C. Baliellas

Análisis de 500 trasplantes hepáticos en el Hospital de Bellvitge

Fundamento Se presenta la experiencia del programa de trasplante hepatico del Hospital de Bellvitge en 500 trasplantes realizados durante 15 anos, con el objetivo de poner de manifiesto los cambios que se han producido y exponer los resultados a largo plazo de esta terapeutica. Pacientes y metodo Se consideraron y compararon 5 grupos de 100 trasplantes consecutivos (I-V). Resultados Las indicaciones mas frecuentes fueron el hepatocarcinoma (23%), la cirrosis alcoholica (22,8%) y la hepatopatia cronica por virus C (18,8%). En 59 pacientes se llevaron a cabo 65 retrasplantes (13%), cuyas indicaciones mas frecuentes fueron la trombosis arterial (13 pacientes) y el fallo primario del injerto (10 pacientes). En 19 enfermos se realizo un trasplante combinado hepatorrenal. La causa mas frecuente de muerte del donante en el grupo I fueron los traumatismos craneales (80%), mientras que en el grupo V fue la enfermedad vascular (52%). Otras diferencias significativas entre estos grupos se observan en la proporcion de pacientes en estadio 2 y 3 de la clasificacion UNOS (el 45 frente al 19%), en el consumo de hemoderivados (29,6 [26] frente a 4,6 [5,3] concentrados de hematies), en la frecuencia de reintervenciones por hemoperitoneo (el 22 frente al 5%), en la estancia en UCI (13 [13] frente a 7,4 [11] dias) y en el hospital 40 [52] frente a 23,7 [17] dias), y en la incidencia de rechazo (el 46 frente al 20%) y de fallo primario del injerto (el 9 frente al 3%). Sin embargo, la prevalencia de infeccion (el 48 frente al 54,5%) y la incidencia de complicaciones biliares (el 26 frente al 20%) no han presentado variaciones significativas. La supervivencia actuarial de los pacientes trasplantados desde 1990 es del 83 y del 70% al ano y a los 5 anos, respectivamente. Conclusiones Se observa una mejoria notable y progresiva de los resultados del trasplante hepatico. Sin embargo, los tumores de novo, la recidiva de la hepatitis por virus C y el rechazo cronico pueden limitar los resultados a largo plazo.

Postreperfusion biopsy changes predict biliary complications after liver transplantation.

PRESERVATION injury (PI) is a major contributor to primary allograft failure after liver transplantation (LT). However, few studies have analyzed the predictive value of postreperfusion liver biopsies for the development of graft dysfunction and late complications. Extended cold preservation has been associated with biliary strictures. Consequently, it has been postulated that the ischemiareperfusion injury may play a role in the pathogenesis of some biliary complications. This study was performed to assess whether the presence of histologic lesions on postreperfusion (0Post) allograft biopsy is a predictive factor of postoperative biliary complications. Other secondary objectives were to examine the possible relationship between 0Post biopsy features and donor data, and to correlate postreperfusion histologic findings with graft and patient outcome.

Resultados a largo plazo del tratamiento quirúrgico del hepatocarcinoma

Fundamento El tratamiento quirurgico del hepatocarcinoma (HCC) sigue siendo un tema controvertidopor falta de estudios prospectivos aleatorizados. Pacientes y metodo Entre enero de 1990 y diciembre de 2000 se realizaron en nuestro centro121 trasplantes hepaticos (grupo I) y 52 hepatectomias (grupo II) por HCC. La indicacion deuna u otra tecnica dependio de las caracteristicas del paciente y del tumor. Resultados Los pacientes del grupo I presentaron un estadio tumoral mas avanzado, con mayorincidencia de bilobularidad (19 frente a un 4%; p = 0,015) y un mayor numero de nodulos(1,9 DE [2] frente a 1,2 [0,6]; p = 0,001), pero el tamano tumoral medio fue inferior (3 cm[1,5] frente a 4,2 cm [3,2]; p = 0,006). La mortalidad operatoria (4 frente a un 2%; p =0,66), y la supervivencia a los 5 y 10 anos (68 y 42% frente a 63 y 45%; p = 0,23) fueron similarespara los dos grupos. Sin embargo, la incidencia de recidiva a los 5 y 10 anos (10,6 y10,6% frente a 50 y 65,5%; p Conclusiones Con una buena seleccion de los pacientes, tanto el trasplante hepatico como lahepatectomia obtienen excelentes supervivencias a largo plazo en los pacientes con HCC, aunqueel primero permite un mejor control de la enfermedad tumoral. Las causas de mortalidadson diferentes para cada uno de los tratamientos. La prolongacion del tiempo en lista de esperade trasplante que se ha producido en los ultimos anos no ha originado un empeoramiento delos resultados de supervivencia.

Interferon-Free Therapy in Elderly Patients With Advanced Liver Disease

Objectives:Interferon-free therapies have an improved safety and efficacy profile. However, data in elderly patients, who have frequently advanced liver disease, associated comorbidities, and use concomitant medications are scarce. The im of this study was to assess the effectiveness and tolerability of all-oral regimens in elderly patients in real-life clinical practice.Methods:Retrospective analysis of hepatitis C virus (HCV) patients aged ≥65 years receiving interferon-free regimens within the Spanish National Registry (Hepa-C).Results:Data of 1,252 patients were recorded. Of these, 955 (76%) were aged 65–74 years, 211 (17%) were aged 75–79 years, and 86 (7%) were aged ≥80 years at the start of antiviral therapy. HCV genotype-1b was predominant (88%) and 48% were previous non-responders. A significant proportion of patients had cirrhosis (922; 74%), of whom 11% presented decompensated liver disease. The most used regimens were SOF/LDV (33%), 3D (28%), and SOF/SMV (26%). Ribavirin was added in 49% of patients. Overall, the sustained virological response (SVR12) rate was 94% without differences among the three age categories. Albumin ≤3.5 g/dl was the only independent negative predictor of response (0.25 (0.15–0.41); P<0.01). Regarding tolerability, the rate of severe adverse events increased with age category (8.8, 13, and 14%; P=0.04). In addition, the main predictors of mortality (2.3%) were age ≥75 years (2.59 (1.16–5.83); P =0.02) and albumin ≤3.5 (17 (6.3–47); P <0.01).Conclusions:SVR rates with interferon-free regimens in elderly patients are high and comparable to the general population. Baseline low albumin levels (≤3.5 g/dl) was the only predictor of treatment failure. Importantly, the rate of severe adverse events and death increased with age. Elderly patients (≥75 years) or those with advanced liver disease (albumin ≤3.5) presented higher mortality. Thus a careful selection of patients for antiviral treatment is recommended.

Causes of mortality after liver transplantation: period of main incidence.

THE SHORTAGE of donor livers for transplantation means that the use of liver grafts must be optimal. To ensure efficient use of the resources available, a precise definition of the causes of mortality (CMs) in these patients is essential. In the literature on the subject there are major discrepancies regarding the incidence of the CMs. This is so because the immediate cause (IC) of death is generally considered more important than other previous circumstances that contribute to the IC. We term the circumstances involved in the lead-up to death the principal cause (PC). It should also be stressed that the incidence of different CMs changes according to the follow-up time since transplantation. The objectives of the present study are first, to present a retrospective description of the global CMs in our patients and, second, to assess the distribution of mortality in different periods of the follow-up.

«De Novo» Carcinoma after Liver Transplant (L.T.)

Patients who have received a L.T. have a higher risk of developing «de novo» neoplasia than the general population.

HCV Chronic Infection in HD (Hemodialysed) Candidates to KT (Kidney Transplant). Influence of Virus C Genotypes on Response to IFN Treatment

IFN is the most accepted treatment for HCV chronic infection in immunocompetent patients. But IFN is not without risk in transplanted patients, because possible deleterious effects on the graft.