ABSTRACT
ABSTRACT Background: The emergence of potent combined highly active antiretroviral therapy (ART) in 1996 changed the natural history of HIV infection, with a significant reduction in mortality due to opportunistic infections but increased morbidity due to chronic cardiovascular, hepatic, and renal diseases. In May 2016, a reference center for liver transplantation in the Northeast of Brazil performed the first liver transplantations (LT) in HIV patients, with five others until 2021. Methods: The criteria for selection of LT were good adherence and absence of resistance to ART, HIV viral load maximum suppression, T-CD4+ lymphocyte count of more than 100 cells/mm3, and absence of opportunistic infections in the last 6 months. Results: Six liver transplants were performed between May 2016 and May 2021, five men, with a mean age of 53.2 years, and one was a diabetic patient. All patients had access to grafts with short cold ischemia with a mean time of 5 hours and 39 minutes. The 4-month survival rate was 100%, with a range time of follow-up of 4-63 months (mean time of 31 months). The mean pre-transplant T-CD4+ lymphocyte count was 436 cells/mm3. The mean length of hospital stay after transplantation was 16.8 days. One patient presented precocious vena cava thrombosis; another had stenosis of cavocaval anastomosis leading to refractory ascites, renal failure and post-transplant graft dysfunction, and another presented stenosis of choledochal anastomosis. Immunosuppression and prophylaxis were used according to standard protocols, and there were no differences in the profile of infections or rejection after liver transplantation. Conclusion: This case series documents good survival and usual transplant procedures for confirmed HIV cases.
RESUMO Contexto: A emergência da terapia antirretroviral de alta potência, em 1996, mudou a história natural da infecção por HIV, com redução significativa de mortalidade por infecções oportunistas, mas com aumento de morbidade por doenças crônicas cardiovasculares, hepáticas e renais. Em maio de 2016, um centro de referência em transplante hepático no Nordeste do Brasil realizou o primeiro transplante hepático em portadores de HIV, com cinco outros até 2021. Métodos: Os critérios de seleção para o transplante hepático foram: boa aderência e ausência de resistência à terapia antirretroviral, carga viral indetectável, contagem de linfócitos T-CD4+ acima de 100/ mm3 e ausência de infecções oportunistas nos últimos 6 meses. Resultados: Seis transplantes hepáticos foram feitos em portadores de HIV entre maio de 2016 e maio de 2021, cinco homens, com idade média de 53,2 anos, um paciente diabético. Todos os pacientes tiveram acesso a enxertos com tempo de isquemia fria curto com média de 5 horas e 39 minutos. A sobrevida em 4 meses foi de 100%, com tempo de acompanhamento de 4-63 meses (média de 31 meses). A contagem média de linfócitos T-CD4+ pré-transplante foi de 436 células/ mm3. A média de tempo de internação foi de 16,8 dias. Um paciente teve trombose de veia cava proximal; outro teve estenose de anastomose cavo-caval, levando à ascite refratária, falência renal e disfunção de enxerto pós-transplante; e outro teve estenose de anastomose do colédoco. A imunossupressão e a profilaxia foram usadas de acordo com protocolos padrão e não houve diferenças no perfil de infecções ou de rejeição pós-transplante. Conclusão: Esta casuística ilustra que o transplante de fígado em portadores do HIV apresenta complicações usuais e sobrevida satisfatória.
ABSTRACT
SUMMARY OBJECTIVE: Brazil ranks second in gross numbers of kidney and liver transplantations, but deceased organ donation is still far below the national demand for organs. Apart from a high family refusal rate, another significant barrier is healthcare workers' inappropriate knowledge concerning organ donation and transplantation. Since most of them have recently graduated from university, this study aimed to evaluate the awareness and attitudes of medical students concerning organ donation. METHODS: Between August and September 2021, a web-based survey with 10 overlapping questions was sent to medical students from several Brazilian universities after advertisements on social media. RESULTS: A total of 391 (60% female, mean age: 23 [17-41] years) students answered the survey. Most of them (91%) would like to donate organs in case of death, and 75% have already notified their family. The main reasons for not becoming a donor were fear of body manipulation (n=3) or family reaction (n=2) and religious reasons (n=2). When inquired, 54% were unaware of brain death criteria, and half of them claimed to have never discussed the topic in medical classes. Except for Glasgow coma scale (97%), pupillary (72%), and corneal (53%) reflexes, less than 25% knew other reflexes required for brain death diagnosis. CONCLUSION: Most medical students declared themselves as organ donors, and most informed their families. However, many students have never learned about crucial steps toward organ donation, which may impact their adequate recognition of potential organ donors later in life.
ABSTRACT
ABSTRACT - BACKGROUND: Hydatidosis is a rare and endemic parasitic disease in Brazil that causes the proliferation of cysts mainly in the liver, leading to many complications, such as compression of vessels and biliary ducts, liver failure, portal hypertension, and cirrhosis. The treatment of choice is the resection of the lesions combined with albendazole therapy. This disease is a rare indication for liver transplantation, a feasible treatment option in more advanced stages. AIM: The purpose of this study was to describe two cases of patients from northern Brazil who underwent liver transplantation due to hepatic hydatidosis. METHODS: This is a retrospective study with data collected from medical records. RESULTS: Case 1: A 51-year-old female patient presented pain in the right hypochondriac, dyspepsia, consumptive syndrome, and obstructive jaundice, with a previous diagnosis of Caroli's disease with no possibility of surgical resection and a MELD score of 24. She underwent liver transplantation, and the anatomopathological result demonstrated hydatidosis. Case 2: A 52-year-old female patient presented multiple episodes of cholangitis in 30 years, with three liver resections and clinical treatment with albendazole for hydatidosis. She underwent liver transplantation due to recurrent cholangitis with a MELD score of 20. Both patients underwent post-transplant clinical therapy with albendazole, had good outcomes, and remain in follow-up without complications after 5 and 96 months, respectively. CONCLUSION: The patients benefited from the procedure and have a good prognosis due to the absence of metastasis, early reintroduction of antiparasitic drugs, and continuous follow-up.
RESUMO - RACIONAL: A hidatidose é uma doença parasitária rara, endêmica no Brasil, que causa a proliferação de cistos, principalmente no fígado, levando a muitas complicações, como compressão de vasos e ductos biliares, hipertensão portal e cirrose. O tratamento ideal é a ressecção cirúrgica das lesões combinada à terapia com albendazol. Essa doença é uma rara indicação para o transplante hepático, que é um possível tratamento para estágios avançados. OBJETIVO: Descrever dois casos de pacientes provenientes da região Norte do Brasil, que foram submetidos a transplante hepático por hidatidose hepática. MÉTODOS: Estudo retrospectivo com coleta de dados de prontuários. RESULTADOS: Caso 1: Paciente do sexo feminino de 51 anos, apresentava dor em hipocôndrio direito, sintomas dispépticos, síndrome consumptiva e icterícia obstrutiva, com diagnóstico inicial de doença de Caroli sem possibilidade de ressecção cirúrgica e com MELD 24. Foi submetida a transplante hepático, e o resultado anatomopatológico do explante evidenciou hidatidose. Caso 2: Paciente do sexo feminino de 52 anos, apresentava há cerca de 30 anos, múltiplos episódios de colangite, com realização de três ressecções hepáticas e tratamento clínico com albendazol para hidatidose. Foi submetida a transplante hepático por equinococose alveolar difusa, com situação especial por colangite de repetição, com MELD 20. Ambas fizeram tratamento clínico pós transplante com albendazol, apresentaram boas evoluções e permanecem em acompanhamento sem complicações após 5 e 96 meses, respectivamente. CONCLUSÃO: As pacientes se beneficiaram do procedimento e têm bom prognóstico, devido à ausência de metástases, reintrodução precoce das drogas antiparasitárias e acompanhamento contínuo.