P.C. Arroyo

Patients on the waiting list for liver transplantation: Caregiver burden and stress

Over the last few decades, informal caregivers of patients with chronic diseases have received more attention, and there is a growing volume of studies demonstrating high rates of burden, stress, and mental disorders in this group of individuals. The objective of this study was to evaluate the burden, stress, and psychosocial characteristics of informal caregivers of liver transplantation candidates. Participants were assessed by individual evaluations with the following instruments: a semistructured interview, the Caregiver Burden Scale, the Inventário de Sintomas de Stress para Adultos de Lipp, and the Beck Depression Inventory. The Mann‐Whitney test was used for statistical analysis with a significance level of 0.05. The characteristics of the study group (n = 61) were similar to those of groups in other studies with respect to gender (82% were women), kinship (64% were spouses), and age (the mean age was 47.6 years). The main stressors identified by the participants were as follows: doubts about ways to react in a crisis or in emergency situations (42.6%), mood swings of the patient (29.5%), and care involving food and medications (27.9%). Approximately 25% of the caregivers reported that they felt unprepared to adequately perform their roles. Data analysis indicated a greater burden overall on caregivers when the patients Model for End‐Stage Liver Disease score was greater than or equal to 15 points (P = 0.041). Furthermore, caregivers of patients with alcoholic liver disease showed higher depression (P = 0.034) and overall burden scores (P = 0.031) versus caregivers of patients with liver disease due to other etiologies. In conclusion, the participants showed significantly high levels of burden, stress, and depression. Support measures and caregiver preparation should be implemented by health care providers. Liver Transpl 16:1164–1168, 2010.

Prevalence, Treatment, and Outcomes of the Hepatic Artery Stenosis After Liver Transplantation

INTRODUCTION Hepatic artery stenosis (HAS) after liver transplantation can lead to altered hepatic function and/or thrombosis, there by increasing morbidity and mortality. The prevalence of HAS in the literatures varies from 4% to 11%. OBJECTIVE We sought to describe the prevalence and treatment of hepatic artery stenosis. METHODS We performed a descriptive retrospective analysis of 253 liver transplantations from March 1998 to May 2007, including patients with suspected HAS owing to increased hepatic enzymes, altered Doppler ultrasound (us) and hepatic biopsy. The confirmation of HAS was achieved through areriography. RESULTS Nine patients were identified to have HAS, a 3.5% prevalence. Among the HAS patients, seven were male and two female. Their average age was 35.5 years (range, 65 to 53). The average time between the diagnosis and transplantation was 14.2 months (range, 9 to 68). The increase in hepatic enzymes among this group averaged: aspartate aminotransferase 131 U/L (range, 26 to 412) and alanine aminotransferase 192 U/L (range, 35 to 511). Doppler US showed alteration in the resistance level index. All patients underwent areriography; only one could not be treated owing to severe hepatic artery spasm, which also occurred during another attempt weeks after the first one. Among the eight patients, six were treated with stents and two with angioplastis. All treated patients displayed improvements in parameters. Four patients treated with stents required retreatment: two underwent angioplasty and two, a thrombolytic. One graft rethrombosed but evolved in compensated fashion with recanalization by collaterals. There has been no graft loss or mortality in this population. The average time of posttreatment follow-up was 31.28 (range, 9 to 68) months. CONCLUSION The prevalence of HAS in our unit was within that reported in the literature. Treatment with a stent or angioplasty proved to be efficient to control this complication, considering that hepatic function recovered and that there was neither graft nor patient loss.

Hepatopulmonary Syndrome: Morbidity and Survival After Liver Transplantation

Hepatopulmonary Syndrome (HPS) is a triad of liver disease, intrapulmonary vascular dilatation (IPVD), and arterial deoxygenation. Orthotopic liver transplantation (OLT) constitutes the only effective treatment; however, adverse outcomes have been reported. The aim of this study was to evaluate the early morbidity and short- and long-term survival after OLT for patients with and without HPS. We studied 59 transplant recipients divided into 2 groups: with HPS (HPS group n = 25) and without HPS (control group, n = 34) before the OLT. IPVD was diagnosed using transthoracic contrast-enhanced echocardiography. Arterial deoxygenation was defined as PA-a,O(2) >or= 15 mm Hg. The HPS and control groups were homogeneous regarding age (P = .36; 43.8 +/- 12.2 vs 46.9 +/- 13.5), gender (P = .47), male/female ratio (68%:32% and 78%:22%, respectively), and severity of liver disease. The PaO(2) was significantly lower (74.9 +/- 12.1 vs 93 +/- 6.4 mm Hg; P < .001) and the PA-a,O(2) was significantly higher in the HPS group (30.3 +/- 10.6 vs 11.0 +/- 7.0; P < .001). The percentage of severe (n = 3) and very severe (n = 1) hypoxemia was 16%. There were no significant differences between HPS and control groups regarding short- (68% vs 77%; P = .27) and long-term survival (60% vs 64%; P = .67) as well as among patients with mild, moderate, severe, or very severe HPS and the control group (P = .53). Also, intensive care unit (ICU) stay (7.0 vs 5.5; P = .41), duration of mechanical ventilation (38.0 vs 27.5; P = .43), reintubation rate (32.0% vs 23.5%; P = .45), and early postoperative complications (P = .72) were not different. In conclusion, there were no significant differences regarding the outcomes of OLT for patients with versus without HPS related to early morbidity or short- and long-term survival.

Histopathologic characteristics of incidental hepatocellular carcinoma after liver transplantation.

INTRODUCTION Liver transplantation for patients with hepatocellular carcinoma (HCC) is an accepted therapeutic modality, depending on the size and number of nodules. Since a high incidence of incidental HCC at transplantation has been reported, our aim was to evaluate the histopathologic characteristics of these patients. PATIENTS AND METHODS This retrospective analysis from March 1998 to June 2009 included liver transplantation patients without increased alpha-fetoprotein or nodules on imaging methods. We included patients with HCC on anatomopathologic exam, excluding those presenting with HCC on the presurgery evaluation through clinical, laboratory and imaging methods. RESULTS Among the 277 transplanted subjects, 27 showed incidental HCC. The alpha-fetoprotein average level was 8.52 mg/dL (1.6-28.2). One patient presented with adenomatosis and focus of HCC. Histopathologic analyses showed: mean tumor size was 0.9 cm (range = 0.4-3.5); average number of tumors in each explanted liver 1.85 (range = 1-7) nodules; and three (11.1%), microvascular invasion (11.1%). The TNM staging showed 17 (63%) stage I and 6 (22%) stage II. The Edmondson and Steiner classification showed 19 (70%) subjects in degree II. CONCLUSION The histopathologic presentation of incidental HCC after liver transplantation showed tumors in early stage with microvascular invasion in some cases.

Families Who Previously Refused Organ Donation Would Agree to Donate in a New Situation: A Cross-sectional Study

BACKGROUND The limited supply of organs restricts the number of transplantations. Studying the families who refuse donation may help to increase the number of transplantations. METHODS This descriptive cross-sectional study used a questionnaire to obtain information from 61 family members who had refused to donate organs from January 1997 to December 2004. The exclusion criterion was donor death less than 1 year from the study. The mean age of subjects was 41 ± 12.7 years (range, 18 to 79 years) with 66% women. RESULTS More than half (36 of 69; 52%) of the families who refused donation would agree to donate in a new situation. The primary reasons for refusing donation were: disagreement among family members (25 of 128; 19%), lack of knowledge regarding the deceaseds wishes (22 of 128; 17%), and previous request from the deceased not to be a donor (17 of 128; 13%). The most frequent suggestions to increase organ donation were to provide families with more information (43 of 149; 29%), initiate contact among the families (36 of 149; 24%), and involve a trusted physician (30 of 149; 20%). CONCLUSION Most family members who refused organ donation changed their minds and would agree to donate in a few situation. Most of the reasons for refusing to donate reflected a lack of information and discussion on the topic.

Liver Transplantation Using University of Wisconsin or Celsior Preserving Solutions in the Portal Vein and Euro-Collins in the Aorta

INTRODUCTION Orthotopic liver transplantation (OLT) is today the gold standard treatment of the end-stage liver disease. Different solutions are used for graft preservation. Our objective was to compare the results of cadaveric donor OLT, preserved with the University of Wisconsin (UW) or Celsior solutions in the portal vein and Euro-Collins in the aorta. METHODS We evaluated retrospectively 72 OLT recipients, including 36 with UW solution (group UW) and 36 with Celsior (group CS). Donors were perfused in situ with 1000 mL UW or Celsior in the portal vein of and 3000 mL of Euro-Collins in the aortia and on the back table managed with 500 mL UW or Celsior in the portal vein, 250 mL in the hepatic artery, and 250 mL in the biliary duct. We evaluated the following variables: donor characteristics, recipient features, intraoperative details, reperfusion injury, and steatosis via a biopsy after reperfusion. We noted grafts with primary nonfunction (PNF), initial poor function (IPF), rejection episodes, biliary duct complications, hepatic artery complications, re-OLT, and recipient death in the first year after OLT. RESULTS The average age was 33.6 years in the UW group versus 41 years in the CS group (P = .048). There was a longer duration of surgery in the UW group (P = .001). The other recipient characteristics, ischemia-reperfusion injury, steatosis, PNF, IPF, rejection, re-OLT, and recipient survival were not different. Stenosis of the biliary duct occured in 3 (8.3%) cases in the UW group and 8 (22.2%) in the CS (P = .19) with hepatic artery thrombosis in 4 (11.1%) CS versus none in the UW group (P = .11). CONCLUSION Cadaveric donor OLT showed similar results with organs preserved with UW or Celsior in the portal vein and Euro-Collins in the aorta.

Report of Initial Experience in Small Bowel Transplantation at São José do Rio Preto Medical School Hospital

Intestinal failure is the patients inability to maintain hydroelectric and nutritional support by the digestive route, arising from massive enterectomy or diseases in which the bowel is incapable of adequately absorbing fluids and nutrients. Patients with intestinal failure associated with short bowel syndrome (SBS) and with other functional diseases with malabsorption or with total parenteral nutrition-related complications (recurrent sepsis and thrombosis of one or more deep venous accesses) are candidates for small bowel transplantation (SBT), which can be an isolated small bowel, a combined liver and small bowel, or a multivisceral graft. At our institution, three isolated SBTs were performed as our initial experience with this transplant.

Migration of Transjugular Intrahepatic Portosystemic Shunt to the Right Atrium: Complications in the Intraoperative Period of Liver Transplantation

This article reports the case of a patient who underwent transjugular intrahepatic portosystemic shunt, which migrated to the right atrium. During liver transplantation, the extracardiac portion was sectioned and the portion adherent inside the atrium was managed expectantly.

Family Members, Transplantation Candidates, and Patients Who Underwent Liver Transplantation Had Insufficient Information About the Procedure

INTRODUCTION Adherence to treatment is essential for a successful liver transplantation (LT) because LT requires information, abilities, and competencies of patients and family members. OBJECTIVES This study sought to identify whether the information received about the LT process was enough for either patients or family members who attended a liver transplant center in a school hospital. METHODS This was a transversal study using questionnaires to verify received information on LT. It included 50 patients on the waiting list for LT, 50 transplanted patients, and 50 family members. RESULTS There was a prevalence of men (82%) among patients, age range from 19 to 67 years (average: 46.87 ± 10.99), and of women (74%) among family members, age range from 18 to 80 years (average: 43.5 ± 11.77). The majority of subjects (88%) had a low education level. The most frequent etiology of hepatic cirrhosis was viral hepatitis associated with alcohol. A significant number of the listed and transplanted patients as well as all family members reported insufficient information about the process of the transplantation. The kind of insufficient information varied according to the period of treatment. The best way to obtain information, as reported by patients and family members, was a combination of oral and written information. CONCLUSIONS Our data show the need for improvement in the means of delivering information to patients and family members, and an explanatory manual was created from this study.