Liver transplantation and alcoholic liver disease: History, controversies, and considerations.

Alcohol consumption accounts for 3.8% of annual global mortality worldwide, and the majority of these deaths are due to alcoholic liver disease (ALD), mainly alcoholic cirrhosis. ALD is one of the most common indications for liver transplantation (LT). However, it remains a complicated topic on both medical and ethical grounds, as it is seen by many as a "self-inflicted disease". One of the strongest ethical arguments against LT for ALD is the probability of relapse. However, ALD remains a common indication for LT worldwide. For a patient to be placed on an LT waiting list, 6 mo of abstinence must have been achieved for most LT centers. However, this "6-mo rule" is an arbitrary threshold and has never been shown to affect survival, sobriety, or other outcomes. Recent studies have shown similar survival rates among individuals who undergo LT for ALD and those who undergo LT for other chronic causes of end-stage liver disease. There are specific factors that should be addressed when evaluating LT patients with ALD because these patients commonly have a high prevalence of multisystem alcohol-related changes. Risk factors for relapse include the presence of anxiety or depressive disorders, short pre-LT duration of sobriety, and lack of social support. Identification of risk factors and strengthening of the social support system may decrease relapse among these patients. Family counseling for LT candidates is highly encouraged to prevent alcohol consumption relapse. Relapse has been associated with unique histopathological changes, graft damage, graft loss, and even decreased survival in some studies. Research has demonstrated the importance of a multidisciplinary evaluation of LT candidates. Complete abstinence should be attempted to overcome addiction issues and to allow spontaneous liver recovery. Abstinence is the cornerstone of ALD therapy. Psychotherapies, including 12-step facilitation therapy, cognitive-behavioral therapy, and motivational enhancement therapy, help support abstinence. Nutritional therapy helps to reverse muscle wasting, weight loss, vitamin deficiencies, and trace element deficiencies associated with ALD. For muscular recovery, supervised physical activity has been shown to lead to a gain in muscle mass and improvement of functional activity. Early LT for acute alcoholic hepatitis has been the subject of recent clinical studies, with encouraging results in highly selected patients. The survival rates after LT for ALD are comparable to those of patients who underwent LT for other indications. Patients that undergo LT for ALD and survive over 5 years have a higher risk of cardiorespiratory disease, cerebrovascular events, and de novo malignancy.

Model for End-Stage Liver Disease: Is Sex-Based Creatinine Correction a Viable Strategy for Black Females?

BACKGROUND: The model for end-stage liver disease (MELD) is based on objective variables, including serum creatinine (SCr). This study assesses the influence of skin color on MELD scores calculated using SCr or corrected creatinine (CrC) in female candidates for liver transplantation (LTx). METHODS: White and black women were eligible. The glomerular filtration rate (GFR) was calculated by means of the Modification of Diet in Renal Disease formula, using SCr. The GFR was then used for reverse calculation of CrC considering each female as male. The MELD scores were calculated using both creatinine values and compared between white and black candidates. RESULTS: SCr-based and CrC-based scores were similar between groups. Calculated GFR was significantly higher in black women than in white women (P < 0.001). Use of CrC yielded 1-point, 2-point, and 3-point increases in the MELD score in 20.2%, 25.7%, and 17.5% of white patients, respectively. None of the black patients had a MELD score increase greater than 1 point. The CrC-based MELD calculation would benefit 63.4% of white females and only 26.1% of black females. CONCLUSIONS: Use of CrC for MELD calculation would prioritize white females for liver allocation, but does not seem feasible, as it would not ensure equitable allocation across different ethnicities.

Alocação de fígados para transplante em adultos: vantagens e desvantagens do escore meld / Liver transplant allocation in adults: advantages and disadvantages of the meld score

O processo de alocação de enxertos para transplante hepático é muito complexo em razão, principalmente, da discrepância entre o número de candidatos e o de doadores. O Model for End-Stage Liver Disease (MELD) é um escore de gravidade, desenvolvido nos Estados Unidos, que constitui um robusto preditor de sobrevida de pacientes em lista de espera para transplante hepático. Desde 2006, o Brasil adota o escore MELD para ordenar os receptores em uma fila de espera, com a política de atender antes o mais doente. Sua adoção como critério de alocação reduziu o número de óbitos em lista sem comprometer os resultados do transplante. Há situações que não são bem “atendidas” pelo MELD porque, ou a gravidade da situação clínica independe do grau da hepatopatia, ou o risco de permanecer em lista não é a morte, mas sim a doença avançar além de um ponto em que o transplante não possa ser realizado. Nesses casos, considerados “especiais”, os pacientes recebem pontuação diferenciada no escore, com o intuito de transplantá-los em tempo hábil. Há estudos com o objetivo de aperfeiçoar o MELD, mantendo sempre a objetividade e transparência do escore original.

The process of graft allocation for liver transplant is very complex, especially due to the discrepancy between the number of transplant candidates and of donors. The Model for End-Stage Liver Disease (MELD) is a severity score developed in the United States that constitutes a strong survival predictor for patients on the waiting list for liver transplantation. Since 2006, Brazil has been using the MELD score to rank transplant candidates on a waiting line, with the policy of treating the sickest first. The implementation of this score as the allocation criterion reduced the number of deaths on the waiting list without compromising transplant outcomes. However, some situations are not well “treated” by the MELD score because either the severity of the clinical situation does not depend on the degree of liver disease or the risk of remaining on the list is not death but rather disease progression to a point that makes the transplant not feasible. In these so-called “special” cases, patients are graded differently on the MELD score, with the purpose of performing their transplantation in a timely manner. Studies have been conducted aiming to improve the MELD score while keeping the objectivity and transparency of the original score.

Impact of creatinine values on MELD scores in male and female candidates for liver transplantation.

INTRODUCTION: A systematic bias against women, resulting from the use of creatinine as a measure of renal function, has been identified in Model for End-stage Liver Disease (MELD)-based liver allocation. Correction of this bias by calculation of female creatinine levels using the Modification of Diet in Renal Disease (MDRD) formula has been suggested. MATERIAL AND METHODS: A cohort of 639 cirrhotic candidates for first-time liver transplantation was studied. Creatinine levels were corrected for gender using the MDRD formula. The accuracy of MELD, with or without creatinine correction, to predict 3-and 6-month mortality after inclusion in a transplant waiting list was estimated. RESULTS: Women exhibited significantly lower creatinine levels, glomerular filtration rate, and MELD scores than men. After creatinine correction, female MELD scores had a mean increase of 1.1 points. Creatinine correction yielded an increase of 3 points in the MELD score in 15.2% of patients, 2 points in 22.4%, and 1 point in 17.6% of patients. The likelihood of death at 3 and 6 months after enrollment in the transplant waiting list was similar in males and females and the likelihood of receiving a transplant, as assessed by Kaplan-Meier survival curves, was also similar in males and females. CONCLUSION: The survival or the likelihood of receiving a transplant while on the waiting list were similar in men and women in both pre- and post-MELD eras and creatinine correction did not increase the accuracy of the MELD score in estimating 3- and 6-month mortality in female candidates for liver transplantation.

Liver transplantation in HIV-positive patients: the position of the Brazilian groups.

BACKGROUND: Patients infected with the human immunodeficiency virus (HIV) have generally been excluded from consideration for liver transplantation. Recent advances in the management and prognosis of these patients suggest that this policy must be reevaluated. AIM: To identify the current position of Brazilian transplant centers concerning liver transplantation in asymptomatic HIV-infected patients with end-stage liver disease. METHODS: A structured questionnaire was submitted by e-mail to Brazilian groups who perform liver transplantation and were active in late 2003, according to the Brazilian Association of Organ Transplantation. RESULTS: Of the 53 active groups, 30 e-mail addresses have been found of professionals working in 41 of these groups. Twenty-one responses (70%) were obtained. Most of the professionals (62%) reported that they do not include HIV-infected patients in waiting lists for transplants, primarily on account of the limited world experience. They also reported, however, that this issue will soon be discussed by the group. Those who accept these patients usually follow the guidelines provided by the literature: patients must fulfill the same inclusion criteria as the other patients with end-stage liver diseases, present low or undetectable HIV viral load, and a CD4 count above 250/mm3. They reported that there are 10 HIV-infected patients in waiting list and that only one patient has received a liver transplant in the country. CONCLUSION: Most centers do not accept in waiting lists for liver transplantation patients with HIV infection, even asymptomatic ones. However, advances in the management of HIV-infected patients suggest that this policy must be reevaluated. In Brazil, there is practically no experience in liver transplantation in HIV-positive patients.

Liver transplantation in HIV-positive patients: the position of the Brazilian groups

RACIONAL: Pacientes infectados com o vírus da imunodeficiência humana (HIV) têm sido comumente excluídos dos programas de transplantes de fígado. Avanços recentes no tratamento e prognóstico desses pacientes sugerem que essa política deva ser reavaliada. OBJETIVO: Identificar a orientação atual dos transplantadores brasileiros em relação a transplante de fígado em pacientes infectados com HIV, assintomáticos, com doença hepática terminal. MÉTODOS: Envio de questionário estruturado, por correio eletrônico, para grupos que realizam transplante hepático e ativos no final de 2003, segundo Associação Brasileira Transplantes de Órgãos. RESULTADOS: Dos 53 grupos em atividade, identificou-se o endereço eletrônico de 30 profissionais, que atuam em 41 desses grupos. Foram recebidas 21 respostas (70%). A maioria dos profissionais (62%) informou não incluir pacientes anti-HIV reagentes em lista para transplante, fundamentalmente em razão da pequena experiência mundial. Contudo, relataram que o assunto será discutido brevemente pelo grupo. Profissionais que aceitam esses pacientes adotam, em geral, orientações sugeridas na literatura: devem preencher os critérios de inclusão que os demais pacientes com doenças hepáticas terminais, ter carga viral do HIV baixa ou negativa e contagem de CD4 >250/mm3. Informaram haver 10 pacientes anti-HIV reagentes em lista e que apenas 1 paciente foi transplantado no país. CONCLUSÃO: A maioria dos profissionais não aceita pacientes anti-HIV reagentes mesmo que assintomáticos, em lista de espera para transplante hepático. Contudo, os avanços no manejo de pacientes com HIV recomenda que essa posição seja reavaliada. Praticamente não há experiência em nosso país, com transplante hepático em pacientes anti-HIV reagentes.

Retrospective study of the survival of patients who underwent cardiopulmonary resuscitation in an intensive care unit.

OBJECTIVE: To evaluate clinical and evolutive characteristics of patients admitted in an intensive care unit after cardiopulmonary resuscitation, identifying prognostic survival factors. METHODS: A retrospective study of 136 patients admitted between 1995 and 1999 to an intensive care unit, evaluating clinical conditions, mechanisms and causes of cardiopulmonary arrest, and their relation to hospital mortality. RESULTS: A 76% mortality rate independent of age and sex was observed. Asystole was the most frequent mechanism of death, and seen in isolation pulmonary arrest was the least frequent. Cardiac failure, need for mechanical ventilation, cirrhosis and previous stroke were clinically significant (p < 0.01) death factors. CONCLUSION: Prognostic factors supplement the doctor's decision as to whether or not a patient will benefit from cardiopulmonary resuscitation.

Estudo retrospectivo de sobrevida de pacientes submetidos à reanimaçäo cardiorrespiratória em unidade de tratamento intensivo / Retrospective study of the survival of patients who underwent cardiopulmonary resuscitation in an intensive care unit

OBJECTIVE: To evaluate clinical and evolutive characteristics of patients admitted in an intensive care unit after cardiopulmonary resuscitation, identifying prognostic survival factors.METHODS: A retrospective study of 136 patients admitted between 1995 and 1999 to an intensive care unit, evaluating clinical conditions, mechanisms and causes of cardiopulmonary arrest, and their relation to hospital mortality.RESULTS: A 76 percent mortality rate independent of age and sex was observed. Asystole was the most frequent mechanism of death, and seen in isolation pulmonary arrest was the least frequent. Cardiac failure, need for mechanical ventilation, cirrhosis and previous stroke were clinically significant (p<0.01) death factors.CONCLUSION: Prognostic factors supplement the doctor's decision as to whether or not a patient will benefit from cardiopulmonary resuscitation

Eventos cardiovasculares associados ao consumo de cocaína / Cocaine related cardiovascular events

O abuso de cocaína é identificado em todos os níveis sociais, tornando-se um assunto de grande importância médica. Este potente simpaticomimético e estimulante do sistema nervoso central é o mais novo (e algumas vezes desconhecido) fator de risco cardiovascular em indivíduos jovens. Estudos recentes relacionam o uso de cocaína a várias desordens cardiovasculares agudas e crônicas. Estes eventos aumentaram há aproximadamente duas décadas, quando a cocaína tornou-se mais pura, barata e fácil de obter. O abuso de cocaína é um fator de risco para isquemia miocárdica e/ou infarto agudo do miocárdio, edema pulmonar, arritmias cardíacas, ruptura de aneurisma aórtico, infarto cerebral, endocardite infecciosa, trombose vascular, miocardite e miocardiopatia dilatada. Considerando-se que todas as rotas de administração e formas de abuso desta substância são potencialmente cardiotóxicos e podem ser letais, médicos devem estar alertas para a presença de uso de cocaína sempre que se defrontarem com sintomas cardíacos inexplicados

Abordagem diagnóstica em pacientes alcoolistas / Diagnostic approach of alcoholic patients

Em muitos paises o alcoolismo atinge proporções epidêmicas provocando muitas de problemas de saúde. Contudo, os médicos têm sido criticados pelo incapacidade de diagnosticá-lo em seus pacientes...