Trasplante hepático: evolución, curva de aprendizaje y resultados después de los primeros 300 casos / Liver transplantation: development, learning curve and results after the first 300 cases

Background: Liver transplantation (LT) is an option for people with liver failure who cannot be cured with other therapies and for some people with liver cancer. Aim: To describe, and analyze the first 300 LT clinical results, and to establish our learning curve. Material and Methods: Retrospective cohort study with data obtained from a prospectively collected LT Program database. We included all LT performed at a single center from March 1994 to September 2017. The database gathered demographics, diagnosis, indications for LT, surgical aspects and postoperative courses. We constructed a cumulative summation test for learning curve (LC-CUSUM) using 30-day post-LT mortality. Mortality at 30 days, and actuarial 1-, and 5-year survival rate were analyzed. Results: A total of 281 patients aged 54 (0-71) years (129 women) underwent 300 LT. Ten percent of patients were younger than 18 years old. The first, second and third indications for LT were non-alcoholic steatohepatitis, chronic autoimmune hepatitis and alcoholic liver cirrhosis, respectively. Acute liver failure was the LT indication in 51 cases (17%). The overall complication rate was 71%. Infectious and biliary complications were the most common of them (47 and 31% respectively). The LC-CUSUM curve shows that the first 30 patients corresponded to the learning curve. The peri-operative mortality was 8%. Actuarial 1 and 5-year survival rates were 82 and 71.4%, respectively. Conclusions: Outcome improvement of a LT program depends on the accumulation of experience after the first 30 transplants and the peri-operative mortality directly impacted long-term survival.

Conversion to Mycophenolate Mofetil Monotherapy in Liver Recipients: Calcineurin Inhibitor Levels are Key

Abstract: The use of calcineurin inhibitors (CNI) after liver transplantation is associated with post-transplant nephrotoxicity. Conversion to mycophenolate mofetil (MMF) monotherapy improves renal function, but is related to graft rejection in some recipients. Our aim was to identify variables associated with rejection after conversion to MMF monotherapy. Conversion was attempted in 40 liver transplant recipients. Clinical variables were determined and peripheral mononuclear blood cells were immunophenotyped during a 12-month follow- up. Conversion was classified as successful (SC) if rejection did not occur during the follow-up. MMF conversion was successful with 28 patients (70%) and was associated with higher glomerular filtration rates at the end of study. It also correlated with increased time elapsed since transplantation, low baseline CNI levels (Tacrolimus ≤ 6.5 ng/mL or Cyclosporine ≤ 635 ng/mL) and lower frequency of tacrolimus use. The only clinical variable independently related to SC in multivariate analysis was low baseline CNI levels (p = 0.02, OR: 6.93, 95%, CI: 1.3-29.7). Mean baseline fluorescent intensity of FOXP3+ T cells was significantly higher among recipients with SC. In conclusion, this study suggests that baseline CNI levels can be used to identify recipients with higher probability of SC to MMF monotherapy. Clinicaltrials.gov identification: NCT01321112.

Medición volumétrica de grasa visceral abdominal con resonancia magnética y su relación con antropometría, en una población diabética / Quantification of visceral adipose tissue using magnetic resonance imaging compared with anthropometry, in type 2 diabetic patients

Background: Visceral fat accumulation is associated with the development of metabolic diseases. Anthropometry is one of the methods used to quantify it. aim: to evaluate the relationship between visceral adipose tissue volume (VAT), measured with magnetic resonance imaging (MRI), and anthropometric indexes, such as body mass index (BMI) and waist circumference (WC), in type 2 diabetic patients (DM2). Patients and Methods: Twenty four type 2 diabetic patients aged 55 to 78 years (15 females) and weighting 61.5 to 97 kg, were included. The patients underwent MRI examination on a Philips Intera® 1.5T MR scanner. The MRI protocol included a spectral excitation sequence centered at the fat peak. The field of view included from L4-L5 to the diaphragmatic border. VAT was measured using the software Image J®. Weight, height, BMI, WC and body fat percentage (BF%), derived from the measurement offour skinfolds with the equation of Durnin and Womersley, were also measured. The association between MRIVAT measurement and anthropometry was evaluated using the Pearson's correlation coefficient. Results: Mean VAT was 2478 ± 758 ml, mean BMI29.5 ± 4.7 kg/m², and mean WC was 100 ± 9.7 cm. There was a poor correlation between VAT, BMI (r = 0.18) and WC (r = 0.56). Conclusions: BMI and WC are inaccurate predictors of VAT volume in type 2 diabetic patients.

El síndrome metabólico: De factor agravante a principal factor de riesgo patogénico en diversas enfermedades crónicas / The metabolic syndrome: From an aggravating condition to a pathogenic risk factor for chronic diseases

In recent years, a rapidly increasing number of studies have focused on the association between metabolic syndrome and several chronic diseases. However, it is difficult to determine a well defined pathogenic relationship, due to the etiological heterogeneity and comorbidities of these diseases. Research efforts are aiming to identify the convergent biological mechanisms that mediate the effects of hyperinsulinemia, hyperglycemia, dyslipidemia, and hypertension. All these conditions define the metabolic syndrome, that increases the risk for several diseases. The knowledge of these biological mechanisms associated with this syndrome will elucidate the pathogenic association between a variety of chronic diseases, including its pathogenic link with cardiovascular diseases and the most common forms of dementia. The development of new therapeutic and preventive strategies for these diseases will be a corollary of this research.

Trasplante hepático en Chile: Aspectos generales, indicaciones y contraindicaciones (Documento de consenso) / General considerations, indications and contraindications for liver transplantation in Chile: A multicenter consensus development document

Liver transplantation is an excellent therapeutic option for terminal liver disease. During the last decades the results of liver transplantation have improved significantly with a patient survival rate of nearly 90 percent at one year and 80 percent at 5 years of follow-up. The main indications for liver transplantation include: end-stage liver disease associated to cirrhosis, acute liver failure, and hepatic tumors (mainly hepatocarcinoma). The absolute contraindications for a transplant are less frequent than in the past, and include: severe co-morbidity (cardiac or pulmonary), sepsis, advanced HIV disease and extra-hepatic malignancy. This document presents a Consensus of the main groups performing liver transplantation in Chile, about its indications and contraindications. It also reviews general aspects of liver transplantation, including the selection and referral of liver transplant candidates, allocation of organs and the evaluation of severity of liver disease.