Silvina Yantorno

MELD is superior to King's college and Clichy's criteria to assess prognosis in fulminant hepatic failure

Assessment of prognosis in fulminant hepatic failure (FHF) is essential for the need and appropriate timing of orthotopic liver transplantation (OLT). In this study we investigated the prognostic efficacy of Kings College criteria, Clichys criteria, Model for End‐Stage Liver Disease (MELD), and Pediatric End‐Stage Liver Disease (PELD) in 120 consecutive patients with FHF. Survival with medical therapy (18%), death without OLT (15%), and receipt of a liver transplant were similar in adults (n = 64) and children (n = 56). MELD scores were significantly higher in patients who died compared to those who survived without OLT, both in adults (38 ± 7 vs. 26 ± 7, P = 0.0003) and children (39 ± 7 vs. 23 ± 6, P = 0.0004). Using logistic regression analysis in this cohort of patients, concordance statistics were significantly higher for MELD (0.95) and PELD (0.99) when compared to Kings College (0.74) and Clichys criteria (0.68). When data was analyzed in a Cox model including patients receiving transplants and censoring the time from admission, the concordance statistic for MELD (0.77) and PELD (0.79) remained significantly higher than that of Kings College criteria but not higher than that of Clichys criteria. In conclusion, this study is the first to show that MELD and PELD are superior to Kings College and Clichys criteria to assess prognosis in FHF. However, because data was generated from a single center and included a rather low number of patients who survived or died without OLT, further confirmation of our findings is required. Liver Transpl 13:822–828, 2007.

Changing etiologies and outcomes of acute liver failure: Perspectives from 6 transplant centers in Argentina

There is significant geographic variation in the etiologies and prognoses of acute liver failure (ALF). The aims of the present study were to determine the causes and short‐term outcomes of ALF in Argentina, to evaluate the performance of prognostic criteria, and to identify clinical prognostic factors of death. We performed a retrospective analysis of 154 adult patients with ALF who were admitted to 6 liver transplantation (LT) programs between June 2005 and December 2011. The most frequent causes of ALF were viral hepatitis B (46 patients or 30%), autoimmune hepatitis (AIH; 40 patients or 26%), and indeterminate causes (40 patients or 26%). No acetaminophen (ACM) overdose was reported. One hundred and twenty one patients (78%) were included on the waiting list, and LT was performed for 83 patients (54%). Overall survival rate is now corected to 73%. Multivariate logistic regression identified 2 independent variables associated with adverse outcomes on admission: a Model for End‐Stage Liver Disease (MELD) score ≥ 29 and an encephalopathy grade ≥ 3. In a direct comparison using a receiving operating characteristic curve analysis, the MELD score [C statistic = 0.830, 95% confidence interval (CI) = 0.73‐0.93] had better prognostic accuracy for predicting outcomes than the Clichy criteria (C statistic = 0.719, 95% CI = 0.58‐0.85) or the Kings College criteria (C statistic = 0.631, 95% CI = 0.49‐0.77). In conclusion, hepatitis B and AIH were the most frequent causes of fulminant hepatic failure in our series, and no cases of ACM overdosing were identified. A MELD score ≥ 29 and an encephalopathy grade ≥ 3 at admission were associated with death. The MELD score at admission showed the highest prognostic accuracy. Liver Transpl 20:483–489, 2014.

Fibrosis progression in maintenance liver transplant patients with hepatitis C recurrence: a randomised study of everolimus vs. calcineurin inhibitors

Robust clinical data evaluating fibrosis progression in hepatitis C virus (HCV) liver transplant patients receiving an mTOR inhibitor vs. calcineurin inhibitor (CNI) are lacking. To evaluate fibrosis progression in maintenance liver transplant patients receiving everolimus‐ or CNI‐based immunosuppression.

How common is delayed cyclosporine absorption following liver transplantation

The mean time to peak absorption of cyclosporine (CsA) in liver transplant patients is approximately 2 hours, but in some patients the peak occurs later. The goal of this study was, therefore, to investigate the incidence of delayed absorption in 27 de novo liver transplant recipients receiving CsA ≥10 mg/kg/day (C2 monitoring) and in 15 maintenance patients. Patients were categorized as ‘normal’ absorbers (C2 exceeding C4 and C6) or ‘delayed’ absorbers (C4 or C6 exceeding C2), and as ‘good’ (>800 ng/mL at C0, C2, C4, or C6) or ‘poor’ absorbers (C0, C2, C4 and C6 <800 ng/mL) on the day of study. Among de novo patients, 15 (56%) had ‘normal’ CsA absorption and 12 (44%) ‘delayed’ absorption. Good CsA absorption occurred in 16 patients (59%) and poor absorption in 11 (41%). The proportion of poor absorbers was similar in patients with normal (6 / 15, 40%) or delayed (5 / 12, 42%) absorption. Among the 12 delayed absorbers, 11 had peak CsA concentration at C4. Mean C0 level was significantly higher in delayed absorbers (282 ± 96 ng/mL) than in normal absorbers (185 ± 88ng/mL; P = .01). Delayed absorbers reverted to normal absorption (C2 > C4) after a median of 6 days from the day of study, and no cases of delayed absorption were found among maintenance patients. In conclusion, almost 50% of the patients had delayed CsA absorption early posttransplant; around half of these exhibited normal CsA exposure. Measurement of C4 in addition to C2 differentiates effectively between delayed and poor absorbers of CsA such that over‐ or underimmunosuppression can be avoided. (Liver Transpl 2005;11:167–173.)

Three liver transplants after a single cadaveric procurement: Split liver transplantation plus domino liver transplantation, an infrequent but valid alternative for maximizing transplant sharing and applicability—report of the first Latin American case

The development of liver surgery and the need to overcome the shortage of cadaveric grafts have stimulated the creativity of surgeons in describing different options for using segmental liver grafts. Reduced size liver transplantation, ex vivo and in situ split liver transplantation, and living related donor liver transplantation are options that have spread since their original descriptions. In the setting of these accepted strategies, the option of performing sequential or domino liver transplantation with livers from patients with familial amyloidotic polyneuropathy (FAP) has become possible, and these patients have started to be used worldwide as whole living donors for patients who otherwise would not benefit from the current allocation system and cannot apply for a segmental adult living donor graft. The success of some of the aforementioned techniques can be currently followed via Web-based registries such as the Familial Amyloidotic Polyneuropathy World Transplant Registry, which includes 62 centers in 21 countries performing orthotopic liver transplantation with FAP donors. The need to foster maximal sharing has led to surgical innovations for further splitting FAP livers or performing split liver transplants for a pediatric recipient and an adult recipient with FAP followed by sequential or domino liver transplantation; however, only a small number of cases of this kind have been described. Therefore, we report here our experience with the first case of split transplantation plus domino transplantation in Latin America at 2 Argentinean institutions.

Applicability of Liver Transplantation for Patients with Acute on Chronic Liver Failure

Liver transplantation (LT) for acute on chronic liver failure (ACLF) may become the only chance to survive when other therapeutic measures fail. However, to reach a LT in this condition is difficult given its high short term mortality. Prevalence rates were reported between 24 to 34%.This data has not been described in our population Aim: to evaluate the prevalence and outcome of ACLF patients (pts) listed in our LT unit. Patients and Methods: Adults pts with chronic liver disease that were consecutive listed for LT between Jan/15 and Jun/16 were included and divided in two groups: ACLF and Non-ACLF. Age, gender, etiology of liver disease, presence of hepatocellular carcinoma, comorbid conditions, Child-Pugh and MELD, and pre and post LT outcome were compared on both groups. The chronic liver failure (CLIF) Consortium Organ Failure Score was used in the diagnosis and grading of ACLF, and the CLIF Consortium ACLF score (CLIF-C ACLF) was used to estimate probability of dying Results Prevalence of ACLF was 15%, 13 of 86 pts fulfilled ACLF criteria, 4 at the time of inclusion in the waiting list and 9 after 52 (13-360) days Precipitating events were bacterial infection (31%), gastrointestinal bleeding (15%), active alcoholism (8%), hemoperitoneum (8%) and non identified in the remaining 38%. Resolution of ACLF, access to LT or death for ACLF grade 1 (n=6) were 33%/50%/17%, for grade 2 (n=2) 0%,50%,100% and for grade 3 (n=5) 0%, 0%,100% respectively. The real waiting list mortality and the predicted by CLIF-C ACLF on ACLF pts at 28 days were 36%/42% and at 90 days 62%/56% (p=NS). Post-LT survival for non-ACLF/ACLF pts at 28, 90 and 180 days were 96%/75%, 92%/75% and 88%/75% (p=NS) Conclusions 1)Patients with ACLF grade 1 had the higher chance of resolution and / or transplantation 2) CLIF-C ACLF had a good correlation with the mortality found in this study 3) Post-LT survival was lower in pts with ACLF compared to non- ACLF, however, this difference was not statistically significant 4)More studies are required to define criteria to prioritize or reject the inclusion in the list of patients, according to the degree of ACLF