E.C. Ataide

Portal Vein Thrombosis and Liver Transplantation: Long Term

Obstruction of the portal vein may be related to constriction by malignant tumors or thrombosis associated with liver disease. We herein have reported our experience with patients undergoing liver transplantation with portal vein thrombosis (PVT) whose diagnosis was made intraoperatively. From September 1991 to May 2009, we studied 27/419 (6.4%) patients with PVT who were evaluated according to the presence of esophagogastric varices, underlying disease, malignancy, and if there was previous surgery, review of medical records on data collected prospectively. We observed 24 (88.9%) patients with PVT grade 1, 2 (7.4%) with grade 2, and 1 (3.7%) with grade 3. The average age of the PVT patients was 47.5 years; the average model for End-Stage Liver Discase score was 18.3, and the predominant diagnosis, hepatitis C cirrhosis. Eighteen underwent a sclerotherapy/ligature. The sensitivity of ultrasound for grade 1 thrombosis was 39.1%; for grade 2, 50%; and for grade 3, 100%. Portal vein thrombectomy was performed in 24 patients. In other patients (grade 2), we performed an anastomosis of the donor portal vein to the recipient gastric vein or to a greater splanchnic collateral vein. In only 1 patient was the graft performed using the donor portal vein-donor iliac vein-recipient superior mesenteric vein. None of the patients displayed PVT in the immediate postoperative period. Actuarial survivals at the years 1, 3, and 5 were 85%, 74%, and 63%, respectively. We concluded that PVT cannot be considered to be a contraindication for liver transplantation.

Liver transplantation for hepatocellular carcinoma: evaluation of the alpha-fetoprotein model in a multicenter cohort from Latin America.

The French alpha‐fetoprotein (AFP) model has recently shown superior results compared to Milan criteria (MC) for prediction of hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) in European populations. The aim of this study was to explore the predictive capacity of the AFP model for HCC recurrence in a Latin‐American cohort.

Is Isoniazid Safe for Liver Transplant Candidates With Latent Tuberculosis

Isoniazid (INH) is recommended for tuberculosis prophylaxis in non-liver transplant recipients. However, there is a great reluctance to prescribe this agent for liver transplant candidates and recipients due to the risk of precipitating further hepatic decompensation. We analyzed the records of liver transplantation candidates undergoing a purified protein derivative (PPD) test (tuberculosis skin test) between 2008 and 2010. Patients with no respiratory symptoms, PPD test > 10 mm, and normal chest radiography were diagnosed as latent tuberculosis and prescribed INH (300 mg) per day for 6 months. The 191 patients submitted to a PPD test and those on tuberculosis prophylaxis underwent blood tests and clinical evaluations monthly to detect hepatotoxicity of patients The 33 subjects (17.2%) with a PPD test ≥ 10 mm displayed an average model for end-stage liver disease score of 20 (range: 9-29) and child-Pugh A/B score. The main causes for liver disease were chronic hepatitis C, hepatocellular carcinoma, and alcohol abuse. Among 27 patients who received INH, 18 (66.6%) completed 6 months of prophylaxis. Eight who had shorter treatment courses of 2 to 4 months had undergone transplantation. One patient had to stop treatment because of clinical decompensation due to spontaneous bacterial peritonitis without a transaminases elevation. Six patients did not receive INH: previous tuberculosis treatment, transplantation before initiating prophylaxis, or removal from the liver candidacy list. No patient showed clinical decompensation or laboratory abnormalities associated with use of INH. The average values of alanine aminotransferase pre- and posttreatment were similar (69 and 72 U/l respectively), demonstrating that tuberculosis prophylaxis with INH was safe for liver transplant candidates.

Pretransplant hyponatremia could be associated with a poor prognosis after liver transplantation.

INTRODUCTION Predicting the prognosis of hepatic cirrhosis is the most accurate method to achieve a fair allocation among the liver transplant waiting list thereby reducing overall mortality rates. AIM To study the survival rates of recipients who undergo liver transplantation in association with hyponatremia rates. METHODS This retrospective study used a prospectively collected database. The characteristics of liver donors and recipients were: age (years), Model for End-stage Liver Disease (MELD), MELD Na score, recipient body mass index (kg/m(2)), warm ischemia time (minutes), cold ischemia time (minutes), intensive care unit time (days), hemocomponents transfused, recipient glycemia (mg/dL) and serum sodium (mEq/L), Child-Pugh-Turcotte classification (points), and survival time (months). We analyzed all 318 consecutive liver transplantations from February 1994 to May 2010 divided into two groups: A (Na > 130 mEq/L) and B (Na ≤ 130 mEq/L). The Kaplan-Meier method was used to evaluate survival rate and the Cox regression test to identify predictive factors. RESULTS Hyponatremic patients displayed shorter survival (P = .04). The Cox regression for survival time showed that patients with low serum sodium values (group B) had: Child-Pugh scores with 1.13% plus risk of death for each point; cold ischemia time with 1.001% less risk of death for each minute; glycemia with 0.6% for each mg/dL; 0.66% use of cell-saver; plus a risk of death for each 100 mL plus 1.02% risk of death for each year of donor age. CONCLUSION Hyponatremic cirrhotic patients show more advanced stages of disease compared to normonatremic cirrhotics. They usually display metabolic or cirrhotic decompensation and comorbidities. When these symptoms were associated with the use of extended criteria donors, increased cold ischemia time, and intraoperative bleeding, we observed lower survival rates.

Elderly Donors for HCV+ Versus Non-HCV Recipients: Patient Survival Following Liver Transplantation

INTRODUCTION Chronic liver failure due to hepatitis C virus (HCV)-related cirrhosis is the leading indication for liver transplantation. Inferior long-term results have been reported for liver transplantation in HCV(+) patients, especially when marginal donor livers are utilized. AIM The aim of this study was to analyze retrospectively the outcome of liver transplantation patients from elderly donors in the case of HCV(+) versus non-HCV recipients. METHODS Among 330 liver transplantations performed from January 1994 to December 2006, we selected 244 excluding acute hepatic failure, children, and retransplants. Among these patients we analyzed 232 subjects who underwent the piggyback technique. Donor risk index (DRI) as described by Feng et al was applied using 1.7 as a cutoff value. We used Kaplan-Meier survival and Cox hazard regression analyses. We studied 14 donor variables using descriptive statistical tests. RESULTS There were 148 (63.8%) HCV(+) recipients and 84 (36.2%) non-HCV liver transplant recipients. Among HCV(+) recipients, 130/148 (87.8%) patients received livers, from donors less than 50 years old, and 18/148 (12.2%), over 50 years. The descriptive statistics of patient categorical variables are shown in Table 1, and continuous variables in Table 2. The cumulative proportional survival curves are shown in Figs 1 and 2. Mortality predictive factors in HCV(+) liver transplant recipients with donor age > 50 years old as determined by Cox hazard regression showed that death risk was increased with hazard ratios for warm ischemia = 1.01 (P = .001); for red blood cell intraoperative requirements = 2.63 (P = .003); for Child-Turcotte-Pugh classification points = 2.25 (P = .04), and for DRI > 1.7 = 2.19 (P = .03). In conclusion, advancing donor age, as well as the use of nonideal donors, intraoperative bleeding, and prolonged warm ischemia, had an adverse influence on patient survival for HCV(+) recipients.

Assessment of Causes of Early Death After Twenty Years of Liver Transplantation

BACKGROUND Postoperative poor graft function is a serious complication that can lead to graft loss requiring retransplantation or even death. The postoperative complications of primary nonfunction (PNF), early graft dysfunction (EGD), bleeding due to coagulopathy, and hepatic artery thrombosis (HAT) can lead to graft loss requiring retransplantation or even death. We determined the causes of death after liver transplantation. METHODS This was an observational descriptive study on adult liver transplant recipients from September 1991 to December 2011. The cutoff for the definition of death was 30 days after surgery. We included patients older than 18 years of age who underwent liver grafts using the piggyback technique, excluding those who had retransplantations or liver-kidney transplantations. RESULTS We analyzed 561 liver transplantations through chart review. After application of exclusion criteria we had 81 patients for analysis. Overall mortality was classified into 3 main causes: PNF (34/81; 42%), EGD (10/81; 12%), and abdominal bleeding due to coagulopathy (9/81; 11%). CONCLUSION Despite advances, mortality in the first 30 days after surgery is still high, mainly related to the occurrence of PNF and EGD, whose causality was associated with red blood cell transfusion (>5 U).

Prognostic Factors for Hepatocellular Carcinoma Recurrence: Experience With 83 Liver Transplantation Patients

INTRODUCTION Orthotopic liver transplantation (OLT) is a rational therapeutic option for early-stage hepatocellular carcinoma (HCC) providing a potential cure and improving survival. METHODS This retrospective study of a longitudinal cohort used an electronic database collected prospectively from September 1997 to May 2010. The variables were gender, age (years), and alpha-fetoprotein (AFP) level (ng/mL). In explanted livers we observed: microvascular or macrovascular invasion, number of nodules and their largest size, Edmondson-Steiner histological differentiation, incidental tumor transarterial chemoembolization (TACE), Milan criteria, and previous down-staging. RESULTS Five of 83 (6.0%) subjects including 68 (82%) males with a mean time to diagnosis of 9 months experienced tumor relapses. Mean patient age at HCC recurrence was 55.3 years for male and 44.6 years for female subjects. Vascular invasion was detected in 17/83 (20.5%) subjects, namely 2% of macrovascular invasion, and 52.5% with expanded Milan criteria due to an increased number and size of nodules in the explanted livers. An incidental tumor was observed in 29.5% of cases. Preoperative TACE treatment was performed in 13 (15.6%) patients. None of the patients who had a HCC recurrence had undergone TACE. AFP level at the time of recurrence was around 1,900 ng/mL. The predictive factor for mortality was nodule size (P=.04; hazard ratio=0.0269; confidence interval [CI], 95% 0.0094-0.299). CONCLUSION Patients with relapses showed the worst survival and tumor size was a predictive factor for recurrence.

Monitoring and Detection of Cytomegalovirus in Liver Transplant Recipients

Cytomegalovirus (CMV) is a β-herpesvirus. CMV infections are a common complication contributing to morbidity and mortality after liver transplantation. Among organ transplant recipients, CMV can reactivate from latency during the first 6 months. This prospective study performed from February 2008 to December 2009 examined liver transplant recipients during the first 6 months. Two methods were performed to detect CMV infections: antigenemia (AGM) and nested (PCR). Ninety-four patients, including 72 men (76.6%) and 22 women (23.4%) underwent liver transplantation during this period. We analyzed 575 samples including 465 for AGM and PCR. Forty-three (9.25%) showed positive AGM as detected 2 to 179 days posttransplantation with a mean of 50 days and a median of 35 days, and 93/465 (20%) showed positive PCR at 0 to 186 days posttransplantation with a mean of 31 days and a median of 38 days. Among the 43 antigenemia patients, 38 samples were positive for up to 5 cells 18 of which were PCR-positive. Five samples were positive with more than 5 cells, including 3 that were PCR-positive. Only 4.51% had AGM and were PCR-positive in the same sample. Despite only 9.25% (43/465) showing AGM, the current study suggested the utility of routine monitoring to detect early CMV infection among liver transplantation patients seeking to reduce morbidity and mortality.

Identification of Bacterial Infections and Clinical Manifestation Associated With Cytomegalovirus in Liver Transplantation Patients

INTRODUCTION Liver transplantation has become the most effective therapy for the treatment of patients with end-stage liver disease. With new immunosuppressive agents the incidence of acute rejection has been significantly reduced, but infection has become a serious problem. OBJECTIVE Our objective was to correlate cytomegalovirus (CMV) positivity of antigenemia and polymerase chain reaction (PCR) with clinical manifestations and bacterial infections among patients undergoing liver transplantation. METHODS This prospective study included patients monitored for 6 months for early detection of CMV infection. Sample collections were performed at the time of surgery and weekly until the second month followed by fortnightly in the third month, and monthly in the fourth to sixth month. CMV infection was defined by positive antigenemia (>3 cells) or 2 positive PCR tests associated or not with clinical symptoms. The methodology for the diagnosis of bacterial infection was through biochemical tests and the automated VITEK/bioMérieux (identification and antibiogram) using samples of urine and blood cultures. Chi-square test was used for dicotomic variables with significant differences when P < .05. RESULTS Sixteen patients (32%) had CMV infections, including 13 (81%) with concomitant infections. Thirty-four patients (68%) did not have CMV infections and 8 of these (24%) had bacterial infection. There was a high correlation with bacterial infections among CMV-positive patients. CONCLUSION Bacterial infections after liver transplantation were associated with CMV infection.

Perfusion Fluid Contamination in Relation to Recipient Survival and Acute Cellular Rejection in Orthotopic Liver Transplantation: Retrospective Analysis

INTRODUCTION A perfusion fluid used in the preservation of a grafted liver represents a medium suitable for microorganism growth. This study investigated the prevalence of perfusion fluid contamination, acute cellular rejection (ACR) episodes, and patient survival rate. METHOD This is a retrospective study, based on an electronic database allocating cases of orthotopic liver transplantation. The exclusion criteria were as follows: having been submitted to multiple organ transplantation, liver retransplantation only, and those whose samples had not been collected or sent on the back table procedure or were unobtainable (usually the samples were sent when there was donor infection suspicion/positivity). Our posttransplantation infection prophylactic protocol consisted of ampicillin/sulbactam for 72 hours. The variables in the study were as follows: fluid contamination, presence of acute cellular rejection (ACR, Banff classification), and recipient survival at the first year. Statistical analysis was performed using descriptive statistics and chi-square with Fisher exact test considering significant P<.05. RESULTS We observed perfusion fluid contamination in 15/121 (12.39%). The agents were as follows: Klebsiella pneumoniae in 6 (4.96%), Staphylococcus epidermidis in 5 (4.13%), and Acinetobacter baumanii in 3 (2.48%) and negative cultures in 106 (87.60%). Only 1 patient had matching for donor infection and positivity hemoculture after the transplantation (K pneumoniae) and he was the only patient associated with fluid infection and death. The recipients who had their fluid preservation with positive cultures had more ACR and the survival rate was similar among those with or without infection. CONCLUSION Optimization of microbiological procedures can be performed including fungal and bacterial cultures.