Correlation between functional capacity and respiratory assessment of end-stage liver disease patients waiting for transplant.

INTRODUCTION: End-stage liver disease has metabolic complications associated with malnutrition, which involves a great loss of muscle mass. This complication can lead to changes in the diaphragm, which along with ascites may impair daily activities and result in global motor disability and physical inactivity of patients on the waiting list for liver transplantation. OBJECTIVES: This study sought to delineate the profile of candidates for liver transplantation while on the waiting list at the Clinical Hospital of State University Campinas (UNICAMP), and to assess and verify whether there is a correlation between functional status of the individuals tested using the 6-minute walk test (6MWT), pulmonary function test (PFT), and respiratory muscle strength with end-stage liver disease candidates for liver transplantation. METHODS: This study was carried out in the Liver Transplantation Unit of the State University of Campinas (UNICAMP). We included 46 patients with end-stage liver disease who underwent the following evaluations: medical history, 6MWT, PFT, maximal inspiratory pressure (MIP), and maximal expiratory pressure (MEP), and SF-36. RESULTS: Correlations were found between the respiratory variables 6MWT and PFT. The walked distance was correlated with MIP and MEP. There was no correlation between the 6MWT and the variables body mass index and age. CONCLUSION: Candidates for liver transplantation have decreased muscle strength, normal lung function, and impaired quality of life, mainly due to physical limitations. Functional status may be correlated with the respiratory assessment (muscle strength and pulmonary function test) in liver disease candidates for transplantation.

Effects of a respiratory physiotherapeutic program in liver transplantation candidates.

BACKGROUND: Candidates for liver transplantation may have malnutrition, fatigue, loss of muscle mass and function. The combination of these factors leads to overall physical disability and physical inactivity. OBJECTIVE: The aim of the study was to evaluate the effects of a respiratory physiotherapeutic program on liver transplantation candidates. METHOD: Forty-two patients were evaluated by respiratory muscle strength, surface electromyography of the rectus abdominis and diaphragm, and spirometry. We also applied the SF-36. The patients were divided into two groups: 12 randomly assigned to the control group and 5 in the intervention group. The intervention consisted of an explanatory and illustrative manual to be followed at home with diaphragmatic breathing exercises, diaphragmatic isometric exercise, Threshold IMT, lifting the upper limbs with a bat, and strengthening the abdominals. RESULTS: Significant difference was found between initial forced expiratory flow (FEF)25-75% (P = .042) and final FEF25-75 in the intervention group. The control group had significant difference (P = .036) in the diaphragm RMS between initial time and end time. In conclusion, the control group showed greater electrical activity of the diaphragm after 3 months. CONCLUSION: The intervention group benefited from the exercise, thus improving the FEF25-75%.

Evaluation of functional status, pulmonary capacity, body composition, and quality of life of end-stage liver disease patients who are candidates for liver surgery.

INTRODUCTION: Muscular weakness in combination with malnutrition can induce a global motor impairment and physical inactivity, adversely impairing the daily living activities and quality of life of end-stage liver disease patients who are candidates for liver transplantation. OBJECTIVES: To evaluate functional status, pulmonary capacity, body composition and quality of life in end-stage liver disease patients who are candidates for liver transplantation; to verify if there is a correlation between the functional variables of the individuals tested through the 6-minute walk test (6MWT) and covariables: pulmonary function test (PFP), quality of life and body composition. METHODS: This study was carried out at the Liver Transplantation Unit of the State University of Campinas (UNICAMP). We included 46 patients with end-stage liver disease who underwent the following evaluations: medical history, quality of life questionnaire "Short Form 36" (SF-36), surface electromyography (sEMG) of the diaphragm and rectus abdominis muscles, body composition assessment by electrical vioimpedance (BIA), 6MWT and PFP. RESULTS: Univariate analysis and Pearson's correlation found correlations between distance walked on 6MWT and QOL (P = .006 and P = .02) and TBW (P = .5 and P = .02). Pearson's correlation were found between respiratory variables of 6MWT, QOL, and PFP. CONCLUSION: The functional status may be correlated to body composition, quality of life and pulmonary capacity of patients with liver disease, candidates for transplantation.

Correlation between serum magnesium levels and hepatic encephalopathy in immediate post liver transplantation period.

UNLABELLED: Liver transplantation is a complex procedure that interferes with multiple body functions and can cause several complications. Studies have shown varying incidences of neurological complications (8% to 47%) including encephalopathy, as well as cerebrovascular problems, infections, and neurotoxicity induced by immunosuppressive drugs. The majority of these cases occur in the first week after surgery. OBJECTIVE: We sought to evaluate the correlation between serum magnesium levels and the development of encephalopathy in the immediate posttransplantation period. METHODS: We collected data from patients undergoing liver transplantation, both donors and recipients, from 2007 to 2009. Magnesium levels during the first week of hospitalization were compared to reference laboratory results. The West Haven criteria were used to classify whether if the patient experienced encephalopathy. RESULTS: Only the level of magnesium posttransplantation represented a risk for encephalopathy (P = .049). Lower magnesium levels increased the risk of encephalopathy (relative risk = 3.718; 95% confidence interval: 1.001-13.699). CONCLUSION: We verified the importance of low levels of magnesium as a predictive factor to increase the occurrence of encephalopathy after liver transplantation.

Neurological complications prevalence and long-term survival after liver transplantation.

INTRODUCTION: Neurological postsurgical complications are a significant cause of morbidity and mortality occur in transplant recipients impacting their survival. METHODS: We analyzed the medical records of 269 patients who underwent transplantation between 2000 and 2011, after application of the exclusion criteria Neurological complications were examined according to the period in which they appeared: immediate (1-30 day) early (31-180 days), and late (after 180 days). The survival analysis was based on the first complication. RESULTS: The majority of transplant recipients were males (73.2%) and white (97.1%) with an overall median age of 49 (range, 18-73) years. Regarding the etiology for transplantation, the most common causes were hepatitis C virus (56.5%) and alcohol (33.1%). Complications, appearing in 29.4% (immediate), 31.5% (early), and 39.1% (late) cases, were encephalopathy, confusion, tremors, headache, and stroke. Patients who had the first complication between 1 and 6 months showed greater mortality than those who had one after 6 months. CONCLUSIONS: Neurological complications led to longer hospital stays with greater early morbidity and mortality. Knowledge of these complications appears to be extremely important for the multidisciplinary transplantation team to decrease its prevalence as well as to diagnose and treat early.

Is isoniazid safe for liver transplant candidates with latent tuberculosis?

Isoniazid (INH) is recommended for tuberculosis prophylaxis in non-liver transplant recipients. However, there is a great reluctance to prescribe this agent for liver transplant candidates and recipients due to the risk of precipitating further hepatic decompensation. We analyzed the records of liver transplantation candidates undergoing a purified protein derivative (PPD) test (tuberculosis skin test) between 2008 and 2010. Patients with no respiratory symptoms, PPD test > 10 mm, and normal chest radiography were diagnosed as latent tuberculosis and prescribed INH (300 mg) per day for 6 months. The 191 patients submitted to a PPD test and those on tuberculosis prophylaxis underwent blood tests and clinical evaluations monthly to detect hepatotoxicity of patients The 33 subjects (17.2%) with a PPD test ≥ 10 mm displayed an average model for end-stage liver disease score of 20 (range: 9-29) and child-Pugh A/B score. The main causes for liver disease were chronic hepatitis C, hepatocellular carcinoma, and alcohol abuse. Among 27 patients who received INH, 18 (66.6%) completed 6 months of prophylaxis. Eight who had shorter treatment courses of 2 to 4 months had undergone transplantation. One patient had to stop treatment because of clinical decompensation due to spontaneous bacterial peritonitis without a transaminases elevation. Six patients did not receive INH: previous tuberculosis treatment, transplantation before initiating prophylaxis, or removal from the liver candidacy list. No patient showed clinical decompensation or laboratory abnormalities associated with use of INH. The average values of alanine aminotransferase pre- and posttreatment were similar (69 and 72 U/l respectively), demonstrating that tuberculosis prophylaxis with INH was safe for liver transplant candidates.

Serological profile of pretransplantation liver patients.

INTRODUCTION: A liver transplantation is the first choice of treatment for patients with hepatic insufficiency due to chronic diseases. Infections in the postoperative period represent one of the main causes of mortality in these cases. However, few articles have evaluated the predominance of certain infectious diseases and their influence on postoperative mortality. METHODS: We retrospectively evaluated the medical records of 236 patients who underwent liver transplantation from January 1997 to January 2007. In these records we checked the serological profiles for these diseases: toxoplasmosis, syphilis, human T lymphotropic virus (HTLV) I and II infection, Chagas disease, hepatitis A, hepatitis B, hepatitis C, paracoccidioidomycosis, tuberculosis, acquired immunodeficiency syndrome, cytomegalovirus (CMV), and mononucleosis (Epstein-Barr virus [EBV]). The statistical analysis was performed by table frequencies. RESULTS: CMV showed positivity (CMV-IgG) in 94.7% of patients, 95.8% for EBV, 33.3% for toxoplasmosis, 47.9% for hepatitis C, and 5% for hepatitis B. CONCLUSION: Our analysis showed the importance of serological investigations and diagnostic examinations before the transplantation procedure, seeking to minimize possible reactivation of the disease after the use of immunosuppression drugs, particularly in the first 6 months after transplantation, or even to avoid a primary infection.

Survival analysis of obese patients undergoing liver transplantation.

INTRODUCTION: The influence of preoperative obesity in liver transplanted patients remains undetermined. OBJECTIVE: To analyze the survival of obese patients undergoing liver transplantation. METHODS: We calculated the body mass index (BMI; kg/m2) of 244 liver transplantation patients. All transplantations were performed from September 1991 to December 2006. The patients were divided according to the BMI values: nonobese (NO) patients (BMI<30) and obese (O) patients (BMI>30). Pre- and postoperative data were used. The following statistical tests were employed: Student's t test, Kaplan-Meier survival, and Cox-Mantel tests. RESULTS: Group O was composed of 38 individuals (15.3%) with BMI of 33.1, and the BMI of NO was 24. Group O showed an average age of 50.1 years and group NO, 45.5 years (P<.05). Group O postoperative creatinine was higher (P=.001). Both groups had similar MELD scores with an average of 17.5+/-5.9. According to the Child-Pugh classification, group NO included 140 (69.6%) B and 61 (30.3%) C patients; group O, 8 (21%) B and 30 (79%) C patients. There were no significant differences between the groups when comparing cold and warm ischemia times, surgical times, intensive care stay, or blood requirements. The actuarial survivals after 1 and 5 years were 61.3% and 51% for group O and 68% and 47% for NO group (P>.05). A Cox proportional hazard analysis showed that the survival time in this study was related to red blood cell transfusions, recipient sodium, MELD score, donor sodium, and age. Recipient age was a main factor in multiple regression analysis for obese patients in this study. CONCLUSION: There was no significant difference between O and NO for the 1-year and long-term survivals, but older patients displayed lower survival times.