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1.
Khirurgiia (Mosk) ; (10): 21-28, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31626235

RESUMO

OBJECTIVE: To analyze clinical course and the results of salvage liver transplantation in patients with recurrent hepatocellular carcinoma (HCC) after liver resection. MATERIAL AND METHODS: A 54-year-old man with HCV-infection and HCC and 22-year-old woman with fibrolamellar variant of HCC underwent resection of the right and left liver lobe, respectively. The first patient experienced recurrent HCC four times with an interval of 3-6 months within 2 years after surgery. Repeated liver resection was made in first three cases, right liver lobe transplantation - after the fourth recurrence. In the second patient, HCC recurred in 4 months after resection and was accompanied by subtotal portal vein thrombosis. Therefore, repeated liver resection was excluded and patient underwent right liver lobe transplantation. RESULTS: Patients are alive in 5 and 3.5 years after liver resection and in 2.5 and 3 years after transplantation, respectively. There are currently no signs of recurrent HCC in the graft.


Assuntos
Carcinoma Hepatocelular/cirurgia , Neoplasias Hepáticas/cirurgia , Transplante de Fígado , Recidiva Local de Neoplasia/cirurgia , Feminino , Hepatectomia , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação , Terapia de Salvação , Adulto Jovem
3.
Rev Col Bras Cir ; 46(4): e20192224, 2019.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31644721

RESUMO

OBJECTIVE: to evaluate the oral conditions and the main predisposing factors for dental treatment of patients on the waiting list for liver and simultaneous pancreas-kidney transplantation, in a single center. METHODS: we evaluated 100 patients in the waiting list, 50 candidates for liver transplantation and 50 for simultaneous kidney-pancreas transplantation, from August 2015 to February 2018. We correlated extra and intraoral examinations with pre-transplant demographic variables. RESULTS: the main oral alteration in the pancreas-kidney and liver transplant candidates were decayed, lost and filled teeth, present in 83% and 100% of the candidates, respectively (p=0.03). The need for dental treatment was equal in both groups: 71% and 70%. In liver transplant candidates, the predisposing factors for dental treatment were age, color and etiological diagnosis of liver cirrhosis. We did not identify predisposing factors for dental treatment in candidates for simultaneous pancreas-kidney transplant. CONCLUSION: candidates for liver and for simultaneous pancreas-kidney transplantation had poor oral hygiene, with cavities, residual roots, gingivitis and periodontitis, revealing that dental evaluation should be part of the transplantation waiting list.


Assuntos
Cárie Dentária , Transplante de Rim , Transplante de Fígado , Saúde Bucal , Transplante de Pâncreas , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Listas de Espera
4.
Med Oncol ; 36(11): 94, 2019 Oct 11.
Artigo em Inglês | MEDLINE | ID: mdl-31605245

RESUMO

Immune checkpoint inhibitors (ICIs) have demonstrated remarkable efficacy in a variety of solid tumors; nonetheless, they have not been well investigated and are still recognized as a relative contraindication for patients with a liver transplantation (LT) history, since ICIs treatment might potentially lead to graft rejection. The program death-1 (PD-1) and the cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) pathways are implicated in the tolerance of transplanted organ, as well as blockade of the pathways, which contribute to eliminating tumors and may inadvertently lead to peripheral transplant rejection. Currently, no guidelines are available regarding the treatment for ICIs patients with a prior LT history. Therefore, this study was carried out to review the recent studies, attempting to introduce the ICIs-related graft rejection after LT from various aspects. We believed that ICIs could be given for the well-informed patients receiving LT and developed recurrence in a controlled setting. Typically, these patients should be treated according to a clinical care path or a prospective clinical trial, so as obtain a persistent anti-tumor immune response in the meantime of avoiding graft rejection, adjust the immunosuppression, reduce the possibility of graft loss following rejection, and have the opportunity to develop biomarkers for tumor response and transplant rejection.


Assuntos
Antineoplásicos Imunológicos/efeitos adversos , Rejeição de Enxerto/induzido quimicamente , Transplante de Fígado , Antineoplásicos Imunológicos/imunologia , Antineoplásicos Imunológicos/uso terapêutico , Antígeno B7-H1/antagonistas & inibidores , Antígeno B7-H1/imunologia , Antígeno CTLA-4/antagonistas & inibidores , Antígeno CTLA-4/imunologia , Rejeição de Enxerto/imunologia , Humanos , Neoplasias/tratamento farmacológico , Neoplasias/imunologia , Receptor de Morte Celular Programada 1/antagonistas & inibidores , Receptor de Morte Celular Programada 1/imunologia
5.
Medicine (Baltimore) ; 98(43): e17457, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31651849

RESUMO

The activity of p70S6 kinase located downstream of the mammalian target of rapamycin (mTOR) pathway is sensitive to mTOR inhibitors. However, the methods of assessing p70S6 kinase activity are still unclear. This study aimed to investigate p70S6 kinase activity in CD4-positive cells of liver transplant patients.Liver transplant patients treated with mTOR inhibitors were recruited from Beijing Chaoyang Hospital between October 2014 and October 2016. The influence of mycophenolic acid (MPA) derivatives and prednisone on p70S6 kinase phosphorylation in CD4-positive cells was examined in liver transplant patients and healthy controls (HCs). The phosphorylation of p70S6K in CD4 + CD25 regulatory T cells (Treg cells) and CD4 + CD25- T effector cells was analyzed by phospho-flow cytometry.The phospho-flow technique detected a significant loss of p70S6 kinase phosphorylation in CD4-positive cells of patients treated with mTOR inhibitors compared with HCs. MPA derivatives and prednisone did not affect p70S6 kinase phosphorylation significantly. No significant difference in p70S6 kinase phosphorylation was observed when the whole blood was stored within 3 hours at room temperature. The phosphorylation of p70S6K was significantly lower in CD4 + CD25 Treg cells than in CD4 + CD25-T effector cells in HCs. After liver transplant patients were treated with mTOR inhibitors, p70S6K phosphorylation was more reduced in CD4 + CD25-T effector cells than in CD4 + CD25 Treg cells.The presence of phosphorylation of p70S6 kinase in CD4-positive cells was reduced in liver transplant patients who were treated by mTOR inhibitors.


Assuntos
Linfócitos T CD4-Positivos/enzimologia , Inibidores Enzimáticos/farmacologia , Transplante de Fígado , Ácido Micofenólico/farmacologia , Fosforilação/efeitos dos fármacos , Serina-Treonina Quinases TOR/antagonistas & inibidores , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Resultado do Tratamento , Adulto Jovem
6.
Acta Gastroenterol Belg ; 82(3): 417-420, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31566330

RESUMO

Cholangiocarcinoma (CC) represent 3% of all gastrointestinal tumours and can be classified anatomically in 3 types: intrahepatic (ICC), perihilar (PCC) and distal (DCC) cholangiocarcinomas. Resection is the treatment of choice but is only achieved in a few cases (<20%) because of invasion of the biliary tract and/or vascular structures. The outcome of advanced CC is poor with an overall survival (OS) of maximum 15 months with chemotherapy. In the 1990s, CC was regarded as a contraindication for liver transplantation (LT). LT has recently been proposed as potentially curative option for ICC and PCC. Careful patient selection has changed OS. This article provides an update on current status of LT for patients with unresectable CC.


Assuntos
Neoplasias dos Ductos Biliares/cirurgia , Ductos Biliares Intra-Hepáticos/patologia , Colangiocarcinoma/cirurgia , Transplante de Fígado , Neoplasias dos Ductos Biliares/patologia , Colangiocarcinoma/patologia , Humanos , Resultado do Tratamento
7.
Medicine (Baltimore) ; 98(38): e17230, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31567986

RESUMO

RATIONALE: Liver transplantation is an increasingly common treatment for patients with liver cirrhosis or hepatocellular carcinoma. Liver transplantation in patients with heart disease can pose a significant challenge to the transplant teams. PATIENT CONCERNS: A 46-year-old woman was diagnosed with hepatitis B virus-related hepatocellular carcinoma 3 years ago and had received 3 times transarterial chemoembolization. DIAGNOSES: The patient was diagnosed as end-stage liver disease due to hepatocellular carcinoma and was scheduled to undergo living-donor liver transplantation. The preoperative echocardiogram revealed mass in the right atrium and the inferior vena cava. INTERVENTIONS: The patient underwent mass removal under cardiopulmonary bypass followed by liver transplantation. OUTCOMES: A month later, she was discharged without any complications. LESSONS: There have only been a few reported cases of anesthetic liver transplantation after a cardiopulmonary bypass. The successful experience described in this case report suggests that some patients may be eligible to undergo a liver transplantation after a cardiopulmonary bypass.


Assuntos
Ponte Cardiopulmonar , Transplante de Fígado , Carcinoma Hepatocelular/cirurgia , Feminino , Humanos , Neoplasias Hepáticas/cirurgia , Transplante de Fígado/métodos , Pessoa de Meia-Idade
8.
Medicine (Baltimore) ; 98(39): e17339, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31574872

RESUMO

INTRODUCTION: During the past decade, the rate of carbapenem resistance among Enterobacteriaceae, mostly in Escherichia coli and Klebsiella pneumoniae, has significantly increased worldwide. It is a great challenge for the choice of drug treatment especially in children.Tigecycline is the first drug in the glycylcycline class of antibiotics. For children, the China Food and Drug Administration and US Food and Drug Administration postulated that tigecycline is not recommended. It must be used only as salvage therapy for life-threatening infections in critically ill children who have no alternative treatment options. PATIENT CONCERNS: A male pediatric case of 4.5 months was blood stream infection after liver transplantation. The blood cultures obtained grew Gram-negative rods, which reportedly grew a strain of extended-spectrum ß-lactamase and carbapenemases-producing Escherichia coli within 10 hours. All bacterial isolates were found to be resistant to all antimicrobial agents except aminoglycosides and tigecycline. DIAGNOSES: Complicated intra-abdominal infection, central line-associated blood stream infection. INTERVENTIONS: The blood stream infection with carbapenem-resistant Escherichia coli after liver transplantation was cured by tigecycline. OUTCOMES: The patient's condition continued to improve, then transferred to general ward. CONCLUSION: The following report, to our knowledge, is the youngest liver transplantation patient who used tigecycline treatment around the world. It provides reference and experience for the use of tigecycline in infants with severe infections.


Assuntos
Antibacterianos/uso terapêutico , Enterobacteriáceas Resistentes a Carbapenêmicos , Infecções por Enterobacteriaceae/tratamento farmacológico , Infecções por Escherichia coli/tratamento farmacológico , Complicações Pós-Operatórias/tratamento farmacológico , Tigeciclina/uso terapêutico , Infecções por Enterobacteriaceae/microbiologia , Infecções por Escherichia coli/microbiologia , Humanos , Lactente , Transplante de Fígado/efeitos adversos , Masculino , Complicações Pós-Operatórias/microbiologia
9.
Rev Soc Bras Med Trop ; 52: e20190302, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31618309

RESUMO

INTRODUCTION: Solid-organ transplant recipients are at risk of hepatitis E virus (HEV) infection. We analyzed the seroprevalence/risk factors of HEV in Croatian liver transplant recipients. METHODS: Two hundred forty-two serum samples were tested for HEV immunoglobuline IgG/IgM and HEV RNA. Sociodemographic data and risk factors were collected using a questionnaire. RESULTS: HEV IgG seroprevalence rate was 24.4%. Positive/equivocal HEV IgM were found in two patients. HEV RNA was not detected. Logistic regression showed that older age, female gender, rural area/farm, water well, and septic tank were associated with HEV seropositivity. CONCLUSIONS: This study revealed a high exposure rate to HEV in Croatian liver recipients.


Assuntos
Vírus da Hepatite E/imunologia , Hepatite E/epidemiologia , Transplante de Fígado/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Croácia/epidemiologia , Estudos Transversais , Feminino , Anticorpos Anti-Hepatite/sangue , Hepatite E/imunologia , Humanos , Imunoglobulina G/sangue , Imunoglobulina M/sangue , Masculino , Pessoa de Meia-Idade , RNA Viral/sangue , Fatores de Risco , Estudos Soroepidemiológicos , Fatores Socioeconômicos
10.
Zentralbl Chir ; 144(5): 437-438, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31634966
11.
12.
Am Surg ; 85(9): 1025-1027, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31638518

RESUMO

From 1991 to 2013, Mississippi was without liver transplant services. In 2013, a new liver transplant program was established at the University of Mississippi Medical Center. Here, we describe our experience with the first 150 transplants over a 4.5-year period. This study is a review of 147 patients who underwent the first 150 liver transplants at the University of Mississippi Medical Center between March 5, 2013, and January 4, 2018. There were no exclusion criteria for this study. Donor, recipient, and outcome variables were analyzed. Recipients were 46% female and 74% white. Age at the time of transplant was 57 [IQR 49-63]. BMI at transplant was 30 [IQR 25-35]. Thirty per cent of transplants were for alcoholic cirrhosis, 25% non-alcoholic steatohepatitis, 24% hepatitis C, and 12% cholestatic. Mean model for end-stage liver disease (MELD) at the time of transplant was 20 [95% confidence interval 19-21] and MELD-Na was 22 [95% confidence interval 20-23]. One-year patient- and graft survival were 89% and 87%, respectively, which were as expected based on Scientific Registry of Transplant Recipient reports after risk adjustment. The data published here verifies it is possible to establish a new liver transplant center in an underserved area previously lacking comprehensive liver care and to achieve results similar to other high-volume centers across the country.


Assuntos
Centros Médicos Acadêmicos , Transplante de Fígado , Índice de Massa Corporal , Colestase/cirurgia , Fígado Gorduroso/cirurgia , Feminino , Sobrevivência de Enxerto , Hepatite C/cirurgia , Humanos , Tempo de Internação , Cirrose Hepática Alcoólica/cirurgia , Transplante de Fígado/efeitos adversos , Transplante de Fígado/normas , Masculino , Pessoa de Meia-Idade , Mississippi , Avaliação de Resultados (Cuidados de Saúde) , Complicações Pós-Operatórias , Desenvolvimento de Programas , Reoperação
14.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 31(9): 1137-1142, 2019 Sep.
Artigo em Chinês | MEDLINE | ID: mdl-31657340

RESUMO

OBJECTIVE: To investigate the protective effect of bone marrow mesenchymal stem cells (BMMSC) combined with normothermic mechanical perfusion (NMP) on biliary epithelial cells (BEC) in rats receiving donation after cardiac death (DCD) donor liver transplantation. METHODS: The BMMSC were isolated from male Sprague-Dawley (SD) rats aged 2-3 weeks and weighing 40-60 g, and then cultured, identified and expanded to the third generation in vitro. Male SD rats aged 6-8 weeks and weighing 200-220 g were divided into sham-operated group (Sham group), static cold storage (SCS group), simple NMP group (NMP group) and BMMSC combined with NMP group (BMMSC+NMP group) by random number table method with 44 rats in each group. The DCD donor liver transplantation models in rats were reproduced with 30-minute warm ischemic time. While the rats in Sham group merely received perihepatic ligaments-separation, which did not affect their liver blood supply, and then their incisions were sutured after 30 minutes. The DCD donor grafts in SCS group were preserved in the University of Wisconsin (UW) cold storage solution for 4 hours. While the DCD donor grafts in the NMP group and the BMMSC+NMP group were perfused with the DMEM/F12-based culture solution or combined with BMMSC for 4 hours through the established ex vivo NMP system. The orthotopic liver transplantation model was reproduced, and the survival rate of the recipients was observed at 0, 1, 7 and 14 days after liver transplantation. The biochemical liver function of rats in different groups was determined at each time point after operation. The morphological changes in bile ducts of liver grafts were observed by hematoxylin-eosin (HE) staining, and the expression of cytokeratin 19 (CK19) was determined qualitatively by immunohistochemistry and quantitatively by Western Blot after protein extraction from BEC in liver samples. RESULTS: The morphology, differentiation function and phenotypic identification of BMMSC confirmed that the stem cells used in this experiment were standard BMMSC. The survival rates of rats in the NMP group and the BMMSC+NMP group were significantly higher than that in the SCS group at 0, 1, 7 and 14 days after operation. The increase was more significant in the BMMSC+NMP group, with 100% on postoperative day (POD) 0, and the 14-day survival rate was still significantly higher than that in the SCS group and the NMP group [80.0% (16/20) vs. 20.0% (4/20), 70.0% (14/20), both P < 0.05]. As the time after liver transplantation prolonged, the liver function parameters of rats in the SCS group were deteriorated gradually, which reached the peak at 1-7 days after operation. The damage of biliary tissue increased gradually under the microscope, and the injury was most serious on POD 7 in the SCS group, showing a lot of balloon-like changes in hepatocytes, with obvious bile duct dilatation accompanied by large area inflammatory cell infiltration. Immunohistochemistry and Western Blot showed that the expression of CK19 in BEC cytoplasm was decreased gradually in the SCS group, reached the lowest on POD 7, and then gradually increased. The BMMSC+NMP group and the NMP group were significantly better than the SCS group in terms of liver function, pathological injury of biliary tract and CK19 expression in BEC, and the improvement was more significant in the BMMSC+NMP group. These results suggested that the protective effects of BMMSC combined with NMP on BEC was significantly better than that of the SCS and NMP. CONCLUSIONS: Preservation of rat DCD donor liver by BMMSC combined with NMP can reduce the BEC injury after liver transplantation significantly, thus improving both the prognosis and the survival rate after transplantation.


Assuntos
Transplante de Fígado , Células-Tronco Mesenquimais , Animais , Humanos , Doadores Vivos , Masculino , Preservação de Órgãos , Perfusão , Ratos , Ratos Sprague-Dawley
15.
Vnitr Lek ; 65(9): 588-594, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31635470

RESUMO

To achieve satisfactory results of liver transplantation, proper selection of transplant candidates is essential. Moreover, indication process is crucial regulator to solve disparity between need for transplantation and capacity of transplant services. Any patient entering the transplant waiting list must have a chance to achieve at least average transplant benefit, currently described as 50% chance to survive 5 years after liver replacement. Until now, liver transplantation is procedure designed to treat life threatening liver disorders with aim to offer long-term survival. Nevertheless, an increase in incidence of hepatocellular carcinoma, and nonalcoholic fatty liver disease caused changes in indication spectrum. Improvement in intensive care turned interest to patients with acute-on-chronic liver failure even caused by acute alcoholic hepatitis. Advances in surgery and oncology broadened indications of patients with hepatocellular carcinoma behind standard criteria, and reopened interest in field of cholangiocellular cancer and even liver metastases of colorectal cancer. These criteria are still under development, and full of controversies and broad local variation in clinical practice is present. Entity of futile transplantation is discussed recently with aim to define generally acceptable criteria to deny transplant treatment in too risky patients.


Assuntos
Carcinoma Hepatocelular , Neoplasias Hepáticas , Transplante de Fígado , Carcinoma Hepatocelular/cirurgia , Humanos , Neoplasias Hepáticas/cirurgia , Recidiva Local de Neoplasia , Listas de Espera
16.
J Surg Oncol ; 120(7): 1126-1136, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31578753

RESUMO

BACKGROUND AND OBJECTIVES: Albumin-bilirubin (ALBI) score was shown to correlate with liver function and tumor recurrence after hepatectomy for hepatocellular carcinoma (HCC). The aim of this study was to assess the prognostic value of ALBI grade in liver transplantation (LT) patients with HCC. METHODS: Pre-LT available independent predictors of recurrence-free survival (RFS) and microvascular tumor invasion (MVI) were determined in 123 patients with HCC. RESULTS: Posttransplant HCC recurrence rates were 10.5%, 15.9%, and 68.2% in ALBI grade 1, 2, and 3, respectively (P < .001). Along with serum α-fetoprotein (AFP) and C-reactive protein (CRP) levels, ALBI grades 1 or 2 was identified as an independent predictor of RFS (hazard ratio, 3.52; 95% confidence interval [CI], 1.577-7.842; P = .002). Furthermore, ALBI grade 3 proved to be the strongest indicator of MVI (odds ratio, 11.59; 95% CI, 3.412-39.381; P < .001). A novel oncological risk score-based on AFP, CRP, and ALBI grade provided the best discriminative capacity (c-statistic 0.806) in selecting liver recipients with low oncological risk profile. CONCLUSION: Preoperative ALBI grade seems to be valuable for refinement of oncological risk stratification at LT for HCC.


Assuntos
Bilirrubina/metabolismo , Carcinoma Hepatocelular/patologia , Neoplasias Hepáticas/patologia , Transplante de Fígado/mortalidade , Recidiva Local de Neoplasia/patologia , Medição de Risco/métodos , Albumina Sérica/metabolismo , Adulto , Idoso , Carcinoma Hepatocelular/metabolismo , Carcinoma Hepatocelular/cirurgia , Tomada de Decisão Clínica , Feminino , Seguimentos , Humanos , Neoplasias Hepáticas/metabolismo , Neoplasias Hepáticas/cirurgia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/metabolismo , Recidiva Local de Neoplasia/cirurgia , Cuidados Pré-Operatórios , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Taxa de Sobrevida
17.
Am Surg ; 85(8): 900-903, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31560310

RESUMO

The United Network for Organ Sharing (UNOS) implemented a policy that requires patients with hepatocellular carcinoma seeking liver transplantation to wait six months before being granted Model for End-Stage Liver Disease exception points. We investigated the difference in resource utilization between patients who underwent liver transplantation before and after the present policy. We conducted a retrospective cohort study of adult liver transplants from 2013 to 2018. Patients were classified into prepolicy or postpolicy groups based on 964 days before or after the wait-time policy. We also retrieved national survival outcome data from United Network for Organ Sharing. Differences across compared groups for continuous variables were assessed using the independent sample t test, and the chi-squared test was used for binary variables. We found statistical differences in recipient age (P = 0.005), days on wait-list (P = 0.001), sustained virological response (P < 0.001), and hepatocellular carcinoma recurrence one year posttransplant (P = 0.04). There were statistically significant differences in the number of treatment days pretransplant and length of transplant admission stay, indicating an increase in resource utilization in the postpolicy group. No statistically significant differences were found between groups in one-year graft or patient survival despite an observed increase in resource utilization by the hepatocellular carcinoma postpolicy group.


Assuntos
Carcinoma Hepatocelular/cirurgia , Neoplasias Hepáticas/cirurgia , Transplante de Fígado , Listas de Espera , Adulto , Feminino , Humanos , Masculino , Sistema de Registros , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos
18.
Am Surg ; 85(8): 918-922, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31560312

RESUMO

Incisional hernias occur after abdominal organ transplantation with rates of 1.6 per cent to 18 per cent in kidney transplants (KTs) and 1.7 to 32.4 per cent in liver transplants (LTs). We hypothesized a difference in KT and LT outcomes in patients with and without repair of incisional hernias. We conducted a retrospective cohort study of abdominal transplants from 2012 through 2016. The difference across compared groups for continuous variables was assessed using the independent sample t test, and for binary variables, using the chi-squared test. A total of 1518 transplants were performed, including 1138 KTs and 380 LTs. There were 83 KT incisional hernias (67 repaired) and 59 LT incisional hernias (48 repaired). There was no difference between groups with regard to smoking, diabetes, age, BMI, days on dialysis (KTs), pretransplant Model for End-Stage Liver Disease (MELD) (LTs), cold ischemic time, graft survival, or recurrence rate by repair method. In the LT population, there was a statistically significant difference in days on the waitlist (P = 0.02), drain placement (P = 0.04), and cytomegalovirus (CMV) mismatch (P = 0.02). Patient survival was also statistically significant for KTs (P = 0.04) and LTs (P = 0.01). KT and LT patients who have their incisional hernias repaired have better overall survival, regardless of the repair technique.


Assuntos
Herniorrafia/métodos , Hérnia Incisional/cirurgia , Transplante de Rim , Transplante de Fígado , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento
19.
Am Surg ; 85(8): 927-933, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31560314

RESUMO

Selection of orthotopic liver transplantation (OLT) candidates is increasingly inclusive of patients with high BMI. We aim to characterize the influence of obesity on the surgical outcome measures of prolonged operative time and unplanned reoperation. We reviewed the records of obese and normal weight OLT recipients over a 10-year period from a single institution. Variables that trended (P < 0.1) with endpoints on univariate analysis were put into multivariate logistic regression models to determine independent association (P < 0.05). We included 195 obese and 171 normal weight OLT recipients in our study. On multivariate analysis, obesity was the only preoperative risk factor that trended with unplanned reoperation (odds ratio 2, P = 0.05). Similarly, only obesity remained independently associated with prolonged length of operation (defined as ≥275 minutes) on multivariate analysis (odds ratio 1.7, P = 0.04). In summary, obesity may make OLT more technically challenging and, thus, represents an independent risk factor for unplanned reoperations and prolonged operative time.


Assuntos
Transplante de Fígado , Obesidade/complicações , Duração da Cirurgia , Reoperação/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Tennessee/epidemiologia
20.
Cochrane Database Syst Rev ; 9: CD013103, 2019 09 12.
Artigo em Inglês | MEDLINE | ID: mdl-31513287

RESUMO

BACKGROUND: Hepatorenal syndrome is defined as renal failure in people with cirrhosis in the absence of other causes. In addition to supportive treatment such as albumin to restore fluid balance, the other potential treatments include systemic vasoconstrictor drugs (such as vasopressin analogues or noradrenaline), renal vasodilator drugs (such as dopamine), transjugular intrahepatic portosystemic shunt (TIPS), and liver support with molecular adsorbent recirculating system (MARS). There is uncertainty over the best treatment regimen for hepatorenal syndrome. OBJECTIVES: To compare the benefits and harms of different treatments for hepatorenal syndrome in people with decompensated liver cirrhosis. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trial registers until December 2018 to identify randomised clinical trials on hepatorenal syndrome in people with cirrhosis. SELECTION CRITERIA: We included only randomised clinical trials (irrespective of language, blinding, or publication status) in adults with cirrhosis and hepatorenal syndrome. We excluded randomised clinical trials in which participants had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS: Two authors independently identified eligible trials and collected data. The outcomes for this review included mortality, serious adverse events, any adverse events, resolution of hepatorenal syndrome, liver transplantation, and other decompensation events. We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the odds ratio (OR), rate ratio, hazard ratio (HR), and mean difference (MD) with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. MAIN RESULTS: We included a total of 25 trials (1263 participants; 12 interventions) in the review. Twenty-three trials (1185 participants) were included in one or more outcomes. All the trials were at high risk of bias, and all the evidence was of low or very low certainty. The trials included participants with liver cirrhosis of varied aetiologies as well as a mixture of type I hepatorenal syndrome only, type II hepatorenal syndrome only, or people with both type I and type II hepatorenal syndrome. Participant age ranged from 42 to 60 years, and the proportion of females ranged from 5.8% to 61.5% in the trials that reported this information. The follow-up in the trials ranged from one week to six months. Overall, 59% of participants died during this period and about 35% of participants recovered from hepatorenal syndrome. The most common interventions compared were albumin plus terlipressin, albumin plus noradrenaline, and albumin alone.There was no evidence of a difference in mortality (22 trials; 1153 participants) at maximal follow-up between the different interventions. None of the trials reported health-related quality of life. There was no evidence of differences in the proportion of people with serious adverse events (three trials; 428 participants), number of participants with serious adverse events per participant (two trials; 166 participants), proportion of participants with any adverse events (four trials; 402 participants), the proportion of people who underwent liver transplantation at maximal follow-up (four trials; 342 participants), or other features of decompensation at maximal follow-up (one trial; 466 participants). Five trials (293 participants) reported number of any adverse events, and five trials (219 participants) reported treatment costs. Albumin plus noradrenaline had fewer numbers of adverse events per participant (rate ratio 0.51, 95% CrI 0.28 to 0.87). Eighteen trials (1047 participants) reported recovery from hepatorenal syndrome (as per definition of hepatorenal syndrome). In terms of recovery from hepatorenal syndrome, in the direct comparisons, albumin plus midodrine plus octreotide and albumin plus octreotide had lower recovery from hepatorenal syndrome than albumin plus terlipressin (HR 0.04; 95% CrI 0.00 to 0.25 and HR 0.26, 95% CrI 0.07 to 0.80 respectively). There was no evidence of differences between the groups in any of the other direct comparisons. In the network meta-analysis, albumin and albumin plus midodrine plus octreotide had lower recovery from hepatorenal syndrome compared with albumin plus terlipressin. FUNDING: two trials were funded by pharmaceutical companies; five trials were funded by parties who had no vested interest in the results of the trial; and 18 trials did not report the source of funding. AUTHORS' CONCLUSIONS: Based on very low-certainty evidence, there is no evidence of benefit or harm of any of the interventions for hepatorenal syndrome with regards to the following outcomes: all-cause mortality, serious adverse events (proportion), number of serious adverse events per participant, any adverse events (proportion), liver transplantation, or other decompensation events. Low-certainty evidence suggests that albumin plus noradrenaline had fewer 'any adverse events per participant' than albumin plus terlipressin. Low- or very low-certainty evidence also found that albumin plus midodrine plus octreotide and albumin alone had lower recovery from hepatorenal syndrome compared with albumin plus terlipressin.Future randomised clinical trials should be adequately powered; employ blinding, avoid post-randomisation dropouts or planned cross-overs (or perform an intention-to-treat analysis); and report clinically important outcomes such as mortality, health-related quality of life, adverse events, and recovery from hepatorenal syndrome. Albumin plus noradrenaline and albumin plus terlipressin appear to be the interventions that should be compared in future trials.


Assuntos
Síndrome Hepatorrenal/terapia , Cirrose Hepática/complicações , Qualidade de Vida , Adulto , Teorema de Bayes , Feminino , Humanos , Transplante de Fígado , Masculino , Pessoa de Meia-Idade , Meta-Análise em Rede , Ensaios Clínicos Controlados Aleatórios como Assunto , Vasoconstritores/uso terapêutico
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