Blood salvage and autotransfusion during orthotopic liver transplantation for hepatocellular carcinoma: A systematic review and meta-analysis.

BACKGROUND: Hepatocellular carcinoma (HCC) is a significant cause of oncologic mortality worldwide. Liver transplantation represents a curative option for patients with significant liver dysfunction and absence of metastases. However, this therapeutic option is associated with significant blood loss and frequently requires various transfusions and intraoperative blood salvage for autotransfusion (IBS-AT) with or without a leukocyte reduction filter. This study aimed to analyze available evidence on long-term oncologic outcomes of patients undergoing liver transplantation for HCC with and without IBS-AT. METHODS: Per PRISMA guidelines, a systematic review of keywords "Blood Salvage," "Auto-transfusion," "Hepatocellular carcinoma," and "Liver-transplant" was conducted in PubMed, EMBASE, and SCOPUS. Studies comparing operative and postoperative outcomes were screened and analyzed for review. RESULTS: Twelve studies totaling 1704 participants were included for analysis. Length of stay, recurrence rates, and overall survival were not different between IBS-AT group and non IBS-AT group. CONCLUSION: IBS-AT use is not associated with increased risk of recurrence in liver transplant for HCC even without leukocyte filtration. Both operative and postoperative outcomes are similar between groups. Comparison of analyzed studies suggest that IBS-AT is safe for use during liver transplant for HCC.

Percutaneous Balloon Dilatation for Hepaticojejunostomy Stricture Following Paediatric Liver Transplantation: Long-Term Results of an Institutional "Three-Session" Protocol.

PURPOSE: The aim of this study was to report the long-term results of an institutional protocol of percutaneous biliary balloon dilatation (PBBD) on paediatric patients with benign anastomotic stricture after liver transplantation. As a secondary objective, we evaluated risk factors associated with post-treatment re-stricture. MATERIALS AND METHODS: Fourteen paediatric, post-liver transplant patients with benign anastomotic stricture of Roux-en-Y hepaticojejunostomy were included. All patients underwent the same treatment protocol of three PBBD procedures with 15-day intervals. Clinical outcome was analysed using the Terblanche classification. Primary patency rate was assessed with the Kaplan-Meier test. RESULTS: All patients had an initial successful result (Terblanche grade, excellent/good) after PBBD. At the end of the follow-up time of 35.7 ± 21.1 months (CI95%, 23.5-47.9), 10 patients persisted with excellent/good grading, while the remaining 4 had re-stricture, all of the latter occurring within the first 19 months. Patency rate after percutaneous treatment at 1, 3, and 5 years were 85.7%, 70%, and 70%, respectively. History of major complication after liver transplantation was associated with 5 times higher risk of re-stricture, HR 5.48 [95% CI, 2.18-8.78], p = 0.018. CONCLUSION: In paediatric patients with benign anastomotic stricture of hepaticojejunostomy after liver transplantation, the "Three-session" percutaneous biliary balloon dilatation protocol is associated with a high rate of long-term success. In this limited series, the history of post-liver transplant major complication, defined as complications requiring a reintervention under general anaesthesia or advanced life support, seems to be an independent risk factor for stricture recurrence.

Care transition for liver transplanted patients during the Covid-19 pandemic / Transición del cuidado de pacientes sometidos a transplante hepático durante la pandemia del Covid-19 / Transição do cuidado de pacientes submetidos ao transplante hepático durante a pandemia da Covid-19

ABSTRACT Objective: to submit the experience lived in the care transition for hospital discharge of patients undergoing liver transplantation due to the COVID-19 pandemic. Method: an experience report on hospital discharge planning and care transition for patients undergoing liver transplantation at a teaching hospital. Results: after COVID-19 pandemic has been declared, several technological means were used to support self-care strategies at the time of the hospital-home transition, as well as remote care for patients focusing on doubts about the routine of care and treatments. In addition, new counterreferral strategies were structured, prioritizing safety and social isolation. Conclusion: the adjustments in care transition with the support of the technologies provided transplanted patients access to all the information that guides self-care. Likewise, they regulated the flow of the support network and the health network, decreasing the possibility for COVID-19 spread, infection and development.

RESUMEN Objetivo: presentar la experiencia en la transición del cuidado para el alta hospitalaria de pacientes sometidos a trasplante hepático en vistas de la pandemia del COVID-19. Método: informe de experiencia sobre la planificación del alta hospitalaria y la transición del cuidado de pacientes sometidos a trasplante hepático en un hospital escuela. Resultados: después de declarada la pandemia del COVID-19 se utilizaron diversos medios tecnológicos para respaldar las estrategias de autocuidado al momento de la transición entre el hospital y el domicilio, al igual que la asistencia remota a los pacientes enfocada en dudas acerca de la rutina de cuidados y tratamientos. También se estructuraron nuevas estrategias de contra-derivación, priorizando la seguridad y el aislamiento social. Conclusión: los ajustes en la transición del cuidado con el respaldo de las tecnologías viabilizaron el acceso de los pacientes trasplantados a todas las informaciones que guían el autocuidado. De igual manera, regularon el flujo de la red de apoyo y de la red de salud, reduciendo así la posibilidad de propagación, infección y desarrollo del COVID-19.

RESUMO Objetivo: apresentar a experiência vivenciada na transição do cuidado para alta hospitalar de pacientes submetidos ao transplante hepático em razão da pandemia da COVID-19. Método: relato de experiência sobre planejamento da alta hospitalar e transição do cuidado de pacientes submetidos ao transplante hepático em um hospital-escola. Resultados: após a declaração da pandemia da COVID-19 foram utilizados diversos meios tecnológicos para apoiar as estratégias de autocuidado no momento da transição entre hospital e domicílio. Assim como, atendimento remoto aos pacientes com foco em dúvidas acerca da rotina de cuidados e tratamentos. Além disso, novas estratégias de contrarreferência foram estruturadas, priorizando a segurança e o isolamento social. Conclusão: os ajustes na transição de cuidado com apoio das tecnologias oportunizaram acesso aos pacientes transplantados a todas as informações que orientam o autocuidado. Igualmente, regularam o fluxo da rede de apoio e rede de saúde, diminuindo a possibilidade de propagação, infecção e desenvolvimento da COVID-19.

Liver Transplant Complications Radiologist Can't Miss.

Liver transplantation is considered the ideal and definitive therapy for patients with end-stage liver disease. Since 1963 advances in liver transplant surgical techniques and immunosuppressive therapies have improved outcomes and patients' survival. However, early diagnosis of graft dysfunction, through different imaging modalities, is crucial for graft survival. Imaging plays a fundamental role before, during and after the transplantation process. In this review, we will discuss the importance of imaging in the diagnosis of vascular and biliary post-transplant complications through different imaging modalities such as Doppler ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI).

Acute-on-Chronic Liver Failure: A Portuguese Single-Center Reference Review.

Acute-on-chronic liver failure (ACLF) is a syndrome characterized by an acute deterioration of a patient with cirrhosis, frequently associated with multi-organ failure and a high short-term mortality rate. We present a retrospective study that aims to characterize the presentation, evolution, and outcome of patients diagnosed with ACLF at our center over the last 3 years, with a comparative analysis between the group of patients that had ACLF precipitated by infectious insults of bacterial origin and the group of those with ACLF triggered by a nonbacterial infectious insult; the incidence of acute kidney injury and its impact on the prognosis of ACLF was also analyzed. Twenty-nine patients were enrolled, the majority of them being male (89.6%), and the mean age was 53 years. Fourteen patients (48.3%) developed ACLF due to a bacterial infectious event, and 9 of them died (64.2%, overall mortality rate 31%); however, no statistical significance was found (p < 0.7). Of the remaining 15 patients (51.7%) with noninfectious triggers, 11 died (73.3%, overall mortality rate 37.9%); again there was no statistical significance (p < 0.7). Twenty-four patients (83%) developed acute kidney injury (overall mortality rate 65.5%; p < 0.022) at the 28-day and 90-day follow-up. Twelve patients had acute kidney injury requiring renal replacement therapy (41.37%; overall mortality rate 37.9%; p < 0.043). Hepatic transplant was performed in 3 patients, with a 100% survival at the 28-day and 90-day follow-up (p < 0.023). Higher grades of ACLF were associated with increased mortality (p < 0.02; overall mortality 69%). CONCLUSIONS: ACLF is a heterogeneous syndrome with a variety of precipitant factors and different grades of extrahepatic involvement. Most cases will have some degree of renal dysfunction, with an increased risk of mortality. Hepatic transplant is an efficient form of therapy for this syndrome.

A Doença Hepática Crónica Agudizada/Falência é um síndrome caracterizado por uma deterioração aguda de um doente com cirrose, frequentemente associada com falência multiorgânica e elevada mortalidade a curto prazo. Apresentamos estudo retrospetivo que teve como objetivo caracterizar a apresentação, evolução e prognóstico de doentes diagnosticados com Doença Hepática Crónica Agudizada/Falência no nosso Centro nos últimos 3 anos, comparando o grupo de doentes que tiveram Doença Hepática Crónica provocada por infeções bacterianas e os doentes com Doença Hepática Crónica Agudizada/Falência desencadeada por precipitantes que não a infeção bacteriana; foi também analisada a incidência de lesão renal aguda e o seu impacto no prognóstico na Doença Hepática Crónica Agudizada/Falência. Vinte e nove doente foram incluídos no estudo, a maioria do género masculino (89.6%), idade media de 53 anos. Catorze doentes (48.3%) desenvolveram Doença Hepática Crónica Agudizada devido a infeção bacteriana, 9 dos quais faleceram (64.2%, mortalidade global 31%), contudo, sem significado estatístico (p < 0.7); dos restantes 15 (51.7%) sem infeção bacteriana, 11 faleceram (73.3%, mortalidade global 37.9%), também sem significado estatístico (p < 0.7%). Vinte e quatro doentes (83%) desenvolveram lesão renal, mortalidade global de 65.5% (p < 0.022) aos 28 e 90 dias de seguimento. Doze doentes desenvolveram lesão renal aguda com necessidade de terapêutica de substituição da função renal (41.37%), mortalidade global de 37.9% (p < 0.043). O transplante hepático foi realizado em 3 doentes, com uma sobrevida de 100% aos 28 e 90 dias de seguimento (p < 0.023); Graus elevados de Doença Hepática Crónica Agudizada estão associadas a mortalidade mais elevada (p < 0.02); mortalidade global de 69%. CONCLUSIONS: A Doença Hepática Crónica Agudizada é um síndrome heterogéneo, com uma variedade de fatores precipitantes e diferentes graus de envolvimento extra-hepático; a maioria das situações estará associada a disfunção renal, com aumento do risco de mortalidade; O transplante hepático será uma eficaz de tratamento deste síndrome.

Successful liver transplantation for non-resectable desmoplastic nested spindle cell tumor complicated by Cushing's syndrome.

Desmoplastic spindle cell tumors of liver are rare tumors of low malignant potential characterized by well-demarcated nests of spindle and epithelioid cells in a dense desmoplastic stroma. While surgery remains the definitive treatment, there have been reports of tumor recurrence locally and metastasis which respond poorly to chemotherapy. Hepatic transplant has been attempted in cases of recurrence or large size of primary tumor. Long-term follow-up and imaging surveillance are required as these tumors have shown a tendency for recurrence many years after initial therapy.

Redução do MELD em pacientes na lista de transplante hepático após o uso de aminoácidos de cadeia ramificada: relato de caso / Reduction of MELD in patients on the liver transplant list after using chain amino acids: case report

A cirrose hepática (CH) é uma doença com altas taxas de mortalidade e que apresenta, como único tratamento definitivo, o transplante hepático (TH). Infelizmente, nem todos os pacientes têm acesso ao TH e muitos acabam morrendo ainda na lista de transplante. O uso de aminoácidos de cadeia ramificada (AACR) já é amplamente conhecido como tratamento eficaz para a melhora da qualidade de vida destes pacientes. Neste relato, pela primeira vez, documentou-se uma grande melhora clínica e laboratorial em um paciente após o tratamento com AACR, que permitiu ao paciente sair inclusive da lista de transplante. Além da diminuição do escore MELD, houve reestabilização do peso corporal e melhora da qualidade de vida, documentada pelo questionário SF-36.

Liver cirrhosis (LC) is a disease with high mortality rates and its only definitive treatment is the orthotopic liver transplantation (OLT). Unfortunately, not all patients have access to OLT and many of them end up dying on the transplant waiting list. The use of branched chain amino acids (BCAA) is widely known as an effective treatment for improving the quality of life of these patients. For the first time, in this paper we documented a great improvement of clinical and laboratorial tests of a patient treated with BCAA, which allowed him to be out of the transplant waiting list. In addition to the increase of the MELD score, the patient achieved restabilization of body weight and recovery of the quality of life registered by the SF-36 questionnaire.

Serviço social e transplante hepático pediátrico: o perfil sociocultural das famílias avaliadas e a intervenção do assistente social nas contra-indicações sociais para o transplante / Social service and pediatric hepatic transplant: the sociocultural profile of the evaluated families and the intervention of the social worker on the social contraindications for transplant

Introdução: Trabalhar os aspectos sociais que podem comprometer a adesão ao tratamento pós-transplante é um dos cuidados da equipe do Programa de Transplante Hepático Infantil (PTHI) do Hospital de Clínicas de Porto Alegre. O serviço social possui um protocolo de avaliação e trabalha em parceria com a rede de apoio do paciente pediátrico, otimizando a sua entrada em lista de espera para transplante hepático após o equacionamento dos principais problemas sociais. Objetivo: Traçar o perfil sociocultural dos pacientes atendidos e mostrar a intervenção do serviço social nas principais contra-indicações sociais para o transplante. Método: Foi realizada pesquisa documental nos protocolos de avaliação utilizados para avaliar 22 famílias de crianças candidatas ao transplante, encaminhadas ao serviço social no período de janeiro de 2006 a janeiro de 2007. Resultados: Os resultados mostram que 81,8% das famílias apresentam baixa renda. Contudo, o trabalho desenvolvido pela assistente social junto a essas famílias viabilizou que 90,9% das crianças tivessem seus nomes incluídos nas listas para transplante hepático. Conclusão: A partir dos resultados, torna-se evidente a necessidade do olhar social sobre a questão dos transplantes de órgãos, considerando a complexidade do procedimento e o perfil das famílias atendidas. Trabalhar em parceria com a rede social de apoio do paciente é fundamental para o trabalho social junto a famílias de baixa renda, que somam a essa condição a ausência de saúde e a indicação de transplante.

Background: To find solutions for the social problems that could hinder compliance with posttransplant treatment is one of the concerns of the Program of Pediatric Hepatic Transplant (PTHI) from Hospital de Clínicas of Porto Alegre. The social service team uses an evaluation protocol and works along with a support network for pediatric patients, optimizing their inclusion on the waiting list for hepatic transplant after evaluation of the main social problems. Objective: To provide information on the sociocultural profile of the families and to present the intervention of the social service team on the main social contraindication for transplant. Methods: The protocols used to evaluate 22 families of young candidates for transplant who were referred to social service between January 2006 and January 2007 were reviewed. Results: The results showed that despite the low income of 81.8% of the families, the work done by the social service team enabled 90.0% of the children to be included on the waiting list for hepatic transplant. Conclusion: Based on the results, the need of a social intervention on the aspects related to organ transplantation becomes evident, considering the complexity of the procedure and the profile of the families. Working in partnership with a social support network is vital for the social work involving low-income families who, in addition to the economic difficulties, have to deal with poor health and transplant indication.

Retrasplante hepático: primer reporte en México / Liver retransplantation: first report in Mexico

Introducción: La única opción terapéutica para pacientes con falla del injerto hepático es el retrasplante. En México todavía es escaso el número de trasplantes hepáticos y menos aún de retrasplantes. Caso clínico: Hombre de 32 años de edad, trasplantado inicialmente por cirrosis hepática secundaria a colangitis esclerosante primaria y virus de la hepatitis C y retrasplantado después a los cuatro meses 18 días por rechazo severo del injerto que no respondió a inmunosupresión de rescate. El paciente estuvo en buen estado y su evolución fue satisfactoria después de tres años cuatro meses. Describimos su evolución clínica.

BACKGROUND: The only therapeutic option for patients with hepatic graft failure is retransplant. In Mexico, the number of hepatic transplants is scarce and is even less for retransplants. There are no reports of patients with good results after hepatic retransplant. Here we present the first published case. CLINICAL CASE: We present the case of a 32-year-old male who was transplanted initially for secondary hepatic cirrhosis, sclerosing primary cholangitis and hepatitis C and retransplanted 4 months and 18 days later for severe rejection of the transplant that did not respond to rescue immunosuppressant therapy. After 3 years, 4 months and 4 days the patient shows a good general status. We describe the patient's clinical evolution.

Hepatitis B y trasplante hepático / Hepatitis B and Hepatic Transplant

El trasplante hepático es una opción de tratamiento para los pacientes con enfermedad hepatica terminal por HBV. El uso de HBIg disminuye el riesgo de reinfección.

The liver transplantation is one of the possible treatments for those end-stage patients with liver diseasse for HBV. The use of HBIg lowers the risk of reinfection.

Linfoma não-Hodgkin em crianças com imunodeficiência: relato de cinco casos / Non-Hodgkin's lymphoma in children with immunodeficiency: report of five cases

Neste estudo é relatado o quadro clínico de cinco crianças com linfoma não-Hodgkin secundário a imunodeficiência ou imunossupressão: três portadoras do vírus da imunodeficiência humana, uma com imunodeficiência primária e uma após transplante hepático. De acordo com a classificação atual, os tipos histológicos foram: linfoma linfoblástico de células B precursoras (2), linfoma cutâneo de grandes células anaplásico (1), linfoma de células B periféricas, sugestivo de Burkitt (1), e linfoma linfoblástico de células T precursoras (1). Todos os pacientes foram submetidos a quimioterapia, sendo que dois estão em remissão clínica, dois morreram e um continua em tratamento. Após a introdução da terapia anti-retroviral combinada e o aumento dos transplantes de órgãos sólidos ocorre maior risco de neoplasia nesses pacientes. Desse modo, é importante o seguimento desses pacientes para determinar os fatores de risco para o desenvolvimento de neoplasias e definir adequada estratégia de tratamento.

The outcomes of five children with non-Hodgkin's lymphomas associated with immunodeficiency or immunosuppression is reported: three children with HIV, one with primary immunodeficiency and one after liver transplantation. According to the REAL classification, two patients had precursor B-lymphoblastic lymphomas, one had an anaplastic large cell lymphoma, one had a peripheral B-cell neoplasm suggestive of Burkitt's lymphoma, and one had precursor T-lymphoblastic lymphoma. All patients received chemotherapy. Two are in complete remission, two died and one remains under treatment. There has been an increasing awareness of the risk of non-Hodgkin's lymphoma and lymphoproliferative disorders after active antiretroviral therapy and with the expansion of solid organ transplant programs in the pediatric setting. Thus, for these patients it is important to establish risk factors for hematological disorders and determine the optimal and safest treatment.

Hamartoma mesenquimal del hígado gigante irresecable a propósito de un caso

Se reporta el caso de una paciente femenina de 21 años con diagnóstico de hamartoma mesenquimal del hígado gigante sintomático, como presentación inusual en pacientes adultos jóvenes, con tratamiento único definitivo el trasplante hepático debido al tamaño y localización anatómica del tumor. Se revisa la literatura relativa a casos reportados según edad más frecuente, métodos diagnósticos y tratamiento quirúrgico utilizados para esta patología excepcional en adultos. Palabras clave: hamartoma mesenquimal del hígado, trasplante hepático gigante.

The case of a 21 years old female patient with the diagnosis of symptomatic Gigantic Mesenchymal Hamartoma of the Liver is reported as an unusual presentation in young adult patients, with liver transplant as the only therapeutic option due to the size and anatomical location of the tumor. The literature is reviewed in relation to cases reported according to age, diagnostic methods and surgical treatment, for this exceptional pathology in adults.

Post-transplant hepatic complications: Imaging findings.

Transplantation is considered definitive therapy for acute or chronic irreversible pathologies of the liver, and the increased survival rates are mainly due to improved immunosuppressive therapies and surgical techniques. However, early diagnosis of possible graft dysfunction is crucial to liver graft survival. Diagnostic imaging plays an important role in the evaluation of the liver before and after transplant and in the detection of complications such as vascular and biliary diseases, acute and chronic rejection and neoplastic recurrence. Integrated imaging using color-Doppler, CT, MRI and traditional x-ray reach a high level of sensitivity and specificity in the management of transplanted patients.

SommarioIl trapianto epatico è il migliore trattamento per l'insufficenza epatica terminale.Il miglioramento della sopravvivenza postoperatoria è dovuta soprattutto al perfezionamento della terapia immunosoppressiva e delle tecniche chirurgiche.L'imaging radiologico riveste un ruolo importante sia per la valutazione preoperatoria dei pazienti, identificando eventuali varianti anatomiche che richiedono una modifica della tecnica chirurgica, sia per la diagnosi e la terapia precoce delle complicanze post trapianto, contribuendo alla riduzione della mortalità e della morbilità.