ABSTRACT
ABSTRACT Background: The criterion of Milan (CM) has been used as standard for indication of liver transplantation (LTx) for hepatocellular carcinoma (HCC) worldwide for nearly 20 years. Several centers have adopted criteria expanded in order to increase the number of patients eligible to liver transplantation, while maintaining good survival rates. In Brazil, since 2006, the criterion of Milan/Brazil (CMB), which disregards nodules <2 cm, is adopted, including patients with a higher number of small nodules. Aim: To evaluate the outcome of liver transplantation within the CMB. Methods: The medical records of patients with HCC undergoing liver transplantation in relation to recurrence and survival by comparing CM and CMB, were analyzed. Results: 414 LTx for HCC, the survival at 1 and 5 years was 84.1 and 72.7%. Of these, 7% reached the CMB through downstaging, with survival at 1 and 5 years of 93.1 and 71.9%. The CMB patient group that exceeded the CM (8.6%) had a survival rate of 58.1% at five years. There was no statistical difference in survival between the groups CM, CMB and downstaging. Vascular invasion (p<0.001), higher nodule size (p=0.001) and number of nodules >2 cm (p=0.028) were associated with relapse. The age (p=0.001), female (p<0.001), real MELD (p<0.001), vascular invasion (p=0.045) and number of nodes >2 cm (p<0.014) were associated with worse survival. Conclusions: CMB increased by 8.6% indications of liver transplantation, and showed survival rates similar to CM.
RESUMO Racional: O critério de Milão (CM) vem sendo utilizado como padrão para indicação do transplante hepático (TxH) por hepatocarcinoma (HCC) em todo mundo há quase 20 anos. Diversos centros têm adotado critérios expandidos com intuito de aumentar o número de pacientes candidatos ao transplante, mantendo bons índices de sobrevida. No Brasil, desde 2006, o critério de Milão/Brasil (CMB), que desconsidera nódulos <2 cm, é adotado, incluindo pacientes com maior número de nódulos pequenos. Objetivo: Avaliar o resultado do transplante hepático dentro do CMB. Métodos: Foram analisados os prontuários dos pacientes com HCC submetidos ao TxH em relação à recidiva e sobrevida através da comparação entre CM e CMB. Resultados: Em 414 TxH por HCC, a sobrevida em 1 e 5 anos foi de 84,1 e 72,7%. Destes, 7% atingiram o CMB através de downstaging, com sobrevida em 1 e 5 anos de 93,1 e 71,9%. O grupo de pacientes do CMB que excederam o CM (8,6%) teve sobrevida de 58,1% em cinco anos. Não houve diferença estatística na sobrevida entre os grupos CM, CMB e downstaging. A invasão vascular (p<0,001), tamanho do maior nódulo (p=0,001) e número de nódulos >2 cm (p=0,028) associaram-se com recidiva. A idade (p=0,001), sexo feminino (p<0,001), MELD real (p<0,001), invasão vascular (p=0,045) e o número de nódulos >2 cm (p<0,014) estiveram associados com a piora na sobrevida. Conclusões: O CMB aumentou em 8,6% as indicações de TxH e apresentou índices de sobrevida semelhantes ao CM.
Subject(s)
Humans , Male , Female , Middle Aged , Liver Transplantation , Carcinoma, Hepatocellular/surgery , Carcinoma, Hepatocellular/diagnosis , Liver Neoplasms/surgery , Liver Neoplasms/diagnosis , Brazil , Survival Rate , Retrospective Studies , Carcinoma, Hepatocellular/mortality , Italy , Liver Neoplasms/mortalityABSTRACT
OBJECTIVES: Liver transplantation has not increased with the number of patients requiring this treatment, increasing deaths among those on the waiting list. Models predicting post-transplantation survival, including the Model for Liver Transplantation Survival and the Donor Risk Index, have been created. Our aim was to compare the performance of the Model for End-Stage Liver Disease, the Model for Liver Transplantation Survival and the Donor Risk Index as prognostic models for survival after liver transplantation. METHOD: We retrospectively analyzed the data from 1,270 patients who received a liver transplant from a deceased donor in the state of São Paulo, Brazil, between July 2006 and July 2009. All data obtained from the Health Department of the State of São Paulo at the 15 registered transplant centers were analyzed. Patients younger than 13 years of age or with acute liver failure were excluded. RESULTS: The majority of the recipients had Child-Pugh class B or C cirrhosis (63.5%). Among the 1,006 patients included, 274 (27%) died. Univariate survival analysis using a Cox proportional hazards model showed hazard ratios of 1.02 and 1.43 for the Model for End-Stage Liver Disease and the Model for Liver Transplantation Survival, respectively (p<0.001). The areas under the ROC curve for the Donor Risk Index were always less than 0.5, whereas those for the Model for End-Stage Liver Disease and the Model for Liver Transplantation Survival were significantly greater than 0.5 (p<0.001). The cutoff values for the Model for End-Stage Liver Disease (≥29.5; sensitivity: 39.1%; specificity: 75.4%) and the Model for Liver Transplantation Survival (≥1.9; sensitivity 63.9%, specificity 54.5%), which were calculated using data available before liver transplantation, were good predictors of survival after liver transplantation (p<0.001). CONCLUSIONS: The Model for Liver Transplantation Survival displayed similar death prediction ...
Subject(s)
Adolescent , Adult , Aged , Female , Humans , Male , Middle Aged , Young Adult , End Stage Liver Disease/mortality , Liver Transplantation/mortality , Tissue Donors/statistics & numerical data , Brazil , End Stage Liver Disease/surgery , Liver Transplantation/adverse effects , Multivariate Analysis , Predictive Value of Tests , Proportional Hazards Models , Retrospective Studies , Risk Assessment , Sensitivity and Specificity , Severity of Illness Index , Survival Rate , Waiting Lists/mortalityABSTRACT
Nosocomial pneumonia is a common complication in patients on mechanical ventilation and results in significant mortality. Diagnosis of pneumonia in patients who are intubated and under mechanical ventilation is difficult, even with the aid of clinical, laboratorial, and endoscopic tests. The objective of this study was to compare three methods of tracheal sputum collection in patients with a clinical and radiological diagnosis of pneumonia. Twenty-two patients with a clinical diagnosis of liver disease were enrolled, 18 years of age or older, 13 males and nine females, who had been mechanically ventilated over an intubation period of 5.86 ± 4.62 days. These patients were being treated in intensive care unit (ICU) of the Liver Transplantdepartment. Secretion collection was carried out according to a protocol with three distinct methods: endotracheal aspiration with a closed aspiration system, Bal cath and bronchoalveolar lavage. Of the 22 patients analyzed, 21 (95.4 percent) showed one or more infectious agent when the closed aspiration system was used. With the Bal cathâ collection, 19 patients (86.3 percent) had one or more infectious agents; in the collection by bronchoalveolar lavage, 10 patients (45.4 percent) presented one or more infectious agent. According to the laboratorial analysis, 14 different microorganisms were isolated, the most frequent of which were Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pneumoniae. We concluded that aspiration with the closed system produced the most effective results in comparison with those of bronchoalveolar lavage and the Bal cathâ, and may be an acceptable method for diagnosing hospital-acquired pneumonia when no fiberoptic technique is available.
Subject(s)
Adult , Aged , Female , Humans , Male , Middle Aged , Cross Infection/microbiology , Gram-Negative Bacteria/isolation & purification , Gram-Positive Bacteria/isolation & purification , Pneumonia, Bacterial/microbiology , Sputum/microbiology , Bronchoalveolar Lavage , Bronchoscopy , Cross Infection/diagnosis , Intubation, Intratracheal/adverse effects , Prospective Studies , Pneumonia, Bacterial/diagnosis , Respiration, Artificial/adverse effects , Specimen Handling/methodsABSTRACT
PURPOSE: To study the indications and results of tacrolimus as rescue therapy for acute cellular or chronic rejection in liver transplantation. PATIENTS AND METHODS: Eighteen liver transplant recipients who underwent rescue therapy with tacrolimus between March 1995 and August 1999 were retrospectively studied. The treatment indication, patients, and graft situation were recorded as of October 31st, 1999. The response to tacrolimus was defined as patient survival with a functional graft and histological reversal of acute cellular, or for chronic rejection, bilirubin serum levels decreasing to up to twice the upper normal limit. RESULTS: Fourteen cases (77.8 percent) presented a good response. The response rate for the different indications was: (1) acute cellular + sepsis - 0/1 case; (2) recurrent acute cellular - 1/1 case; (3) OKT3-resistant acute cellular - 2/2 cases; (4) steroid-resistant acute cellular + active viral infection - 3/3 cases; (5) chronic rejection - 8/11 cases (72.7 percent response rate). The 4 patients who did not respond died. CONCLUSION: Tacrolimus rescue therapy was successful in most cases of acute cellular and chronic rejection in liver transplantation
Subject(s)
Humans , Adolescent , Adult , Middle Aged , Graft Rejection , Immunosuppressive Agents , Liver Transplantation , Tacrolimus , Follow-Up Studies , Graft Survival , Retrospective Studies , Treatment OutcomeABSTRACT
A alta mortalidade na lista de espera por transplante de figado (Tx) tem estimulado a adocao de criterios de gravidade...
Subject(s)
Humans , Male , Female , Child , Adolescent , Adult , Middle Aged , Tissue and Organ Procurement/standards , Liver Transplantation/mortalityABSTRACT
BACKGROUND: Use of polyclonal anti-hepatitis B surface antigen immunoglobulin (HBIg) has been shown to reduce hepatitis B virus (HBV) recurrence after liver transplantation (LT) and to decrease the frequency of acute cellular rejection (ACR). However, the protective role of HBIg against ACR remains controversial, since HBV infection has been also associated with a lower incidence of ACR. AIM: To assess the relationship between HBIg immunoprophylaxis and the incidence of rejection after LT. METHODS: 260 patients (158 males, 43 + or - 14 years old) submitted to LT were retrospectively evaluated and divided into three groups, according to the presence of HBsAg and the use of HBIg. Group I was comprised of HBsAg-positive patients (n = 12) that received HBIg for more than 6 months. Group II was comprised of HBsAg-positive patients that historically have not received HBIg or have been treated irregularly for less than 3 months (n = 10). Group III was composed of 238 HBsAg-negative subjects that have not received HBIg. RESULTS: HBIg-treated patients (group I) had significantly less ACR episodes, when compared to group II and III. No differences between groups II and III were observed. CONCLUSIONS: Long-term HBIg administration contributes independently to reduce the number of ACR episodes after LT
Subject(s)
Humans , Male , Female , Adult , Graft Rejection , Hepatitis B Antibodies , Hepatitis B, Chronic , Liver Transplantation , Receptors, Antigen, B-Cell , Antigens, Surface , Graft Rejection , Hepatitis B Antibodies , Hepatitis B, Chronic , Receptors, Antigen, B-Cell , Retrospective StudiesABSTRACT
A pressao portal (PP) apos o transplante de figado (Tx) e frequentemente avaliada por meio da pressao da veia hepatica ocluida (PVHO). Entretanto...
Subject(s)
Humans , Male , Female , Adolescent , Adult , Middle Aged , Budd-Chiari Syndrome , Portal Pressure , Liver Transplantation/adverse effects , Portal Vein , Catheterization , Linear Models , Prospective Studies , Liver CirculationABSTRACT
O transplante de fígado deve ser considerado em todo cirrótico que apresente sanagramento por varizes esofágicas. A indicaçäo ocorre quando surgem sinais de insuficiência hepática. Até este momento, o doente dever ser controlado clinicamente. O tratamento cirúrgico está indicado na emergência, na falha do conservador. A opçäo cirúrgica deve considerar a reserva funcional hepática e prever a necessidade do transplante. O advento das derivaçöes portosistêmicas intra-hepáticas transjugulares (TIPS) promete revolucionar o tratamento cirúrgico e, provavelmente, tornar-se o principal método de controle da recidiva hemorrágica até a realizaçäo do transplante
Subject(s)
Liver Cirrhosis/therapy , Gastrointestinal Hemorrhage/therapy , Liver Transplantation , Esophageal and Gastric Varices/surgeryABSTRACT
A esquistossomose hepatesplenica e uma das principais causas de hipertensao portal no Brasil, estimando-se a existencia de cerca de 1 milhao de pessoas com esta forma de doenca em nosso pais. A hemorragia por varizes gastresofagianas e a principal manifestacao da doenca e a indicacao do tratamento. A preservacao da funcao hepatica e a ineficacia do tratamento endoscopico justificam a opcao pelo tratamento cirurgico. Estudo prospectivo randomizado realizado em nosso Grupo levou a escolha da desconexao azigo-portal associada a esplenectomia como a opcao preferencial no tratamento da hipertensao portal na esquistossomose mansonica