Carmelo Loinaz Segurola

Using old liver grafts for liver transplantation: where are the limits?

The scarcity of ideal liver grafts for orthotopic liver transplantation (OLT) has led transplant teams to investigate other sources of grafts in order to augment the donor liver pool. One way to get more liver grafts is to use marginal donors, a not well-defined group which includes mainly donors > 60 years, donors with hypernatremia or macrosteatosis > 30%, donors with hepatitis C virus or hepatitis B virus positive serologies, cold ischemia time > 12 h, non-heart-beating donors, and grafts from split-livers or living-related donations. Perhaps the most practical and frequent measure to increase the liver pool, and thus to reduce waiting list mortality, is to use older livers. In the past years the results of OLT with old livers have improved, mainly due to better selection and maintenance of donors, improvements in surgical techniques in donors and recipients, and intra- and post-OLT management. At the present time, sexagenarian livers are generally accepted, but there still exists some controversy regarding the use of septuagenarian and octogenarian liver grafts. The aim of this paper is to briefly review the aging process of the liver and reported experiences using old livers for OLT. Fundamentally, the series of septuagenarian and octogenarian livers will be addressed to see if there is a limit to using these aged grafts.

Trasplante hepático como tratamiento de la polineuropatía amiloidótica familiar en pacientes mayores de 60 años

BACKGROUND AND OBJECTIVE Familial amyloid polyneuropathy (FAP) is the most prevalent type of hereditary systemic amyloidosis. It is an autosomal dominant disease characterized by the deposition of an abnormal variant transthyretin. It has a worldwide distribution, with localized endemic areas in Portugal, Sweden and Japan. In Spain there is an endemic focus, located in Mallorca. Liver transplantation is the only curative option for patients with FAP. The aim of this study was to describe the clinical and demographic characteristics of patients transplanted with a diagnosis of PAF. MATERIAL AND METHOD Six patients with PAF underwent liver transplantation between April 1986 and December 2012. RESULTS The mean age was 57.7+16 years, patients of Spanish origin were older than 60 years. All patients had progressive symptoms as mixed polyneuropathy. In 2 patients, combined heart-liver transplants sequentially were performed. Patient survival and graft was 80% at one, 3 and 5 years. CONCLUSIONS The only effective treatment for etiologic PAF is liver transplantation. Early detection is the key to the treatment and control, avoiding the irreversible organ damage.

Trasplante hepático con injerto procedente de donación después de muerte cardiocirculatoria controlada. Situación actual

An increasing pressure on the liver transplant waiting list, forces us to explore new sources, in order to expand the donor pool. One of the most interesting and with a promising potential, is donation after cardiac death (DCD). Initially, this activity has developed in Spain by means of the Maastricht type II donation in the uncontrolled setting. For different reasons, donation after controlled cardiac death has been reconsidered in our country. The most outstanding circumstance involved in DCD donation is a potential ischemic stress, that could cause severe liver graft cell damage, resulting in an adverse effect on liver transplant results, in terms of complications and outcomes. The complex and particular issues related to DCD Donation will be discussed in this review.An increasing pressure on the liver transplant waiting list, forces us to explore new sources, in order to expand the donor pool. One of the most interesting and with a promising potential, is donation after cardiac death (DCD). Initially, this activity has developed in Spain by means of the Maastricht type II donation in the uncontrolled setting. For different reasons, donation after controlled cardiac death has been reconsidered in our country. The most outstanding circumstance involved in DCD donation is a potential ischemic stress, that could cause severe liver graft cell damage, resulting in an adverse effect on liver transplant results, in terms of complications and outcomes. The complex and particular issues related to DCD Donation will be discussed in this review.

Liver Transplantation from Donor after Cardiac Death (DCD) Maastricht type IIA, our Experience after 10 years

Introduction Ten years after the beginning of the donation after cardic death (DCD) programme in the University Hospital 12 de Octubre, we study the evolution of the results of said programme over time. Objectives To compare the results of liver transplantation (LT) using grafts obtained from donors after cardiac death (DCD type Maastricht IIA) performed during the first period (A) of the programme (January 2006 to December 2010) versus those performed during a later period defined from January 2011 to December 2016 (B). Materials and Methods Retrospective analysis of the DCD liver transplantation series in the University Hospital 12 de Octubre. Results 75 LT from DCD type IIA have been reviewed, 44 performed during period A and 31 during period B. Mean recipient ages were 59+8 y 58+6 (NS) respectively, with a similar number of male patients (79,5% vs. 71% NS). There were no statistically significant differences found regarding other recipient characteristics such as MELD score, hepatocellular carcinoma or HCV infection. Mean donor age was 38+9 years in group A and 46+7 in group B (p 0.000). When reviewing ischemia times (IT), cold IT was shorter in group B (A 7:00 vs. B 6:05; p 0.046) as was warm IT (A 1:08 vs. B 0:58, p 0.025). However NECMO time was significantly shorter during the first period (3:16 vs. 3:37 min, p 0.027). Recipient survival during period A at 1, 3 and 5 years was 77.3%, 61.4% and 59.1% while during period B it was 87.1%, 83.7% and 83.7% (p 0.039). Graft survival after period A was significantly lower as well (63.6%, 50% and 47.7% vs. 83.9%, 80.5% and 80.5% in group B; p 0.008). The incidence of ischemic cholangiopathy was higher in group A (43.2% vs. 13.3%; p 0.006), as well as the retransplantation rate (A 18.2% vs. B 3.2%; p 0.05). There were non-statistically significant differences found regarding the incidence of primary graft non-function (A 11.4% vs. 3.3% in group B; p 0.214). Conclusions The study shows a significant improvement in the results of DCD liver transplantation through time, possibly related to graft ischemia time optimization.

Risk Factors and Consequences of Ischemic Cholangiopathy in Liver Transplantation from DCD Maastricht IIA

Introduction Although donors after cardiac death (DCD) Maastricht type IIA have been established as an acceptable source of grafts in the current setting of organ shortage, biliary complications, especially ischemic cholangiopathy (IC), remain a considerable difficulty in the management of these patients, with a significant impact in long term results and quality of life. Objectives To study the incidence and impact of ischemic cholangiopathy among DCD IIA liver transplant recipients, and identify risk factors related to this complication. Materials and Methods Retrospective analysis of the DCD Maastricht type IIA liver transplantation series in University Hospital 12 de Octubre, registered from January 2006 to December 2016. Results 75 LT from DCD type IIA were performed during the study period, with 23 cases of IC diagnosed (30.7%). Comparing patients who suffered this complication (IC) with those who did not (no-IC), there were no significant differences found in recipient age (no-IC 58.4+7.7, IC 59.5+7.7 years), MELD score (no-IC 13.9+4.8 vs IC 15.6+4.8), donor age, HCV infection or hepatocellular carcinoma prevalence. Mean MELD-Na was 19+7 in those patients who developed IC, and 15.9+5.8 in those who did not, although the difference was not significant. Ischemia times and ECMO flow rates were similar in both groups. Retransplantation rate was higher in the no-IC group (11.5% vs. 13%, NS). No differences were achieved comparing liver function tests. Median time from transplantation to development of ischemic cholangiopathy was 5.8 months (range 1.2-70.3). Multivariate analysis shows an increased risk of IC in those grafts with AST levels over four times the upper limit of the normal range in the last blood sample obtained during NECMO (OR, 5.93; 95% CI, 1.001-35.208; p 0.05). No other statistically relevant risk factors were identified in this analysis. Differences found when comparing actuarial survival at 1, 3 and 5 years in recipients who did not develop IC (76.5%, 70.3% and 70.3%) with those who did (91.3%, 69.6% and 65.2%) were not statistically significant (p 0.915). Similar results were obtained when studying graft survival (no IC 70.6%, 64.3%, 64.3% vs. IC 78.3%, 60.9%, 56.5%; p 0.958). Conclusions AST levels 4 times above the usual laboratory range have been identified as a significant risk factor in the developement of ischemic cholangiopathy, suggesting that grafts with this characteristic should be discarded to minimize said complication.

Proteína C reactiva como predictor de fuga anastomótica en cirugía colorrectal. Comparación entre cirugía abierta y laparoscópica

INTRODUCTION Anastomotic leak (AL) is a serious complication in colorectal surgery due to its increase in morbidity and mortality. The aim of this prospective non-randomised study is to determine whether C-reactive Protein (CRP) is useful as a predictor of AL in patients undergoing open versus laparoscopic surgery. METHODS A total of 168 patients undergoing elective colorectal surgery were included. CRP was measured daily during the first 5postoperative days. Complications, specially AL, were analysed. RESULTS Following an open approach 32 patients (45.7%) presented complications, 15 (18.7%) in the laparoscopic group and 12 (29.4%) in the converted group (P=0.153). Following open surgery 9 patients experienced AL, 5 were detected in the laparoscopic group and none in those converted (P=0.153). There were significant differences in CRP values between the 3 groups (P=0.03). ROC Curves showed AUC for the open and laparoscopic approach of 0.731 and 0.760 respectively. On day 4 the AUC was 0.867 for the open group and 0.914 for the laparoscopic group. Cut-off points on day 4 were: Open: 159.2mg/L; sensitivity 75%, specificity 89% and NPP 96% (P<0.001). Following laparoscopic surgery the cut-off point was 67.3%; sensitivity 100%, specificity 89.5% and NPP 100% (P=0.016). CONCLUSION CRP on day 4 is useful to diagnose AL. Different cut-off values should be taken into account depending on the approach used.