Detection of Leishmania spp. in Bats from an Area of Brazil Endemic for Visceral Leishmaniasis.

The multihost parasites Leishmania spp. infect a broad range of wild mammalian species including bats. Several species of bats have adapted to a variety of food resources and shelters in urban areas. This study aimed to detect Leishmania spp. DNA in bats present in forest fragments located in metropolitan areas endemic for leishmaniasis in Campo Grande, Mato Grosso do Sul (MS), Brazil. Blood samples were obtained from 80 individuals, including eight species of Phyllostomidae and one species of Vespertilionidae. Thirty of the 80 bats were positive for Leishmania spp. using conventional PCR, all belonging to the family Phyllostomidae. Eighteen samples tested by real-time PCR (qPCR) using specific primers for the kDNA of Leishmania infantum were positive. To the best of our knowledge, this is the first report detecting Leishmania spp. in Platyrrhinus incarum in addition to being the first reported detection of L. infantum in the bat species Phyllostomus discolor, Platyrrhinus lineatus, Artibeus planirostris and Artibeus lituratus. Our results show that bats can host Leishmania spp. in areas endemic for leishmaniasis, which must be taken into account in disease control operations by public health authorities.

Time of Dropout From the Liver Transplant List in Patients With Hepatocellular Carcinoma: Clinical Behavior According to Tumor Characteristics and Severity of Liver Disease.

BACKGROUND: Prolonged time on the waiting list affects post-transplant survival of patients with hepatocellular carcinoma (HCC). However, it is not yet known which patients will be at higher risk for early dropout from the list. We investigate specific risk factors for early waiting list dropout in patients with HCC. METHODS: This was a single-center, intention-to-treat analysis of adults with HCC, within the Milan criteria, from July 2006 through September 2013. Patients were divided into groups according to waiting list time. The main end point was dropout from the list. RESULTS: The dropout rates of the study cohort at 3, 6, and 12-months were 6.4%, 12.4%, and 17.7%, respectively. Patients who dropped out from the list tended to be older, with blood types A and O, and with higher Child-Pugh and Model for End-Stage Liver Disease (MELD) scores. They also had larger nodules, responded poorly to trans-arterial chemo-embolization (TACE), and had a higher alpha-fetoprotein. Those with blood types B and AB appeared to be protected for dropout (odds ratio [OR] = 0.21, P = .02). Patients who responded to TACE were also protected (OR = 0.22, P < .001). When we looked into time to dropout, the only baseline characteristic that stood out was a higher MELD score (13 for those dropping out up to 90 days vs 10 for those dropping out after 180 days, P = .0025). CONCLUSIONS: We conclude that patients who drop out early from the list are primarily driven by the severity of liver disease. Patients who had progressive HCC had a high tumor load and poor response to loco-regional therapies, dropping out from the list after 180 days of inclusion.

Right Accessory Hepatic Artery Arising From Celiac Trunk-Case Report of a Variation that Must Be Looked for During Multiorgan Procurement.

Knowledge of the anatomy of the hepatic artery and its variations is important to hepatobiliary and liver transplant surgeons and interventional radiologists. We report a rare anatomic variation of liver hepatic arterial supply: a right accessory hepatic artery arising directly from the celiac trunk and observed at the time of multiorgan procurement. The anatomic variation described in this case occurs in up to 2% of cases and their knowledge is essential to avoid injuries during multiorgan procurement that could require multiple anastomoses or lead to inadvertent vessel injury. This variation is very rarely reported in the medical literature. We document successful deceased-donor liver transplantation with a graft that had an accessory right accessory hepatic artery from the celiac trunk.

List and liver transplant survival according to waiting time in patients with hepatocellular carcinoma.

The time that patients with hepatocellular carcinoma (HCC) can safely remain on the waiting list for liver transplantation (LT) is unknown. We investigated whether waiting time on the list impacts transplant survival of HCC candidates and transplant recipients. This is a single-center retrospective study of 283 adults with HCC. Patients were divided in groups according to waiting-list time. The main endpoint was survival. The median waiting time for LT was 4.9 months. The dropout rates at 3-, 6-, and 12-months were 6.4%, 12.4%, and 17.7%, respectively. Mortality on the list was 4.8%, but varied depending of the time on the list. Patients who waited less than 3-months had an inferior overall survival when compared to the other groups (p = 0.027). Prolonged time on the list significantly reduced mortality in this analysis (p = 0.02, HR = 0.28). Model for End Stage Liver Disease (MELD) score at transplantation did also independently impact overall survival (p = 0.03, HR = 1.06). MELD was the only factor that independently impacted posttransplant survival (p = 0.048, HR = 1.05). We conclude that waiting time had no relation with posttransplant survival. It is beneficial to prolong the waiting list time for HCC candidates without having a negative impact in posttransplant survival.

Response to transarterial chemoembolization in candidates with hepatocellular carcinoma within Milan criteria does not predict post-transplant disease-free survival.

INTRODUCTION: Few groups have studied the impact of pretransplant transarterial chemoembolization (TACE) in the outcomes of liver transplant recipients with hepatocellular carcinoma (HCC). We verified whether response to TACE in HCC candidates impacts post-transplant disease-free survival. METHODS: This a single center retrospective study of patients who underwent liver transplantation from 2006-2013. Included were those transplanted due to HCC within the Milan criteria who were treated with TACE in the pre-transplant period. Response to TACE followed the modified RECIST (mRECIST) criteria. Disease free-survival was the main endpoint of the study. RESULTS: We included 187 patients in this study. The population had an average age of 57.5 years, predominantly formed by men (82.5%), with an average IMC of 26.7, MELD of 13, with viral hepatitis as main cause of liver disease. Average waiting time was 253 days and follow-up was 27.3 months. Based on response to TACE, 3-year disease-free survival was 84.1% for those with complete response to TACE, 84.1% for those with partial response to TACE, 85.7% for those with stable disease and 100% for patients with progressive disease. Multivariate analysis did not identify response to TACE as a predictor of disease-free post-transplant survival. CONCLUSIONS: Response to TACE in candidates with HCC within Milan criteria does not predict post-transplant disease-free survival.

Results of retransplantation for primary nonfunction in a single center.

INTRODUCTION: Early graft dysfunction has a negative impact on allograft and patient survivals, evolving to retransplantation or death in the majority of cases. The outcome of a second liver transplant is usually worse than the first procedure. Considering the increasing number of recipients on the waiting list, and the discrepancy between the number of accessible donors and recipients, we sought to analyze the results of retransplantation at our institution and at those within the State of Sao Paulo. METHODS: We reviewed the data of 419 deceased donor transplants on 367 patients from June 2005 to April 2010. Twenty-three patients underwent retransplantation due primary nonfunction (PNF) or early graft dysfunction. The following variables were studied: age, gender, disease that lead to the first transplant, Model for End-Stage Liver Disease (MELD) score on the day before the retransplantation, intensive care unit (ICU) length of stay, and duration of orotracheal intubation (OTI). We compared our patient survival at 30 days and 1 year with that of other patients undergoing retransplantation due to PNF in the Sao Paulo State during the same period. RESULTS: The majority of patients were females (60.87%), with a mean age of 44.6 years. The etiology that led to our first transplantation was cirrhosis due to hepatitis C virus (HCV; n = 6), followed by acute liver failure, (n = 5). The average of ICU stay was 15.08 days (range, 5-45). The mean MELD score was 34.43 (range, 19-50). The survival was 73.92% and 60.78% at 30 days and 1 year postretransplantation, respectively, whereas for São Paulo State, it was 63.04% and 51.63%, respectively.

Analysis of liver transplantation outcome in patients with MELD Score > or = 30.

Since July 2006, the liver graft allocation has been changed from the waiting time to the Model for End-stage Liver Disease (MELD), prioritizing the sickest patients, who have a higher risk of dying on the waiting list, and sometimes in such poor clinical condition that it compromises transplantation outcomes. The aim of this study was to analyze the impact of a MELD score > or = 30 on 30-day survival after liver transplantation (OLT). We prospectively collected the data on 178 liver transplants on 163 patients performed from March 2003 to August 2007. The subjects were divided in two groups according to their MELD scores: group 1, MELD > or = 30 (n = 15) and group 2, MELD < 30 (n = 96). The groups were compared with regard to hospital and intensive care unit (ICU) length of stay, intraoperative blood products transfusion, early survival (30 days), and need for retransplantation. We excluded, patients with prioritization criteria, those receiving extra points for any special situation, and six other patients without significant data for MELD calculation (of whom only one has died after transplantation). Patients under a "special situation" were those with hepatocelular carcinoma, hepatopulmonary syndrome, and metabolic diseases, who initially received a MELD/PELD score 20, and 24, and 29. The mean MELD score at group I was 34 (range, 30 to 42), and for group II it was 16 (range, 6 to 29). Group I displayed a mean hospital length of stay of 24 days (4 to 155), with 12.60 days (ranges, 1 to 103) in the ICU versus 15.55 (range, 1 to 48) and 5.13 (range, 1 to 45) days, respectively, for group II. The need for blood component transfusions were greater in group I; 25.28% of patients in group II did not receive any transfusion during the entire inpatient period. There were nine retransplants in group II, and none in group I. The 30-day survivals were 93.3% for group I and 84.37% for group II. Besides the increased complexity of these sickest patients, there was no negative impact on early survival rates.

Impact of cumulative risk factors for expanded criteria donors on early survival after liver transplantation.

There are various options to help overcome the organ shortage, including performing transplants using grafts from marginal donors with characteristics previously described as unacceptable because of the high risk of graft failure. Nowadays, expanded criteria donors for liver transplantation (OLT) is a strategy used routinely by many teams. Some donor features have been suggested to jeopardize initial function or survival; when these features are aggregated, they may impact prognosis. The aim of this study was to evaluate the impact of donor risk factors on early patient survival and retransplantation. Donor risk factors were considered to be older than 60 years, body mass index > 30, serum sodium level > 155 mEq/L, cold ischemia time > 12 hours, and intensive care unit stay > 4 days. We prospectively recorded data from 139 patients who underwent 152 OLT from March 2003 to May 2007. Patients were classified into four groups: I, no risk factors; II, one risk factor; III, two risk factors; IV, three or more risk factors. Retransplantation or OLT due to acute liver failure was considered to be an exclusion criterion. Early overall survival rate was 83.76%; 12 retransplantations were required (10.25%). Comparing the four groups, patient survivals (P = .41) and retransplantation rates (P = .518) were similar. In conclusion, cumulative risk factors showed no impact on early (30-day) recipient survival and or on the necessity of retransplantation after OLT.

Impact of renal failure on liver transplantation survival.

Renal failure after orthotopic liver transplantation (OLT) is a common complication (ranging from 12% to 70%) associated with worse outcomes, particularly when it requires renal replacement therapy (RRT). Renal dysfunction is a common scenario among waiting list patients. It can lead to a worse prognosis after OLT, due to an increased incidence of postoperative renal failure. The aim of this study was to analyze the incidence of renal failure after OLT, its relationship to pretransplant renal dysfunction, and its impact on outcomes. We analyzed data collected prospectively from 152 consecutive OLTs in 139 patients performed by the same team from March 2003 to November 2007. Exclusion criteria for 34 cases included transplantation due to acute liver failure, combined liver-kidney transplantation, retransplantation, and patients who died up to 2 days posttransplantation. Based on creatinine clearance (CCr) calculated at the time of OLT, the 118 patients were classified in two groups: group I, normal pre-OLT renal function (CCr > or = 70 mL/min) versus group II, pre-OLT renal failure (CCr < 70 mL/min). Each group was analyzed according to the development of post-OLT renal failure, being classified as subgroup A (normal renal function post-OLT), subgroup B (mild renal impairment post-OLT-serum creatinine level between 2.0 and 3.0 mg/dL or doubled basal value up to 3.0 mg/dL) versus subgroup C (severe renal impairment post-OLT-serum creatinine level > or = 3.0 mg/dL or utilization of RRT). The overall incidence of post-OLT renal impairment was 41.52% with RRT in 22 patients (18.64%). Group II patients showed a greater incidence of post-OLT renal failure when compared with other patients (P < .05), but without a statistical difference when compared according to RRT requirement. Comparison of average hospital stay was similar between groups I and II, and also among its subgroups (A, B, and C, respectively). There was no statistical difference in early (30-day) and 1-year survival rates between groups I and II. Comparing all subgroups for early and 1-year survival, we observed that patients who developed severe renal failure post-OLT (subgroups I-C and II-C) showed worse outcomes compared with other patients (subgroups I-A, I-B, II-A, and II-B), respectively 95.29% versus 69.69% and 86.95% versus 41.66% for early and 1-year survivals (P < .001). In conclusion, our findings suggested that patients who developed severe renal failure post-OLT, independent of pretransplant renal function, showed worse outcomes.

Total hepatectomy and liver transplantation as a two-stage procedure for toxic liver: case reports.

Total hepatectomy with temporary portocaval shunt was employed as a bridging procedure before liver transplantation, in the setting of fulminant hepatic failure with "toxic liver syndrome"; acute, severe, and extensive liver necrosis associated with cardiovascular shock and acute renal failure with or without respiratory failure. This procedure sought to improve metabolic acidosis and hemodynamic instability related to advanced liver necrosis. The aim of this study was to report our experience with three patients who underwent total hepatectomy and protocaval shunt, followed by liver transplantation (two-stage procedure).

Analysis of Model for End-Stage Liver Disease (MELD) score in a liver transplantation waiting list.

BACKGROUND: The Model for End-Stage Liver Disease (MELD) was introduced in 1999 to quantify the 3-month prognosis of cirrhotic patients after a transjugular intrahepatic portosystemic shunt (TIPS). Because of the imbalance between organ donors and patients on the waiting list, the MELD was adopted by the United States in 2002 to allocate liver grafts for transplantation. Preliminary results have indicated a reduction in waiting list deaths and an increase in transplantation rates for candidates. Seeking to find a new model to predict death on the waiting list and after liver transplantation, retrospective studies have examined MELD scores in waiting list patients. The aim of this study was to analyze the MELD scores of patients on the liver waiting list for comparisons between transplanted patients. PATIENTS AND METHODS: A retrospective study was performed analyzing 131 registrations of 127 orthotopic liver transplant (OLT) patients (4 underwent retransplantation) grafted between November 2000 and January 2006, excluding 24 patients: 2 had urgent retransplantations due to hepatic artery thrombosis and 22 had incomplete data. These patients were divided into 3 groups: group I (transplanted patients)-53 patients underwent 55 OLT; group II-29 patients who died on the waiting list; group III-patients on the waiting list including 23 patients still waiting as of the date of the study. RESULTS: The main indication for OLT was hepatitis C virus cirrhosis (50.50%), followed by alcoholic liver cirrhosis (23.30%), cryptogenic cirrhosis (12.60%), autoimmune hepatitis (5.80%), hepatitis B virus cirrhosis (4.85%), and primary biliary cirrhosis (2.91%). Group I: MELD score 15.62 (range, 6-39) on admission to the list, and 18.87 (range, 7-39) at transplantation. The mean waiting time for OLT was 478.39 days (range, 2-1270 days). The 38 patients who survived underwent 39 OLT (1 retransplantation). The MELD score at entrance to the list was 14.62 (range, 7-30) and at transplantation, 17.70 (range, 7-39). The mean time between admission to the list and transplantation was 505.37 days (range, 6-1270 days). The 15 patients who died had received 16 OLT (1 retransplantation). Their MELD scores were 17.80 (range, 6-39) and 21.81 (range, 9-39) at admission to the list and at transplantation, respectively, with a mean time on the waiting list of 417.93 days (range, 2-872 days). Group II: 29 patients died before OLT, at a mean age of 52.60 years (range, 22-67 years). Their MELD score was 19.24 (range, 7-45), and the interval between admission to the waiting list and death was 249.55 days (range, 3-1247 days). Group III: 23 patients still active on the OLT waiting list at the time of study displayed a mean MELD score of 13.65 (range, 6-28) and 354.30 days (range, 2-905 days) waiting until the moment. In conclusion, MELD score at the time of admission to the waiting list was higher among those patients who died either awaiting a liver graft (19.24) or after OLT (17.80) compared with those who survived after OLT (14.60) or are still awaiting OLT (13.65).

Correlation between graft arterial anatomy and biliary complications after liver transplantation.

Knowledge of the arterial vascular anatomy of the liver is important for orthotopic liver transplantation (OLT) because the lack of an adequate arterial blood supply results in biliary and parenchymal complications or graft loss. A number of reports have shown a relationship between aberrations of graft arteries and an increased incidence of early or late complications. Recent studies suggest no differences unless multiple anastomoses are required. The aim of this study was to report the incidence of aberrant hepatic arterial anatomy and its impact on vascular and biliary complications. We retrospectively reviewed data of 90 OLT performed on 82 patients, including 4 who underwent retransplantation from March 2003 to March 2006. The means recipient age was 52.47 years and 49 were men. The main caval vein reconstruction technique was piggyback (n = 55; 61.2%). The biliary reconstruction was performed by an end-to-end choledocho-choledocho anastomosis in 83 cases (92.3%) with choledocho-jejunal anastomosis (Roux-in-Y) in 7 cases (7.7%). Aberrant arterial anatomy was noted in 20 liver grafts (22.2%), namely, accessory right hepatic artery (n = 6; 6.6%), accessory left (n = 10; 11%), both accessory right and left (n = 3; 3.3%), and hepatic common artery from mesenteric artery (n = 1; 1.1%). Among the transplantations of grafts with aberrant arterial anatomy, 2 cases (10%) developed hepatic artery thrombosis (HAT) and 4 (20%) biliary complications. The rate of HAT and biliary complications among grafts with normal arterial anatomy was 3 and 8 cases (4.2% and 11.42%), respectively. Despite a greater number of complications among OLT with aberrant arterial anatomy, the Fisher test showed no significant relationship between HAT or biliary complications and aberrant arterial anatomy.

Donor liver dysfunction: application of a new scoring system to identify the marginal donor.

Livers from marginal donors are increasingly used for transplantation due to the shortage of donor organs. The definition of a marginal donor remains unclear; prediction of organ function is a challenge. In the literature the use of steatotic livers has been associated with poor liver function or even primary dysfunction of the allograft. Tekin et al created a scoring system that classifies a donor as marginal or nonmarginal, using a mathematical model based on donor age and steatosis degree. The aims of this study were to apply the Tekin method to identify marginal and nonmarginal donors and evaluate the influence of the cold ischemia time (CIT) on allograft evolution. We retrospectively reviewed deceased donor liver transplantations performed from October 1995 to March 2006, namely, 177 adult liver transplantations in 163 patients. Fifty-five were excluded due to retransplantation (14) or insufficient data (41). Donor age and macrovesicular steatosis were evaluated according to the mathematical formula proposed by Tekin et al, classifying the donors as marginal versus nonmarginal. The authors also analyzed the CIT, 3-month mortality, and development of primary nonfunction or primary dysfunction. The median donor age was 38.9 years (range, 6-71). The postreperfusion biopsy specimen showed moderate to intense steatosis (>30%) in 14.75% of specimens, with no steatosis or mild steatosis in 85.25%. Sixty-one grafts (50%) developed primary graft dysfunction (PGD): 10 grafts, with primary nonfunction (PNF); and 51 with initial poor function (IPF). Using the criteria provided by Tekin et al, we obtained 41 marginal and 81 nonmarginal allografts. The marginal group showed 61.9% PGD, compared with 59.2% of PGD by the nonmarginal group. The CIT was greater than 12 hours in 5 marginal group transplants and 4 PGD cases (80%). Of the nonmarginal allografts, the CIT was greater than 12 hours in 29.6%, with 75% PGD. The 3-month graft survival rate was 80% in the marginal group with ischemia time more than 12 hours: 86.1% of the same group when CIT was less than 12 hours, and 82.7% in the nonmarginal group. In contrast, when we analyzed the occurrence of allograft dysfunction, the 3-month mortality rate was 34% among, grafts with dysfunction, whereas, in those without initial dysfunction, it was 4.1%. In conclusion, the score suggested by Tekin et al that classifies the donors as ideal (nonmarginal) or marginal was not able to predict initial primary dysfunction.

Results of urgent liver retransplantation in the state of São Paulo, Brazil.

The treatment of end-stage liver disease includes transplantation as a life-saving procedure although it has serious complications of hepatic artery thrombosis, liver dysfunction, or primary nonfunction, which frequently lead to the need for retransplantation. According to various reports, the incidence of retransplantation is around 10%. Given the critical organ shortage, the chance for a second transplant remains a controversial discussion in medical, ethical, and economic grounds because patient and graft survival rates after retransplantation are lower than those for primary transplantations. We retrospectively reviewed all of the urgent liver retransplants from October 2001 to February 2005 (52 months) by analyzing the number of retransplants, blood group, time between first and second liver transplantation, age, sex, and mortality. Data were obtained from the Transplantation System, State of Sao Paulo Health Secretariat. Among 1252 liver transplants performed during this period, 98 (7.82%) were urgent retransplantations. The primary procedure employed 955 (76.28%) deceased donors and 297 (23.72%) living donors. All 98 retransplants were performed using an organ from the pool of deceased donors. The retransplant rate was acceptable according to the literature, although we observed high rates of early mortality (<60 days), leading to a discussion of which patients had a better chance of survival and the best time to perform the second transplantation to use this scarce and precious resource in the best possible way.