métodos , Pandemias/estatística & dados numéricos , Adulto , Infecções por Coronavirus/complicações , Infecções por Coronavirus/epidemiologia , Cuidados Críticos/tendências , Aglomeração , Doença Hepática Terminal/complicações , Doença Hepática Terminal/epidemiologia , Doença Hepática Terminal/cirurgia , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Itália/epidemiologia , Transplante de Fígado/normas , Transplante de Fígado/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/complicações , Pneumonia Viral/epidemiologia
4.
Transplantation ; 104(8): 1560-1565, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732832

RESUMO

The 25th Annual Congress of the International Liver Transplantation Society was held in Toronto, Canada, from May 15 to 18, 2019. Surgeons, hepatologists, anesthesiologists, critical care intensivists, radiologists, pathologists, and research scientists from all over the world came together with the common aim of improving care and outcomes for liver transplant recipients and living donors. Some of the featured topics at this year's conference included multidisciplinary perioperative care in liver transplantation, worldwide approaches to organ allocation, donor steatosis, and updates in pediatrics, immunology, and radiology. This report presents excerpts and highlights from invited lectures and select abstracts, reviewed and compiled by the Vanguard Committee of International Liver Transplantation Society. This will hopefully contribute to further advances in clinical practice and research in liver transplantation.


Assuntos
Congressos como Assunto , Seleção do Doador/organização & administração , Transplante de Fígado , Assistência Perioperatória/métodos , Sociedades Médicas/organização & administração , Adulto , Fatores Etários , Canadá , Criança , Cuidados Críticos/métodos , Cuidados Críticos/organização & administração , Seleção do Doador/métodos , Doença Hepática Terminal/cirurgia , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/prevenção & controle , Hepatectomia/efeitos adversos , Humanos , Imunossupressão/efeitos adversos , Imunossupressão/métodos , Cooperação Internacional , Doadores Vivos , Preservação de Órgãos/instrumentação , Preservação de Órgãos/métodos , Segurança do Paciente , Seleção de Pacientes , Perfusão/instrumentação , Perfusão/métodos , Melhoria de Qualidade , Alocação de Recursos/organização & administração , Resultado do Tratamento
5.
Transplantation ; 104(8): 1591-1603, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732836

RESUMO

BACKGROUND: Combined liver-kidney transplantation (CLKT) improves survival for liver transplant recipients with renal dysfunction; however, the tenuous perioperative hemodynamic and metabolic milieu in high-acuity CLKT recipients increases delayed graft function and kidney allograft failure. We sought to analyze whether delayed KT through pumping would improve kidney outcomes following CLKT. METHODS: A retrospective analysis (University of California Los Angeles [n = 145], Houston Methodist Hospital [n = 79]) was performed in all adults receiving CLKT at 2 high-volume transplant centers from February 2004 to January 2017, and recipients were analyzed for patient and allograft survival as well as renal outcomes following CLKT. RESULTS: A total of 63 patients (28.1%) underwent delayed implantation of pumped kidneys during CLKT (dCLKT) and 161 patients (71.9%) received early implantation of nonpumped kidneys during CLKT (eCLKT). Most recipients were high-acuity with median biologic model of end-stage liver disease (MELD) score of, 35 for dCLKT and 34 for eCLKT (P = ns). Pretransplant, dCLKT had longer intensive care unit stay, were more often intubated, and had greater vasopressor use. Despite this, dCLKT exhibited improved 1-, 3-, and 5-year patient and kidney survival (P = 0.02) and decreased length of stay (P = 0.001), kidney allograft failure (P = 0.012), and dialysis duration (P = 0.031). This reduced kidney allograft futility (death or continued need for hemodialysis within 3 mo posttransplant) for dCLKT (6.3%) compared with eCLKT (19.9%) (P = 0.013). CONCLUSIONS: Delayed implantation of pumped kidneys is associated with improved patient and renal allograft survival and decreased hospital length of stay despite longer kidney cold ischemia. These data should inform the ethical debate as to the futility of performing CLKT in high-acuity recipients.


Assuntos
Doença Hepática Terminal/cirurgia , Rejeição de Enxerto/epidemiologia , Transplante de Rim/efeitos adversos , Transplante de Fígado/efeitos adversos , Preservação de Órgãos/métodos , Idoso , Aloenxertos/imunologia , Aloenxertos/provisão & distribução , Isquemia Fria/instrumentação , Isquemia Fria/métodos , Isquemia Fria/estatística & dados numéricos , Doença Hepática Terminal/complicações , Estudos de Viabilidade , Feminino , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto/imunologia , Humanos , Rim/imunologia , Transplante de Rim/ética , Transplante de Rim/métodos , Transplante de Rim/estatística & dados numéricos , Transplante de Fígado/ética , Transplante de Fígado/métodos , Transplante de Fígado/estatística & dados numéricos , Masculino , Futilidade Médica/ética , Pessoa de Meia-Idade , Preservação de Órgãos/instrumentação , Preservação de Órgãos/estatística & dados numéricos , Perfusão/instrumentação , Perfusão/métodos , Perfusão/estatística & dados numéricos , Insuficiência Renal/etiologia , Insuficiência Renal/cirurgia , Estudos Retrospectivos , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricos , Transplante Homólogo/efeitos adversos , Transplante Homólogo/ética , Transplante Homólogo/métodos , Resultado do Tratamento
6.
Transplantation ; 104(8): 1604-1611, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732837

RESUMO

BACKGROUND: Donor livers with ≥30% macrosteatosis (steatotic livers) represent a possible expansion to the donor pool, but are frequently discarded as they are associated with an increased risk of mortality and graft loss. We hypothesized that there are certain recipient phenotypes that would tolerate donor steatosis well, and are therefore best suited to receive these grafts. METHODS: Using national registry data from the Scientific Registry of Transplant Recipients between 2006 and 2017, we compared 2048 liver transplant recipients of steatotic livers with 69 394 recipients of nonsteatotic (<30%) livers. We identified recipient factors that amplified the impact of donor steatosis on mortality and graft loss using interaction analysis, classifying recipients without these factors as preferred recipients. We compared mortality and graft loss with steatotic versus nonsteatotic livers in preferred and nonpreferred recipients using Cox regression. RESULTS: Preferred recipients of steatotic livers were determined to be first-time recipients with a model for end-stage liver disease 15-34, without primary biliary cirrhosis, and not on life support before transplant. Preferred recipients had no increased mortality risk (hazard ratio [HR]: 0.921.041.16; P = 0.5) or graft loss (HR: 0.931.031.15; P = 0.5) with steatotic versus nonsteatotic livers. Conversely, nonpreferred recipients had a 41% increased mortality risk (HR: 1.171.411.70; P < 0.001) and 39% increased risk of graft loss (HR: 1.161.391.66; P < 0.001) with steatotic versus nonsteatotic livers. CONCLUSIONS: The risks of liver transplantation with steatotic donor livers could be minimized by appropriate recipient matching.


Assuntos
Doença Hepática Terminal/cirurgia , Fígado Gorduroso/diagnóstico , Rejeição de Enxerto/epidemiologia , Transplante de Fígado/efeitos adversos , Seleção de Pacientes , Adulto , Idoso , Aloenxertos/patologia , Aloenxertos/provisão & distribução , Modificador do Efeito Epidemiológico , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/mortalidade , Fígado Gorduroso/patologia , Feminino , Rejeição de Enxerto/patologia , Rejeição de Enxerto/prevenção & controle , Rejeição de Enxerto/cirurgia , Sobrevivência de Enxerto , Humanos , Estimativa de Kaplan-Meier , Fígado/patologia , Transplante de Fígado/métodos , Masculino , Pessoa de Meia-Idade , Sistema de Registros/estatística & dados numéricos , Reoperação/estatística & dados numéricos , Medição de Risco , Índice de Gravidade de Doença , Transplantados/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos/epidemiologia
7.
Transplantation ; 104(8): 1612-1618, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732838

RESUMO

BACKGROUND: Steatotic donor livers (SDLs, ≥30% macrosteatosis on biopsy) are often declined, as they are associated with a higher risk of graft loss, even though candidates may wait an indefinite time for a subsequent organ offer. We sought to quantify outcomes for transplant candidates who declined or accepted an SDL offer. METHODS: We used Scientific Registry of Transplant Recipients offer data from 2009 to 2015 to compare outcomes of 759 candidates who accepted an SDL to 13 362 matched controls who declined and followed candidates from the date of decision (decline or accept) until death or end of study period. We used a competing risk framework to understand the natural history of candidates who declined and Cox regression to compare postdecision survival after declining versus accepting (ie, what could have happened if candidates who declined had instead accepted). RESULTS: Among those who declined an SDL, only 53.1% of candidates were subsequently transplanted, 23.8% died, and 19.4% were removed from the waitlist. Candidates who accepted had a brief perioperative risk period within the first month posttransplant (adjusted hazard ratio [aHR]: 2.493.494.89, P < 0.001), but a 62% lower mortality risk (aHR: 0.310.380.46, P < 0.001) beyond this. Although the long-term survival benefit of acceptance did not vary by candidate model for end-stage liver disease (MELD), the short-term risk period did. MELD 6-21 candidates who accepted an SDL had a 7.88-fold higher mortality risk (aHR: 4.807.8812.93, P < 0.001) in the first month posttransplant, whereas MELD 35-40 candidates had a 68% lower mortality risk (aHR: 0.110.320.90, P = 0.03). CONCLUSIONS: Appropriately selected SDLs can decrease wait time and provide substantial long-term survival benefit for liver transplant candidates.


Assuntos
Seleção do Doador/estatística & dados numéricos , Doença Hepática Terminal/cirurgia , Fígado Gorduroso/patologia , Transplante de Fígado/métodos , Transplantados/estatística & dados numéricos , Idoso , Aloenxertos/patologia , Aloenxertos/provisão & distribução , Biópsia , Tomada de Decisões , Doença Hepática Terminal/mortalidade , Fígado Gorduroso/diagnóstico , Feminino , Seguimentos , Humanos , Fígado/patologia , Transplante de Fígado/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Período Perioperatório/mortalidade , Período Perioperatório/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Índice de Gravidade de Doença , Análise de Sobrevida , Transplantados/psicologia , Resultado do Tratamento , Estados Unidos/epidemiologia , Listas de Espera/mortalidade
8.
Transplantation ; 104(8): 1619-1626, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732839

RESUMO

BACKGROUND: Living donor liver transplantation (LDLT) in children has achieved promising outcomes during the past few decades. However, it still poses various challenges. This study aimed to analyze perioperative risk factors for postoperative death in pediatric LDLT. METHODS: We retrospectively analyzed medical records of pediatric patients who underwent LDLT surgery from January 1, 2014, to December 31, 2016, in our hospital. Predictors of mortality following LDLT were analyzed in 430 children. Cox regression and Kaplan-Meier curve analysis were used for covariates selection. A nomogram was developed to estimate overall survival probability. The performance of the nomogram was assessed using calibration curve, decision curve analysis, and time-dependent receiver operating characteristic curve. RESULTS: Among the 430 patients in this cohort (median [interquartile range] age, 7 [6.10] mo; 189 [43.9%] female; 391 [90.9%] biliary atresia), the overall survival was 91.4% (95% confidence interval, 89.2-94.4), and most of the death events (36/37) happened within 6 months after the surgery. Multivariate analysis indicated that the Pediatric End-stage Liver Disease score, neutrophil lymphocyte ratio, graft-to-recipient weight ratio, and intraoperative norepinephrine infusion were independent prognostic factors. A novel nomogram was developed based on these prognostic factors. The C index for the final model was 0.764 (95% confidence interval, 0.701-0.819). Decision curve analysis and time-dependent receiver operating characteristic curve suggested that this novel nomogram performed well at predicting mortality of pediatric LDLT. CONCLUSIONS: We identified several perioperative risk factors for mortality of pediatric LDLT. And the newly developed nomogram can be a convenient individualized tool in estimating the prognosis of pediatric LDLT.


Assuntos
Atresia Biliar/cirurgia , Doença Hepática Terminal/cirurgia , Transplante de Fígado/estatística & dados numéricos , Nomogramas , Período Perioperatório/mortalidade , Atresia Biliar/complicações , Atresia Biliar/diagnóstico , Atresia Biliar/mortalidade , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/etiologia , Doença Hepática Terminal/mortalidade , Estudos de Viabilidade , Feminino , Humanos , Lactente , Estimativa de Kaplan-Meier , Transplante de Fígado/métodos , Doadores Vivos , Masculino , Curva ROC , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Índice de Gravidade de Doença , Resultado do Tratamento
9.
Transplantation ; 104(8): 1627-1632, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732840

RESUMO

BACKGROUND: In December 2018, United Network for Organ Sharing approved an allocation scheme based on recipients' geographic distance from a deceased donor (acuity circles [ACs]). Previous analyses suggested that ACs would reduce waitlist mortality overall, but their impact on pediatric subgroups was not considered. METHODS: We applied Scientific Registry of Transplant Recipients data from 2011 to 2016 toward the Liver Simulated Allocation Model to compare outcomes by age and illness severity for the United Network for Organ Sharing-approved AC and the existing donor service area-/region-based allocation schemes. Means from each allocation scheme were compared using matched-pairs t tests. RESULTS: During a 3-year period, AC allocation is projected to decrease waitlist deaths in infants (39 versus 55; P < 0.001), children (32 versus 50; P < 0.001), and teenagers (15 versus 25; P < 0.001). AC allocation would increase the number of transplants in infants (707 versus 560; P < 0.001), children (677 versus 547; P < 0.001), and teenagers (404 versus 248; P < 0.001). AC allocation led to decreased median pediatric end-stage liver disease/model for end-stage liver disease at transplant for infants (29 versus 30; P = 0.01), children (26 versus 29; P < 0.001), and teenagers (26 versus 31; P < 0.001). Additionally, AC allocation would lead to fewer transplants in status 1B in children (97 versus 103; P = 0.006) but not infants or teenagers. With AC allocation, 77% of pediatric donor organs would be allocated to pediatric candidates, compared to only 46% in donor service area-/region-based allocation (P < 0.001). CONCLUSIONS: AC allocation will likely address disparities for pediatric liver transplant candidates and recipients by increasing transplants and decreasing waitlist mortality. It is more consistent with federally mandated requirements for organ allocation.


Assuntos
Doença Hepática Terminal/cirurgia , Acesso aos Serviços de Saúde/organização & administração , Transplante de Fígado/métodos , Modelos Organizacionais , Alocação de Recursos/organização & administração , Índice de Gravidade de Doença , Adolescente , Adulto , Fatores Etários , Aloenxertos/provisão & distribução , Criança , Simulação por Computador , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/mortalidade , Feminino , Acesso aos Serviços de Saúde/normas , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/normas , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Lactente , Transplante de Fígado/estatística & dados numéricos , Masculino , Sistema de Registros/estatística & dados numéricos , Alocação de Recursos/normas , Alocação de Recursos/estatística & dados numéricos , Análise de Sobrevida , Transplantados/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos/epidemiologia , Listas de Espera/mortalidade
10.
Transplantation ; 104(8): 1633-1643, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732841

RESUMO

BACKGROUND: The cellular infiltrate in protocol liver biopsies (PB) following pediatric liver transplantation remains mostly uncharacterized, yet there is increasing concern about the role of inflammation and fibrosis in long-term liver allografts. We aimed to define cell types in PB and to analyze their relationship with donor-specific antibodies (DSA) and histological phenotype. METHODS: PB were performed at least 1 year after transplantation. We identified 4 phenotypes: normal, fibrosis, inflammation, inflammation with fibrosis. Cell types were counted after immunostaining for CD3, CD4, CD8, CD68, CD20, MUM1, and FoxP3. RESULTS: Forty-four patients underwent 1 PB between 2000 and 2015. Eleven percent (5/44) of PB displayed normal histology, 13.6% (6/44) fibrosis, 34.1% (15/44) inflammation, and 40.9% (18/44) inflammation and fibrosis. The main cell types in the portal tracts and lobules were CD3+ and CD68+ cells. Frequency of de novo DSA was 63% (27/44). The presence of CD8+ cells in the lobules was associated with fibrosis. Inflammation and fibrosis in PB were associated with the presence of circulating de novo DSA, number of de novo DSA, and C1q binding activity when compared to other phenotypes. CONCLUSIONS: T cells (CD3+) and macrophages (CD68+) were the most prevalent cell-types in PB. In the presence of inflammation, portal tracts were enriched in CD3+, CD20+ but displayed fewer CD68+. This coincided with the presence and number of de novo DSA. How these cellular and humoral actors interact is unclear, but peripheral DSA may be a marker of immune cellular activity in the seemingly quiescent allograft.


Assuntos
Doença Hepática Terminal/cirurgia , Rejeição de Enxerto/imunologia , Isoanticorpos/imunologia , Transplante de Fígado/efeitos adversos , Sistema Porta/imunologia , Adolescente , Adulto , Aloenxertos/irrigação sanguínea , Aloenxertos/imunologia , Aloenxertos/patologia , Biópsia , Criança , Pré-Escolar , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/etiologia , Feminino , Fibrose , Seguimentos , Rejeição de Enxerto/patologia , Sobrevivência de Enxerto/imunologia , Antígenos HLA/imunologia , Teste de Histocompatibilidade/estatística & dados numéricos , Humanos , Imunidade Celular , Lactente , Isoanticorpos/análise , Fígado/irrigação sanguínea , Fígado/imunologia , Fígado/patologia , Doadores Vivos/estatística & dados numéricos , Macrófagos/imunologia , Masculino , Sistema Porta/citologia , Índice de Gravidade de Doença , Linfócitos T/imunologia , Transplantados/estatística & dados numéricos , Transplante Homólogo/efeitos adversos , Adulto Jovem
12.
Acta Gastroenterol Belg ; 83(2): 340-343, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32603060

RESUMO

Since January 2020, the Novel Coronavirus Disease 2019 (COVID-19) pandemic has dramatically impacted the world. In March 2020, the COVID-19 epidemic reached Belgium creating uncertainty towards all aspects of life. There has been an impressive capacity and solidarity of all healthcare professionals to acutely reconvert facilities to treat these patients. In the context of liver transplantation (LTx), concerns are raised about organ donation shortage and safety, the ethics of using limited healthcare resources for LTx, selection criteria for LTx during the epidemic and the risk of de novo COVID-19 infection on the waiting list and after LTx. BeLIAC makes several recommendations to try to mitigate the deleterious effect that this epidemic has/will have on donation and LTx, taking into account the available resources, and trying to maximize patients and healthcare professionals' safety.


Assuntos
Infecções por Coronavirus , Doença Hepática Terminal/cirurgia , Controle de Infecções/métodos , Transplante de Fígado/métodos , Pandemias , Pneumonia Viral , Bélgica , Betacoronavirus , Coronavirus , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Doença Hepática Terminal/epidemiologia , Humanos , Pandemias/prevenção & controle , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão
13.
Transplant Proc ; 52(5): 1247-1250, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32499144

RESUMO

BACKGROUND: The number of liver transplantations is increasing worldwide, and Brazil ranks in the second position. It has one of the biggest public health care systems, which is responsible for the coordination and financial funding of transplantation procedures. Meeting the demands of such a large system of transplantation has become a challenge, particularly when attempting to minimize costs of scarce and expensive resources. The aim of this study was to investigate the process of donation, the retrieval of organs, and the transplantation itself using engineering methods based on logistics analyses. METHODS: Three steps were used: study planning, data gathering, and data analysis. Researchers surveyed professionals to acquire raw information based on their observations, experience, and knowledge. Then, a data analysis was conducted, putting together all the information gathered during the previous steps. Bias was removed, and conflicting perceptions were resolved in order to have a standard view on the transplantation process. RESULTS: Data was gathered between 2014 and 2018 and included 5502 liver donors and 2678 (48.7%) patients who received liver transplants organs. A total of 2824 organs were refused because of logistics issues (transport and handling). Interviews of health care professionals enabled the design of a process map in which 4 stakeholders were identified: patient, physician, organ, and information. CONCLUSIONS: The liver transplantation process is analyzed based on a supply chain methodology applying this knowledge and putting together medical and engineering sciences to promote better efficiency and outcomes for the transplantation program. Future studies should focus on the implementation of these ideas aiming to promote optimization gains in any step of the process.


Assuntos
Doença Hepática Terminal/cirurgia , Transplante de Fígado/economia , Obtenção de Tecidos e Órgãos/organização & administração , Transplantes/provisão & distribução , Brasil , Humanos , Modelos Organizacionais , Avaliação de Processos e Resultados em Cuidados de Saúde , Período Pós-Operatório , Obtenção de Tecidos e Órgãos/economia , Listas de Espera
15.
J Surg Res ; 255: 23-32, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32540577

RESUMO

BACKGROUND: Up to 30% of patients with sickle cell disease (SCD) develop chronic liver disease via etiologies including sickle cell hepatopathy, acquired viral hepatitis, or secondary hemochromatosis. It is unclear how many patients with SCD ultimately undergo liver transplantation (LT) and what factors are associated with survival after LT. In this study, we examined LT outcomes in these patients by reviewing the Scientific Registry of Transplant Recipients (SRTR) and our institutional experience. METHODS: Analysis of the SRTR identified 23 LT recipients and five simultaneous liver and kidney transplantation (SLKT) recipients with SCD. Patient demographics and graft and patient survival were analyzed. Two patients with SCD at our institution underwent SLKT. RESULTS: Review of the SRTR revealed that recipients with SCD had significantly higher model for end-stage liver disease scores (33 versus 21, P = 0.004), preoperative intensive care unit admission (43.5% versus 19.1%, P = 0.007), preoperative dialysis (17.4% versus 4.9%, P = 0.009), and were more likely to be status 1 (26.1% versus 12.1%, P = 0.041) when compared with the reference population of African American LT recipients. Despite being higher risk at the time of LT, patients with SCD had equivalent posttransplant graft and patient survival when compared with the reference population (P = 0.5 and P = 0.2, respectively) and a 2:1 propensity score-matched group (P = 0.5 and P = 0.2, respectively). Two recent SLKT recipients with SCD from our institution have performed well with stable allograft function. CONCLUSIONS: Data from the SRTR demonstrate that patients with SCD can expect equivalent graft and patient survival after LT despite exhibiting more comorbidities at the time of LT. The low number of patients with SCD who underwent LT in the SRTR in comparison with the rate of chronic liver disease in this population raises the question as to whether a disparity in access to LT exists for this complex population.


Assuntos
Anemia Falciforme/terapia , Doença Hepática Terminal/cirurgia , Falência Renal Crônica/terapia , Transplante de Rim/estatística & dados numéricos , Transplante de Fígado/estatística & dados numéricos , Adolescente , Adulto , Afro-Americanos/estatística & dados numéricos , Anemia Falciforme/complicações , Anemia Falciforme/mortalidade , Criança , Pré-Escolar , Doença Hepática Terminal/etiologia , Doença Hepática Terminal/mortalidade , Feminino , Sobrevivência de Enxerto , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Falência Renal Crônica/etiologia , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , Diálise Renal , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto Jovem
17.
Transplant Proc ; 52(5): 1262-1264, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32507487

RESUMO

BACKGROUND: The Institut Georges Lopez 1 (IGL-1) solution was developed to improve the outcomes of solid organ transplantation. Nevertheless, follow-up of liver transplants using IGL-1-preserved organs is still scarce. AIM: To compare morbidity, postoperative complications, and early survival between liver grafts perfused with IGL-1 and those perfused with histidine-tryptophan-ketoglutarate (HTK) solutions. METHODS: Prospective liver grafts perfused with IGL-1 (n = 65) were paired with a historical control group of recipients whose grafts were preserved with HTK solution (n = 130). The primary endpoint was the sum of the incidence of primary graft dysfunction (PGD) and primary graft nonfunction (PGNF). Secondary endpoints included resource utilization, complications, and survival analysis. RESULTS: In the HTK group, 52 patients (40%) exhibited either PGD or PGNF, compared to 20 patients (31%) in the IGL-1 group (P = .208). Patients from the HTK group had higher mean values for cryoprecipitate transfusion (P = .0064), first day serum lactate (P = .0099), higher incidence of vascular complications (11% vs 2% in the IGL-1 group; P = .0226), but a lower incidence of infection (7% vs 28% in the IGL-1 group; P < .0001). The IGL-1 group presented a lower mean aspartate aminotransferase and alanine aminotransferase (ALT) on the first and second postoperative day and a lower ALT on the seventh day. Recipients of grafts perfused with IGL-1 had a better early survival than those whose grafts were perfused with HTK. CONCLUSIONS: Both solutions are safe and present good results. Grafts perfused with IGL-1 showed decreased enzymatic peaks and better short-term survival rates than the HTK group. The use of the IGL-1 solution might be preferable.


Assuntos
Doença Hepática Terminal/cirurgia , Transplante de Fígado , Soluções para Preservação de Órgãos , Preservação de Órgãos/instrumentação , Alanina Transaminase/sangue , Aspartato Aminotransferases/sangue , Isquemia Fria , Glucose , Histidina , Humanos , Fígado/cirurgia , Manitol , Análise Multivariada , Complicações Pós-Operatórias , Cloreto de Potássio , Disfunção Primária do Enxerto , Procaína , Estudos Prospectivos , Fatores de Risco
18.
J Surg Res ; 255: 99-105, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32543385

RESUMO

BACKGROUND: Patients undergoing liver transplantation (LT) frequently receive platelet transfusion (PLT) to minimize their risk of hemorrhage. Alloimmunization to platelets may lead to refractoriness to PLT. Data on the implications of platelet alloimmunization in patients undergoing LT remain limited. We examined the effect of human leukocyte antigen class I (HLA-I) antibodies on PLT refractoriness and short-term outcomes after LT. METHODS: Peritransplant clinical and PLT factors were reviewed for all adult liver or simultaneous liver-kidney transplantations from 2012 to 2017. Sensitized patients (SE) with pretransplant HLA-I calculated panel-reactive antibody ≥20% were compared with unsensitized patients (US) with calculated panel-reactive antibody <20%. The mean follow-up was 21.4 mo. RESULTS: Alloimmunization was observed in 39% of the study cohort. SE (n = 28) received 272 PLTs, and US (n = 44) received 246 PLTs. History of pregnancy was higher among SE than US (P < 0.01); otherwise, both groups had similar clinical characteristics. SE had higher rates of PLT refractoriness (66% versus 47%; P < 0.01) than US. The mean platelet corrected count increment was lower among SE compared with US up to 100 min after PLT (P < 0.05). Alloimmunization and simultaneous liver-kidney transplantation independently predicted refractoriness on multivariate logistic regression (P < 0.05). Early allograft rejection and patient survival rates were comparable for both groups. CONCLUSIONS: LT patients experienced high rates of HLA-I alloimmunization and PLT refractoriness. SE had higher rates of refractoriness and lower mean corrected count increment after transfusion compared with US. Our study suggests that further research to evaluate the utility of HLA-matched PLTs in HLA-I alloimmunized LT patients is warranted.


Assuntos
Antígenos HLA/imunologia , Isoanticorpos/imunologia , Transplante de Fígado/efeitos adversos , Transfusão de Plaquetas/efeitos adversos , Trombocitopenia/terapia , Perda Sanguínea Cirúrgica/prevenção & controle , Doença Hepática Terminal/sangue , Doença Hepática Terminal/complicações , Doença Hepática Terminal/cirurgia , Feminino , Antígenos HLA/sangue , Teste de Histocompatibilidade , Humanos , Isoanticorpos/sangue , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/prevenção & controle , Estudos Prospectivos , Estudos Retrospectivos , Trombocitopenia/sangue , Trombocitopenia/etiologia , Resultado do Tratamento
19.
Zhonghua Wai Ke Za Zhi ; 58(5): 397-400, 2020 May 01.
Artigo em Chinês | MEDLINE | ID: mdl-32393008

RESUMO

Liver transplantation is currently the only effective treatment for end-stage liver disease. The preservation of donor liver before transplantation is important. But both traditional static cold storage and machine perfusion are limited by the preservation time, so that the allotment space of donor liver is limited, which inevitably leads to the abandonment of part of donor liver.At present, to find a preservation technology that not only guarantees the quality of donor liver but also has a longer effective preservation time is the direction of joint efforts of all clinicians. Supercooling liver preservation(SLP) to find a preservation technology that not only guarantees the quality of donor liver but also has a longer effective preservation time is the direction of joint efforts of all clinicians. SLP, a new method based on using cryoprotectants to keep donor liver under -6 ℃ and recovering the graft with subnormothermic machine perfusion that enables long-term transplantation survival following 4 days of liver preservation, made a revolutionary breakthrough in the field of liver preservation, carved out a new field for the research of liver preservation. This article reviews the latest experimental research progress of SLP in the field of liver transplantation.


Assuntos
Criopreservação/métodos , Doença Hepática Terminal/cirurgia , Transplante de Fígado , Fígado , Preservação de Órgãos/métodos , Criopreservação/tendências , Humanos , Preservação de Órgãos/tendências , Perfusão/métodos
20.
J Hepatol ; 73(4): 873-881, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32454041

RESUMO

BACKGROUND & AIMS: The outbreak of COVID-19 has vastly increased the operational burden on healthcare systems worldwide. For patients with end-stage liver failure, liver transplantation is the only option. However, the strain on intensive care facilities caused by the pandemic is a major concern. There is an urgent need for ethical frameworks to balance the need for liver transplantation against the availability of national resources. METHODS: We performed an international multicenter study of transplant centers to understand the evolution of policies for transplant prioritization in response to the pandemic in March 2020. To describe the ethical tension arising in this setting, we propose a novel ethical framework, the quadripartite equipoise (QE) score, that is applicable to liver transplantation in the context of limited national resources. RESULTS: Seventeen large- and medium-sized liver transplant centers from 12 countries across 4 continents participated. Ten centers opted to limit transplant activity in response to the pandemic, favoring a "sickest-first" approach. Conversely, some larger centers opted to continue routine transplant activity in order to balance waiting list mortality. To model these and other ethical tensions, we computed a QE score using 4 factors - recipient outcome, donor/graft safety, waiting list mortality and healthcare resources - for 7 countries. The fluctuation of the QE score over time accurately reflects the dynamic changes in the ethical tensions surrounding transplant activity in a pandemic. CONCLUSIONS: This four-dimensional model of quadripartite equipoise addresses the ethical tensions in the current pandemic. It serves as a universally applicable framework to guide regulation of transplant activity in response to the increasing burden on healthcare systems. LAY SUMMARY: There is an urgent need for ethical frameworks to balance the need for liver transplantation against the availability of national resources during the COVID-19 pandemic. We describe a four-dimensional model of quadripartite equipoise that models these ethical tensions and can guide the regulation of transplant activity in response to the increasing burden on healthcare systems.


Assuntos
Infecções por Coronavirus/epidemiologia , Doença Hepática Terminal , Recursos em Saúde/tendências , Transplante de Fígado , Pandemias , Pneumonia Viral/epidemiologia , Obtenção de Tecidos e Órgãos , Betacoronavirus , Doença Hepática Terminal/mortalidade , Doença Hepática Terminal/cirurgia , Humanos , Cooperação Internacional , Transplante de Fígado/ética , Transplante de Fígado/métodos , Inovação Organizacional , Pandemias/ética , Pandemias/prevenção & controle , Seleção de Pacientes/ética , Inquéritos e Questionários , Obtenção de Tecidos e Órgãos/ética , Obtenção de Tecidos e Órgãos/organização & administração , Obtenção de Tecidos e Órgãos/tendências , Listas de Espera/mortalidade
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