Francisco Suárez

Liver transplantation from Maastricht category 2 non-heart-beating donors.

Background. The demand for liver transplantation has increasingly exceeded the supply of cadaver donor organs. Non-heart-beating donors (NHBDs) may be an alternative to increase the cadaver donor pool. Methods. The outcome of 20 liver transplants from Maastricht category 2 NHBDs is compared with 40 liver transplants from heart-beating donors (HBDs). After unsuccessful cardiopulmonary resuscitation (CPR), cardiopulmonary support (CPS) with simultaneous application of chest and abdominal compression (n=6), and cardiopulmonary bypass (CPB; n=14), which was hypothermic (n=7) or normothermic (n=7), were used to preserve the organs from NHBDs. Factors that may influence the outcome of livers from Maastricht category 2 NHBDs were also investigated. Results. With a minimum follow-up of 2 years, actuarial patient and graft survivals with livers from Maastricht category 2 NHBDs were 80% and 55%, respectively. Transplantation of organs from these donors was associated with a significantly higher incidence of primary nonfunction, biliary complications, and more severe initial liver dysfunction compared with livers from HBDs. Graft survival was 83% in livers from NHBDs preserved with CPS and 42% in those maintained with CPB. No graft failed if the duration of warm ischemia did not exceed 130 min with CPR or CPS, and if the period of CPB did not surpass 150 min when this method was used after CPR, regardless if it was hypothermic or normothermic. Conclusion. Livers from Maastricht type 2 NHBDs may be used for transplantation if the period of warm ischemia during CPR or CPS does not exceed 130 min. Hypothermic or normothermic CPB after CPR preserves liver viability for an additional 150 min.

Biliary Complications After Liver Transplantation From Maastricht Category-2 Non-Heart-Beating Donors

Background. There are unresolved issues regarding the security of liver transplantation with non-heart-beating donors (NHBDs). Recently, an increased incidence of biliary complications, mainly intrahepatic ischemic-type biliary strictures, has been described after controlled NHBDs. Methods. We studied the incidence and risk factors for biliary complications among uncontrolled NHBDs recipients compared with a large population of HBD recipients. Results. Overall, 16.8% of patients in the HBD group and 41.7% of patients in the NHBD group suffered any type of biliary complication (P=0.66). However, the incidence of nonanastomotic biliary strictures was significantly greater in the NHBD group (P<0.001). Multivariate analysis showed that independent risk factors for nonanastomotic strictures were hepatic artery thrombosis (relative risk; 98.7) and receiving a liver from a NHBD (relative risk; 47.1). Conclusions. If this type of donors is accepted as a source of liver organs, the high incidence of biliary complications should be considered and efforts should be made to decrease ischemic injury.

Cytomegalovirus Colitis Mimicking A Colonic Neoplasm Or Ischemic Colitis 4 Years After Heart Transplantation

BACKGROUND Cytomegalovirus (CMV) colitis is a polymorphous disease presenting in immunodepressed patients in a variety of clinical forms that can delay diagnosis and therapy. We report the case of a patient who presented with abdominal pain 4 years after heart transplantation; clinical and x-ray findings were suggestive of a neoplastic or ischemic stenosis, and histopathological examination likewise initially suggested an ischemic etiology. METHODS Tissue samples were fixed in 10% formaldehyde, embedded in paraffin, cut, and stained with hematoxylin/eosin and periodic acid-Schiff-Alcian Blue. Immunohistochemistry with monoclonal antibodies was performed using an indirect immunoperoxidase method. RESULTS CMV colitis was eventually diagnosed and resolved with surgery and specific anti-CMV therapy. CONCLUSIONS CMV colitis should be suspected in any heart transplant patient with signs or symptoms of abdominal pathology, even without classical signs or symptoms of CMV infection. If stenotic lesions are present, surgery may be required not only to remove the obstruction but also to rule out malignancy.

Incidencia, factores de riesgo e influencia sobre la supervivencia de las complicaciones infecciosas en el trasplante hepático

Introduccion El trasplante hepatico es eficaz en pacientes con enfermedades hepaticas en situacion terminal. La infeccion es una amenaza para la vida de los pacientes trasplantados. Los objetivos del estudio han sido estudiar la supervivencia general tras el trasplante hepatico, la influencia en la supervivencia de las complicaciones infecciosas y determinar los factores de riesgo asociados con el primer episodio de infeccion (bacteriana, fungica, fungica invasora y enfermedad por citomegalovirus) Metodos Se han incluido 165 trasplantes realizados en 152 receptores en el periodo: mayo de 1994 hasta mayo de 1998. Se ha realizado un estudio descriptivo de 100 variables incluidas estratificadas segun aspectos prequirugicos, quirurgicos y posquirugicos, la determinacion de las variables asociadas con la presencia de las diferentes infecciones se ha realizado con un analisis de regresion de Cox y el estudio de la supervivencia mediante la metodologia de Kaplan-Meier Resultados La infeccion se ha presentado en el 66% de los pacientes y se ha distribuido de la siguiente forma: viral (41,8%), bacteriana (33,9%), fungica (20,6%) y fungica invasora (4,2%). La supervivencia tras el trasplante ha sido del 90% al primer ano y del 75% al cuarto ano. Todas las infecciones han disminuido la supervivencia. Las variables asociadas con la presencia de las diferentes infecciones en el analisis multivariante han sido las siguientes; con la infeccion bacteriana, la dialisis, la ventilacion mecanica y el tiempo de isquemia fria del injerto; con la infeccion fungica; el numero de horas de la cirugia y el valor de la albumina plasmatica antes del trasplante; con la infeccion fungica invasora, el numero de unidades de sangre transfundidas, el valor de la albumina plasmatica antes del trasplante y el retrasplante. La enfermedad por citomegalovirus se asocio en el analisis univariado con la infeccion fungica y la infeccion fungica invasora pero en el analisis multivariante no se encontro ninguna variable que incrementara el riesgo

Tratamiento quirúrgico del hepatocarcinoma: experiencia del CHU A Coruña

INTRODUCTION Liver cancer (LC) is one of the most frequent tumours, in which the potentially curative treatment is surgery: partial surgical resection or liver transplant. OBJECTIVES To determine the morbidity and mortality, survival, and their associated factors in patients with LC, according to the type of surgical treatment: partial surgical resection or liver transplant. MATERIAL AND METHODS A retrospective, observational follow-up study of LC patients diagnosed and treated from June 1994 to December 2007. A descriptive analysis of the variables was performed, as well as a Kaplan- Meier survival analysis and Cox regression. RESULTS The incidence of tumour recurrence in the 150 transplant patients was 13.3%, with a survival at 1, 3, and 5 years of 89.3%, 73.1% and 61.4%, respectively. The multivariate analysis showed that only the histological grade/differentiation was an independent risk factor. In the 33 patients with partial surgical resection, the incidence of tumour was 51.5%, with a survival at 1, 3, and 5 years of 90.9%, 60.2%, and 38.6%, respectively. A significantly higher mortality was observed in patients with higher tumour and TNM staging. CONCLUSIONS The survival throughout follow-up was higher in liver transplant, and tumour recurrence was more frequent in patients with partial surgical resection. The survival results in transplanted patients are consistent with the Spanish and European Liver Transplant Register and with the United Network for Organ Sharing register.

Surgical treatment of liver cancer: Experience of the A Coruña UHC (Spain)

Abstract Introduction Liver cancer (LC) is one of the most frequent tumours, in which the potentially curative treatment is surgery: partial surgical resection or liver transplant. Objectives To determine the morbidity and mortality, survival, and their associated factors in patients with LC, according to the type of surgical treatment: partial surgical resection or liver transplant. Material and methods A retrospective, observational follow-up study of LC patients diagnosed and treated from June 1994 to December 2007. A descriptive analysis of the variables was performed, as well as a Kaplan- Meier survival analysis and Cox regression. Results The incidence of tumour recurrence in the 150 transplant patients was 13.3%, with a survival at 1, 3, and 5 years of 89.3%, 73.1% and 61.4%, respectively. The multivariate analysis showed that only the histological grade/differentiation was an independent risk factor. In the 33 patients with partial surgical resection, the incidence of tumour was 51.5%, with a survival at 1, 3, and 5 years of 90.9%, 60.2%, and 38.6%, respectively. A significantly higher mortality was observed in patients with higher tumour and TNM staging. Conclusions The survival throughout follow-up was higher in liver transplant, and tumour recurrence was more frequent in patients with partial surgical resection. The survival results in transplanted patients are consistent with the Spanish and European Liver Transplant Register and with the United Network for Organ Sharing register.

LIVER TRANSPLANTATION IN PATIENTS WITH HEPATOCELLULAR CARCINOMA: FACTORS IMPLICATED IN TUMOUR RELAPSE

Aims: This investigation analyses different factors affecting survival after liver transplant for hepatocellular (HCC) carcinoma, where macroscopic vascular invasion and tumour nodules larger than 5 cm were both identified as risk factors for tumour relapse after transplantation. Methods: We revised the cases of patients with HCC who underwent liver transplantation during the period 1994-2000, and present an analysis of variables, which may be probably implicated in tumour relapse, affecting survival. Results: After a mean follow-up of 33 months, mortality rate was 27.5% and relapse occurred in 18.75% of cases. No history of alcohol abuse, the number and size of the nodules, the presence of macro and microscopic vascular invasion, and pTNM stage T4 were all factors associated with a significantly increased risk of relapse (p 0.05). These factors and positive HCV were associated to decreased survival. After a multivariate analysis, the size of the nodules and the presence of macroscopic vascular invasion were considered the only independent risk factors for tumour relapse and post-transplantation relapse and mortality, respectively. Conclusions: Macroscopic vascular invasion and tumour nodules larger than 5 cm are both independent risk factors of tumour relapse after transplantation. Nevertheless, only macroscopic vascular invasion seems to have a significant effect on survival.

How do Hepatologists access to Liver Transplant Units

Liver transplantation has evolved from an experimental treatment to be considered as the most effective therapy for end-stage liver disease and selected cases of hepatocellular carcinoma. Transplant hepatologists must have specific knowledge and abilities to treat those patients who receive a liver transplant. In Spain, approximately 1100 liver transplants are performed each year, and most centers assume both postoperative care and long-term follow-up, which has led to a significant work load in liver transplant units. Despite previous attempts to establish an official training program in hepatology, the Spanish health system does not presently have a specific liver transplant training program to guarantee that future needs of physicians are covered. Collaboration between health authorities and scientific societies is required to guarantee adequate assistance to liver transplant recipients in the future.

Paritaprevir-Ritonavir, Ombitasvir and Dasabuvir plus Ribavirin to Treat Hepatitis C Genotype 1 Infection after Liver Transplantation: A Single-Center Experience

Hepatitis C virus (HCV) infection is a disease with a significant worldwide impact. In Europe and the United States, chronic hepatitis C is the most common cause of chronic hepatic disease and the main indication for liver transplantation. Recurrent hepatitis C infection is universal among transplant recipients who have detectable viremia at the time of transplantation. Hepatitis C treatment was revolutionized with the introduction of safe, powerful direct action antivirals (DAA), which allow the use of multidrug combinations that can selectively inhibit the targets required for viral replication. One of these regimens combined paritarpevir [NS3/4A protease inhibitor], ombitasvir [NS5A inhibitor] and dasabuvir [NS5B polymerase inhibitor], plus ribavirin and was found to be highly effective (SVR rates of 97% in genotype 1). We report the results of a real-world clinical practice study in a single clinical unit in 22 liver graft recipients, transplanted due to cirrhosis caused by genotype 1 HCV with post-transplantation viral recurrence, who received ombitsavir combined with paritaprevir-ritonavir plus dasabuvir and ribavirin. We found an SVR rate at 12 weeks post-treatment of 100% and a remarkably low rate of adverse events. Conclusion: oral ombitasvir combined with ritonavir-paritaprevir plus dasabuvir and ribavirin for 24 weeks is a highly effective treatment for eliminating HCV in liver transplant recipients with genotype 1 and scant fibrosis, producing few serious adverse effects. Abbreviations: CBC: Complete Blood Count; CMP: Comprehensive Metabolic Panel; DAA: Direct Action Antivirals; DSV: Dasabuvir; HCV: Hepatitis C Virus; OBV: Ombitasvir; PTV: Paritaprevir; PEGIFN: Pegylated Interferon; r: Ritonavir; RBV: Ribavirin; SVR: Sustained Virologic Response