Intensified blood glucose treatment in diabetic patients undergoing a liver transplant: impact on graft evolution at 3 months and at 5 years.

PURPOSE: The debate about the impact of intensified hyperglycemia treatment is still ranging. The main objective was to assess whether intensive glycemic control in hospitalized diabetic patients undergoing a liver transplant is associated with a lower rate of graft rejection at 3 months and at 5 years post-transplant. METHODS: Cross-sectional study comparing a cohort of patients undergoing liver transplant in 2010 and 2011, in whom an intensive insulin protocol was applied, with a retrospective group of patients undergoing a liver transplant in 2005 and 2006, in whom a conventional insulin protocol was applied. Both diabetics and non-diabetics were compared. As intensive insulin therapy is applied mainly in diabetic patients, it is expected that, when comparing both periods, the treatment would only benefit those patients. RESULTS: The logistic regression model showed a statistically significant interaction between the treatment group and the presence of diabetes for the rejection rate 3 months and 5 years post-transplant. At both time points, the intensive insulin treatment group had lower rejection rates in the case of diabetic patients, which did not occur in non-diabetic patients. CONCLUSIONS: Our study shows a decrease in the rate of liver graft rejection in diabetic patients undergoing intensive insulin treatment.

Donor-derived Strongyloides stercoralis hyperinfection syndrome after simultaneous kidney/pancreas transplantation.

Most cases of strongyloidiasis associated with solid organ transplantation have been due to the reactivation of a latent infection in the recipient as a result of the immunosuppressive therapy; however, donor-derived infections are becoming increasingly frequent. The case of a patient who nearly died of a Strongyloides stercoralis hyperinfection after receiving simultaneous kidney/pancreas transplants is described herein. No specific parasitological tests were performed pre-transplantation, despite the fact that both the recipient and the donor originated from endemic areas. Serological analysis of the donor's serum performed retrospectively revealed the origin of the infection, which if it had been done beforehand would have prevented the serious complications. Current practice guidelines need to be updated to incorporate immunological and molecular techniques for the rapid screening of Strongyloides prior to transplantation, and empirical treatment with ivermectin should be applied systematically when there is the slightest risk of infection in the donor or recipient.

Importance of technical aspects in the beginnings of a pancreas transplantation program.

Pancreas and kidney transplantation is the treatment of choice for patients with type 1 diabetes mellitus and terminal renal insufficiency. Herein we have presented a series of 35 patients transplanted between 2002 and 2009 including periods before and after 2007 divided based on introduction of some technical aspects. In the first phase (learning period) we have noted complications related to pancreatic surgery with a morbidity among 12 of 18 patients (66.6%). In the second period (stabilization period), complications appeared in 6 out of 17 patients (35.2%; P < .028). The reoperation rate was 83.3% in the learning period and 23.5% in the stabilization period (P < .03). Seven transplantectomies were performed in the first period (P < .004). Five patients died, all of them in the learning group (P < .019). Changes in the technical aspects of the procedure were responsible for improved outcomes obtained among pancreas and kidney transplantations.

Indications for and results of liver retransplantation.

Liver retransplantation (LReTx) is the therapeutic option for the irreversible failure of a hepatic graft. Our aim was to evaluate the rate of and indications for LReTx and actuarial patient survivals. Among 1260 LTx were 79 LReTx (6.3%). During the first LTx, there were no apparent differences between patients who did or did not required LReTx. The most frequent reasons were hepatic artery thrombosis (31.6%), recurrence of the VHC cirrhosis (30.4%), and primary graft failure (21.5%). The actuarial survivals at 1 and 5 years were 83% and 69% among those without LReTx versus 71% and 61% among early LReTx, and 64% and 34% among late LReTx (P < .001). Although there exists high morbidity and mortality with LReTx, it seems that this therapeutic alternative continues to be valid for patients with early hepatic loss, but not when the graft loss was late. It becomes necessary to define the minimal acceptable results that patient can benefit from LReTx.

[Malignant tumors of the Vater's ampulla. Presentation of 28 cases and review of the literature]. / Tumores malignos de la ampolla de Vater. Presentación de 28 cases y revisión de la literatura.

We present a study of 28 patients, treated for adenocarcinoma of Vater's ampulla. We emphasize the distinct behavior of each one of the peri-ampullar tumors, those which affect Vater's ampulla yielding the best prognosis. We gathered data regarding gender, age, clinical manifestations, and analytical data. The confirmatory diagnosis gives us 100% of CPRE cases. All of the patients were submitted to surgical treatment with anatomic pathological confirmation of the diagnosis, be it pre or postoperative. We practiced curative surgery in 57.2% of the cases and palliative in 42.8% of the cases. We observed postoperative complications in 17.8% of the patients and peroperative mortality in 3.5%. Actual survival of the series of patients for whom exeretic surgery was performed is significantly superior to that of the other patients.