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ABSTRACT: OBJECTIVE: To identify peri-transplant predictors of early graft survival and post-transplant parameters to predict early graft outcome after paediatric liver transplantation (LT). BACKGROUND: Children's response to liver dysfunction after LT is poor. No data have been reported regarding early predictors of poor graft survival that would be of potential value in rescuing children at risk after LT. METHODS: A retrospective, cohort study of 422 paediatric LT performed from 2000-2010 in a single center was conducted. Multiple peri-transplant variables were analyzed. Univariate and multivariate analyses with ROC curves were performed to identify predictors of early (30-, 60-, and 90-days) graft loss (EGL). The number of patients needed to treat (NNT) was calculated when risk factors were identified. Comparisons with Olthoff criteria of early-graft-dysfunction in adults were performed. RESULTS: Overall 30-, 60-, and 90-days graft survival was 93.6%, 92.6% and 90.7%, respectively. Recipient age (0-2 and 6-16 years), acute liver failure (ALF) and post-transplant day-7-serum bilirubin >200 µmol/L were risk factors of graft loss in the three-strata Cox-models. The product of peak-AST, day-2-INR and day-7-bilirubin (30-, 60-, and 90-days AUROCs of 0.77, 0.75 and 0.71) and Day-7-bilirubin levels >200 µmol/L (30-, 60-, and 90-days AUROCs of 0.75, 0.66 and 0.63) had excellent rates of prediction of EGL in the paediatric population (Sensitivity=72.7%; Specificity=96.6%; Positive-predictive-value=95.5%; Negative-predictive-value=78%). The NNT with early re-transplantation when Day-7-bilirubin is >200 µmol/L would be 2.17 (non-adjusted) and 2.76 (adjusted to graft survival). CONCLUSIONS: Two scores have been identified (Peak AST*Day-2-INR*Day-7-Bilirubin and/or post-transplant day-7 bilirubin >200 µmol/L) as clinically valuable tools with high accuracy to predict EGL. A more aggressive attitude to considering early re-transplantation in this group may further improve survival after LT. Liver Transpl, 2012. © 2012 AASLD.
Liver Transplantation 08/2012; · 3.39 Impact Factor
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ABSTRACT: Auxiliary liver transplantation (ALT) has developed as a technique for treating patients with acute liver failure. The surgical techniques of ALT have been refined and current patient survival appears to be similar to that observed with conventional liver replacement for acute liver failure.
Our understanding of liver regeneration has improved with experience and it is possible to identify patient and disease groups that are more likely to regenerate and wean off immunosuppression after ALT. Withdrawal of immunosuppression is possible in at least two thirds of survivors up to 4 years post transplant. Young patients have most to gain in the long term from immunosuppression withdrawal. Documentation of liver regeneration should be performed by liver histology, nuclear medicine scanning and CT volumetry. Weaning should be gradual to allow for graft atrophy to avoid complications. ALT has also been utilised for the management of inborn errors of metabolism based in the liver and for other rare problems and these will be briefly addressed in the review.
Auxiliary liver transplantation should be considered for the treatment of children with acute liver failure satisfying current criteria for liver transplantation.
Current opinion in organ transplantation 10/2011; 16(5):489-93. · 1.22 Impact Factor
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ABSTRACT: Hepatorenal syndrome (HRS) is a complication of cirrhosis with a poor prognosis without transplantation. The aim of this study is to analyze the influence of extended criteria donors (ECD) on the postoperative outcome of recipients with HRS. The last 498 patients were divided according to pre-transplant type 1 or 2 HRS. Sixty-six (13.25%) recipients fulfilled HRS criteria. Three-month graft survival was 84% with at-listing recipient serum creatinine ranging from 0-0.8 mg/dL; 80% with s-creatinine = 0.9-1.5 mg/dL; 79% with s-creatinine = 1.6-2.5 mg/dL; and 58% with s-creatinine >2.6 mg/dL (log-rank = 18.039; p = 0.001). Recipients with HRS presented higher levels of pre-transplant creatinine and lower levels of sodium, more episodes of hemodialysis and ascitis, and higher model of end-stage liver disease-scores. Three-month graft survival in recipients with HRS relative to ECD-variables showed differences in univariate analysis according to graft steatosis (85% in absent steatosis = 0-10%; 78% in mild steatosis = 10-30%; 76% in moderate steatosis = 30-60%; and 49% when severe steatosis >60%; log-rank = 5.146; p = 0.023). Cox-proportional-hazard-model revealed that graft macrosteatosis per-30%-increments (p = 0.000; HR = 1.303 [1.24-1.33] per-30%-increment) and donors >65 yr (p = 0.089; HR = 1.622 [1.17-1.94]) were independent predictors of graft loss in recipients with HRS. In conclusion, the use of ECD in recipients with cirrhosis and HRS is a good option. However, grafts from moderate-to-severe steatosis and those from aged donors must be carefully allocated in candidates with HRS.
Clinical Transplantation 02/2011; 25(3):E257-63. · 1.67 Impact Factor
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ABSTRACT: To examine the effectiveness of fibrin sealants as supportive treatment to improve hemostasis and decrease the incidence of bile leakage and intra-abdominal collections.
Prospective, controlled, quasiexperimental study.
Tertiary referral center, University Hospital Reina Sofía.
A total of 115 patients (58 in the control group and 57 in the collagen sponge group) scheduled for conventional hepatectomies.
Patients were distributed into groups for major and minor hepatectomies with or without application of a carrier-bound collagen sponge on the raw surface of the liver.
The main outcome measures were postoperative mortality, incidence and severity of postoperative surgical complications, and length of hospital stay. The secondary outcome measures were postoperative drainage output volume, transfusion requirements, and changes in biochemical parameters (hemoglobin, bilirubin, alanine aminotransferase, and platelet levels).
The fibrin sealant after major liver resection was effective for decreasing drainage volume (mean [SD] volume, 1124.7 [842.8] mL in the control group and 691.2 [499.5] mL in the collagen sponge group; P = .007) with a higher volume of output by drain each postoperative day in the control patients (P = .003); postoperative blood transfusion requirements (18.9% vs 7.0%, respectively; P = .04); moderate to severe postoperative complications (21% vs 8%, respectively; P = .03); and mean (SD) hospital stay (12.6 [6.7] vs 9.6 [5.1] days, respectively; P = .03).
The use of a new carrier-bound collagen sponge after major liver resection may be recommended because of its clinical and cost-savings effectiveness.
Archives of surgery (Chicago, Ill.: 1960) 05/2010; 145(5):482-8. · 4.32 Impact Factor
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ABSTRACT: To identify new markers of hepatocellular carcinoma (HCC) using a proteomic analysis.
Patients with liver cirrhosis of the three most frequent etiologies: hepatitis C virus, hepatitis B virus and alcoholic liver disease, were included in the study. The samples were analysed by 2D-electrophoresis in order to determine the differential protein expression. The proteins were separated according to the charge in immobilized pH 3-10 gradient strips and then by sodium dodecyl sulfate polyacrylamide gel electrophoresis. Proteins of interest were excised, digested with trypsin and the resulting peptides were separated and identified.
Three differentially expressed apolipoproteins (Apo) were identified based on the protein profile using proteomic techniques: Apo-A1, Apo-A4 and Apo-E. Apo-A4 levels were significantly lower in HCC than in non-HCC patients regardless of etiology (P < 0.01). Multivariate logistic regression showed that Apo-A4 and Apo-A1 were the only independent factors related to HCC diagnosis (P < 0.05). The receiver operating characteristic (ROC) curve including both Apo-A4 and Apo-A1 showed an area under the ROC of 0.944 (P < 0.001), a sensitivity of 0.89 and a specificity of 0.81 for diagnosis of HCC.
Apo-A4 and Apo-A1 may be used clinically as biomarkers of HCC with a high sensibility and specificity. These findings may provide additional insights into the mechanism of HCC development and progression.
World journal of hepatology. 03/2010; 2(3):127-35.
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ABSTRACT: The aim of this study was to determine the influence of donor graft steatosis on overall outcome, viral recurrence, and fibrosis progression in orthotopic liver transplantation (OLT) for hepatitis C virus (HCV) cirrhosis. One hundred twenty patients who underwent OLT for HCV cirrhosis between 1995 and 2005 were included in the study. Donor steatosis was categorized as absent (0%-10%; n = 40), mild (10%-30%; n = 32), moderate (30%-60%; n = 29), or severe (>60%; n = 19). A Cox multivariate analysis for marginal donor variables and a Model for End-Stage Liver Disease index were performed. Fibrosis evolution was analyzed in liver biopsies (fibrosis < 2 or > or =2) 3, 6, and 12 months post-OLT and in the late post-OLT period. Fifty-six grafts were lost (46%). The survival of the grafts was inversely proportional to donor liver steatosis: 82%, 72%, and 72% at 1, 2, and 3 years post-OLT in the absence of steatosis; 73%, 63%, and 58% with mild steatosis; 74%, 62%, and 43% with moderate steatosis; and 62%, 49%, and 42% with severe steatosis (P = 0.012). HCV recurrence was earlier and more frequent in recipients with steatosis > 30% (46% versus 32% at 3 months, P = 0.017; 58% versus 43% at 6 months, P = 0.020; 70% versus 56% at 12 months, P = 0.058; and 95% versus 69% at 3 years post-OLT, P = 0.0001). Graft survival was lower in alcoholic liver disease recipients versus HCV recipients when steatosis was >30% at 3, 6, and 12 months post-OLT (P = 0.042) but not when steatosis was <30% (P = 0.53). A higher fibrosis score was obtained 3 months post-OLT (P = 0.033), 6 months post-OLT (P = 0.306), 12 months post-OLT (P = 0.035), and in the late post-OLT period (P = 0.009). In conclusion, donor graft steatosis influences the outcome of OLT for HCV cirrhosis. HCV recurrence is more frequent and earlier in recipients of moderately and severely steatotic livers. Fibrosis evolution is higher when graft steatosis is >30%. OLT with >30% steatotic donor livers should be precluded in HCV recipients.
Liver Transplantation 01/2009; 15(1):37-48. · 3.39 Impact Factor
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ABSTRACT: We report an unusual pathological entity of a pseudoaneurysm of the right hepatic artery, which developed two years after the resection of a type II hilar cholangiocarcinoma and secondary to an excessive skeletonization for regional lymphadenectomy and neoadjuvant external-beam radiotherapy. After a sudden and massive hematemesis, a multidetector computed tomographic angiography (MDCTA) showed a hepatic artery pseudoaneurysm. Angiography with embolization of the pseudoaneurysm was attempted using microcoils with adequate patency of the hepatic artery and the occlusion of the pseudoaneurysm. A new episode of hematemesis 3 wk later revealed a partial revascularization of the pseudoaneurysm. A definitive interventional radiological treatment consisting of transarterial embolization (TAE) of the right hepatic artery with stainless steel coils and polyvinyl alcohol particles was effective and well-tolerated with normal liver function tests and without signs of liver infarction.
World Journal of Gastroenterology 11/2008; 14(38):5920-3. · 2.47 Impact Factor
