Caracterización clínico-epidemiológica de los pacientes sometidos a trasplante hepático por cirrosis alcohólica en el Hospital Pablo Tobón Uribe de Medellín entre 2004 y 2015 / Clinical-epidemiological characterization of patients undergoing liver transplantation for alcoholic cirrhosis at the Pablo Tobón Uribe Hospital in Medellín between 2004 and 2015

Introducción. El alcohol ha sido asociado con más de 60 enfermedades diferentes y es el tercer factor de riesgo más común relacionado con muerte y discapacidad en el mundo. La enfermedad alcohólica hepática (EAH) es la causa más común de enfermedad hepática terminal (EHT) en los países occidentales. El objetivo de este estudio fue caracterizar la población adulta sometida a trasplante ortotópico hepático (TOH) indicado por EHT secundaria a EAH, en el Hospital Pablo Tobón Uribe (HPTU) de Medellín entre 2004 y 2015. Metodología. Estudio observacional retrospectivo. Se revisaron las historias clínicas electrónicas de todos los pacientes trasplantados en el HPTU entre los años 2004 y 2015, sometidos a TOH indicado por EHT secundaria a EAH. Se registraron las características demográficas, comorbilidades médicas y psiquiátricas, complicaciones tempranas y tardías, recaída en el consumo de alcohol posterior al TOH, supervivencia y causa de la muerte. Resultados. Se encontraron 59 pacientes trasplantados por cirrosis de origen alcohólico. El 91,5 % fueron de sexo masculino, el 82,6 % (38/46) tuvo un período abstinencia previo al TOH mayor o igual a 6 meses, y solamente el 10,2 % (6/59) de los pacientes estuvieron vinculados a un programa de adicciones. Se encontró comorbilidad psiquiátrica en el 30 % (18/59) con predomino de depresión. Se identificó recaída pesada en el consumo de alcohol postrasplante en 6 pacientes, este subgrupo se caracterizó por una alta mortalidad (66 %), pobre adherencia a la terapia inmunosupresora y alta frecuencia de depresión (83 %). En general, la cohorte tuvo una supervivencia a 5 y 10 años de 60,8 % y 28,1 %, respectivamente. Conclusiones. Las características epidemiológicas de la población son compartidas con reportes previos en relación al predominio de sexo masculino y adultos en la sexta década de la vida. La recaída en el consumo pesado de alcohol no es la regla, sin embargo, se encuentra asociada con abandono del tratamiento inmunosupresor y muerte. En comparación con reportes de otros países, nuestras tasas de complicaciones y mortalidad a 5 años son superiores.

Introduction. Alcohol has been associated with more than 60 different diseases and is the third most common risk factor related to death and disability throughout the world. Alcoholic liver disease is the most common cause of end-stage liver disease in Western countries. The main objective of this study was to characterize adult patients with orthotopic liver transplant due to alcoholic cirrhosis at the Pablo Tobón Uribe Hospital in Medellín between 2004 to 2015. Methodology. Observational retrospective study. We reviewed clinical records of all patients with orthotopic liver transplant due to alcoholic cirrhosis at the HPTU between 2004 and 2015, and retrieved demographic data, comorbidities, complications, consumption relapse and survival. Results. We analyzed 59 patients, 91.5% were male, 82.6% had an abstinence period previous to liver transplant equal or greater to six months, 10.2% were part of an addiction program, and 30% had psychiatric morbidities, mainly depression. We identified 6 patients with heavy alcoholic relapse after transplantation, this subgroup was characterized by a high mortality (66%), poor adherence to immunosuppressive therapy and high rates of depression (83%). In general, this cohort had a 5- and 10-year survival of 60.8% and 20.1%, respectively. Conclusions. The epidemiological characteristics of the population are shared with previous reports regarding the predominance of males and adults in the sixth decade of life. Relapse into heavy alcohol consumption is not the rule, however, it is associated with discontinuation of immunosuppressive treatment and death. In comparison with other reports, we have higher complications and mortality rates at 5 five years.

Frecuencia de síndrome hepatopulmonar en pacientes pediátricos trasplantados en un hospital de alta complejidad en Medellín, Colombia / Frequency of hepato-pulmonary syndrome in pediatric transplanted patients in a high complexity hospital in Medellín, Colombia

Introducción. El síndrome hepatopulmonar (SHP) es una complicación grave en los pacientes con enfermedad hepática crónica y/o hipertensión portal. La frecuencia descrita en adultos es entre 4 % y 47 %. En pediatría, los reportes también son muy variables y van desde el 3 % hasta el 40 %, desconociendo la real incidencia de este. El objetivo de esta descripción es conocer la frecuencia del SHP en pacientes pediátricos en un hospital de alta complejidad, por medio de una búsqueda activa del SHP en los estudios pretrasplante hepático hallados en las historias clínicas. Metodolo-gía. Estudio retrospectivo de 5 años, en un hospital de alta complejidad en Colombia, en menores de 15 años con un primer trasplante hepático. Resultados. Se contó con la información de 24 pacientes, se analizaron variables demográficas y se confirmó el SHP en 18 pacientes (75 %), encontrando una gravedad leve o moderada en el 33 % y 44 %, respectivamente, siendo en este grupo la cirrosis con complicaciones por hipertensión portal la indicación más frecuente para el trasplante, y como etiología de base, la atresia de vías biliares en un 61 %. Conclusión. El SHP en nuestra población se encontró con una alta frecuencia de presentación, por encima de lo reportado en la literatura, llevando a recomendar una búsqueda activa, con el objetivo de brindar un manejo integral y oportuno.

Introduction. Hepatopulmonary syndrome (HPS) is a serious complication in patients with chronic liver disease and/or portal hypertension. The frequency described in adults is between 4% and 47%. In pediatrics, reports are also highly variable and range from 3% to 40%, with the real incidence not clear yet. The objective of this study is to know the frequency of HPS in our population through an active search for HPS in pre-liver transplant studies in clinical records. Methodology. This is a 5-year retrospective study, in a reference hospital in Colombia, that included children under 15 years of age with a first liver transplant. Results. In 24 patients, the information was available, demographic variables were analyzed, and HPS was confirmed in 18 patients (75%), finding mild and moderate severity in 33% and 44%, respectively. In this group, cirrhosis with complications due to portal hyper-tension was the most frequent indication for transplantation and biliary atresia was the main etiology in 61%. Conclusion. HPS in our population was found with a high frequency, higher than is described in the literature, leading to the recommendation of an active search, with the aim of providing com-prehensive and timely management.

Experiencia de downstaging versus criterios de Milán para trasplante hepático por carcinoma hepatocelular en una cohorte prospectiva / Experience with downstaging versus Milan criteria for liver transplantation in patients with hepatocellular carcinoma in a prospective cohort

Introducción. El acceso al trasplante hepático (TH) en pacientes con carcinoma hepatocelular (CHC) se basa en la aplicación de criterios morfológicos rigurosos estipulados desde 1996, co-nocidos como criterios de Milán. Una de las estrategias descritas para expandir estos criterios se conoce como downstaging (reducción del estadiaje tumoral mediante terapias locorregionales). El objetivo de este estudio fue describir el comportamiento postrasplante de pacientes con CHC que ingresaron dentro de los parámetros de Milán, comparado con el de aquellos pacientes llevados a terapia de downstaging en un centro colombiano. Metodología. Se incluyeron pacientes adultos con cirrosis hepática (CH) y CHC que fueron llevados a TH en el Hospital Pablo Tobón Uribe, entre julio de 2012 a septiembre de 2021. Como desenlace principal se definió recurrencia y tiempo de recurrencia de la enfermedad tumoral, muerte por todas las causas y tiempo al fallecimiento. Se evaluaron las características sociodemográficas y clínicas de cada grupo. Se incluyeron scores pronósticos de recurrencia de la enfermedad tumoral. Resultados. Se trasplantaron 68 pacientes con CH y CHC, 50 (73,5 %) eran hombres y la edad promedio fue 59 años; 51 pacientes (75 %) cumplían con los criterios de Milán y 17 (25 %) fueron llevados a terapia de downstaging previo al TH. No hubo diferencias significativas en la supervivencia global y supervivencia libre de trasplante entre los dos grupos evaluados, p=0,479 y p=0,385, respectivamente. Tampoco hubo diferencia significativa en la recurrencia de la enfermedad tumoral entre ambos grupos (p=0,81). En total hubo 7 casos de recurrencia tumoral (10,2 %) y 11 casos de muerte (16,2 %). Conclusiones. No se encontraron diferencias significativas en recurrencia y mortalidad entre los pacientes que cumplían los criterios de Milán y los trasplantados luego de la terapia de downstaging, en un tiempo de se-guimiento de 53 meses hasta el último control posterior al trasplante hepático. Esta sería la primera evaluación prospectiva de un protocolo de downstaging para CHC en Colombia.

Introduction. Access to liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) is based on the application of rigorous morphological criteria stipulated since 1996, known as the Milan criteria. One of the strategies described to expand these criteria is known as downstaging (tu-mor staging reduction through locoregional therapies). The objective of this study was to describe the post-transplant performance of patients with HCC who were admitted within the Milan parameters, compared with those of patients taken to downstaging therapy, in a Colombian center. Methodolo-gy. Adult patients with cirrhosis and HCC that received LT between July 2012 and September 2021 at the Pablo Tobón Uribe Hospital were included. The main outcome was defined as recurrence and time to recurrence of the tumor disease, death from all causes, and time to death. The socio-demographic and clinical characteristics of each group were evaluated. Tumor disease recurrence prognostic scores were included. Results. Sixty-eight patients with cirrhosis and HCC received LT in the time frame, 50 (73.5%) were men and the mean age was 59 years. Fifty-one patients were trans-planted (75%) fulfilling Milan criteria, and 17 (25%) patients received downstaging therapies before LT. There were no significant differences in overall survival and transplant-free survival between the two groups, p=0.479 and p=0.385, respectively. There was also no significant difference in the recurrence of the tumor disease between both groups (p=0.81). In total there were 7 tumoral recurrences (10.2%) and 11 deaths (16.2%). Conclusions. There were no differences in recurrence and survival between patients transplanted fulfilling Milan criteria and those receiving downstaging therapies, following a mean time of 53 months after LT. This is the first prospective evaluation of the downstaging protocol in Colombia.

Urgent liver retransplantation due to transmission of intrahepatic cholangiocarcinoma by donor: the first report in the literature / Retransplante de fígado urgente devido à transmissão de colangiocarcinoma intra-hepático pelo doador: o primeiro relato da literatura

ABSTRACT BACKGROUND: Liver transplantation represents the best therapeutic modality in end-stage chronic liver disease, severe acute hepatitis, and selected cases of liver tumors. AIMS: To describe a double retransplant in a male patient diagnosed with Crohn's disease and complicated with primary sclerosing cholangitis, severe portal hypertension, and cholangiocarcinoma diagnosed in the transplanted liver. METHODS: A 48-year-old male patient diagnosed with Crohn's disease 25 years ago, complicated with primary sclerosing cholangitis and severe portal hypertension. He underwent a liver transplantation in 2018 due to secondary biliary cirrhosis. In 2021, a primary sclerosing cholangitis recurrence was diagnosed and a liver retransplantation was indicated. Recipient's hepatectomy was very difficult by reason of complex portal vein thrombosis requiring extensive thromboendovenectomy. Intraoperative ultrasound with liver doppler evaluation was performed. Two suspicious nodules were incidentally diagnosed in the donor's liver and immediately removed for anatomopathological evaluation. RESULTS: After pathological confirmation of carcinoma, probable cholangiocarcinoma, at frozen section, the patient was re-listed as national priority and a new liver transplantation was performed within 24 hours. The patient was discharged after 2 weeks. CONCLUSIONS: The screening for neoplasms in donated organs should be part of our strict daily diagnostic arsenal. Moreover, we argue that, for the benefit of an adequate diagnosis and the feasibility of a safer procedure, the adoption of imaging tests routine for the liver donor is essential, allowing a reduction of the costs and some potential risks of liver transplant procedure.

RESUMO RACIONAL: O transplante de fígado representa a melhor modalidade terapêutica na doença hepática crônica terminal, hepatite aguda grave e casos selecionados de tumores hepáticos. OBJETIVOS: Descrever um retransplante duplo em paciente do sexo masculino, diagnosticado com doença de Crohn e complicado com colangite esclerosante primária, hipertensão portal grave e colangiocarcinoma diagnosticado no fígado transplantado. MÉTODOS: Paciente do sexo masculino, 48 anos, diagnosticado com doença de Crohn há 25 anos e complicado com colangite esclerosante primária e hipertensão portal grave. Foi submetido a um transplante de fígado em 2018 devido a cirrose biliar secundária. Em 2021, foi diagnosticada recidiva de colangite esclerosante primária e indicado retransplante hepático. A hepatectomia do receptor foi de alta complexidade devido à trombose complexa da veia porta, exigindo extensa tromboendovenectomia. Foi realizada ultrassonografia intraoperatória com doppler hepático. Dois nódulos suspeitos foram diagnosticados incidentalmente no fígado do doador e imediatamente removidos para avaliação anatomopatológica. RESULTADOS: Após confirmação patológica de carcinoma, provável colangiocarcinoma, pela congelação, o paciente foi relistado como prioridade nacional, e novo transplante hepático foi realizado em 24 horas. O paciente teve alta após 2 semanas. CONCLUSÕES: O rastreamento de neoplasias em órgãos doados deve fazer parte de nosso estrito arsenal diagnóstico diário. Além disso, defendemos que, em benefício de um diagnóstico correto e da viabilidade de um procedimento mais seguro, a adoção de uma rotina de exames de imagem é essencial em doadores hepáticos, permitindo a redução dos custos e alguns riscos potenciais do procedimento de transplante hepático.

Diálisis de albúmina de paso único (SPAD) como soporte hepático extracorpóreo en paciente COVID-19 crítico. Caso clínico / Single-pass albumin dialysis as treatment of acute on chronic liver failure during COVID-19 pneumonia. report of one case

Liver transplantation is the only effective therapy to reduce the high mortality associated with acute liver failure and acute on chronic liver failure (ACLF). Single-pass albumin dialysis (SPAD) is an extracorporeal supportive therapy used as a bridge to liver transplantation or regeneration. We report a 44-year-old man with alcoholic cirrhosis admitted for critical COVID-19 pneumonia that evolves with ACLF. SPAD technique was performed completing six sessions, with a reduction of bilirubin and ammonia levels. He evolved with severe respiratory failure and refractory septic shock, dying. SPAD is a safe and efficient technique aimed to eliminate liver toxins, preventing multiorgan damage interrupting the process known as the "autointoxication hypothesis". It is easy to implement in any critical patient unit and has lower costs than other extracorporeal liver support therapies.

Remisión a largo plazo de la hipertensión portopulmonar mediante trasplante hepático en paciente con cirrosis asociada a hepatitis autoinmune / Long term remission of portopulmonary hypertension with liver transplantation in a patient with cirrhosis associated to autoimmune hepatitis

La hipertensión portopulmonar (HTPP) es una complicación infrecuente de la hipertensión portal, que sigue un curso progresivo con un pronóstico sombrío. Los reportes en pacientes pediátricos son escasos y con períodos de seguimiento cortos. Se describe una paciente con cirrosis descompensada que desarrolló HTPP resuelta mediante trasplante hepático, que permanece asintomática tras diez años de seguimiento.

Portopulmonary hypertension is an uncommon complication of portal hypertension, running a progressive course with a negative prognosis. Reports in pediatric patients are scarce with short follow up. We describe the case of decompensated cirrhosis who developed PoPH and resolved with liver transplantation, remaining asymptomatic after ten years of follow up.

Colangitis biliar primaria: caracterización de una cohorte retrospectiva / Primary biliary cholangitis: characterization of a retrospective cohort

Introducción. La colangitis biliar primaria (CBP) es una enfermedad hepática crónica de origen autoinmune, caracterizada por inflamación y destrucción progresiva de las células epiteliales de los conductos biliares intralobulillares, que causa de manera secundaria colestasis, fibrosis, cirrosis e insuficiencia hepática. La historia natural de la enfermedad ha cambiado en los últimos años debido a la mejoría en los métodos diagnósticos y terapéuticos. Metodología. Estudio observacional descriptivo de cohorte retrospectivo, en el cual se efectuó la revisión y análisis de las historias clínicas de los pacientes mayores de 16 años con diagnóstico de CBP, atendidos en la Unidad de Hepatología y Trasplante Hepático del Hospital Pablo Tobón Uribe, entre los años 2013 a 2021, con el fin de obtener información sobre las características de esta patología a nivel local. Resultados. Se evaluó un total de 239 pacientes, con un promedio de edad de 61,6±12,31 años, el 97,07% fue del sexo femenino, con criterios serológicos como anticuerpos antimitocondriales (AMA) positivos en un 76,89%, el 66,95% de los pacientes presentaban alguna enfermedad autoinmune concomitante y el 31,60% tuvieron sobreposición con hepatitis autoinmune. La manifestación clínica más frecuente fue el prurito en un 61,92% de los pacientes, seguido por la astenia en un 51,88%. La presencia de hipertensión portal al diagnóstico fue del 29,29%. La colangitis no supurativa y la ductopenia en la biopsia de hígado se documentó en un 43,79% de los casos. El ácido ursodesoxicólico (UDCA) fue la terapia de primera línea en el 100% de los pacientes, se identificó refractariedad del 16,36% según criterios de París II y del 31,79% con los criterios de Toronto. La no respuesta al UDCA, se asoció de manera significativa con mayor mortalidad (p=0,039) y presencia de hepatocarcinoma (p=0,042). Conclusión. Se caracterizó la CBP en nuestra población. El diagnóstico serológico por AMA fue bajo, con altos requerimientos de biopsia hepática en el contexto de síndromes de sobreposición. Los signos de hipertensión portal al momento del diagnóstico fueron prevalentes. La refractariedad bioquímica a la terapiafue descrita en relación con mayor progresión de fibrosis, aumento de mortalidad y presencia de hepatocarcinoma.

ntroduction. Primary biliary cholangitis (PBC) is a chronic liver disease of autoimmune origin, characterized by inflammation and progressive destruction of the epithelial cells of the intralobular bile ducts, causing secondary cholestasis, fibrosis, cirrhosis, and liver failure. The natural history of the disease has changed in recent years due to the improvement in diagnostic and therapeutic methods. Methodology. Cross-sectional descriptive observational study, where the medical records of patients older than 16 years with a diagnosis of PBC, treated at the Hepatology and Liver Transplant Unit of the Pablo Tobón Uribe Hospital, between the years 2013 to 2021, were reviewed and analyzed in order to obtain information on the characteristics of this pathology at a local level. Results. A total of 239 patients were evaluated, with a mean age of 61.6±12.31 years, 97.07% were females, with serological criteria such as positive antimitochondrial antibodies (AMA) in 76.89%. Of all included patients, 66.95% had some concomitant autoimmune disease and 31.60% had an overlap with autoimmune hepatitis. The most frequent clinical manifestation was pruritus in 61.92% of the patients, followed by asthenia in 51.88%. The presence of portal hypertension at diagnosis was 29.29%. Non-suppurative cholangitis and ductopenia on liver biopsy were documented in 43.79% of the cases. Ursodeoxycholic acid (UDCA) was the first line therapy in 100% of patients, 16.36% were refractory to treatment according to the Paris II criteria and 31.79% according to the Toronto criteria. Non-response to UDCA was significantly associated with higher mortality (p=0.039) and presence of hepatocarcinoma (p=0.042). Conclusion. PBC was characterized in our population. Serological diagnosis by AMA was low, with high requirements for liver biopsy in the context of overlap syndromes. Signs of portal hypertension at diagnosis were prevalent. Biochemical refractoriness to therapy was described in relation to greater progression of fibrosis, increased mortality, and the presence of hepatocarcinoma.

Fatores de risco para a mortalidade em candidatos ao transplante de fígado em lista de espera: estudo de coorte retrospectivo / Risk factors for mortality in liver transplant candidates in waiting list: a retrospective cohort study

O transplante de fígado é procedimento cirúrgico complexo que possibilita o tratamento de pessoas com doenças hepáticas progressivas, terminais e irreversíveis, promovendo a melhoria da qualidade de vida. Porém, a mortalidade em candidatos ao transplante de fígado é preocupação constante, tanto para os pacientes quanto para os profissionais da saúde. O objetivo geral do estudo foi estimar a taxa de incidência de mortalidade em candidatos ao transplante de fígado em lista de espera. Trata-se de estudo de coorte retrospectivo. A população foi composta por pacientes com idade ≥ 18 anos, de ambos os sexos e inscritos em lista de espera para o transplante de fígado, no período de 1 de janeiro de 2015 até 31 de julho de 2018. Com o auxílio de um roteiro, os dados foram transcritos de prontuários eletrônicos de hospital de nível terciário, do interior do estado de São Paulo. A coleta de dados foi realizada no período de outubro de 2020 até abril de 2021. A análise estatística foi realizada em duas etapas (descritiva e analítica). Curvas de sobrevivência bruta e estratificadas foram calculadas por meio do estimador produto de Kaplan-Meier. Para a identificação de fatores associados à mortalidade foram construídos modelos univariados, parciais e multivariados, utilizando-se os modelos de Cox Estendidos (Hazards proporcionais). Os dados foram analisados utilizando o software Stata (versão 13.1). No período delimitado do estudo, 284 inscrições foram realizadas para o transplante de fígado, sendo que a amostra da pesquisa foi composta de 177 candidatos, desses, 130 foram considerados censuras e 47 faleceram devido às complicações hepáticas. As médias de idade nas censuras e óbitos foram de 55,8 e 58,1 anos, respectivamente. A maioria dos pacientes era do sexo masculino nas censuras (74,6%) e óbitos (70,2%). O diagnóstico principal para indicação do transplante de fígado com frequência maior foi a cirrose alcoólica, tanto nas censuras (37,7%) quanto nos óbitos (34,0%). Na entrada da lista de espera, as médias do Model for End-stage Liver Disease (MELD) nas censuras e óbitos foram de 15,2 e 19,0 pontos, respectivamente. As médias do tempo de permanência na lista de espera, nas censuras e óbitos foram de 209,1 e 227,9 dias, respectivamente. A taxa geral de incidência de mortalidade foi de 0,18%. No modelo final 1, os fatores de risco independentes associados com a mortalidade foram a idade (Razão de hazards ajustada (aHR)=1,05; IC 95%:1,01-1,11), MELD na entrada da lista de espera (aHR=1,10; IC 95%:1,01-1,19), ascite (aHR=1,01; IC 95%: 1,01-1,02) e infecção (aHR= 1,02; IC95%; 1,01-1,03). No modelo final 2, os fatores de risco independentes foram a idade (aHR=1,06; IC 95%; 1,01-1,12), peritonite bacteriana espontânea (aHR=1,02; IC 95%: 1,00-1,03) e internação (aHR= 1,01; IC95%: 1,01-1,02). Os resultados do presente estudo produziram conhecimento sobre o perfil epidemiológico, complicações decorrentes da doença hepática, taxa de incidência de mortalidade e fatores de risco associados à mortalidade de candidatos ao transplante de fígado, sendo que as evidências geradas podem subsidiar a tomada de decisão do enfermeiro para o gerenciamento do cuidado de enfermagem

Liver transplantation is a complex surgical procedure that enables the treatment of people with progressive, terminal and irreversible liver diseases, improving their quality of life. However, mortality in candidates for liver transplantation is a constant concern for both patients and health professionals. The overall objective of the study was to estimate the mortality incidence rate in candidates for liver transplantation on a waiting list. This is a retrospective cohort study. The population consisted of patients aged ≥ 18 years, of both sexes and enrolled on the waiting list for liver transplantation, from January 1, 2015 to July 31, 2018. With the help of a script, the data were transcribed from electronic medical records of a tertiary-level hospital, in the interior of the state of São Paulo. Data were collected from October 2020 to April 2021. Statistical analysis was performed in two stages (descriptive and analytical). Crude and stratified survival curves were calculated using the Kaplan-Meier product estimator. Univariate, partial and multivariate models were constructed to identify factors associated with mortality, using the Extended Cox models (proportional hazards). Data were analyzed using the software Stata (version 13.1). A total of 284 applications were made for liver transplantation in the study period, and the research sample was composed of 177 candidates, of which 130 were censored and 47 died due to liver complications. The mean age at censoring and death was 55.8 and 58.1 years, respectively. Most patients were male at censoring (74.6%) and death (70.2%). The main diagnosis for indication of liver transplantation was alcoholic cirrhosis, both at censoring (37.7%) and at death (34.0%). At the entrance to the waiting list, the averages of the Model for End-stage Liver Disease (MELD) in censoring and death were 15.2 and 19.0 points, respectively. The average length of stay on the waiting list, in censoring and death were 209.1 and 227.9 days, respectively. The overall mortality rate was 0.18%. In the final model 1, the independent risk factors associated with mortality were age (adjusted hazards ratio (aHR)=1.05; 95% CI:1.01-1.11), MELD at the entrance of the waiting list (aHR=1.10; 95% CI:1.01-1.19), ascites (aHR=1.01; 95% CI: 1.01-1.02) and infection (aHR= 1.02; 95% IC; 1.01-1.03). In the final model 2, the independent risk factors were age (aHR=1.06; 95% CI; 1.01-1.12), spontaneous bacterial peritonitis (aHR=1.02; 95% CI: 1.00-1.03) and hospitalization (aHR= 1.01; 95% IC: 1.01-1.02). The results of the present study contributed to the assessment of the epidemiological profile, complications resulting from liver disease, mortality incidence rate and risk factors associated with mortality of candidates for liver transplantation, and the evidence generated can support the nurse's decision-making for the management of nursing care

Desenvolvimento neuropsicomotor em crianças e adolescentes com doenças hepáticas: revisão sistemática com meta-análise / Neuropsychomotor development in children and adolescents with liver diseases: systematic review with meta-analysis

ABSTRACT BACKGROUND: The nature of liver disease, the evolutionary course and duration of liver diseases, as well as the degree of severity and disability can trigger multiple outcomes with repercussions on neuromotor acquisition and development. OBJECTIVE: To systematically review and conduct a meta-analysis to evaluate the effects of liver disease on the neuropsychomotor development of children and adolescents with their native livers and those who underwent liver transplantation. METHODS: Observational studies published since the early 1980s until June 2019 were sought in the PubMed and Scopus databases. An α value of 0.05 was considered significant. The statistical heterogeneity of the treatment effect between the studies was assessed by the Cochran's Q test and the I2 inconsistency test, in which values above 25 and 50% were considered indicative of moderate and high heterogeneity, respectively. Analyses were performed with Review Manager 5.3. RESULTS: Twenty-five studies met the eligibility criteria, including 909 children and adolescents with liver disease. Meta-analyses showed deficits in total IQ -0.41 (95%CI: -0.51 to -0.32; N: 9,973), verbal IQ -0.38 (95%CI: -0.57 to -0.18; N: 10,284) and receptive language -0.85 (95%CI: -1.16 to -0.53; N: 921) in liver transplantation, and those with native livers who had symptoms early had total and verbal IQ scores (85±8.8; 86.3±10.6 respectively) lower than the scores of those with late manifestations (99.5±13.8; 96.2±9.2). Gross motor skill was reduced -46.29 (95%CI: -81.55 to -11.03; N: 3,746). CONCLUSION: Acute or chronic liver disease can cause declines in cognitive, motor and language functions. Although the scores improve after liver transplantation, children remain below average when compared to healthy children.

RESUMO CONTEXTO: A natureza da doença hepática, curso evolutivo e duração das hepatopatias, bem como grau de severidade e incapacidade podem desencadear desfechos múltiplos e com repercussões na aquisição e desenvolvimento neuromotores. OBJETIVO: Revisar sistematicamente e avaliar por meta-análise os efeitos da doença hepática sobre o desenvolvimento neuropsicomotor de crianças e adolescentes com seus fígados nativos e aquelas que realizaram transplante hepático. MÉTODOS: As buscas foram realizadas nas bases de dados PubMed e periódicos Scopus desde as primeiras publicações na década de 1980 até junho de 2019, de estudos observacionais. Um valor de 0,05 foi considerado significativo. A heterogeneidade estatística do efeito do tratamento entre os estudos foi avaliada pelo teste Q de Cochran e o teste de inconsistência I2, no qual valores acima de 25 e 50% foram considerados indicativos de heterogeneidade moderada e alta, respectivamente. As análises foram realizadas com o Review Manager 5.3. RESULTADOS Vinte e cinco estudos preencheram os critérios de elegibilidade, incluindo 909 crianças e adolescentes com doenças hepáticas. As meta-análises mostraram déficits QI total -0,41 (IC 95%: -0,51 até -0,32; N: 9.973), QI verbal -0,38 (IC 95%; -0,57 até -0,18; N: 10.284) e linguagem receptiva -0,85 IC 95%: -1,16 até -0,53; N: 921) nos transplantes hepáticos e as com fígados nativos que apresentaram sintomas precocemente tinham escores de QI total e verbal (85±8,8; 86,3±10,6 respectivamente) menores do que aquelas com manifestações tardias (99,5±13,8; 96,2±9,2). Habilidade motora grossa apresentou-se reduzida -46,29 (IC 95%: -81,55 até -11,03; N: 3.746). CONCLUSÃO: A doença hepática aguda ou crônica pode determinar declínios nas funções cognitivas, motoras e de linguagem. Muito embora, os escores melhorem após transplante hepático, as crianças continuam abaixo da média quando comparadas às crianças sadias.

Dental Findings of Kidney and Liver Transplantation Patients from a Brazilian Oral Health Care Service

ABSTRACT Objective: To describe dental findings of kidney and liver, pre and post-transplant patients of an oral health care service from a Brazilian Southeast state. Material and Methods: A descriptive cross-sectional study was developed with a sample of patients attending the oral health care program for transplantation of Universidade Federal de Minas Gerais. Participants were divided into two groups according to the kind of transplantation-kidney or liver. Characteristics of the sample, sex (male/female), age (18-44; 45-54; 55-80), living region (Belo Horizonte, or outside), phase of transplantation (pre-Tx or post-Tx), and self-report of diabetes mellitus and hypertension were presented by frequencies. Dental caries experienced was measured by Decayed, Missing and Filled-Teeth (DMF-T) index. Results: 185 patients, kidney (46; 24.9%), and liver (139; 75.1%) were included. Mean DMFT was 18.3 (20.0). DMFT scores of males (18.7; 20.0), females (17.2; 18.0), pre-transplanted (18.3; 20.0), and post-transplanted (18.1; 20.0) were similar. The liver transplantation group (19.3; 20.0) showed higher caries experience comparing to kidney´s (15.2; 17.0). Conclusion: Dental caries experience was high in kidney and liver patients under transplantation therapy. This highlights the demand for treatment need in this population.

Short-term effect of whey protein supplementation on the quality of life of patients waiting for liver transplantation: a double blinded randomized clinical trial / Efeito a curto prazo da suplementação com proteína do soro do leite sobre a qualidade de vida de pacientes em fila de espera para o transplante hepático: ensaio clínico randomizado

ABSTRACT Background: Chronic liver disease is associated with malnutrition that negatively impacts a patient's health-related quality of life (HRQoL). Aim: To evaluate the short-term effect of whey protein supplementation on the HRQoL and nutritional and functional status of patients waiting for liver transplantation. Methods: This was a double-blind randomized clinical trial with patients waiting for liver transplantation who were randomized into two groups: WP (whey protein supplementation) and the control (casein supplementation). Both groups received 40 g (20 g in the morning and 20 g in the evening) for 15 days. Nutritional and functional status were evaluated. Energy balance was calculated as the difference between energy intake (24-hour recall) and total energy expenditure (assessed by indirect calorimetry). The chronic liver disease questionnaire was used to assess HRQoL. All measurements were performed before and after the intervention. Results: Fifty-six patients were evaluated. Malnutrition was present in 56.9%, and it was directly associated with a poor HRQoL (p<0.05). No improvement on the nutritional and functional status was observed, in either group after protein supplementation. HRQoL improved after WP and casein supplementation, with no differences between groups (p>0.05). Patients who met protein requirements and had a positive energy balance demonstrated a higher HRQoL score (4.9, p<0.05), without between-group differences. Conclusion: Malnutrition substantially reduces HRQoL. Short-term WP or casein supplementation improved similarly the HRQoL.

RESUMO Racional: A doença hepática crônica está associada à desnutrição que afeta negativamente a qualidade de vida relacionada à saúde (QVRS). Objetivo: Avaliar o efeito da suplementação aguda de proteína do soro de leite na QVRS e no estado nutricional e funcional dos pacientes em lista de espera para o transplante hepático. Métodos: Ensaio clínico randomizado com pacientes à espera do transplante hepático que foram randomizados em dois grupos: PS (suplementação com proteína do soro de leite) e Controle (suplementação com caseína). Ambos os grupos receberam 40 g das proteínas (20 g pela manhã e 20 g à noite) por 15 dias. O estado nutricional e funcional foi avaliado. O balanço energético foi calculado como a diferença entre a ingestão energética (recordatório de 24 horas) e o gasto energético total (avaliado por calorimetria indireta). O questionário de doença hepática crônica (CDLQ) foi utilizado para avaliar a QVRS. Todas as medidas foram realizadas antes e após a intervenção. Resultados: Cinquenta e seis pacientes foram avaliados. A desnutrição esteve presente em 56,9% e, diretamente associada à baixa QVRS (p<0,05). A suplementação, com ambas as proteínas, não alterou o estado nutricional e funcional dos pacientes (p>0,05). Entretanto, a QVRS melhorou após a suplementação com PS e caseína, sem diferenças entre os grupos (p>0,05). Pacientes que alcançaram as necessidades proteicas e com balanço energético positivo tiveram maior escore de QVRS (4,9; p<0,05), sem diferenças entre os grupos (p>0,05). Conclusão: A desnutrição reduz substancialmente a QVRS. A suplementação aguda com PS ou caseína melhorou de forma similar a QVRS.

Aplicación de la escala de MELD en los pacientes del Programa de Trasplante Hepático / Application of the MELD scale in patients of the Liver Transplant Program

INTRODUCCIÓN. La escala Model for End-Stage Liver Desease se utiliza para conocer el estadio de la enfermedad hepática y para la asignación de órganos en los pacientes candidatos a trasplante. OBJETIVO. Validar la utilidad de la escala en pacientes adultos del Programa de Trasplante Hepático y su aplicación en la priorización de injertos para pacientes en lista de espera. MATERIALES Y MÉTODOS. Estudio observacional, descriptivo. De una población de 103 Historias Clínicas, se tomó una muestra de 95 registros del Programa de Trasplante Hepático del Hospital de Especialidades Carlos Andrade Marín en el período mayo 2016 a marzo 2020. Criterios de inclusión: datos de pacientes con diagnóstico de enfermedad hepática terminal, de ambos sexos, con edades comprendidas entre 14 y 65 años. La información se tomó del sistema AS400 y se analizaron en el programa estadístico International Business Machines Statistical Package for the Social Sciences, versión 23.0 y el estimador Kaplan-Meier. RESULTADOS. La sobrevida en lista de espera fue del 86,3% (82; 95) y en el post trasplante del 72,5% (44; 62) a los 12 meses y 68,9% (42; 62) a los 46 meses de seguimiento. DISCUSIÓN. Esta escala se consideró para los pacientes graves, asignándoles un puntaje que les permitió tener la opción de recibir un trasplante en relación a otros pacientes. CONCLUSIÓN. Se validó la utilidad de la escala, no se encontró diferencia significativa, pero mantuvo el principio de prioridad para los pacientes con mayor severidad.

INTRODUCTION. The Model for End-Stage Liver Desease scale is used to determine the stage of liver disease and for organ allocation in transplant candidates. OBJECTIVE. To validate the usefulness of the scale in adult patients of the Liver Transplantation Program and its application in the prioritization of grafts for patients on the waiting list. MATERIALS AND METHODS. Observational, descriptive study. From a population of 103 Medical Records, a sample of 95 records was taken from the Liver Transplantation Program of the Carlos Andrade Marín Specialty Hospital in the period may 2016 to march 2020. Inclusion criteria: data from patients with a diagnosis of terminal liver disease, of both sexes, aged between 14 and 65 years. The information was taken from the AS400 system and analyzed using the International Business Machines Statistical Package for the Social Sciences, version 23.0 and the Kaplan-Meier estimator. RESULTS. Survival on the waiting list was 86,3% (82; 95) and post-transplant survival was 72,5% (44; 62) at 12 months and 68,9% (42; 62) at 46 months of follow up. DISCUSSION. This scale was considered for seriously ill patients, assigning them a score that allowed them to have the option of receiving a transplant in relation to other patients. CONCLUSIONS. The utility of the scale was validated, no significant difference was found, but it maintained the principle of priority for patients with greater severity.

Trasplante Hepático: Supervivencia global del receptor en el Hospital de Especialidades Carlos Andrade Marín / Liver Transplantation: Overall survival at the Carlos Andrade Marín Specialty Hospital

INTRODUCCIÓN. El primer trasplante hepático en el mundo se realizó en Estados Unidos en 1963 por Thomas Starzl, hasta la década de los 90 la supervivencia al año fue de 73% y a los 5 años de 64%, según diferentes series que abarcaron más de 1 000 trasplantes realizados hasta 1989. El Ecuador requiere de estas estadísticas. El Hospital de Especialidades Carlos Andrade Marín inició la actividad del programa en mayo del 2016. OBJETIVO. Conocer la supervivencia global de los pacientes sometidos a trasplante hepático. MATERIALES Y MÉTODOS. Estudio observacional, descriptivo, con una población igual a la muestra de 62 datos de Historias Clínicas del Programa de Trasplante Hepático en la Unidad Técnica de Trasplante del Hospital de Especialidades Carlos Andrade Marín en el período mayo 2016 a diciembre 2019. Criterios de inclusión: pacientes so-metidos a trasplante hepático, con seguimiento durante 43 meses. La información se obtuvo de la base de datos del sistema AS400; se analizaron en el programa estadístico International Business Machines Statistical Package for the Social Sciences, versión 23.0. RESULTADOS. La supervi-vencia global a los 12 meses fue 72% (17; 62) y a los 43 meses fue 69% (19; 62). DISCUSIÓN. Se evidenció similares resultados descritos de supervivencia en centros con actividad en periodos cortos, menor a 5 años. CONCLUSIÓN. Se pudo conocer la supervivencia global de los pacientes trasplantados del hospital, cuya expectativa motiva a potenciar el programa para mejorar la calidad de vida de los pacientes candidatos a trasplante.

INTRODUCTION. The first liver transplant in the world was performed in the United States in 1963 by Thomas Starzl, until the 90s the survival at one year was 73% and at 5 years it was 64%, accor-ding to different series that included more than 1 000 transplants carried out until 1989. Ecuador re-quires these statistics. The Carlos Andrade Marín Specialty Hospital began program activity in May 2016. OBJECTIVE. To know the overall survival of patients undergoing liver transplantation. MATE-RIALS AND METHODS. Observational, descriptive study, with a population equal to the sample of 62 data from the Medical Records of the Liver Transplant Program in the Technical Transplant Unit of the Carlos Andrade Marín Specialty Hospital in the period May 2016 to December 2019. Inclusion criteria: patients submitted to liver transplantation, with follow-up for 43 months. The information was obtained from the AS400 system database; were analyzed in the statistical program Internatio-nal Business Machines Statistical Package for the Social Sciences, version 23.0. RESULTS. Ove-rall survival at 12 months was 72% (17; 62) and at 43 months it was 69% (19; 62). DISCUSSION. Similar survival results described were evidenced in centers with activity in short periods, less than 5 years. CONCLUSION. It was possible to know the overall survival of the transplanted patients at the hospital, whose expectation motivates us to promote the program to improve the quality of life of the transplant candidates.

Recomendaciones para manejo de pacientes con enfermedad hepática crónica y trasplantados hepáticos durante pandemia por COVID-19 / Recommendations for the management of patients with chronic liver disease and liver transplanted recipients during the COVID-19 pandemic

The SARS-CoV-2 virus and the associated disease COVID-19 has quickly become a pandemic. People with underlying chronic diseases or in an immunosupressed state are at risk of having a worse outcome. Cirrhotic patients and liver transplant recipients are considered to be in this higher risk group due to their immunosuppressed state. The aim of this article is to present recommendations based on expert opinion regarding the management of patients with compensated and decompensated liver pathologies who take medication for their immunosuppressed state in medical check-ups and basic treatment management both of patients with and without the COVID-19 disease.

El virus SARS-CoV-2 asociado a la enfermedad COVID-19, se han instalado a nivel de pandemia mundial. Las personas portadoras de enfermedades crónicas o estados de inmunosupresión se encuentran en riesgo de desarrollar un curso más grave. Se considera que los pacientes con cirrosis hepática, patología autoinmune o trasplante hepático se encontrarían dentro de este grupo de mayor riesgo por su estado de inmunosupresión. Presentamos recomendaciones de manejo basadas en opinión de experto, en pacientes con patología hepática compensada y descompensada e inmunosuprimidos farmacológicos, en relación a controles médicos y manejo de terapia de base tanto en pacientes sin COVID-19 como en pacientes infectados.

Síndrome da doença hepática crônica agudizada - resultados clínicos de uma unidade de terapia intensiva em centro de transplante hepático / Acute-on-chronic liver failure syndrome - clinical results from an intensive care unit in a liver transplant center

RESUMO Objetivo: Caracterizar uma coorte de pacientes com insuficiência hepática crônica agudizada em unidade de terapia intensiva e analisar os fatores de risco da mortalidade global aos 28 dias presentes no dia da admissão e no dia 3. Métodos: Estudo de coorte retrospectiva de pacientes consecutivamente admitidos à unidade de terapia intensiva entre março de 2013 e dezembro de 2016. Resultados: Incluímos 71 pacientes com idade mediana de 59 (51 - 64) anos, sendo 81,7% do sexo masculino. Consumo de álcool isoladamente (53,5%) foi a etiologia mais frequente de cirrose, e infecção (53,5%) foi o evento que mais frequentemente precipitou a agudização da insuficiência hepática crônica. No momento da admissão à unidade de terapia intensiva, os escores de severidade foram: APACHE II 21 (16 - 23), CLIF-SOFA 13 (11 - 15), Child-Pugh 12 (10 - 13) e MELD 27 (20 - 32). Dentre os indivíduos, 14,1% tiveram escore 1 de insuficiência hepática crônica agudizada, 28,2% pontuaram 2, 64,5% pontuaram 3, e 11,3% se apresentaram sem insuficiência hepática crônica agudizada. Sobre o número de falências de órgãos, 4,2% tiveram um órgão; 42,3%, dois órgãos; 32,4%, três órgãos; 16,9%, quatro órgãos; e 4,2% cinco órgãos. Foi realizado transplante hepático em 15,5% dos pacientes. A taxa de mortalidade aos 28 dias foi de 56,3%, e a taxa de mortalidade na unidade de terapia intensiva foi de 49,3%. Foram fatores independentes de risco: falências do órgãos quando da admissão à unidade de terapia intensiva (p = 0,02; RC 2,1; IC95% 1,2 - 3,9), concentração de lactato em sangue arterial no dia 3 (p = 0,02; RC 6,3; IC95% 1,4 - 28,6) e RC internacional no dia 3 (p = 0,03; RC 10,2; IC95% 1,3 - 82,8). Conclusão: Pacientes com insuficiência hepática crônica agudizada apresentaram elevados níveis de severidade e taxa de mortalidade. O número de falências de órgãos no momento da admissão à unidade de terapia intensiva e o nível de lactato, assim como a razão normalizada internacional no dia 3 de permanência na unidade foram fatores independentes de risco para a mortalidade ao 28º dia. Consideramos que a terapia intensiva é essencial para pacientes com insuficiência hepática crônica agudizada, e a realização de um transplante hepático em tempo adequado foi vital para os pacientes selecionados.

ABSTRACT Objective: To characterize a cohort of acute-on-chronic liver failure patients in Intensive Care and to analyze the all-cause 28-day mortality risk factors assessed at ICU admission and day 3. Methods: This was a retrospective cohort study of consecutive patients admitted to the intensive care unit between March 2013 and December 2016. Results: Seventy-one patients were included. The median age was 59 (51 - 64) years, and 81.7% of patients were male. Alcohol consumption alone (53.5%) was the most frequent etiology of cirrhosis and infection (53.5%) was the most common acute-on-chronic liver failure precipitating event. At intensive care unit admission, the clinical severity scores were APACHE II 21 (16 - 23), CLIF-SOFA 13 (11 - 15), Child-Pugh 12 (10 - 13) and MELD 27 (20 - 32). The acute-on-chronic liver failure scores were no-acute-on-chronic liver failure: 11.3%; one: 14.1%; two: 28.2% and three: 46.5%; and the number of organ failures was one: 4.2%; two: 42.3%; three: 32.4%; four: 16.9%; and five: 4.2%. Liver transplantation was performed in 15.5% of patients. The twenty-eight-day mortality rate was 56.3%, and the in-ICU mortality rate was 49.3%. Organ failure at intensive care unit admission (p = 0.02; OR 2.1; 95%CI 1.2 - 3.9), lactate concentration on day 3 (p = 0.02; OR 6.3; 95%CI 1.4 - 28.6) and the international normalized ratio on day 3 (p = 0.03; OR 10.2; 95%CI 1.3 - 82.8) were independent risk factors. Conclusion: Acute-on-chronic liver failure patients presented with high clinical severity and mortality rates. The number of organ failures at intensive care unit admission and the lactate and international normalized ratio on day 3 were independent risk factors for 28-day mortality. We consider intensive care essential for acute-on-chronic liver failure patients and timely liver transplant was vital for selected patients.

Pacientes com carcinoma hepatocelular são favorecidos no atual sistema brasileiro de alocação de fígados para transplante. Análise de riscos competitivos / Hepatocellular carcinoma patients are advantaged in the current brazilian liver transplant allocation system. a competing risk analysis

ABSTRACT BACKGROUND: In Brazil, the Model for End-Stage Liver Disease (MELD) score is used to prioritize patients for deceased donor liver transplantation (DDLT). Patients with hepatocellular carcinoma (HCC) receive standardized MELD exception points to account for their cancer risk of mortality, which is not reflected by their MELD score. OBJECTIVE: To compare DDLT rates between patients with and without HCC in Rio Grande do Sul, the Southernmost state of Brazil. METHODS - We retrospectively studied 825 patients on the liver-transplant waiting list from January 1, 2007, to December 31, 2016, in a transplant center located in Porto Alegre, the capital of Rio Grande do Sul, to compare DDLT rates between those with and without HCC. The time-varying hazard of waiting list/DDLT was estimated, reporting the subhazard ratio (SHR) of waiting list/DDLT/dropout with 95% confidence intervals (CI). The final competing risk model was adjusted for age, MELD score, exception points, and ABO group. RESULTS: Patients with HCC underwent a transplant almost three times faster than patients with a calculated MELD score (SHR 2.64; 95% CI 2.10-3.31; P<0.001). The DDLT rate per 100 person-months was 11.86 for HCC patients vs 3.38 for non-HCC patients. The median time on the waiting list was 5.6 months for patients with HCC and 25 months for patients without HCC. CONCLUSION: Our results demonstrated that, in our center, patients on the waiting list with HCC have a clear advantage over candidates listed with a calculated MELD score.

RESUMO CONTEXTO: No Brasil, o escore MELD (Model for End-Stage Liver Disease) é utilizado para priorizar os pacientes para transplante hepático de doador falecido (THDF). Pacientes com carcinoma hepatocelular (CHC) recebem pontos de exceção padronizados pelo MELD para contrapesar o risco de mortalidade do seu câncer, que não é refletido pelo seu escore MELD. OBJETIVO: Comparar as taxas de THDF entre pacientes com e sem CHC no Rio Grande do Sul, o Estado mais ao sul do Brasil. MÉTODOS: Foram estudados retrospectivamente 825 pacientes em lista de espera de transplante de fígado entre 1 de janeiro de 2007 e 31 de dezembro de 2016 em um centro de transplantes localizado em Porto Alegre, capital do Rio Grande do Sul, para comparação das taxas de THDF entre aqueles com e sem CHC. Foi estimado o risco variável no tempo de lista de espera/THDF, com relato da taxa de sub-risco (SHR) de lista de espera/THDF/desistência com intervalos de confiança (IC) de 95%. O modelo final de risco competitivo foi ajustado para idade, escore MELD, pontos de exceção e grupo ABO. RESULTADOS: Os candidatos com CHC foram submetidos a um transplante quase três vezes mais rápido do que os pacientes com um escore MELD calculado (SHR 2,64; IC 95% 2,10-3,31; P<0,001). A taxa de THDF por 100 pessoas-mês foi de 11,86 para os pacientes com CHC vs 3,38 para os pacientes sem CHC. O tempo mediano de permanência em lista de espera foi de 5,6 meses para os pacientes com CHC e 25 meses para os pacientes sem CHC. CONCLUSÃO: Nossos resultados demonstraram que, em nosso centro, pacientes em lista de espera com CHC têm evidente vantagem sobre candidatos listados com um escore MELD calculado.

Implicaciones hepáticas en la pandemia por COVID-19 / Liver implications during the COVID-19 Pandemic

La infección generada por el coronavirus, denominado SARS-CoV-2, llamada coronavirus disease 2019(COVID-19), surgió en China a finales de diciembre de 2019. Actualmente ha sido categorizada como una pandemia por la Organización Mundial de la Salud (OMS). Se han documentado alteraciones de pruebas hepáticas, sin embargo, los estudios se han enfocado en los efectos cardíacos, pulmonares y renales de esta infección. La alteración de pruebas hepáticas en el contexto de COVID-19 puede ser consecuencia de hepatitis viral, toxicidad farmacológica, inflamación o choque. También se considera como un marcador de pronóstico y gravedad de la enfermedad. El impacto de la infección por SARS-CoV-2 en pacientes con enfer-medad hepática preexistente o receptores de trasplante hepático no es claro, y se plantean distintas hipótesis sobre mayor o menor riesgo de enfermedad grave y de descompensación de la enfermedad de base.(AU)

The infection generated by the novel coronavirus SARS-CoV-2, named Coronavirus Disease 2019 (COVID-19) emerged late December of 2019 in China. It is currently categorized as a pandemic by the World Health Organization. Studies have focused on cardiac, pulmonary, and renal effects of this infection, but liver test abnormalities have also been documented. This alteration may be a consequence of viral hepatitis, phar-macological toxicity, inflammation, or shock. It is also considered a marker of prognosis and severity of the disease. The impact of SARS-CoV-2 infection in patients with pre-existing liver disease or liver transplant recipients is unclear, and different hypotheses exist regarding the higher or lower risk of severe disease and decompensation of the underlying disease.

Transplantes de órgãos sólidos no Brasil: estudo descritivo sobre desigualdades na distribuição e acesso no território brasileiro, 2001-2017 / Trasplantes de órganos sólidos en Brasil: estudio descriptivo sobre desigualdades en la distribución y acceso en el territorio brasileño, 2001-2017 / Solid organ transplantation in Brazil: a descriptive study of distribution and access inequalities across the Brazilian territory, 2001-2017

Objetivo: descrever a distribuição dos transplantes de órgãos sólidos no Brasil, bem como informações da lista de espera (demanda) e origem dos pacientes transplantados, por tipo de órgão e Unidade da Federação, de 2001 a 2017. Métodos: estudo descritivo, com dados das Centrais Estaduais de Transplantes, da Associação Brasileira de Transplantes de Órgãos e do Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH/SUS). Resultados: 153 centros de transplante foram identificados em 2017, apenas 11,8% deles localizados nas regiões Norte e Centro-Oeste; no período em estudo, foram realizados 99.805 transplantes, variando de 3.520 (2001) a 8.669 (2017); as regiões Sul e Sudeste concentraram o maior número de transplantes. Conclusão: existem desigualdades regionais na realização dos transplantes, possivelmente por não haver uniformidade na distribuição dos serviços.

Objetivo: describir la distribución de los trasplantes de órganos sólidos en Brasil, así como informaciones de la lista de espera (demanda) y origen de los pacientes trasplantados por tipo de órgano y unidad federativa, entre 2001 y 2017. Métodos: estudio descriptivo usando datos extraídos de Centrales Estatales de Trasplantes, Asociación Brasileña de Trasplantes de Órganos y Sistema de Informaciones Hospitalarias del Sistema Único Nacional de Salud (SIH/SUS). Resultados: 153 centros de trasplante identificados en 2017, solamente 11,8% están ubicados en las regiones Norte y Centro-Oeste; se realizaron 99.805 trasplantes, desde 3.520 (2001) hasta 8.669 (2017); Sur y Sudeste concentran el mayor número de trasplantes. Conclusión: hay desigualdad en el acceso a los trasplantes, posiblemente debido a la falta de uniformidad en la distribución de los servicios.

Objective: to describe the distribution of solid organ transplants in Brazil, as well as information about the waiting list (demand) and origin of transplant patients by organ type and Federative Unit, from 2001 to 2017. Methods: this was a descriptive study using data from State Transplantation Centers, the Brazilian Organ Transplant Association, and the Brazilian National Health System Hospital Information System (SIH/SUS). Results: 153 transplant units were identified in 2017, with only 11.8% located in the Northern and Midwest regions; within the study period, 99,805 transplants were performed, ranging from 3,520 (2001) to 8,669 (2017); the highest number of transplants was concentrated in the Southern and Southeastern regions. Conclusion: there are inequalities in transplantation access, possibly due to lack of uniformity in service distribution.

Desordens mentais e qualidade de vida em pacientes em lista de espera para realização de transplante de fígado / Mental disorders and quality of life in patients awaiting liver transplantation

ABSTRACT BACKGROUND: Liver transplantation is the main therapeutic alternative for patients with advanced liver disease. These patients have high prevalence of psychiatric comorbidities that may negatively interfere in clinical outcomes and quality of life. It is not clear in the literature whether the different etiologies of hepatic disease have the same prevalence of psychiatric disorders. OBJECTIVE: The aim of this study was to investigate whether patients in the liver transplant list showed differences in psychiatric characteristics, medical variables and quality of life among different etiological groups. METHODS: This is a cross-sectional study that evaluates quality of life, psychiatric and clinical comorbidities through the application of validated questionnaires and instruments in 248 patients who were on transplant waiting list from 2010 to 2014, assisted in a University Hospital and in a Private Hospital in Salvador/Bahia, Brazil. The patients were evaluated through the Mini International Neuropsychiatric Interview (M.I.N.I. PLUS 5.0) and Medical Outcomes Short-Form Health Survey (SF-36). RESULTS: The etiology of the most prevalent liver disease was hepatitis C virus. A prevalence of 50.8% of at least one mental disorder was identified. When alcohol abuse/dependence was excluded, the prevalence was 25.8%. Mental health did not show a statistically significant difference in the diverse etiological groups, but a higher prevalence of psychiatric comorbidities was detected among women and younger than 40 years. No cases of psychotic disorders were detected, possibly by exclusion prior to listing. There was no difference in the quality of life domains in the different liver etiological groups. CONCLUSION: A high-prevalence of psychiatric disorders was found among all clinical conditions most associated with indication for liver transplantation. Attention is drawn to the absence of patients with psychotic disorders, which suggests that transplantation may not have been indicated for this group of patients. For these reasons, professionals caring for liver transplant candidates should be highly vigilant for the presence of mental disorders, regardless of the etiology of liver disease. Specialized care is recommended to minimize the early exclusion of patients with no other therapeutic possibilities, as well as care of all people with mental disorders.

RESUMO CONTEXTO: O transplante hepático é a principal alternativa terapêutica para pacientes com doença hepática avançada. Esses pacientes apresentam alta prevalência de comorbidades psiquiátricas que podem interferir negativamente nos desfechos clínicos e qualidade de vida. Não está claro na literatura se as diferentes etiologias de doença hepática têm a mesma prevalência de transtornos psiquiátricos. OBJETIVO: O objetivo deste estudo foi investigar se os pacientes na lista de transplante hepático apresentavam diferenças nas variáveis psiquiátricas, variáveis clínicas e qualidade de vida em diferentes grupos etiológicos. MÉTODOS: Estudo transversal que avalia as comorbidades psiquiátricas e clínicas e as variáveis de qualidade de vida por meio da aplicação de questionários e instrumentos validados em 248 pacientes inseridos em lista de espera para transplante hepático no período de 2010 a 2014, acompanhados no Hospital Universitário Professor Edgard Santos e Hospital Português (Salvador, BA). Os pacientes foram avaliados através da aplicação do Mini International Neuropsychiatric Interview (M.I.N.I. PLUS 5.0) e Medical Outcomes Short-Form Health Survey (SF-36). RESULTADOS: A etiologia da doença hepática mais prevalente foi o vírus da hepatite C. Prevalência de 50,8% de pelo menos um transtorno mental foi identificada. Quando o abuso/dependência de álcool foi excluído, a prevalência foi de 25,8%. A saúde mental não apresentou diferença estatisticamente significante nos diversos grupos etiológicos. Maior prevalência de comorbidades psiquiátricas foi detectada entre mulheres e menores de 40 anos. Não foram detectados casos de transtornos psicóticos, possivelmente pela não inclusão destes pacientes na lista. Não houve diferença nos domínios de qualidade de vida nos diferentes grupos etiológicos. CONCLUSÃO: Uma alta prevalência de transtornos psiquiátricos foi encontrada nos pacientes com todas as condições clínicas mais associadas à indicação de transplante hepático. Chama a atenção a ausência de pacientes com transtornos psicóticos, o que sugere que possivelmente o transplante não tem sido indicado para esse grupo de pacientes. Por esses motivos, os profissionais que cuidam de candidatos ao transplante de fígado devem ser altamente vigilantes para a presença de transtornos mentais, independentemente da etiologia da doença hepática. A atenção especializada é recomendada para os pacientes com transtornos mentais, com minimização de exclusão precoce da lista de pacientes sem outras possibilidades terapêuticas.