E.C. de Ataide

Neurological complications prevalence and long-term survival after liver transplantation.

INTRODUCTION Neurological postsurgical complications are a significant cause of morbidity and mortality occur in transplant recipients impacting their survival. METHODS We analyzed the medical records of 269 patients who underwent transplantation between 2000 and 2011, after application of the exclusion criteria Neurological complications were examined according to the period in which they appeared: immediate (1-30 day) early (31-180 days), and late (after 180 days). The survival analysis was based on the first complication. RESULTS The majority of transplant recipients were males (73.2%) and white (97.1%) with an overall median age of 49 (range, 18-73) years. Regarding the etiology for transplantation, the most common causes were hepatitis C virus (56.5%) and alcohol (33.1%). Complications, appearing in 29.4% (immediate), 31.5% (early), and 39.1% (late) cases, were encephalopathy, confusion, tremors, headache, and stroke. Patients who had the first complication between 1 and 6 months showed greater mortality than those who had one after 6 months. CONCLUSIONS Neurological complications led to longer hospital stays with greater early morbidity and mortality. Knowledge of these complications appears to be extremely important for the multidisciplinary transplantation team to decrease its prevalence as well as to diagnose and treat early.

Predicting Survival After Liver Transplantation Using Up-to-Seven Criteria in Patients With Hepatocellular Carcinoma

BACKGROUND Liver transplantation is a controversial issue in the initial management of hepatocellular carcinoma (HCC). The aim of this study was to demonstrate that up-to-seven could be useful as a model in evaluating potential candidates for liver transplantation for HCC. METHODS Between January 1997 and December 2010, 84 patients undergoing liver transplantation were analyzed for HCC. Pathologic variables included the number of lesions, maximal tumor diameter, vascular invasion, and tumor grade. The following variables were recorded: Age, gender, recurrence of HCC, survival, donor age, incidental, Milan criteria, Model for End-Stage Liver Disease score, and alpha-fetoprotein (AFP) levels. To evaluate variables we used the Kaplan-Meier method, Cox regression and Kolmogorov-Smirnov test. RESULTS There were 68 (80.9%) patients within up-to-seven criteria and 16 (19.1%) beyond this criteria. AFP levels were 96.4 versus 464.3 ng/dL in patients within versus beyond up-to-seven criteria. The median diameter of the largest nodule was 22.2 versus 32.0 mm in patients within versus beyond up-to-seven criteria, respectively. The median sum of nodules was 1.8 and 5.6 nodules in patients within versus beyond up-to-seven criteria. Vascular invasion was present in 11 (13.0%) patients within versus 7 (8.3%) beyond. Recurrence was observed in 9 (10.7%) patients and only 3 were beyond up-to-seven criteria, 2 had vascular invasion, and another showed poor differentiation. Post liver transplantation survival rates were 87.7%, 74.5%, and 65.3% at 1, 3, and 5 years in patients within up-to-seven versus 80.7%, 51.7%, and 32.1% beyond (P = .03). Similar results were observed when we applied Milan criteria or expanded Milan criteria. The largest nodule was the only predictive factor after proportional hazard Cox regression application (Beta = 0.037; exponent = 1.0377; Wald = 4.542; P = .03). In the present study, up-to-seven criteria could be useful to evaluate potential liver transplant candidates due to HCC.

Can Pre-Liver Transplantation Renal Insufficiency Using a Creatinine Clearance Calculator Predict Long-Term Survival?

INTRODUCTION Renal insufficiency can be associated with poor long-term survival of liver transplant recipients. OBJECTIVE The objective of this study was to study renal insufficiency observed pretransplantation and its long-term impact after liver transplantation. METHODS We analyzed retrospectively an electronic database collected prospectively including transplant records from June 1994 to October 2010 using piggyback venous reconstruction. The exclusion criteria were chronic kidney disease, acute hepatic failure, children up to 12 years of age, and retransplantations. Renal insufficiency was defined by the creatinine clearance (CCr) calculated using the Cockcroft-Gault method. Patients were distributed into 3 groups: CCr >90, between 90 and 60, and >60 mL/min/1.73 m(2). The survival rate was calculated using the Kaplan-Meier method and proportional hazards Cox regression analysis using death and CCr as stratifying variables evaluated predictive factors for survival. The groups were compared using the Kruskal-Wallis test with significant differences at P < .05. RESULTS Among the 305 patients those who showed preoperative and postoperative CCR of >90 were 187/59.9% and 82/26.3%, 60 to 90 were 77/24.7% and 74/23.7%, or <60 mL/min/1.73 m(2) were (41/13.1% and 149 (47.7%). Patients with preoperative CCr <60 mL/min/1.73 m(2) showed worse short- and long-term survivals as well as the longest intensive care unit and hospital stays (P = .034). The only predictive donor factor was age older than 40 years namely, the greatest hemotransfusion needs and postoperative liver and renal dysfunction (Chi square = 100.6064; P = .00001). The area under the curve (AUC) obtained using an receiver operating characteristic (ROC) analysis was 0.563 (95% CI 0.498-0.627) with a cut off of 30.25. CONCLUSION Pre-liver transplantation renal insufficiency seemed to be a predictive factor for long-term survival.

Variables Associated With the Risk of Early Death After Liver Transplantation at a Liver Transplant Unit in a University Hospital

BACKGROUND Graft dysfunction after liver transplantation is a serious complication that can lead to graft loss and patient death. This was a study to identify risk factors for early death (up to 30 days after transplantation). METHODS It was an observational and retrospective analysis at the Liver Transplantation Unit, Hospital de Clinicas, State University of Campinas, Brazil. From July 1994 to December 2012, 302 patients were included (>18 years old, piggyback technique). Of these cases, 26% died within 30 days. For analysis, Student t tests and chi-square were used to analyze receptor-related (age, body mass index, serum sodium, graft dysfunction, Model for End-Stage Liver Disease score, renal function, and early graft dysfunction [EGD type 1, 2, or 3]), surgery (hot and cold ischemia, surgical time, and units of packed erythrocytes [pRBC]), and donor (age, hypotension, and brain death cause) factors. Risk factors were identified by means of logistic regression model adjusted by the Hosmer-Lemeshow test with significance set at P < .05. RESULTS We found that hyponatremic recipients had a 6.26-fold higher risk for early death. There was a 9% reduced chance of death when the recipient serum sodium increased 1 unit. The chance of EGD3 to have early death was 18-fold higher than for EGD1 and there was a 13% increased risk for death for each unit of pRBC transfused. CONCLUSIONS Donor total bilirubin, hyponatremia, massive transfusion, and EGD3 in the allocation graft should be observed for better results in the postoperative period.

Sirolimus as rescue therapy after liver transplantation.

UNLABELLED Sirolimus has immunosuppressive properties and antitumor effects. It was prescribed in liver transplantation initially in association with calcineurin inhibitors because of its lower nephrotoxic and neurotoxic effects and its potential antitumor effects. The aim of this study was to analyze the use of sirolimus as rescue therapy for liver transplant patients. METHODS We retrospectively analyzed all 15 patients treated with sirolimus from 2009 to 2011 among 150 liver transplantations. We analyzed pre- and postconversion data. With statistical analysis using the Students t-test. RESULTS Sirolimus was the immunosuppressant therapy in 15 of 150 (10%) patients. Their average age was 56.2 years (range, 42-69) including 9 men (60%). The mean time between liver transplantation and the introduction of sirolimus was 24.6 months (range, 1-120). Sirolimus remained as the sole medication for 4 patients (26.6%). The overall time of sirolimus thereby averaged 14.3 months (range, 1-18). The reasons for the introduction of sirolimus were acute rejection (n = 8; 53.3%), chronic rejection (n = 2; 13.3%), development of malignancy (n = 3; 20%) or prior hepatocellular carcinoma (n = 2; 13.3%). Among 9 patients who initiated sirolimus because of rejection, 7 (77.7%) showed improvement in serum liver enzymes. Among the 3 (33.3%) patients who displayed renal insufficiency before the introduction of sirolimus (creatinine level > 1.5 mg/dL) 1 showed improvement with a decrease of ≥50%. The average follow-up was 18 months (range, 1-36). The average sirolimus level during the first 3 months was 10.3 ng/mL (range, 6.1-19.3). All patients developed side effects such as anemia, hypertriglyceridemia, hypercholesterolemia, and infection. In conclusion, sirolimus was useful as rescue therapy.

Acute Liver Failure Induced by Carthamus tinctorius Oil: Case Reports and Literature Review

BACKGROUND Acute liver failure (ALF) is a clinical syndrome that results from the abrupt loss of liver function in a patient without previous liver disease. The most frequent causes are viral hepatitis, drug induced, and autoimmune disease, but in 20% of cases no cause is identified. Carthamus tinctorius (safflower) oil is used as a dietary supplement for weight loss and antioxidant. There are 4 cases described in the literature of ALF induced by the use of this substance. The objective of this study was to report 3 cases of ALF treated at the Clinical Hospital of the State University of Campinas that suggest the use of C tinctorius oil as a probable etiologic factor. CASE REPORTS The 3 patients had a diagnosis of ALF according to the Kings College criteria. All had a history of ingestion of this oil for weight loss. During etiologic evaluation, viral hepatitis, autoimmune diseases, or any other drug cause were excluded, thus pointing to C tinctorius oil as the triggering factor. All 3 patients underwent liver transplantation: 2 had good postoperative evolution, and 1 died 12 days after the procedure. CONCLUSIONS Two cases are described in which the hepatic insufficiency induced by C tinctorius oil was successfully treated through liver transplantation. This highlights the risk of misuse of this substance for weight loss.

Immunomodulation, Acute Renal Failure, and Complications of Basiliximab Use After Liver Transplantation: Analysis of 114 Patients and Literature Review

Basiliximab is considered to be effective in preventing cellular rejection (CR) in solid organ transplantation and is commonly used for renal transplants. The aim of this study was describe the population of patients undergoing orthotopic liver transplantation (LT) receiving basiliximab in the period 2012-2016 in the liver transplant service at the State University of Campinas, São Paulo, Brazil. We analyzed 114 patients who underwent LT and received basiliximab; 83 (72.8%) were male and 31 (27.2%) female, with an overall mean age of 54.3 years. Immunosuppression was performed with corticosteroids during anesthetic induction, and postoperatively with tacrolimus in 85.5%, sodium mycophenolate in 81.7%, cyclosporine in 12.7%, and everolimus in 15.5% of patients. CR was observed in 25.43% of patients, confirmed by biopsy in 15 patients: 50% acute CR, 21.42% late acute CR, and 28.57% chronic CR. Thus, the data are consistent with the literature regarding the benefit of using basiliximab as induction therapy while reducing the incidence of CR after LT, but on univariate analysis to evaluate factors associated with the occurrence of CR, the analyzed variables did not present statistical significance. There was acute renal failure (ARF) in 46.84% of patients and hemodialysis was performed in 20% of cases. In a previous series in our service, there was an ARF rate of 50%, so the incidence reduction of ARF after basiliximab use was 3.16%. Moreover, there was 6.95% hepatic artery thrombosis, 2.6% portal vein thrombosis, 2.6% biliary fistulas, 17.4% pneumonia, and 3.4% sepsis, which did not differ from the literature or from our earlier study without the use of basiliximab, suggesting the safety of this medication. In conclusion, in this series, basiliximab influenced the decrease of the CR incidence with no proven benefit on improvement in the ARF.