Ángel Moya-Herraiz

Indications for and Results of Liver Retransplantation

Liver retransplantation (LReTx) is the therapeutic option for the irreversible failure of a hepatic graft. Our aim was to evaluate the rate of and indications for LReTx and actuarial patient survivals. Among 1260 LTx were 79 LReTx (6.3%). During the first LTx, there were no apparent differences between patients who did or did not required LReTx. The most frequent reasons were hepatic artery thrombosis (31.6%), recurrence of the VHC cirrhosis (30.4%), and primary graft failure (21.5%). The actuarial survivals at 1 and 5 years were 83% and 69% among those without LReTx versus 71% and 61% among early LReTx, and 64% and 34% among late LReTx (P < .001). Although there exists high morbidity and mortality with LReTx, it seems that this therapeutic alternative continues to be valid for patients with early hepatic loss, but not when the graft loss was late. It becomes necessary to define the minimal acceptable results that patient can benefit from LReTx.

Indicaciones y resultados de retrasplante hepático: experiencia del hospital universitario La Fe (1.181 pacientes)

UNLABELLED Liver retransplantation (LrT) is the only therapeutic option for irreversible failure of a hepatic graft and accounts for 2.9%-24.0% of all liver transplantations (LT). It is technically difficult and has a high level of immediate morbidity and a lower survival than primary LT. Our aim was to determine the rate of LrT and its indications, morbidity, post-operative mortality and actuarial survival in the retransplanted patient. PATIENTS AND METHOD A historical cohort study of 1181 patients transplanted between 1991 and 2006. RESULTS Of the 1260 LT performed, 79 were LrT. At the time of the first LT there were no differences between those patients and those that did not require an LrT. The LrT rate was 6.3% and the most frequent causes were: hepatic artery thrombosis (31.6%), recurrence of cirrhosis due the HVC (30.4%) and primary graft (21.5%). The ischemia times, perfusion syndrome and hepatic congestion were no different between the primary LT and the LrT. On the other hand, red cell transfusions were higher in LrT (6.3+/-4.9 vs. 3.5+/-3.0 units, P<0.001). The post-operative morbidity and morbidity (up to 30 days after the LT) was higher in retransplanted patients (68.4% vs. 57.0%, P=0.04 and 25.3% vs. 10.9%, P<0.001; respectively). The actuarial survival at 1 and 5 years was 83% and 69% in those without LrT, 71% and 61% in early LrT and 64% and 34% in delayed LrT (P<0.001). CONCLUSIONS Despite the increased morbidity and mortality of LrT, it appears that this treatment alternative is still valid in those patients with an early loss of the liver graft. On the other hand, when the graft loss is delayed, it needs to be defined, what would be the minimum acceptable results to indicate LrT and which patients could benefit from this treatment.Liver retransplantation (LrT) is the only therapeutic option for irreversible failure of a hepatic graft and accounts for 2.9%–24.0% of all liver transplantations (LT). It is technically difficult and has a high level of immediate morbidity and a lower survival than primary LT. Our aim was to determine the rate of LrT and its indications, morbidity, post-operative mortality and actuarial survival in the retransplanted patient.

Indicaciones y resultados del retrasplante hepático

Resumen El retrasplante hepatico (ReTH) es la unica opcion terapeutica para el fracaso irreversible del injerto. Actualmente constituye el 2,9-24% de todos los trasplantes hepaticos. Tecnicamente es muy dificil y conlleva un elevado indice de complicaciones inmediatas; destaca que el 50% de las muertes tras este procedimiento se produce en los primeros 3 meses y, en general, los resultados del ReTH son peores que los de los TH primarios. El ReTH puede ser precoz (cuando se realiza durante los primeros 30 dias) o tardio. Las causas de ReTH precoz son: falta de funcion primaria del injerto, complicaciones por causas tecnicas, rechazo agudo resistente y problemas infecciosos de origen biliar, y las del tardio son: rechazo cronico, trombosis de arteria hepatica, complicaciones biliares y recidiva de la enfermedad primaria. En general, cuando un sujeto presenta un fallo irreversible del injerto, la indicacion de ReTH no se discute, pero hay discrepancias de si la etiologia de la enfermedad de base incidiria o no en esta. Si al momento de indicar un ReTH consideramos el sistema de puntuacion MELD, este solo nos permitiria predecir mortalidad, pero no dar prioridad en la lista de espera. El retrasplante deber ser precoz, y los pacientes deben estar en buenas condiciones fisicas, con bajas concentraciones de bilirrubina y creatinina, y los donantes deben ser jovenes. Considerando el incremento progresivo de la mortalidad en lista de espera para TH, como consecuencia directa de un desequilibrio entre el numero creciente de potenciales candidatos a trasplante y el numero de donantes, parece necesario definir cuales son los resultados minimos aceptables para indicar ReTH y llegar asi a un consenso que nos ayude a decidir que sujeto es candidato a recibirlo.

Estudio cooperativo del Grupo Español de Trasplante de Páncreas (GETP): complicaciones quirúrgicas

UNLABELLED Technical failure in pancreas transplant has been the main cause of the loss of grafts. In the last few years, the number of complications has reduced, and therefore the proportion of this problem. OBJECTIVES The Spanish Pancreas Transplant Group wanted to analyze the current situation with regard to surgical complications and their severity. MATERIAL AND METHODS A retrospective and multicenter study was performed. 10 centers participated, with a total of 410 pancreas transplant recipients between January and December 2013. RESULTS A total of 316 transplants were simultaneous with kidney, 66 after kidney, pancreas-only 10, 7 multivisceral and 11 retrasplants. Surgical complication rates were 39% (n=161). A total of 7% vascular thrombosis, 13% bleeding, 6% the graft pancreatitis, 12% surgical infections and others to a lesser extent. Relaparotomy rate was 25%. The severity of complications were of type IIIb (13%), type II (12%) and type IVa (8.5%). Graft loss was 8%. Early mortality was 0.5%. The percentage of operations for late complications was 17%. CONCLUSIONS The number of surgical complications after transplantation is not negligible, affecting one in 3 patients. They are severe in one out of 5 and, in one of every 10 patients graft loss occurs. Therefore, there is still a significant percentage of surgical complications in this type of activity, as shown in our country.

Alterations in carbohydrate metabolism in cirrhotic patients before and after liver transplant

AIM The main objective of this study is to demonstrate whether carbohydrate metabolism alterations identified in patients with advanced cirrhosis show any improvement after liver transplant. METHODS The study included 86 patients who underwent liver transplant between March 2010 and February 2011. An oral glucose tolerance test was performed before the liver transplant, and 6 and 12 months after. Beta cell function and insulin resistance were also calculated, applying formulae that use basal plasma glycaemia and insulin, and plasma glycaemia and insulin during an oral glucose tolerance test. Risk factors for pre- and post-transplant diabetes were also studied. The diagnosis of diabetes was based on an OGTT. RESULTS The proportion of patients with diabetes before transplant, and at month 6 and 12 after transplant were 70.9%, 48.8% and 39.2%, respectively. Compared to baseline, at month 6 the odds ratio of having diabetes was 0.39 (IC 95% [0.21, 0.73]) and at month 12 it was 0.26 (IC 95% [0.14, 0.50]). The composite insulin sensitivity index values at 6 and 12 months were 1.72 units higher (IC 95% [0.84, 2.58]) and 1.58 units higher (IC 95% [0.68, 2.44)] than baseline. A statistically significant association was found between high MELD values and high body mass index, and risk of pre-transplant diabetes (p=0.001 and p=0.033, respectively). Cirrhosis aetiology did not influence the risk of diabetes. CONCLUSIONS In this study, we were able to ascertain that alterations in carbohydrate metabolism typical of advanced cirrhosis improve after liver transplant. This improvement is mainly due to an improvement in insulin resistance.

Combined resistance and endurance training at a moderate‐to‐high intensity improves physical condition and quality of life in liver transplant patients

Although currently moderate and high intensity concurrent physical exercise is prescribed in populations with special needs due to its greater effect on physical condition and health‐related quality of life (HRQOL), there are no data in the liver transplantation (LT) setting. The aim of this study is to evaluate changes in maximal strength, aerobic capacity, body composition, liver function, and HRQOL in LT patients after a moderate‐to‐high intensity combined resistance‐endurance training. Six months after LT, 54 patients were randomized into 2 groups: intervention group (IG) and control group (CG). A total of 50 patients completed the study with repeat testing at 6 and 12 months after LT. The IG completed a 6‐month exercise training program, consisting of exercising 2 days for 24 weeks in the hospital facilities, whereas the CG followed usual care recommendations. Patients completed a 5‐multijoint exercise circuit with elastic bands involving the major muscle groups. The effects of the concurrent training program on maximal oxygen consumption, overall and regional maximal strength, body composition, liver function, and HRQOL were analyzed. The IG showed a significant improvement (P < 0.05) in outcome measurements compared with the CG in aerobic capacity, hip extension, elbow flexion, overall maximal strength, physical functioning, and vitality of HRQOL, whereas no changes were observed in body composition and liver function tests. In conclusion, this is the first study that combines supervised resistance and aerobic training performed at moderate‐to‐high intensity in LT recipients. It results in significant improvements in aerobic capacity, maximal strength, and HRQOL. Liver Transplantation 23 1273–1281 2017 AASLD.

OriginalIndicaciones y resultados de retrasplante hepático: experiencia del hospital universitario La Fe (1.181 pacientes)Indications and results of liver retransplantation: experience with 1181 patients in the hospital universitario La Fe

UNLABELLED Liver retransplantation (LrT) is the only therapeutic option for irreversible failure of a hepatic graft and accounts for 2.9%-24.0% of all liver transplantations (LT). It is technically difficult and has a high level of immediate morbidity and a lower survival than primary LT. Our aim was to determine the rate of LrT and its indications, morbidity, post-operative mortality and actuarial survival in the retransplanted patient. PATIENTS AND METHOD A historical cohort study of 1181 patients transplanted between 1991 and 2006. RESULTS Of the 1260 LT performed, 79 were LrT. At the time of the first LT there were no differences between those patients and those that did not require an LrT. The LrT rate was 6.3% and the most frequent causes were: hepatic artery thrombosis (31.6%), recurrence of cirrhosis due the HVC (30.4%) and primary graft (21.5%). The ischemia times, perfusion syndrome and hepatic congestion were no different between the primary LT and the LrT. On the other hand, red cell transfusions were higher in LrT (6.3+/-4.9 vs. 3.5+/-3.0 units, P<0.001). The post-operative morbidity and morbidity (up to 30 days after the LT) was higher in retransplanted patients (68.4% vs. 57.0%, P=0.04 and 25.3% vs. 10.9%, P<0.001; respectively). The actuarial survival at 1 and 5 years was 83% and 69% in those without LrT, 71% and 61% in early LrT and 64% and 34% in delayed LrT (P<0.001). CONCLUSIONS Despite the increased morbidity and mortality of LrT, it appears that this treatment alternative is still valid in those patients with an early loss of the liver graft. On the other hand, when the graft loss is delayed, it needs to be defined, what would be the minimum acceptable results to indicate LrT and which patients could benefit from this treatment.Liver retransplantation (LrT) is the only therapeutic option for irreversible failure of a hepatic graft and accounts for 2.9%–24.0% of all liver transplantations (LT). It is technically difficult and has a high level of immediate morbidity and a lower survival than primary LT. Our aim was to determine the rate of LrT and its indications, morbidity, post-operative mortality and actuarial survival in the retransplanted patient.