José Huygens Parente Garcia

Enteral nutrition supplemented with l-glutamine in patients with systemic inflammatory response syndrome due to pulmonary infection

OBJECTIVE To evaluate the effect of enteral nutrition (EN) supplemented with l-glutamine on glycolytic parameters, inflammation, immune function, and oxidative stress in moderately ill intensive care patients with sepsis. METHODS Thirty patients received EN. Fifteen patients received EN supplemented with glutamine (30 g; GLN group) for 2 d followed by EN supplemented with calcium caseinate (30 g, CAS group), also over 2 d. The other 15 patients received EN with calcium caseinate (30 g; CAS group) for 2 d followed by EN with glutamine (30 g; GLN group), also over 2 days. One washout day with only EN was provided between every 2-d period of EN plus supplementation to all patients. Blood samples were taken before and after supplementation. RESULTS There were no changes in glycolytic parameters in either group. Leukocytes decreased in the two groups (from 13 650 to 11 500 in the CAS group, P = 0.019; from 12.850 to 11.000 in the GLN group, P = 0.046). Lymphocytes increased in the GLN group (from 954 to 1916, P < 0.0001) and were more numerous after glutamine supplementation (from 1916 to 1085, P < 0.0001, GLN versus CAS). No significant changes were observed in interleukin levels, but urea levels were higher in the GLN compared with the CAS group (50.0-47.0, P = 0.030). Glutathione plasma concentrations did not differ significantly between the groups. No significant changes were observed in the plasma glutamine and glutamate concentrations. CONCLUSIONS The EN supplemented with glutamine increased the lymphocyte count and helped to decrease lipid peroxidation but presented no effect on the antioxidant glutathione capacity and on cytokine concentrations or glycolytic parameters.

Orthotopic Liver Transplantation for Hepatocellular Carcinoma: One Center's Experience in the Northeast of Brazil

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world and the third leading cause of cancer-related death. In this study, we sought to assess the outcome of patients with HCC who underwent orthotopic liver transplantation (OLT) in a center in the northeast of Brazil. Between May 2002 and July 2008, 294 OLTs were performed at our center. In 45 patients, HCC was confirmed by histological examination of the explant. Patients were predominantly men of ages ranging from 14-67 years. Hepatitis C virus was involved in 55.4% of the cases. Alpha fetoprotein (AFP) levels were normal in 65.2% of the patients and surpassed 100 ng/mL in only 10.4%. The median waiting time on the list was 10 months. Seventeen patients (37.7%) presented a solitary nodule, 19 (42.2%) had 2 or 3 nodules, and 9 patients (20%) had more than 3 nodules. The maximal diameter of the largest tumor was <3 cm in 26 patients (57.7%) and exceeded 5 cm in 6 patients (13.3%). Ten tumors were well differentiated, 32 were moderately differentiated, and 3 were poorly differentiated. Eleven tumors showed microvascular invasion. There have been 4 tumor recurrences. There was an association between microvascular invasion and tumor recurrence with a statistically significant relative risk. In conclusion, OLT is an excellent option for patients with HCC. The recurrence rate was low (<10%). However, we believe that more prospective studies are needed about OLT beyond the Milan criteria because our study suggested that microvascular invasion may be more important than tumor size or number.

Preconditioning with L-alanyl-L-glutamine in a Mongolian Gerbil model of acute cerebral ischemia/reperfusion injury

PURPOSE To investigate the effect of L-alanyl-L-glutamine (L-Ala-Gln) preconditioning in an acute cerebral ischemia/reperfusion (I/R) model in gerbils. METHODS Thirty-six Mongolian gerbils (Meriones unguiculatus), (60-100g), were randomized in 2 groups (n=18) and preconditioned with saline 2.0 ml (Group-S) or 0.75g/Kg of L-Ala-Gln, (Group-G) administered into the femoral vein 30 minutes prior to I/R. Each group was divided into three subgroups (n=6). Anesthetized animals (urethane, 1.5g/Kg, i.p.) were submitted to bilateral occlusion of common carotid arteries during 15 minutes. Samples (brain tissue and arterial blood) were collected at the end of ischemia (T0) and after 30 (T30) and 60 minutes (T60) for glucose, lactate, myeloperoxidase (MPO), thiobarbituric acid reactive substances (TBARS), glutathione (GSH) assays and histopathological evaluation. RESULTS Glucose and lactate levels were not different in studied groups. However glycemia increased significantly in saline groups at the end of the reperfusion period. TBARS levels were significantly different, comparing treated (Group-G) and control group after 30 minutes of reperfusion (p<0.05) in cerebral tissue. Pretreatment with L-Ala-Gln promoted a significant increase in cerebral GSH contents in Group-G at T30 (p<0.001) time-point compared with Group-S. At T30 and T60, increased levels of GSH occurred in both time-points. There were no group differences regarding MPO levels. Pyknosis, presence of red neurons and intracellular edema were significantly smaller in Group-G. CONCLUSION Preconditioning with L-Ala-Gln in gerbils submitted to cerebral ischemia/reperfusion reduces oxidative stress and degeneration of the nucleus (pyknosis) and cell death (red neurons) in the cerebral tissue.

O custo do transplante hepático em um hospital universitário do Brasil

OBJETIVO: Investigar se os transplantes de figado realizados em um hospital universitario do Ceara eram custos-efetivos. METODOS: Foram avaliados os prontuarios dos 62 pacientes transplantados hepaticos em 2007, do dia da internacao para o transplante ate a data da alta hospitalar ou obito. Foram determinados indicadores como o numero de dias e local de internacao, a quantidade de material e medicamentos utilizados, os exames complementares e os procedimentos realizados. RESULTADOS: A maioria da populacao era do sexo masculino, procedente do Nordeste e com idade media de 45 anos. O custo medio do transplante hepatico foi de US

Synchronous hepatocellular carcinoma and renal cell carcinoma in a liver transplant recipient: a case report.

20.605,01. O item que onerou predominantemente o custo foi o repasse para equipe profissional envolvida na captacao e transplante; seguido pelas diarias, medicamentos da cirurgia e internamento; e produtos (materiais e medicamentos) utilizados na captacao. Quanto ao repasse do SUS, o HUWC recebeu US

Transplante de fígado: resultados iniciais

1.322,97 para a captacao, US

Single-Center Transfusion Rate for 555 Consecutive Liver Transplantations: Impact of Two Eras

3.223,56 para os honorarios medicos e US

Preconditioning with L-alanyl-glutamine reduces hepatic ischemia-reperfusion injury in rats

32.235,68 pelo pacote do transplante hepatico que inclui do procedimento cirurgico ate o setimo dia de internamento. CONCLUSAO: Os valores encontrados foram semelhantes aos determinados por outros centros transplantadores brasileiros. O transplante hepatico no Ceara e um procedimento economicamente viavel tomando como base o repasse financeiro do SUS.

L-alanyl-glutamine pretreatment attenuates acute inflammatory response in children submitted to palatoplasty

A 52-year-old male with liver cirrhosis secondary to hepatitis virus C, Child-Pugh score of C10, and Model for End-stage Liver Disease score of 20 was listed for liver transplant. During the pretransplant management, an abdominal computed tomography (CT) and magnetic resonance imaging (MRI, Fig. 1) showed a 2.7 2.2 cm mass in the liver and a 1.7 1.2 cm tumor in the right kidney. The liver mass on the CT was hyperdense with the liver parenchyma in the early arterial phase of contrast enhancement and hypodense in the portal phase; on the MRI, on T1-weighted sequences, it was hypointense to the liver and, on T2weighted, it was hyperintense, suggesting hepatocellular carcinoma (HCC). The renal tumor on the CT and was a solitary solid lesion with contrast enhancement during the arterial phase; on the MRI, on T2-weighted images, it was hyperintense to the liver; on T1-weighted, it was hypointense, with a high degree of confidence in diagnosing renal cell carcinoma (RCC). Being a Child-Pugh C patient, he had a prohibitive risk to perform either a biopsy of the kidney tumor or its resection. Based on the fact that renal metastasis from a primary hepatocellular carcinoma is a extremely rare event (1), on the initial stage of both tumors and finally on the MRI and CT findings, we considered the possibility of two synchronous tumors and decided not to contraindicate the liver transplant. During the liver transplantation procedure, after the recipient’s hepatectomy, we performed a partial nephrectomy to resect the kidney mass. Then, the donor liver was implanted. Histopathological analysis confirmed a synchronous HCC and RCC. He showed a good recovery and left the hospital 7 days after the transplant. His immunosuppression regimen was based on tacrolimus and prednisone. After a 12-month followup, patient is alive with good graft function and has no clinical or CT sign of any other tumor. Synchronous early primary cancers are rare. One study showed an incidence of 3.7% of synchronous cancers related to RCC. The most common sites involved were prostate, bladder, and lung. The occurrence of synchronous RCC and HCC is extremely rare (2). There is just one case of synchronous HCC and RCC resected simultaneously during a liver transplantation procedure, recently published on the literature (3). The prognosis of RCC is not likely to be changed by immunosuppression. However, a 5-year follow-up is necessary to confirm the results. The possibility of a synchronous tumor should be considered in cirrhotic patients with HCC. Jose Huygens Parente Garcia Gustavo Rego Coelho Fernanda Paula Cavalcante Jose Telmo Valenca Junior Ivelise Regina Canito Brasil Gleydson Cesar-Borges Paulo Everton Garcia Costa Cyntia Ferreira Gomes Viana Tarciso Daniel Santos Rocha Joao Batista Marinho Vasconcelos Centro de Transplante de Figado do Ceara Hospital Universitario Walter Cantidio Fortaleza, Brazil

Brazilian society of hepatology recommendations for the diagnosis and treatment of hepatocellular carcinoma

OBJETIVO: Apresentar os resultados iniciais de um servico de transplante hepatico que utiliza a tecnica piggyback como padrao. METODO: Analise retrospectiva de 19 transplantes de figado enfatizando as complicacoes pos-operatorias e a taxa de sobrevida dos pacientes. A indicacao mais frequente de transplante foi cirrose pelo virus C em nove pacientes (47%). De acordo com a gravidade da doenca hepatica, nove casos (47,3%) foram classificados como Child C e oito (42%) como B. Os dois casos restantes foram hepatite fulminante e trombose tardia de arteria hepatica. RESULTADOS: Foram realizados 19 transplantes em 18 pacientes com doador cadaver empregando a tecnica com preservacao da veia cava (piggyback) em 100% dos casos. A indicacao mais frequente de transplante foi cirrose pelo virus C em nove pacientes (47%). De acordo com a gravidade da doenca hepatica nove casos (47,3%) foram classificados como Child C e oito (42%) como B. Os dois casos restantes foram hepatite fulminante e trombose tardia de arteria hepatica. A idade media foi de 45,6 anos. O tempo de isquemia fria do enxerto foi em media de 7,8 horas e a permanencia hospitalar media de 18 dias. As complicacoes mais frequentes foram as biliares (21%), sendo que tres pacientes necessitaram de reoperacao e um foi tratado por endoscopia. Houve dois casos de trombose tardia de arteria hepatica, sendo um deles tratado por retransplante. Houve um obito (5,2%) no 8o dia de pos-operatorio ocasionado por disfuncao primaria do enxerto. A sobrevida inicial maior que 30 dias foi de 94,7%. CONCLUSOES: E possivel ter bons resultados no inicio de um programa de transplante de figado, desde que haja uma tecnica padronizada e uma equipe bem treinada e envolvida com as complicacoes pos-operatorias.