Evaluation of the treatment of the hepatocarcinoma nodules in the patients in waiting list for liver transplant. / Avaliação do tratamento dos nódulos do hepatocarcinoma nos pacientes em lista de espera para transplante hepático.

OBJECTIVE: to compare the outcome of liver transplantation for hepatocarcinoma in submitted or not to locoregional treatment and downstaging regarding survival and risk of recurrence in transplant waiting list patients. METHODS: retrospective study of patients with hepatocarcinoma undergoing liver transplantation in the metropolitan region of São Paulo, between January 2007 and December 2011, from a deceased donor. The sample consisted of 414 patients. Of these, 29 patients were included in the list by downstaging. The other 385 were submitted or not to locoregional treatment. RESULTS: the analysis of 414 medical records showed a predominance of male patients (79.5%) with average age of 56 years. Treatment of the lesions was performed in 56.4% of patients on the waiting list for transplant. The most commonly used method was chemoembolization (79%). The locoregional patients undergoing treatment had a significant reduction in nodule size greater (p<0.001). There was no statistical difference between groups with and without locoregional treatment (p=0.744) and on mortality among patients enrolled in the Milan criteria or downstaging (p=0.494). CONCLUSION: there was no difference in survival and recurrence rate associated with locoregional treatment. Patients included by downstaging process had comparable survival results to those previously classified as Milan/Brazil criteria.

OBJETIVO: comparar o resultado do transplante de fígado por hepatocarcinoma em pacientes submetidos ou não ao tratamento loco-regional e downstaging, em relação à sobrevida e risco de recidiva na fila de transplante. MÉTODOS: estudo retrospectivo dos pacientes portadores de hepatocarcinoma submetidos a transplante hepático na região metropolitana de São Paulo, entre janeiro de 2007 e dezembro de 2011, a partir de doador falecido. A amostra foi constituída de 414 pacientes. Destes, 29 foram incluídos na lista por downstaging. Os demais 385 foram submetidos ou não ao tratamento loco-regional. RESULTADOS: as análises dos 414 prontuários demonstraram um predomínio de pacientes do sexo masculino (79,5%) e com média de idade de 56 anos. O tratamento dos nódulos foi realizado em 56,4% dos pacientes em fila de espera para o transplante. O método mais utilizado foi a quimio-embolização (79%). Os pacientes submetidos ao tratamento loco-regional tiveram redução significativa no tamanho do maior nódulo (p<0,001). Não houve diferença estatística entre grupos com e sem tratamento loco-regional (p=0,744) e em relação à mortalidade entre pacientes incluídos no Critério de Milão ou ao downstaging (p=0,494). CONCLUSÕES: não houve diferença na sobrevida e ocorrência de recidiva associadas ao tratamento loco-regional. Os pacientes incluídos através do processo de downstaging apresentaram resultados de sobrevida comparáveis àqueles previamente classificados como Critério de Milão/Brasil.

Use of fibrinogen and thrombin sponge in pediatric split liver transplantation.

PURPOSE:: To analyze the use of this sponge in pediatric patients undergoing split-liver transplantation. METHODS:: Retrospective study, including 35 pediatric patients undergoing split-liver transplantation, divided into two groups according to the use of the sponge: 18 patients in Group A (no sponge) and 17 in Group B (with sponge). RESULTS:: The characteristics of recipients and donors were similar. We observed greater number of reoperation due to bleeding in the wound area in Group A (10 patients - 55.5%) than in Group B (3 patients - 17.6%); p = 0.035. The median volume of red blood cells transfused in Group A was significantly higher (73.4 ± 102.38 mL/kg) than that in Group B (35.1 ± 41.67 mL/kg); p = 0.048. Regarding bile leak there was no statistical difference. CONCLUSION:: The use of the human fibrinogen and thrombin sponge, required lower volume of red blood cell transfusion and presented lower reoperation rates due to bleeding in the wound area.

Duodenum-stomach anastomosis: a new technique for exocrine drainage in pancreas transplantation.

INTRODUCTION: Poor vascular access due to previous surgery can be a major obstacle in pancreas transplantation for which new exocrine and vascular outflow techniques might be useful. A 34-year-old female with early onset type 1 diabetes who underwent living donor kidney transplantation 20 years ago and a failed pancreas transplantation 2 years ago presented for pancreas retransplantation. METHODS: The inferior vena cava was used in the previous deceased donor pancreas transplantation and both iliac arteries had intense perivascular fibrosis, making arterial anastomosis impossible. The only remaining option for the implant was the infrarenal aorta, with venous drainage to the superior mesenteric vein and exocrine drainage to the gastric antrum. RESULTS: The patient had an uneventful recovery and graft function appeared normal. This report shows that when the recipient's abdominal cavity does not provide clear access for the usual surgical techniques regarding exocrine drainage, the stomach drainage procedure is an option. CONCLUSION: Duodenum-stomach anastomosis might be an alternative to portal enteric drainage because there is easy access for graft biopsies and even for procedures involving the papilla major.

Evaluation of the efficacy and reproducibility of cholangiopancreatography by magnetic resonance for detecting biliary complications following orthotopic liver transplantation / Estudo da eficácia e da reprodutibilidade da colangiopancreatografia por ressonância magnética na detecção das complicações biliares pós-transplantes hepáticos

PURPOSE: To evaluate the accuracy and reproducibility of magnetic resonance cholangiopancreatography (MRCP) in the detection of biliary complications in liver transplanted patients. METHODS: A study was conducted, with blinded review of 28 MRCP exams of 24 patients submitted to liver transplantation. The images were reviewed by two independent observers, at two different moments, regarding the degree of biliary tree visualization and the presence or absence of biliary complications. The MRCP results were compared, when negative, to at least 3 months of clinical and biochemical follow-up, and when positive, to the findings at surgery or endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: The degree of intrahepatic biliary tree visualization was considered good or excellent in 78.6 percent and 82.1 percent of the exams by the two observers and visualization of the donor duct, recipient duct and biliary anastomosis was considered good or excellent in 100 percent of the exams, by both observers. Six biliary complications were detected (21.4 percent), all of them anastomotic strictures. Intra and interobserver agreement were substantial or almost perfect (kappa k values of 0.611 to 0.804) for the visualization of the biliary tree and almost perfect (k values of 0.900 to 1.000) for the detection of biliary complications. MRCP achieved 100 percent sensitivity, 95.45 percent specificity, 85.7 percent positive predictive value and 100 percent negative predictive value for the detection of biliary complications. CONCLUSIONS: MRCP is an accurate examination for the detection of biliary complications after orthotopic liver transplantation and it is a highly reproducible method in the evaluation of the biliary tree of liver transplanted patients.

OBJETIVO: Medir a acurácia e reprodutibilidade da colangiopancreatografia por ressonância magnética (CPRM) na avaliação da visibilização de complicações biliares em pacientes submetidos a transplantes hepáticos ortotópicos. MÉTODOS: Realizado estudo retrospectivo de 28 exames de CPRM de 24 pacientes submetidos a transplantes hepáticos. Os exames foram interpretados por dois observadores independentes, em dois momentos distintos, quanto ao grau de visibilização das estruturas estudadas e quanto à presença ou ausência de alterações nas vias biliares. Os resultados da CPRM foram comparados, nos casos de CPRM negativa, à evolução clínico-laboratorial por pelo menos 3 meses e, nos casos de CPRM alterada, aos achados de colangiopancreatografia retrógrada endoscópica (CPRE) e cirurgia, quando indicados. RESULTADOS: A visibilização das vias biliares intra-hepáticas foi considerada boa ou excelente em 78,6 por cento e 82,1 por cento dos exames pelos dois observadores. A visibilização da via biliar extra-hepática do doador e do receptor, bem como da anastomose biliar, foi considerada boa ou excelente em 100 por cento dos casos por ambos os observadores. Foram detectadas seis complicações biliares (21,4 por cento dos casos), todas elas estenoses anastomóticas. A concordância intra e intra-observador foi substancial ou quase perfeita (índices de kappa- k de 0,611 a 0,804) para a visualização das estruturas estudadas e quase perfeita (k de 0,900 a 1,000) para a detecção das complicações biliares. A CPRM apresentou sensibilidade de 100 por cento, especificidade de 95,45 por cento, valor preditivo positivo de 85,7 por cento e valor preditivo negativo de 100 por cento para a detecção de complicações biliares. CONCLUSÕES: A colangiopancreatografia por ressonância magnética (CPRM) é um exame acurado para a detecção de complicações biliares em pacientes submetidos a transplantes hepáticos ortotópicos por CPRM. Este exame configura-se como um método eficiente ...

Evaluation of the efficacy and reproducibility of cholangiopancreatography by magnetic resonance for detecting biliary complications following orthotopic liver transplantation.

PURPOSE: To evaluate the accuracy and reproducibility of magnetic resonance cholangiopancreatography (MRCP) in the detection of biliary complications in liver transplanted patients. METHODS: A study was conducted, with blinded review of 28 MRCP exams of 24 patients submitted to liver transplantation. The images were reviewed by two independent observers, at two different moments, regarding the degree of biliary tree visualization and the presence or absence of biliary complications. The MRCP results were compared, when negative, to at least 3 months of clinical and biochemical follow-up, and when positive, to the findings at surgery or endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: The degree of intrahepatic biliary tree visualization was considered good or excellent in 78.6% and 82.1% of the exams by the two observers and visualization of the donor duct, recipient duct and biliary anastomosis was considered good or excellent in 100% of the exams, by both observers. Six biliary complications were detected (21.4%), all of them anastomotic strictures. Intra and interobserver agreement were substantial or almost perfect (kappa k values of 0.611 to 0.804) for the visualization of the biliary tree and almost perfect (k values of 0.900 to 1.000) for the detection of biliary complications. MRCP achieved 100% sensitivity, 95.45% specificity, 85.7% positive predictive value and 100% negative predictive value for the detection of biliary complications. CONCLUSIONS: MRCP is an accurate examination for the detection of biliary complications after orthotopic liver transplantation and it is a highly reproducible method in the evaluation of the biliary tree of liver transplanted patients.

The evolution of diabetic chronic complications after pancreas transplantation.

Pancreas transplantation is an invasive procedure that can restore and maintain normoglycemic level very successfully and for a prolonged period in DM1 patients. The procedure elevates the morbimortality rates in the first few months following the surgery if compared to kidney transplants with living donors, but it offers a better quality of life to patients.Although controversial, several studies have shown the stabilization or the improvement of some of the chronic complications related to diabetes, as well as the extra number of years of life that patients submitted to a double pancreas-kidney transplantation may gain.Recent studies have demonstrated clashing outcomes regarding isolated pancreas transplantations, a fact which reinforces the need for a more discerning selection of patients for this procedure.

Kidney transplant in diabetic patients: modalities, indications and results.

BACKGROUND: Diabetes is a disease of increasing worldwide prevalence and is the main cause of chronic renal failure. Type 1 diabetic patients with chronic renal failure have the following therapy options: kidney transplant from a living donor, pancreas after kidney transplant, simultaneous pancreas-kidney transplant, or awaiting a deceased donor kidney transplant. For type 2 diabetic patients, only kidney transplant from deceased or living donors are recommended. Patient survival after kidney transplant has been improving for all age ranges in comparison to the dialysis therapy. The main causes of mortality after transplant are cardiovascular and cerebrovascular events, infections and neoplasias. Five-year patient survival for type 2 diabetic patients is lower than the non-diabetics' because they are older and have higher body mass index on the occasion of the transplant and both pre- and posttransplant cardiovascular diseases prevalences. The increased postransplant cardiovascular mortality in these patients is attributed to the presence of well-known risk factors, such as insulin resistance, higher triglycerides values, lower HDL-cholesterol values, abnormalities in fibrinolysis and coagulation and endothelial dysfunction. In type 1 diabetic patients, simultaneous pancreas-kidney transplant is associated with lower prevalence of vascular diseases, including acute myocardial infarction, stroke and amputation in comparison to isolated kidney transplant and dialysis therapy. CONCLUSION: Type 1 and 2 diabetic patients present higher survival rates after transplant in comparison to the dialysis therapy, although the prevalence of cardiovascular events and infectious complications remain higher than in the general population.

O impacto da função do enxerto renal e da ocorrência de infecção intra-abdominal na sobrevida em 1 ano do paciente após o transplante simultâneo de pâncreas-rim (TSPR) / The impact of kidney function and intra-abdominal infection on patient 1-yr survival after simultaneous pancreas-kidney transplantation (SPKT)

O transplante de pâncreas-rim (TSPR) é um dos tratamentos mais efetivos para o paciente com diabetes melito e insuficiência renal crônica. Métodos: Foram realizadas análises retrospectivas da sobrevida de 150 pacientes submetidos ao TSPR pela regressão de COX e determinação das curvas de Kaplan-Meier, além das análises uni - e multivariadas para identificação dos fatores de risco tradicionais e aqueles relacionados ao transplante. Resultados: As taxas de sobrevidas em um ano dos pacientes, dos enxertos renais e pancreáticos foram de 82,0%, 80,0% e 76,7%, respectivamente. Função retardada do enxerto renal (FRR) (P = 0,001, RR 5,41), rejeição aguda renal (P = 0,016, RR 3,36) e infecção intra-abdominal (IIA) (P < 0,0001, RR 4,15) foram os principais fatores de risco que influenciaram a sobrevida do paciente em um ano. A sobrevida do paciente em um ano esteve relacionada à ocorrência de FRR (P = 0,013, RC 3,39), à rejeição aguda renal (P = 0,001, RC 4,74) e à IIA (P = 0,003, RC 6,29). A sobrevida do enxerto pancreático em um ano esteve relacionada à IIA (P < 0,0001, RC 12,83), à trombose vascular (P = 0,002, RC 40,55), à rejeição aguda renal (P = 0,027, RC 3,06), ao sódio do doador > 155 mEq/L (P = 0,02, RC 3,27) e ao uso de dopamina > 7,6 µcg/kg/min (P = 0,046, RC 2,85). Discussão: A ocorrência de função retardada do enxerto renal e infecção intraabdominal teve impacto na sobrevida em um ano tanto do paciente quanto dos enxertos renal e pancreático

Simultaneous pancreas-kidney transplantation (SPKT) is one of the treatments for insulin-dependent patients with chronic renal failure. Methods: One-year patient and kidney allograft survival rates of 150 patients submitted to SPKT analyzed by COX regression and Kaplan-Meier. Uni- and multivariate analysis identified the risk factors involved with either allograft or patient survival. Results: One-year patient and kidney allograft survival rates were 82% and 80%, respectively. Delayed graft function from kidney (DGF) (P = 0.001, HR 5.41), acute kidney rejection (P = 0.016, HR 3.36) and intra-abdominal infection (IAI) (P < 0.0001, HR 4.15) were related to the 1-yr patient survival. One-year kidney allograft survival was also related to DGF (P = 0.013, OR 3.39), acute rejection (P = 0.001, OR 4.74) and IAI (P = 0.003, OR 6.29). Main risk factors for DGF: time on dialysis > 27 months (P = 0.046, OR 2.59), kidney cold ischemia time > 14 hours (P = 0.027, OR 2.94), donor age > 25 years (P = 0.03, OR 2.82) and donor serum sodium > 155 mEq/l (P < 0.0001, OR 1.09). Conclusions: Delayed kidney allograft function and IAI had an important impact on either patient or kidney allograft survival rates. Improving deceased donor care may reduce DGF occurrence.

Impact of pancreatic allograft function on 1-year survival rates after simultaneous pancreatic-renal transplant.

OBJECTIVES: Simultaneous pancreatic-renal transplant is an effective treatment for insulin-dependent patients with chronic renal failure. We sought to identify the main influences on pancreatic and patient survival rates after simultaneous pancreas-kidney transplants. PATIENTS AND METHODS: The 1-year patient and pancreas survival rates of 150 patients who had undergone simultaneous pancreas-kidney transplant were analyzed by the Cox proportional hazards regression model and the Kaplan-Meier method. Uni and multivariate analyses were performed in terms of transplant-, recipient-, and donor-related risk factors. RESULTS: At 1 year, patient and pancreatic allograft survival rates were 82% and 76.7%, respectively. Delayed graft function in the kidney (P = .001, HR 5.41), acute kidney rejection (P = .016, HR 3.36), and intra-abdominal infection (P < .0001, HR 4.15) were the main factors related to 1-year patient survival. Pancreatic allograft survival at 1 year was related to intra-abdominal infection (P < .0001, OR 12.83), vascular thrombosis (P = .002, OR 40.55), acute kidney rejection (P = .027, OR 3.06), donor sodium greater than 155 mEq/L (P = .02, OR 3.27), and dopamine administration exceeding 7.6 microg/kg/min (P = .046, OR 2.85). CONCLUSIONS: Delayed kidney allograft function and intra-abdominal infection had an important effect on both patient and pancreatic allograft survival rates.

Living donor liver transplantation for children in Brazil weighing less than 10 kilograms.

Infants with end-stage liver disease represent a treatment challenge. Living donor liver transplantation (LDLT) is the only option for timely liver transplantation in many areas of the world, adding to the technical difficulties of the procedure. Factors that affect morbidity and mortality can now be determined, which opens a new era for improvement. We have accumulated an 11-year experience with LDLT for children weighing<10 kg. From October 1995 to October 2006, a total of 222 LDLT in patients<18 years of age were performed; 129 primary LDLT and 7 retransplants (4 LDLT and 3 deceased donor grafts) were performed in 129 infants weighing<10 kg. Forty-seven patients received grafts with graft-to-recipient weight ratio (GRWR) of >4%. Two patients received monosegmental grafts, and 2 patients underwent delayed abdominal wall closure. Portal vein thrombosis occurred in 5.4% of the patients, hepatic artery thrombosis in 3.1%, and both in 1.5%. Among several variables studied, only the bilirubin level at the time of transplantation was associated with increased risk of death (P=0.009). Grafts with GRWR>4% had no negative effect on patient survival. There were 7 retransplants, and 4 patients received a second parental LDLT. Patient survival rates at 1, 3, and 10 years after transplantation were 88.8%, 84.7%, and 82% for all children, and 87.5%, 84.9%, and 84.9% for infants weighing<10 kg. LDLT has results comparable to other modalities of liver transplantation in infants. Monosegment grafts were rarely required in this series, although they may be necessary in patients with lower body weight.