Combined liver and kidney transplantation in a multicenter transplantation program in Chile.

INTRODUCTION: Combined liver and kidney transplantation (CLKT) is an exceptional therapeutic procedure limited to a few diseases with advanced compromise of these organs. Hyperoxaluria type I and polycystic disease are the most frequent indications. The aim of this article was to report our indications and results of CLKT in a multicenter transplantation program in Chile. MATERIAL AND METHODS: Our Excel database was reviewed to select patients who were treated with CLKT between 1993 and July 2004. RESULTS: Among 242 liver transplantations (LT) and 48 kidney transplantations (KT), 7 were CLKT, representing 2.8% of LT and 14.5% of KT. Four patients were women and 3 were male of average age 46.8 years. One patient was a child. Most frequent indications were chronic renal failure associated with terminal liver disease and polycystic disease. One patient needed liver retransplantation due to hepatic vein thrombosis. One patient had a biliary fistula and another had a urinary fistula, treated conservatively. Acute liver rejection took place in 3 cases, 1 of which required antibodies. Two patients died, 1 due to aspergillosis and the other due to vascular complications in the transplanted liver. Actuarial survival rates were 71.4% at 1 and 5 years. Chronic renal failure is not a contraindication to LT. CONCLUSION: CLKT is an acceptable option for these patients.

ABO-incompatible liver transplantation: a new therapeutic option for patients with acute liver failure in Chile.

Different ways have been suggested to expand donor numbers for liver transplantation. Transplantation using ABO-incompatible hepatic grafts has recently been a controversial issue due to the high risk of hyperacute rejection mediated by preformed anti-ABO antibodies. We report three patients with acute liver failure who were transplanted with ABO-incompatible livers: A to O in two patients and A to B in one case. We used pre- and posttransplant total plasma exchange, splenectomy, and triple immunosuppression. All three patients are alive; one graft was lost, probably secondary to thrombotic microangiopathy with low isohemagglutinin titers of 1:8. One patient developed acute cellular rejection that was reversed with a bolus of methylprednisolone. No antibody-mediated rejection occurred. Financial and infectious considerations have to be considered. In our series, the final liver transplantation cost was higher than average for acute liver failure. Plasmapheresis has the highest cost of all the additional procedures. ABO-incompatible liver transplantation, because of the splenectomy it requires, has been associated with more infections due to encapsulated organisms. However, with splenectomy in our three patients, none had infections due to these bacteria. In our country, we do not consider ABO-incompatible liver transplantation as a first-line option, except for highly selected patients.

[Chronic hepatitis C and celiac sprue: an infrequent association]. / Hepatitis crónica por virus C y enfermedad celíaca: una asociación infrecuente.

Celiac sprue (CS) has been described in association with hepatitis C virus (HCV) as another immunologic manifestation of this infectious disease. We report 2 patients, a 42-year-old woman and a 59-year-old man, with chronic HCV hepatitis. Upper digestive endoscopy and duodenal biopsy were performed to investigate diverse symptoms. The results of histological analysis and serological study were compatible with CS. The association between both diseases, including immunological aspects and the implications of anti-HCV treatment, is discussed.

Enfermedad veno-oclusiva hepática, colitis ulcerosa idiopática y trombosis portal: comunicación de un caso clínico / Hepatic veno-occlusive disease, idiopathic ulcerative colitis and portal thrombosis. Report of one case

We report a previously healthy 29 years old man, presenting with a sudden episode of abdominal pain, mild jaundice, hepatomegaly and ascites. Magnetic resonance imaging study and liver biopsy were compatible with veno-occlusive disease. Incidentally, an ulcerative colitis and portal vein thrombosis were diagnosed. Anticoagulant treatment was started, with good clinical and radiological response. Veno-occlusive disease of the liver must be suspected In cases of liver failure and ascites associated to procoagulant conditions.

Outcomes of orthotopic liver transplantation in Chile.

Our liver transplant program was started in 1993 in a private clinic and a public hospital. Thereafter, a rapid increase in adults and pediatric candidates for this therapeutic option lead to this analysis of results in 165 orthotopic liver transplants (OLT) in 143 patients between November 1993 and December 2002. Seventy-four OLT were performed in 66 adult patients and 91 in the pediatric group. Liver grafts came from cadaveric donors in 145 cases (74 adults and 71 children). The technique of living-related donor was utilized in 20 pediatric cases. Main indications for OLT in the adult group were HCV cirrhosis, primary biliary cirrhosis; biliary atresia and acute liver failure were the indications in pediatric patients. Retransplantation was needed for 23 patients, including 9 adults and 14 children. The most frequent causes of death were sepsis, graft primary nonfunction, and vascular complications. Actuarial survivals at 1 and 5 years were 80.7% and 72.6% for the adult group and 82% and 74.8% for the pediatric group, respectively. Our results are comparable to those published by large, experienced, international centers, with much better financial support.

Daño hepático por fármacos: características clínicas e histológicas en 33 casos / Drug induced liver disease: clinical and pathological patterns in 33 cases

BACKGROUND: Drug induced liver disease (DILD) is common and of difficult diagnosis. AIM: To report the clinical, laboratory and pathological findings in 33 patients with DILD. PATIENTS AND METHODS: We revised 1,164 liver biopsies and 57 were selected as suspicious of DILD. In these, the scale proposed by Maria et al was applied to assess the possibility of hepatotoxicity reactions and 33 were selected. RESULTS: The 33 cases had a mean age of 48 +/- 18 years and 14 were male. Forty eight medications were involved, with an average of 1.4 drugs per patient. The main drugs were antimicrobials, antineoplastics-immunosuppressives and non-steroidal antiinflammatory drugs. The clinical presentations in order of frequency were cholestasis, hepatitis, asymptomatic, fulminant hepatitis and cirrhosis. The laboratory alterations observed in cases with hepatitis were 20 fold transaminase and bilirubin elevation. In cholestasis, moderate elevations of alkaline phosphatases and gamma glytamyl transferase were observed. Pathology showed hepatocellular damage, cholestasis and mixed damage, but also submassive necrosis and cirrhosis in one case. CONCLUSIONS: The present study confirms that DILD is frequently unpredictable and that it can cause a wide variety of clinical and pathological presentations, that can even evolve to chronicity.

Transmisión familiar del virus de la hepatitis C en un grupo de población chilena / Familial transmission of hepatitis C virus infection in Chilean subjects

BACKGROUND: Intravenous drug use, sexual promiscuity and a longer cohabitation period are considered risk factors for familial transmission of hepatitis C virus. The relative importance of this type of transmission is a subject of controversy. AIM: To study familial clustering of hepatitis C virus infection and its risk factors. MATERIAL AND METHODS: HCV positive patients (91 with chronic hepatitis, 88 with cirrhosis, nine with hepatic carcinoma and 29 hemophiliacs) were the index cases. HCV antibodies were measured by ELISA and the type of relationship with the index case was investigated in 317 family members. RESULTS: Positive anti HVC antibodies were detected in 12 of 243 family members of patients with chronic liver disease and in none of the family members of patients with hemophilia. Of these, five were couples of an index case with a long cohabitation period. Ten members had an index case with a severe liver disease (three with Child C cirrhosis and seven with liver carcinoma). CONCLUSIONS: Family transmission of HCV infection is uncommon in Chile. The association of severe liver disease and family transmission could be due to a higher viral load as responsible for transmission during the early periods of a long lasting disease.

Colecistectomía laparoscópica y clásica en pacientes con cirrosis hepática / Laparoscopic and classic cholecystectomy in patients with liver cirrhosis

BACKGROUND: The prevalence of gallstones is increased in patients with cirrhosis. However the presence of cirrhosis has been generally considered a relative contraindication to cholecystectomy. AIM: To investigate the complications and the outcomes of laparoscopic and open cholecystectomy in patients with cirrhosis. PATIENTS AND METHODS: Sixty seven patients with gallstones with well-documented cirrhosis undergoing cholecystectomy (laparoscopic cholecystectomy (LC) in 35 and open cholecystectomy (OC) in 32), were studied. The mean age was 57.7 + 10.3 years for LC and 58.9 + 11.6 years for OC. In the LC group, 26 were classified as Child-Pugh class A, 8 as Child's B class and 1 as Child's class C. In the OC group, 12 were classified as Child's class A, 15 as Child's B and 5 as Child's C. RESULTS: Complications occurred in 4 of 35 (12.3 per cent) LC patients (1 patients was Child A and 3 were B). In the OC group 14 of 32 patients had complications (4 Child A, 7 B and 3 C, 43.7 per cent p < 0.05 as compared with LC group). Three patients in the OC group died (9.4 per cent). Mean hospital stay was 2.8 + 1.9 and 13 + 12 days in LC and OC patients, respectively (p < 0.05). CONCLUSIONS: LC has a lower rate of complications than OC and is a reasonable option for Child's class A and B patients with cirrhosis and gallstones.

[Prevalence and genotypes of hepatitis C virus in blood donors and in patients with chronic liver disease and hepatocarcinoma in a Chilean population]. / Prevalencia y genotipos del virus de la hepatitis C en donantes de sangre y en pacientes con enfermedad hepática crónica y hepatocarcinoma en población Chilena.

BACKGROUND: The impact of hepatitis C virus infection in Chile has not been well established. AIM: To assess hepatitis C virus infection in normal Chileans and in patients with liver disease. SUBJECTS AND METHODS: Antibodies against hepatitis C virus were investigated in 21,000 blood donors, 133 patients with non alcoholic chronic liver disease and in 50 patients with hepatocarcinoma. Viral RNA was studied by polymerase chain reaction in all positive blood donors, in 51 patients with chronic liver disease and in all patients with hepatocarcinoma. Hepatitis C virus genotype was established using restriction fragment length polymorphism in 118 RNA positive samples. RESULTS: In blood donors, a 0.3% prevalence of positive antibodies was found. The figure for chronic liver disease was 53% and for hepatocarcinoma, 48%. Viral RNA was detected in 100% of patients with chronic liver disease and hepatocarcinoma and in 68% of blood donors with positive antibodies. Genotype 1b was identified in all infected patients with hepatocarcinoma, in 86% of patients with chronic liver disease and in 46% of blood donors. CONCLUSIONS: Hepatitis C virus infection is an important etiologic agent for chronic liver disease in Chile. The predominance of genotype 1b among patients with the most severe form of liver disease is in agreement with observations made abroad.

[Hepatic veno-occlusive disease associated to the use of azathioprine in a renal transplant recipient]. / Enfermedad venooclusiva hepática asociada a terapia con azatioprina en un paciente trasplantado renal.

We report a 30 years old male, recipient of a kidney allograft and treated with azathioprine, who eighteen days after transplantation had a clinically asymptomatic elevation of total bilirubin and alkaline phosphatases. Nineteen months later, he presented with mild ascites, with a total bilirubin of 3.5 mg/dl, alkaline phosphatases of 308 U/L (normal < 170 U/L) and a prothrombin time at 55% of control. A liver biopsy showed sinusoidal and perivenular fibrosis without inflammation, compatible with chronic venous obstruction. Hepatic veno-occlusive disease is an infrequent complication of azathioprine use.

[Hepatitis E virus infection in Chile: preliminary report]. / Infección con el virus de la hepatitis E en Chile. Communicación preliminar.

BACKGROUND: Hepatitis E virus is an enterally transmitted virus that produces an acute self limited infection. AIM: To study serum antibodies against hepatitis E virus in different patients. PATIENTS AND METHODS: Using and ELISA technique, IgG antibodies against hepatitis E virus were measured in 40 alcoholics, 40 hemophiliacs, 174 blood donors, 36 subjects with acute non A-non B-non C hepatitis and 66 subjects with acute hepatitis A. RESULTS: Antibodies were detected in one alcoholic (2.5%), 3 hemophiliacs (7.5%), 7 blood donors (4%), 3 patients with non A-non B-non C hepatitis (8.3%) and 3 patients with acute hepatitis A (4.5%). CONCLUSIONS: A low frequency of hepatitis E infection was detected in the studied subjects.

[Experience of a single center in liver transplantation in adults and children]. / Experiencia de un centro en trasplante hepático en adultos y niños.

Orthotopic liver transplantation (THO) is the treatment of choice for a variety of liver diseases. The national experience before 1993 has been scarce. In November 1993 we started our experience in THO at Clínica Las Condes, as part of a multiorgan transplant program (liver, kidney, pancreas). Until January 1995 we have performed 14 THO in 13 recipients (one retransplantation), of which 5 were in pediatric cases. The recipients range of age fluctuated between 1 and 61 years. In two pediatric cases a liver allograft reduction was performed. Six recipients (46%) required treatment for acute cellular rejection. One recipient had an hepatic artery thrombosis and had to be retransplanted. There was no operative mortality up to 30 days in cases of primary liver transplants. The retransplanted adult recipient, and another pediatric recipient that died from a late recurrence of a hepatoblastoma, accounted for the mortality of this experience. After an average follow up of 10 months, the actual patient survival in 85%. Of the 11 surviving recipients, 9 are in excellent conditions with a very good quality of life. This experience shows that an active liver transplant program in our country can be successful in obtaining results comparable to those published by very experienced foreign transplant centers.

Antimitochondrial antibody detection by indirect immunofluorescence on mouse sperms.

Antimitochondrial antibodies (AMA) are characteristically present in the serum of patients with primary biliary cirrhosis (PBC). AMA detection constitutes an important step for the clinical diagnosis of PBC, the indirect immunofluorescence against cryostat sections of rat of mouse organs being the most common method used. This study presents an alternative method for AMA detection by indirect immunofluorescence using mouse sperms as substrate. Sera of 17 patients with PBC were examined for AMA using mouse sperms and frozen sections of rat kidney. With mouse sperms as substrate, all PBC sera were found to be AMA positive showing an intense fluorescent reaction on the mitochondrial sheath of mouse sperms (100% sensitivity). No false positive results were obtained with normal sera. Sera of 22 patients with collagen diseases (systemic lupus erithematosus and progressive systemic sclerosis) having defined reactivity to antigens other than mitochondrial antigens were also examined for AMA with both substrates; 19 of them resulted AMA negative. AMA diagnosis on mouse sperm substrate was found to be more sensitive than conventional rat kidney substrate. In addition, it has the advantage that it facilitates for the observer the visualization and reading of the fluorescent reaction on the mitochondria, due to the particular distribution of them on mouse sperms.