Iago Justo

Octogenarian liver grafts: Is their use for transplant currently justified?

AIM To analyse the impact of octogenarian donors in liver transplantation. METHODS We present a retrospective single-center study, performed between November 1996 and March 2015, that comprises a sample of 153 liver transplants. Recipients were divided into two groups according to liver donor age: recipients of donors ≤ 65 years (group A; n = 102), and recipients of donors ≥ 80 years (group B; n = 51). A comparative analysis between the groups was performed. Quantitative variables were expressed as mean values and SD, and qualitative variables as percentages. Differences in properties between qualitative variables were assessed by χ2 test. Comparison of quantitative variables was made by t-test. Graft and patient survivals were estimated using the Kaplan-Meier method. RESULTS One, 3 and 5-year overall patient survival was 87.3%, 84% and 75.2%, respectively, in recipients of younger grafts vs 88.2%, 84.1% and 66.4%, respectively, in recipients of octogenarian grafts (P = 0.748). One, 3 and 5-year overall graft survival was 84.3%, 83.1% and 74.2%, respectively, in recipients of younger grafts vs 84.3%, 79.4% and 64.2%, respectively, in recipients of octogenarian grafts (P = 0.524). After excluding the patients with hepatitis C virus cirrhosis (16 in group A and 10 in group B), the 1, 3 and 5-year patient (P = 0.657) and graft (P = 0.419) survivals were practically the same in both groups. Multivariate Cox regression analysis demonstrated that overall patient survival was adversely affected by cerebrovascular donor death, hepatocarcinoma, and recipient preoperative bilirubin, and overall graft survival was adversely influenced by cerebrovascular donor death, and recipient preoperative bilirubin. CONCLUSION The standard criteria for utilization of octogenarian liver grafts are: normal gross appearance and consistency, normal or almost normal liver tests, hemodynamic stability with use of < 10 μg/kg per minute of vasopressors before procurement, intensive care unit stay < 3 d, CIT < 9 h, absence of atherosclerosis in the hepatic and gastroduodenal arteries, and no relevant histological alterations in the pre-transplant biopsy, such as fibrosis, hepatitis, cholestasis or macrosteatosis > 30%.

Complement C3F allotype synthesized by liver recipient modifies transplantation outcome independently from donor hepatic C3

Complement component 3 (C3) presents both slow (C3S) and fast (C3F) variants, which can be locally produced and activated by immune system cells. We studied C3 recipient variants in 483 liver transplant patients by RT‐PCR‐HRM to determine their effect on graft outcome during the first year post‐transplantation. Allograft survival was significantly decreased in C3FF recipients (C3SS 95% vs C3FS 91% vs C3FF 83%; P=.01) or C3F allele carriers (C3F absence 95% vs C3F presence 90%, P=.02). C3FF genotype or presence of C3F allele independently increased risk for allograft loss (OR: 2.38, P=.005 and OR: 2.66, P=.02, respectively). C3FF genotype was more frequent among patients whose first infection was of viral etiology (C3SS 13% vs C3FS 18% vs C3FF 32%; P=.04) and independently increased risk for post‐transplant viral infections (OR: 3.60, P=.008). On the other hand, C3FF and C3F protected from rejection events (OR: 0.54, P=.03 and OR: 0.63, P=.047, respectively). Differences were not observed in hepatitis C virus recurrence or patient survival. In conclusion, we show that, independently from C3 variants produced by donor liver, C3F variant from recipient diminishes allograft survival, increases susceptibility to viral infections, and protects from rejection after transplantation. C3 genotyping of liver recipients may be useful to stratify risk.

Implicaciones clínicas de la enfermedad diverticular del apéndice. Experiencia en los últimos 10 años

BACKGROUND Diverticular disease of the appendix is an uncommon condition, with an incidence from 0.004 to 2.1%. It usually occurs between the fourth or fifth decades of life, does not present gastrointestinal symptoms but only insidious abdominal pain. Patients usually delay consultation, leading to increased morbidity and mortality. The aim of this study was to determine the clinical features of diverticular disease of the appendix. METHODS A retrospective study of all patients undergoing appendectomy in a tertiary hospital between September 2003 and September 2013 was performed. RESULTS During this period, 7,044 appendectomies were performed, and 42 cases of diverticular disease of the appendix were found, which represents an incidence of 0.59%. A total of 27 patients were male. The mean age was 46.6±21 years. The average hospital stay was 4.5 days. A perforated appendix was identified in 46% of patients. In 80% of the cases, a complementary imaging test was performed. The incidence of neoplastic disease with diverticulum of the appendix was 7.1%. CONCLUSIONS Diverticular disease of the appendix is an incidental finding. In its acute phase, it presents as an acute appendicitis. The treatment of choice is appendectomy. It presents a higher risk of developing neoplastic disease of the appendix.

Long-term Outcomes Using Uncontrolled Donors after Circulatory Death (uDCD) for Liver Transplantation. A 10-Year Single Center Experience

Introduction The good results obtained along the years with liver transplantation (LT) have led to an increasing number of candidates on the waiting list, while the number of liver grafts is not enough to attend all patients who need an OLT. That is because many LT teams have proposed to expand the number of available grafts using livers from donors after circulatory death (DCD). The aim of this study is to analyse the use of liver grafts from type 2 uDCD donors for LT, comparing post-OLT complications and recipient outcome at 10-year follow-up with a group of patients who received liver grafts from donors after brain death (DBD). To our knowledge this series represents the largest experience using this kind of donors. Materials and Methods Between January 2006 and December 2016 we performed 783 LT in adult recipients. Seventy-five LT were performed using grafts from uDCD (Maastricht type 2), and 265 LT using livers from DBD donors. We compared the results using uDCD donors vs. DBD donors in adult recipients. Results The mean age of recipients of uDCD donors was 58.8±8 years vs. 54.7±10 (p=0.000) in DBD donors. Comparing both groups of recipients, there were no statistically significant differences in relation with gender, body mass index, Child-Pugh, MELD score, LT indication, and pre-LT laboratory tests. Mean age of uDCD donors was 41.7±10 years vs. 47.8±15 of DBD donors (p=0.001), with a higher frequency use of vasopressors in uDCD group (100%) vs. 48.3% in DBD (p=0.001), and higher significantly levels of AST prior to donation. No differences were found with respect to the presence of esteatosis, preservation injury, and cold ischemia time. Mean warm ischemia time was significantly lower in recipients of uDCD donors: 62±14 min in uDCD vs 70 ±36 in DBD (p=0.010). The units of transfused hemoderivates (packed red blood cells, fresh frozen plasma, platelets and fibrinogen) was significantly higher in recipients of uDCD than in recipients of DBD donors. Primary non-function of liver graft was significantly higher in uDCD group: 8.1% vs 2.1% in DBD group (p=0.031). Retransplant rate was also higher in recipients of uDCD donors: 12% vs. 4.6% in DBD (0.028). Moreover, ischemic cholangiopathy was significantly more frequent in uDCD: 31.1% vs. 5.6% in recipients of DBD liver donors (p=0.000). Patient survival at 1, 3 and 5-year was in recipients of uDCD donors was 81.3%, 70.2% and 68.6%, respectively, while in recipients of DBD donors was 89%, 83.7% and 78.8% (p=0.070). Graft survival at 1, 3 and 5-year in uDCD group was 72%, 62.2% and 60.7%, vs 87.1%, 81.9% and 76.5%, in DBD (p=0.003). Conclusion Even with the associated higher risk of primary non-function of liver graft and higher risk of ischemic cholangiopathy, liver grafts from uDCD donors type 2 constitute a safe source of grafts for LT.

Morbidly Obese Patients Awaiting Liver Transplantation. Sleeve Gastrectomy: Safety and Efficacy from a Liver Transplant Unit Experience

Background The prevalence of obesity has increased dramatically, even in population awaiting a liver transplantation. Despite their associated complications, we cannot consider morbid obesity any longer as an absolute contraindication to liver transplantation. Dietary approaches alone are usually completely ineffective. Bariatric surgery is the gold-standard treatment for morbid obesity, and can be performed before, during or after transplantation. Materials and Methods At our Liver Transplantation Unit we performed a sleeve gastrectomy in 8 patients with liver cirrhosis due to NASH, alcohol or HCV, by a single surgeon. The Child score was A in 6 patients and B in the remaining 2 patients. Two of our patients had portal hypertension with mild esophageal varices. The procedure was performed laparoscopically in 7 cases (87,5%), and in the other case it was performed by open approach due to portal hypertension and according to patient preferences. Results Patients showed no postoperative morbidity or mortality. Mean postoperative BMI of our patients was 37.4/33.3/30.3 kg/m2 at 3/6/12 months after surgery. Mean %EWL of our patients was 42.9%/62.2%/76.3% at 3/6/12 months. Two of the patients have already undergone a successful liver transplant. Conclusion Bariatric surgery in selected patients with compensated cirrhosis and without significative portal hypertension is reasonable. Therefore, there aren´t clear guidelines on the use of bariatric surgery in patients with cirrhosis. In our experience, the sleeve gastrectomy is safe and effective in the treatment of patients with compensated cirrhosis, and in a short time can improve candidacy in morbidly obese patients awaiting transplantation.

A retrospective analysis of patients with gallbladder cancer: surgical treatment and survival according to tumor stage

INTRODUCTION gallbladder cancer is the most common biliary neoplasm and the sixth most common tumor of the digestive system. The disease has an ominous prognosis, with a 5-year survival rate of approximately 5%. It is usually diagnosed late and surgical resection is the only potential cure. METHODS a retrospective study was carried out in 92 patients with a pathological diagnosis of gallbladder cancer from January 2000 to January 2016. RESULTS the mean age of cases was 72 ± 11 years; 64 subjects were females and 28 were males. Symptoms at admission included abdominal pain (78%), anorexia (77%), nausea (76%) and jaundice (45%). Surgery was indicated in 92 (100%) patients and 59 (64%) underwent a curative/intent resection. The initial surgical procedures included simple cholecystectomy in 69 (75%) cases and extended cholecystectomy in eleven (11%) subjects. Rescue surgery was performed in 15 patients with tumor tissue in the cholecystectomy specimen; ten individuals underwent an R0 curative resection. Adjuvant therapy was administered in 30 (33%) patients. The median survival in our series was 12.5 months, with survival rates of 57%, 30% and 20% at one, three and five years, respectively. CONCLUSION to conclude, surgical treatment with a complete tumor resection should be considered for all patients, provided that their clinical status allows it.

Outcome of patients with hemodialysis or peritoneal dialysis undergoing simultaneous pancreas-kidney transplantation. Comparative study

Controversy remains with regard to the higher risk of intra‐abdominal infections and lower patient and graft survival when peritoneal dialysis (PD) rather than hemodialysis (HD) is used in simultaneous pancreas‐kidney transplantation (SPKT).

Kidney transplant from uncontrolled donation after circulatory death donors maintained by nECMO has long-term outcomes comparable to standard criteria donation after brain death

Uncontrolled donation after circulatory death (uDCD) increases organ availability for kidney transplant (KT) with short‐term outcomes similar to those obtained from donation after brain death (DBD) donors. However, heterogeneous results in the long term have been reported. We compared 10‐year outcomes between 237 KT recipients from uDCD donors maintained by normothermic extracorporeal membrane oxygenation (nECMO) and 237 patients undergoing KT from standard criteria DBD donors during the same period at our institution. We further analyzed risk factors for death‐censored graft survival in the uDCD group. Delayed graft function (DGF) was more common in the uDCD group (73.4% vs 46.4%; P < .01), although glomerular filtration rates at the end of follow‐up were similar in the 2 groups. uDCD and DBD groups had similar rates for 10‐year death‐censored graft (82.1% vs 80.4%; P = .623) and recipient survival (86.2% vs 87.6%; P = .454). Donor age >50 years was associated with graft loss in the uDCD group (hazard ratio: 1.91; P = .058), whereas the occurrence of DGF showed no significant effect. uDCD KT under nECMO support resulted in similar graft function and long‐term outcomes compared with KT from standard criteria DBD donors. Increased donor age could negatively affect graft survival after uDCD donation.

Successful Treatment of Ischemic Cholangiopathy in Maastricht Type II Donors after Cardiac Death (DCD) Liver Recipients: 1821

Introduction: The increased number of patients in the waiting list and the donor shortage leads us to consider alternative sources of organs for our liver transplant candidates. One of these organ sources are donors from cardiac death (DCD). An increased incidence of ischemic cholangiopathy (IC) has been reported when these grafts are transplanted on. This complication could lead to severe graft dysfunction or even graft loss. The aim of our study is to analyze the patient and graft outcomes whenever ischemic cholangiopathy is diagnosed and what available treatment options we can offer these patients. Methods: From January 2006 to December 2010, 289 OLT were performed at our hospital. 44 of them (15.2%) were from DCD Maastrich tipe II. The most common cause of end stage liver disease was Hepatitis C, alone or associated with alcohol abuse and/or hepatocellular carcinoma. We defined ischemic cholangiopathy in patients who developed nonanastomotic strictures and dilatations involving the hepatic confluence or the intrahepatic biliary tree, in the absence of arterial thrombosis. The diagnosis was performed on the basis of radiological tests. Liver biopsy was performed in order to confirm it, when necessary. Thus, 14 patients (31.81%) were diagnosed of ischemic cholangiopathy. The average time between transplantation and diagnosis was 6.15 months (± 4.49). Results: The average age of the recipients and donors were 59.14 (± 8.2) and 40.43 (±10.1) years, respectively. 71.4% of our recipients were male. The average MELD value was 14 (± 3.4). Fourteen patients of 44 transplanted with DCD (31.81%) developed IC. Two of these patients (14.28%) did not require any treatment since no symptom or laboratory test deranging was observed, and other 2 patients (14.28%) required retransplant because of sever graft dysfunction. On the other hand most of these patients (12 recipients, 85.7% of those who were found to suffer IC) required radiological treatment by transparietohepatic cholangiography. Seven of the 14 patients (50%) with IC experienced resolution of the biliary complication at the moment, after an average number of procedures performed of 4.75 (± 4.1). We cannot consider cured 4 of the seven patients which have not experienced radiological resolution yet (28.5%) although a minimal impact on graft function has been observed in these cases. The other 3 patients (21.5%) have died (two of them because of HCV recurrence). The overall recipient and graft survival with IC was at 1, 3 and 5 years of follow up was 85.7%, 78.57%, 71.42%, and 85.7%, 64.28%, 57.14%, respectively. Conclusions: The most important complication in DCD transplant is ischemic cholangiopathy. However, a great number of our patients with ischemic cholangiopathy experiments good outcomes with radiologic treatment and even get cured. Not all the patients with ischemic cholangiopathy require retransplant or treatment, but a good multidisciplinary management may be the best solution of this problem in a great percentage of cases. 1809