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1.
Medicine (Baltimore) ; 100(2): e24094, 2021 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-33466174

RESUMO

INTRODUCTION: Bleeding may interfere with the visual field and create difficulties in performing the intended treatment, especially in operations involving a small working space such as endoscopic spinal surgery. Therefore, it is important to reduce the risk of bleeding before surgery. PATIENT CONCERNS: A 76-year-old female presented with a history of right anterior thigh pain along the L3 dermatome for 3-years, following a L3 compression fracture. In addition, the patient had developed autoimmune hepatitis at 50 years of age, and the platelet count on laboratory blood collection was 78 × 109/L. DIAGNOSIS: Magnetic resonance (MR) images showed a narrowed foramen at the L3-4 level. L3 nerve block was effective. L3 foraminal-stenosis was suspected. INTERVENTIONS: Micro-endoscopic laminectomy (MEL) for foraminal decompression was planned due to possible L3 nerve root compression. Lusutrombopag, a thrombopoietin (TPO) receptor agonist, was orally administered for 7 days starting 7 days preoperatively to address the risks of bleeding. OUTCOMES: The patient successfully underwent MEL without any adverse events or complications. CONCLUSION: The results obtained from the use of lusutrombopag suggested that safety measures could be implemented preoperatively, and that lusutrombopag may be a useful supplemental drug for minimally invasive treatment of patients with cirrhosis and thrombocytopenia.


Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Cinamatos/uso terapêutico , Endoscopia , Fraturas da Coluna Vertebral/cirurgia , Tiazóis/uso terapêutico , Trombocitopenia/tratamento farmacológico , Idoso , Doença Hepática Terminal/complicações , Feminino , Humanos , Vértebras Lombares/cirurgia , Trombocitopenia/etiologia
2.
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
3.
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
4.
Zhonghua Gan Zang Bing Za Zhi ; 28(7): 545-547, 2020 Jul 20.
Artigo em Chinês | MEDLINE | ID: mdl-32791786

RESUMO

Patients with end-stage liver disease are more likely to be infected due to the changes in the liver's internal environment, low immune defense capabilities and reduced gut barrier function. Common infections include pneumonia, spontaneous bacterial peritonitis, biliary and urinary tract infections, skin and soft tissue infections, and spontaneous bacteremia, which in severe cases can lead to sepsis and septic shock. Importantly, infections can aggravate and progress to the liver and damage correlated organs, and thus can be life-threatening in severe cases. Therefore, early detection and diagnosis, as well as the use of effective antibacterial agents, and supportive treatment are keys to saving patients' lives.


Assuntos
Infecções Bacterianas/diagnóstico , Infecções Bacterianas/terapia , Doença Hepática Terminal/complicações , Doença Hepática Terminal/terapia , Antibacterianos/uso terapêutico , Bacteriemia , Humanos , Peritonite , Infecções Urinárias
5.
Dermatol Online J ; 26(6)2020 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-32815696

RESUMO

Cryptococcosis is a rare opportunistic infection with morphologically diverse cutaneous presentations. Primary infection typically occurs in the lungs with subsequent hematogenous dissemination to other organ systems, especially in immunocompromised patients. Herein, we report a woman in her 70's who presented with pruritic, umbilicated papulonodules of the bilateral upper and lower extremities present for many weeks. She was diagnosed with disseminated Cryptococcus and subsequently evaluated for potential pulmonary and meningeal disease involvement. She died as a result of multiple medical comorbidities.


Assuntos
Criptococose/diagnóstico , Cryptococcus neoformans/isolamento & purificação , Extremidades/microbiologia , Idoso , Candida albicans/isolamento & purificação , Criptococose/etiologia , Criptococose/microbiologia , Dermatomicoses , Diabetes Mellitus Tipo 2/complicações , Doença Hepática Terminal/complicações , Extremidades/patologia , Evolução Fatal , Feminino , Virilha/microbiologia , Humanos , Falência Renal Crônica/complicações , Infecções Oportunistas , Fatores de Risco
6.
Aliment Pharmacol Ther ; 52(1): 107-122, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32478917

RESUMO

BACKGROUND: Palliative care remains suboptimal in end-stage liver disease. AIM: To inform a definitive study, we assessed palliative long-term abdominal drains in end-stage liver disease to determine recruitment, attrition, safety/potential effectiveness, questionnaires/interview uptake/completion and make a preliminary cost comparison. METHODS: A 12-week feasibility nonblinded randomised controlled trial comparing large-volume paracentesis vs long-term abdominal drains in refractory ascites due to end-stage liver disease with fortnightly home visits for clinical/questionnaire-based assessments. Study success criteria were attrition not >50%, <10% long-term abdominal drain removal due to complications, the long-term abdominal drain group to spend <50% ascites-related study time in hospital vs large-volume paracentesis group and 80% questionnaire/interview uptake/completion. RESULTS: Of 59 eligible patients, 36 (61%) were randomised, 17 to long-term abdominal drain and 19 to large-volume paracentesis. Following randomisation, median number (IQR) of hospital ascitic drains (long-term abdominal drain group vs large-volume paracentesis group) were 0 (0-1) vs 4 (3-7); week 12 serum albumin (g/L) and serum creatinine (µmol/L) were 29 (26.5-32.5) vs 30 (25-35) and 104.5 (81-115.5) vs 127 (63-158) respectively. Total attrition was 42% (long-term abdominal drain group 47%, large-volume paracentesis group 37%). Median (IQR) fortnightly community/hospital/social care ascites-related costs and percentage study time in hospital were lower in the long-term abdominal drain group, £329 (253-580) vs £843 (603-1060) and 0% (0-0.74) vs 2.75% (2.35-3.84) respectively. Self-limiting cellulitis/leakage occurred in 41% (7/17) in the long-term abdominal drain group vs 11% (2/19) in the large-volume paracentesis group; peritonitis incidence was 6% (1/17) vs 11% (2/19) respectively. Questionnaires/interview uptake/completion were ≥80%; interviews indicated that long-term abdominal drains could transform the care pathway. CONCLUSIONS: The REDUCe study demonstrates feasibility with preliminary evidence of long-term abdominal drain acceptability/effectiveness/safety and reduction in health resource utilisation. TRIAL REGISTRATION: ISRCTN30697116, date assigned: 07/10/2015.


Assuntos
Ascite/terapia , Drenagem , Doença Hepática Terminal/terapia , Cirrose Hepática/terapia , Idoso , Ascite/sangue , Ascite/etiologia , Creatinina/sangue , Doença Hepática Terminal/sangue , Doença Hepática Terminal/complicações , Feminino , Humanos , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos , Albumina Sérica
7.
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
8.
Aliment Pharmacol Ther ; 51(12): 1397-1405, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32363684

RESUMO

BACKGROUND: Hepatic encephalopathy is a devastating complication of cirrhosis. AIM: To describe the outcomes after developing hepatic encephalopathy among contemporary, aging patients. METHODS: We examined data for a 20% random sample of United States Medicare enrolees with cirrhosis and Part D prescription coverage from 2008 to 2014. Among 49 164 persons with hepatic encephalopathy, we evaluated the associations with transplant-free survival using Cox proportional hazard models with time-varying covariates (hazard ratios, HR) and incidence rate ratios (IRR) for healthcare utilisation measured in hospital-days and 30-day readmissions per person-year. We validated our findings in an external cohort of 2184 privately insured patients with complete laboratory values. RESULTS: Hepatic encephalopathy was associated with median survivals of 0.95 and 2.5 years for those ≥65 or <65 years old and 1.1 versus 3.9 years for those with and without ascites. Non-alcoholic fatty-liver disease posed the highest adjusted risk of death among aetiologies, HR 1.07 95% CI (1.02, 1.12). Both gastroenterology consultation and rifaximin utilisation were associated with lower mortality, respective adjusted-HR 0.73 95% CI (0.67, 0.80) and 0.40 95% CI (0.39, 0.42). Thirty-day readmissions were fewer for patients seen by gastroenterologists (0.71 95% CI [0.57-0.88]) and taking rifaximin (0.18 95% CI [0.08-0.40]). Lactulose alone was associated with fewer hospital-days, IRR 0.31 95% CI (0.30-0.32), than rifaximin alone, 0.49 95% CI (0.45-0.53), but the optimal therapy combination was lactulose/rifaximin, IRR 0.28 95% CI (0.27-0.30). These findings were validated in the privately insured cohort adjusting for model for endstage liver disease-sodium score and serum albumin. CONCLUSIONS: Hepatic encephalopathy remains morbid and associated with poor outcomes among contemporary patients. Gastroenterology consultation and combination lactulose-rifaximin are both associated with improved outcomes. These data inform the development of care coordination efforts for subjects with cirrhosis.


Assuntos
Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/mortalidade , Idoso , Estudos de Coortes , Doença Hepática Terminal/complicações , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/epidemiologia , Doença Hepática Terminal/terapia , Feminino , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/terapia , Humanos , Tempo de Internação/estatística & dados numéricos , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico , Cirrose Hepática/epidemiologia , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Prognóstico , Análise de Sobrevida , Estados Unidos/epidemiologia
9.
PLoS One ; 15(5): e0231044, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32357147

RESUMO

BACKGROUND/AIMS: The aim of our study was to evaluate the diagnostic accuracy of B-Mode ultrasound and Hepatorenal Index (HRI) by high-end devices for the detection and classification of hepatic steatosis in patients with various causes of chronic liver disease (CLD). METHODS: We retrospectively enrolled patients with CLD who underwent liver biopsy and baseline ultrasound between March 2016 and May 2019. Sonographic graduation of steatosis (0°-III°) using B-Mode criteria and HRI were correlated with the histological graduation (S0 (<5% fat), S1 (≥5-33%), S2 (>33-66%) and S3 (>66%). Interobserver agreement was calculated. RESULTS: 157 patients were evaluated. B-Mode ultrasound had a sensitivity of 75.6% and a specificity of 76.0% to differentiate between steatosis and no steatosis (AUROC 0.758). Using B-Mode criteria for advanced steatosis (≥II°), specificity for presence of histological steatosis was ≥98.7%. For detection of advanced steatosis (≥S2), sensitivity of B-mode criteria was 90.9%. In a subgroup of patients with advanced liver fibrosis, sensitivity of B-mode criteria was 95.0% for detection of advanced steatosis (S≥2). A HRI cut-off-value of 1.46 differentiates between patients with steatosis and patients without steatosis with a sensitivity of 42.7% and a specificity of 90.7% (AUROC 0.680). Interobserver agreement of both B-Mode and HRI was good to excellent. CONCLUSION: B-Mode ultrasound using high-end devices is an excellent method to detect advanced steatosis in patients with various CLD. For diagnosis of mild steatosis, modern ultrasound devices may have higher sensitivity but at the expense of specificity. Stage of fibrosis and etiology of CLD seem not to impact on diagnostic accuracy. The additional calculation of HRI seems to have no additional benefit with regard to detect or grade hepatic steatosis in our study population.


Assuntos
Doença Hepática Terminal/complicações , Fígado Gorduroso/diagnóstico , Rim/patologia , Fígado/patologia , Ultrassonografia/métodos , Doença Hepática Terminal/diagnóstico por imagem , Doença Hepática Terminal/patologia , Fígado Gorduroso/diagnóstico por imagem , Fígado Gorduroso/etiologia , Feminino , Humanos , Rim/diagnóstico por imagem , Fígado/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos
10.
Medicine (Baltimore) ; 99(20): e20205, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32443344

RESUMO

BACKGROUND: Autoimmune liver disease (ALD) is a chronic liver disease caused by immune dysfunction in the body. However, no causative or curative medical treatment with proven efficacy exists to cure ALDs, and liver transplantation (LT) remains the only effective treatment available. However, the problem of recurrence of ALDs (rALDs) still remains after LT, which seriously affects the survival rate of the patients. Therefore, clinicians need to be aware of the risk factors affecting rALDs after LT. Therefore, this meta-analysis aims to define the risk factors for rALDs, which include the recurrence of primary biliary cirrhosis, primary sclerosing cholangitis and autoimmune hepatitis. METHODS: A systematic search in Pubmed, Embase, Cochrane library and Web of Science databases was performed from 1980 to 2019. The inclusion criteria were risk factors for developing rALDs after LT. However, case series, case reports, reviews, meta-analysis and studies only including human immunodeficiency virus cases, children, and pregnant patients were excluded. RESULTS: The electronic database search yielded 1728 results. Sixty-three retrospective cohort studies met the inclusion criteria and 13 were included in the meta-analysis. The final cohort included 5077 patients, and among them, 21.96% developed rALDs. Colectomy before LT, HR 0.59 (95% confidence interval [CI]: 0.37-0.96), cholangiocarcinoma, HR 3.42 (95% CI: 1.88-6.21), multiple episodes of acute cellular rejection, HR 2.07 (95% CI: 1.27-3.37), model for end-stage liver disease score, HR 1.05 (95% CI: 1.02-1.08), use of mycophenolate mofetil, HR 1.46 (95% CI: 1.00-2.12) and the use of cyclosporin A, HR 0.69 (95% CI: 0.49-0.97) were associated with the risk of rprimary sclerosing cholangitis. In addition, the use of tacrolimus, HR 1.73 (95% CI: 1.00-2.99) and cyclosporin A, HR 0.59 (95% CI: 0.39-0.88) were associated with the risk of rALD. CONCLUSIONS: Multiple risk factors for rALDs were identified, such as colectomy before LT, cholangiocacinoma, multiple episodes of acute cellular rejection, model for end-stage liver disease score, and especially the use of mycophenolate mofetil, cyclosporin A and tacrolimus.


Assuntos
Colangite Esclerosante/etiologia , Hepatopatias/imunologia , Transplante de Fígado/efeitos adversos , Adulto , Inibidores de Calcineurina/efeitos adversos , Colangiocarcinoma/complicações , Colangite Esclerosante/induzido quimicamente , Colangite Esclerosante/epidemiologia , Colectomia/efeitos adversos , Colectomia/estatística & dados numéricos , Ciclosporina/efeitos adversos , Doença Hepática Terminal/complicações , Inibidores Enzimáticos/efeitos adversos , Feminino , Rejeição de Enxerto/complicações , Hepatite Autoimune/complicações , Hepatite Autoimune/epidemiologia , Humanos , Cirrose Hepática Biliar/complicações , Cirrose Hepática Biliar/epidemiologia , Hepatopatias/etiologia , Hepatopatias/mortalidade , Hepatopatias/patologia , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Ácido Micofenólico/efeitos adversos , Recidiva , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Tacrolimo/efeitos adversos
11.
Am J Transplant ; 20(7): 1840-1848, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32330351

RESUMO

In January 2020, Novel Coronavirus Disease 2019 (COVID-19) resulted in a global pandemic, creating uncertainty toward the management of liver transplantation (LT) programs. Lombardy has been the most affected region in Italy: the current mortality rate of COVID-19 patients is 18.3% (10 022 deaths; April 10th) with hospitals in Lombardy having to expand the total number of ICU beds from 724 to 1381 to accommodate infected patients. There has been a drastic decrease in liver donors. From February 23rd until April 10th, 17 LTs were performed in Lombardy. Mean donor age was 49 years (range 18-74) whereas mean recipient age was 55 (13-69); mean MELD score was 12 (6-24). All donors underwent screening for SARS-CoV-2 prior to LT. Two patients tested positive after LT, and one patient died for COVID on POD 30. Sixteen patients are alive after an average of 30 days post-LT (range 3-46). 10 patients have been discharged. This study has found no specific reason concerning the safety of recipients, to stop LT programs. Several key lessons from our experience are reported. However, due to the complex circumstances which surround the viral outbreak, the cessation or a reduction in LT activity is a pragmatic requirement.


Assuntos
Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Doença Hepática Terminal/cirurgia , Transplante de Fígado/tendências , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Adolescente , Adulto , Idoso , Betacoronavirus , Técnicas de Laboratório Clínico , Infecções por Coronavirus/diagnóstico , Doença Hepática Terminal/complicações , Feminino , Seguimentos , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Doadores de Tecidos , Obtenção de Tecidos e Órgãos , Resultado do Tratamento , Adulto Jovem
12.
Am J Transplant ; 20(7): 1885-1890, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32330356

RESUMO

With the rapidly expanding pandemic of SARS-CoV-2, there is concern that solid organ transplant recipients will be particularly vulnerable to infection and may experience a more severe clinical course. We report four cases of COVID-19 in solid organ transplant recipients including recipients of kidney, liver, lung, and heart transplants. We describe each patient's medical history including transplantation history, their clinical presentation and workup, and their course from diagnosis to either hospital discharge or to improvement in symptoms. These reports demonstrate a range of symptoms, clinical severity, and disease course in solid organ transplant recipients with COVID-19, including two hospitalized patients and two patients managed entirely in the outpatient setting.


Assuntos
Infecções por Coronavirus/complicações , Imunossupressão/métodos , Pneumonia Viral/complicações , Transplantados , Idoso , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Doença Hepática Terminal/complicações , Doença Hepática Terminal/cirurgia , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/cirurgia , Transplante de Coração , Hospitalização , Humanos , Imunossupressão/efeitos adversos , Falência Renal Crônica/complicações , Falência Renal Crônica/cirurgia , Transplante de Rim , Transplante de Fígado , Pneumopatias/complicações , Pneumopatias/cirurgia , Transplante de Pulmão , Masculino , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Estados Unidos/epidemiologia , Populações Vulneráveis , Washington
13.
Am J Transplant ; 20(7): 1891-1895, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32243673

RESUMO

Coronavirus disease 2019 (COVID-19) pandemic spreads rapidly and may be an increasing challenge for transplant community. Clinical data on COVID-19 infection in transplant population is very limited. Herein we presented the clinical course and outcome of a 50-year-old male post liver transplantation who contracted COVID-19, with subsequent infection of his wife. The process of illness was representative. A therapeutic regime with temporary immunosuppression withdrawal and systemic low-dose corticosteroid as principle was involved in the management of the patient which made him recover from severe COVID-19 pneumonia.


Assuntos
Infecções por Coronavirus/complicações , Infecções por Coronavirus/terapia , Doença Hepática Terminal/complicações , Doença Hepática Terminal/cirurgia , Hepatite B/complicações , Transplante de Fígado , Pneumonia Viral/complicações , Pneumonia Viral/terapia , Corticosteroides/administração & dosagem , Betacoronavirus , China , Infecções por Coronavirus/diagnóstico por imagem , Hepatite B/cirurgia , Humanos , Imunossupressão/efeitos adversos , Imunossupressores/administração & dosagem , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/diagnóstico por imagem , Radiografia Torácica , Tomografia Computadorizada por Raios X , Transplantados , Resultado do Tratamento
14.
Medicine (Baltimore) ; 99(16): e19766, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32311980

RESUMO

BACKGROUND: Chronic liver disease is traditionally conceived as a risk factor for cardiovascular surgery. Transcatheter aortic valve implantation (TAVI) has recently burgeoned to precede surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis at intermediate to high surgical risk. The evidence regarding TAVI in the patients with chronic liver disease is currently scarce. METHODS: This article aims to assess the application of TAVI technique in the patients with chronic liver disease. RESULTS: TAVI in the patients with chronic liver disease produced acceptable postoperative results. The post-TAVI outcomes were comparable between the patients with or without chronic liver disease, except for a lower rate of pacemaker implantation in the patients with chronic liver disease (OR, 0.49[0.27-0.87], P = .02). In the patients with chronic liver disease, compared to SAVR, TAVI led to a decrease in the in-hospital mortality (OR, 0.43[0.22-0.86], P = .02) and need for transfusion (OR, 0.39[0.25-0.62], P < .0001). The rest outcomes were similar between the 2 groups. CONCLUSIONS: This systematic review and meta-analysis supported that TAVI is a reliable therapeutic option for treating severe aortic stenosis in the patients with chronic liver disease. Future large-scale randomized controlled trials investigating the mid-term and long-term prognosis are needed to further verify these results.


Assuntos
Estenose da Valva Aórtica/cirurgia , Doença Hepática Terminal/complicações , Substituição da Valva Aórtica Transcateter , Estenose da Valva Aórtica/complicações , Humanos
15.
Am J Transplant ; 20(7): 1907-1910, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32277591

RESUMO

Liver injury is common in patients with COVID-19, but little is known about its clinical presentation and severity in the context of liver transplant. We describe a case of COVID-19 in a patient who underwent transplant 3 years ago for hepatocellular carcinoma. The patient came to clinic with symptoms of respiratory disease; pharyngeal swabs for severe acute respiratory syndrome coronavirus 2 were positive. His disease progressed rapidly from mild to critical illness and was complicated by several nosocomial infections and multiorgan failure. Despite multiple invasive procedures and rescue therapies, he died from the disease. The management of COVID-19 in the posttransplant setting presents complex challenges, emphasizing the importance of strict prevention strategies.


Assuntos
Carcinoma Hepatocelular/complicações , Infecções por Coronavirus/complicações , Doença Hepática Terminal/complicações , Hepatite B/complicações , Neoplasias Hepáticas/complicações , Transplante de Fígado , Pneumonia Viral/complicações , Betacoronavirus , Carcinoma Hepatocelular/cirurgia , Infecções por Coronavirus/terapia , Infecção Hospitalar/complicações , Doença Hepática Terminal/cirurgia , Evolução Fatal , Hepatite B/cirurgia , Humanos , Hospedeiro Imunocomprometido , Imunossupressão , Imunossupressores/uso terapêutico , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/terapia , Complicações Pós-Operatórias , Radiografia Torácica , Tomografia Computadorizada por Raios X , Transplantados , Resultado do Tratamento
16.
Metabolism ; 106: 154204, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32173406

RESUMO

BACKGROUND: Short-term survival after orthotopic liver transplantation (OLT) has improved over the past decades, but long-term survival remains impaired. The effects of obesity on long-term survival after OLT are controversial. Because pre-transplant body mass index (BMI) can be confounded by ascites, we hypothesized that post-transplant BMI at 1 year could predict long-term survival. METHODS: A post-hoc analysis was performed of an observational cohort study consisting of adult recipients of a first OLT between 1993 and 2010. Baseline BMI was measured at 1-year post-transplantation to represent a stable condition. Recipients were stratified into normal weight (BMI < 25 kg/m2), overweight (25 ≤ BMI ≤ 30 kg/m2), and obese (BMI > 30 kg/m2). Kaplan-Meier survival analyses were performed with log-rank testing, followed by multivariable Cox proportional hazards regression analysis. RESULTS: Out of 370 included recipients, 184 had normal weight, 136 were overweight, and 50 were obese at 1-year post-transplantation. After median follow-up for 12.3 years, 107 recipients had died, of whom 46 (25%) had normal weight, 39 (29%) were overweight, and 22 (44%) were obese (log-rank P = 0.020). Obese recipients had a significantly increased mortality risk compared to normal weight recipients (HR 2.00, 95% CI 1.08-3.68, P = 0.027). BMI was inversely associated with 15 years patient survival (HR 1.08, 95% CI 1.03-1.14, P = 0.001 per kg/m2), independent of age, gender, muscle mass, transplant characteristics, cardiovascular risk factors, kidney- and liver function. CONCLUSION: Obesity at 1-year post-transplantation conveys a 2-fold increased mortality risk, which may offer potential for interventional strategies (i.e. dietary advice, lifestyle modification, or bariatric surgery) to improve long-term survival after OLT.


Assuntos
Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Obesidade/mortalidade , Adulto , Índice de Massa Corporal , Estudos de Coortes , Doença Hepática Terminal/complicações , Doença Hepática Terminal/mortalidade , Doença Hepática Terminal/cirurgia , Feminino , Seguimentos , Humanos , Testes de Função Hepática , Masculino , Pessoa de Meia-Idade , Obesidade/etiologia , Sobrepeso/complicações , Sobrepeso/mortalidade , Complicações Pós-Operatórias/mortalidade , Fatores de Risco , Análise de Sobrevida
17.
Transplantation ; 104(7): e188-e198, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32150034

RESUMO

BACKGROUND: Cystatin C (CysC) is an early biomarker of renal dysfunction scarcely studied in patients awaiting liver transplantation (LT). Sarcopenia is frequent in cirrhosis and impacts prognosis. We aimed to assess the capability of these factors to predict survival and acute-on-chronic liver failure (ACLF) in patients awaiting LT, as well as early post-LT outcomes. METHODS: Single-center study that included all cirrhotic patients listed for LT between 2014 and 2017. Competing risk regression analysis was used to evaluate the capability of liver-, kidney-, and global status-related variables at waitlist (WL) inclusion to predict WL mortality and ACLF. Variables associated with post-LT outcomes were evaluated with logistic regression analysis. RESULTS: One-hundred-and-eighty patients were included. Fifty-six (31%) patients developed ACLF, 54 (30%) underwent LT and 35 (19%) died. In the adjusted competing risk regression analysis, CysC ≥ 1.5 mg/L, sarcopenia and MELD-Na were independent predictors of ACLF in the WL, while CysC ≥ 1.5 mg/L, sarcopenia and albumin were independent predictors of mortality. The cumulative incidence of ACLF and mortality at 12 months were 50% and 34% in patients with sarcopenia and CysC ≥1.5 mg/L. An estimated glomerular filtration rate by chronic kidney disease (CKD)-EPI-CysC-creatinine <60 mL/min/1.73 m at WL inclusion was an independent predictor of the need for renal replacement therapy (RRT) in the first month post-LT. CONCLUSIONS: Higher levels of CysC and sarcopenia are strongly associated with the ACLF and mortality in WL. The assessment of both risk factors may improve the prognostic evaluation and allow identifying a group of patients with a very high risk of poor outcomes while awaiting LT.


Assuntos
Insuficiência Hepática Crônica Agudizada/diagnóstico , Cistatina C/sangue , Doença Hepática Terminal/mortalidade , Cirrose Hepática/mortalidade , Transplante de Fígado/efeitos adversos , Sarcopenia/embriologia , Lesão Renal Aguda/sangue , Lesão Renal Aguda/epidemiologia , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/terapia , Insuficiência Hepática Crônica Agudizada/epidemiologia , Insuficiência Hepática Crônica Agudizada/etiologia , Insuficiência Hepática Crônica Agudizada/terapia , Idoso , Biomarcadores/sangue , Creatinina/sangue , Doença Hepática Terminal/sangue , Doença Hepática Terminal/complicações , Doença Hepática Terminal/diagnóstico , Feminino , Taxa de Filtração Glomerular , Humanos , Incidência , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Prognóstico , Insuficiência Renal Crônica/sangue , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/etiologia , Insuficiência Renal Crônica/terapia , Terapia de Substituição Renal/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Sarcopenia/sangue , Sarcopenia/etiologia , Índice de Gravidade de Doença , Listas de Espera/mortalidade
18.
Transplant Proc ; 52(5): 1236-1242, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32217009

RESUMO

INTRODUCTION: In the era of shortage of organs for donation, transplantation from suboptimal donors is an expanding alternative to minimize waitlist mortality. In that sense, the safety of using organs from bacteremic donors has been a recurrent matter of discussion. We aimed to evaluate the influence of donor positive blood culture in the recipient and graft outcomes after liver transplantation from deceased donors. MATERIAL AND METHODS: Blood culture results from 255 deceased liver donors were retrospectively reviewed. Patients were categorized into 2 groups based on the recipients who obtained a graft from a donor with negative or positive blood culture. Graft and recipient outcomes were compared between the 2 groups using univariate survival analysis and multivariate regression models. Transmission of bloodstream infection from donor to recipient was assessed by reviewing recipients' microbiologic status when there was evidence of infection. RESULTS: Positive blood culture in donors was not associated with negative outcomes after transplantation. Death within 30 days after transplantation and overall recipient and graft survival did not differ between the 2 groups. Only Child-Pugh score ≥10 and retransplantation status were considered independent predictors of recipient death and graft failure. We identified 1 potential case of bacteremia transmission from donor to recipient. CONCLUSION: Donor positive blood culture was not associated with negative outcomes after liver transplantation. Transmission of infection from donor to recipient is possible, but rare. The results support the usage of bacteremic donors as a safe alternative to the scarcity of optimal donors.


Assuntos
Bacteriemia/prevenção & controle , Infecções Bacterianas/prevenção & controle , Doença Hepática Terminal/cirurgia , Transplante de Fígado/efeitos adversos , Doadores de Tecidos , Adulto , Bacteriemia/complicações , Infecções Bacterianas/complicações , Hemocultura , Doença Hepática Terminal/complicações , Feminino , Sobrevivência de Enxerto , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
19.
Cochrane Database Syst Rev ; 3: CD011573, 2020 03 05.
Artigo em Inglês | MEDLINE | ID: mdl-32133620

RESUMO

BACKGROUND: Portal hypertension commonly accompanies advanced liver disease and often gives rise to life-threatening complications, including bleeding (haemorrhage) from oesophageal and gastrointestinal varices. Variceal bleeding commonly occurs in children with chronic liver disease or portal vein obstruction. Therefore, prevention is important. Primary prophylaxis of variceal bleeding in adults is the established standard of care because of the results of numerous randomised clinical trials demonstrating the efficacy of non-selective beta-blockers or endoscopic variceal ligation in decreasing the incidence of variceal bleeding. In children, band ligation, beta-blockers, and sclerotherapy have been proposed as alternatives for primary prophylaxis of oesophageal variceal bleeding. However, it is unknown whether those treatments are of benefit or harm when used for primary prophylaxis in children. OBJECTIVES: To assess the benefits and harms of sclerotherapy compared with sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. SEARCH METHODS: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, PubMed, Embase Elsevier, and two other registers in February 2019. We scrutinised the reference lists of the retrieved publications, and performed a manual search of the main paediatric gastroenterology and hepatology conference (NASPGHAN and ESPGHAN) abstracts from January 2008 to December 2018. We searched four registries for ongoing clinical trials. There were no language or document type restrictions. SELECTION CRITERIA: We included randomised clinical trials irrespective of blinding, language, or publication status assessing sclerotherapy versus sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodology to perform this systematic review. We used the intention-to-treat principle to analyse outcome data, and GRADE to assess the certainty of evidence per outcome. MAIN RESULTS: We found only one randomised clinical trial that fulfilled our inclusion criteria. The trial was at high risk of bias. The trial included 108 Brazilian children with median age of 4.3 years (range 11 months to 13 years). Fifty-six children were randomised to prophylactic sclerotherapy (ethanolamine oleate 2%) and 52 children to no intervention (control). Children were followed up for a median of 4.5 years. Eight children (six from the sclerotherapy group versus two from the control group) dropped out before the end of the trial. The follow-up was from 18 months to eight years. Mortality was 16% (9/56 children) in the sclerotherapy group versus 15% (8/52 children) in the control group (risk ration (RR) 1.04, 95% confidence interval (CI) 0.44 to 2.50; very low-certainty evidence). Upper gastrointestinal bleeding occurred in 21% (12/56) of the children in the sclerotherapy group versus 46% (24/52) in the control group (RR 0.46, 95% CI 0.26 to 0.83; very low-certainty evidence). There were more children with congestive hypertensive gastropathy in the sclerotherapy group than in the control group (14% (8/56) versus 6% (3/52); RR 2.48, 95% CI 0.69 to 8.84; very low-certainty evidence). The incidence of gastric varices was similar between the sclerotherapy group and the control group (11% (6/56) versus 10% (5/52); RR 1.11, 95% CI 0.36 to 3.43; very low-certainty evidence). The incidence of bleeding from gastric varices was higher in the sclerotherapy group than in the control group (4% (3/56) versus 0% (0/52); RR 6.51, 95% CI 0.34 to 123.06; very low-certainty evidence). The study did not assess health-related quality of life. Oesophageal variceal bleeding occurred in 5% (3/56) of the children in the sclerotherapy group versus 40% (21/52) of the children in the control group (RR 0.13, 95% CI 0.04 to 0.42; very low-certainty evidence). The most prevalent complications (defined as non-serious) were pain and fever after the procedure, which promptly resolved with analgesics. However, numerical data on the frequency of these adverse events and their occurrences in the two groups were lacking. No funding information was provided. We found no ongoing trials. AUTHORS' CONCLUSIONS: The evidence, obtained from one randomised clinical trial at high risk of bias, is very uncertain on whether sclerotherapy has an influence on mortality and if it may decrease first upper gastrointestinal or oesophageal variceal bleeding in children. The evidence is very uncertain on whether sclerotherapy has an influence on congestive hypertensive gastropathy, incidence on gastric varices, and incidence of bleeding from gastric varices. Health-related quality of life was not measured. There were no serious events caused by sclerotherapy, and analysis of non-serious adverse events could not be performed due to lack of numerical data. The GRADE assessment of each outcome showed a very low-certainty evidence. The results of the trial need to be interpreted with caution. Larger randomised clinical trials, following the SPIRIT and CONSORT statements, assessing the benefits and harms of sclerotherapy compared with sham or no intervention for primary prophylaxis of oesophageal variceal bleeding in children with chronic liver disease or portal vein thrombosis are needed. The trials should include important clinical outcomes such as death, failure to control bleeding, and adverse events.


Assuntos
Doença Hepática Terminal/complicações , Hemorragia Gastrointestinal/prevenção & controle , Hipertensão Portal/complicações , Escleroterapia/métodos , Trombose Venosa/complicações , Varizes Esofágicas e Gástricas/complicações , Humanos , Ligadura/métodos , Veia Porta , Prevenção Primária , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto
20.
J Surg Res ; 250: 45-52, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32018142

RESUMO

BACKGROUND: The Model for End-Stage Liver Disease Sodium (MELD-Na) incorporates hyponatremia into the MELD score and has been shown to correlate with surgical outcomes. The pathophysiology of hyponatremia parallels that of ascites, which purports greater surgical risk. This study investigates whether MELD-Na accurately predicts morbidity and mortality in patients with ascites undergoing general surgery procedures. MATERIALS AND METHODS: We used the National Surgical Quality Improvement Program database (2005-2014) to examine the adjusted risk of morbidity and mortality of cirrhotic patients with and without ascites undergoing inguinal or ventral hernia repair, cholecystectomy, and lysis of adhesions for bowel obstruction. Patients were stratified by the MELD-Na score and ascites. Outcomes were compared between patients with and without ascites for each stratum using low MELD-Na and no ascites group as a reference. RESULTS: A total of 30,391 patients were analyzed. Within each MELD-Na stratum, patients with ascites had an increased risk of complications compared with the reference group (low MELD-Na and no ascites): low MELD-Na with ascites odds ratio (OR) 4.33 (95% confidence interval [CI] 1.96-9.59), moderate MELD-Na no ascites OR 1.70 (95% CI 1.52-1.9), moderate MELD-Na with ascites OR 3.69 (95% CI 2.49-5.46), high MELD-Na no ascites OR 3.51 (95% CI 3.07-4.01), and high MELD-Na ascites OR 7.18 (95% CI 5.33-9.67). Similarly, mortality risk was increased in patients with ascites compared with the reference: moderate MELD-Na no ascites OR 3.55 (95% CI 2.22-5.67), moderate MELD-Na ascites OR 13.80 (95% CI 5.65-33.71), high MELD-Na no ascites OR 8.34 (95% CI 5.15-13.51), and high MELD-Na ascites OR 43.97 (95% CI 23.76-81.39). CONCLUSIONS: MELD-Na underestimates morbidity and mortality risk for general surgery patients with ascites.


Assuntos
Ascite/cirurgia , Doença Hepática Terminal/diagnóstico , Hiponatremia/diagnóstico , Cirrose Hepática/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Índice de Gravidade de Doença , Adulto , Idoso , Ascite/sangue , Ascite/etiologia , Doença Hepática Terminal/sangue , Doença Hepática Terminal/complicações , Feminino , Mortalidade Hospitalar , Humanos , Hiponatremia/sangue , Hiponatremia/etiologia , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Sódio/sangue , Resultado do Tratamento
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