Introduction Vascular thrombosis is one of the most severe complications related to organ transplantation. While immunocomplex presence has been associated with this complication in both kidney and heart transplantation, its etiology in the setting of liver transplantation remains unknown. Objectives To evaluate whether immunocomplexes have an impact in the development of graft vascular thrombosis in liver transplant recipients. Methods We performed a retrospective comparative study, including patients who underwent liver transplantation (n=373) during the study period between March 2000 and June 2013, at the University Hospital "12 de Octubre” (Madrid-Spain). Two groups were defined according to immunocomplex analysis: group 1 with a positive result and group 2 with negative immunocomplex study. Results Mean age was 54±10,5 years in group 1 vs 54 ± 10,5 years in group 2 (p=NS). 75% and 68.5% of patients were male in groups 1 and 2 respectively. There were no statistically significant differences when comparing BMI or average MELD score, which was 15.49 in group 1 and 15.94 in group 2 (p=NS). The rate of hepatocellular carcinoma was 16.1% in group 1 vs 27.6% in group 2 (p 0.007), while HCV infection was 38.5% in group 1 and 54.7% in group 2 (p 0.002). No statistically significant differences were found related to blood product transfusion, ICU or ward stay. Pretransplant portal thrombosis was 13.2% in group 1 vs 16% in group 2 (p 0.05). However, there were no statistically significant differences regarding post-transplant arterial thrombosis (4.2% group 1 vs 3.4% group 2; p 0.63) or in relation to post-transplant portal thrombosis, which was 1% in group 1 and 1.1% in group 2 (p 0.95). Actuarial survival rates at 1, 3 and 5 years for group 1 were 85.6%, 76.6%, and 71.3% respectively, while for group 2 they were 80.7%, 72.9% and 66.3%, without significant differences identified (p 0.109).Conclusion In our series, immunocomplex presence has not been confirmed to be a relevant factor in the development of graft vascular thrombosis in liver transplantation. Hospital 12 de Octubre.
Introduction The presence of pretransplant AbIGA is one of the factors associated with the highest risk of thrombosis and graft loss in patients who have received either kidney or heart transplantation, without any evidence of impact in orthotopic liver transplant (OLT). Vascular complications are a serious setback both in patients who are candidates for liver transplantation and probably in post-transplant patients. The aim of this study is to evaluate whether the presence of these antibodies (Ab) is related to those vascular complications in OLT recipients. Methods We have performed a comparative retrospective analysis of transplanted patients with antibodies studies between March 2000 and June 2013. Subgroups were established as follows: group A included patients who were positive for AbIGA antibodies (+) while group B included patients with negative results (-). Results We have compared the clinical characteristics of patients in group A vs group B, not obtaining statistically significant results in terms of age (54 years ± 10,1 vs 52 years ± 11,5, p=NS), body mass index (BMI) ( 27,1 vs 26,5, p=NS), MELD score (group A 15,49 vs group B 16,45, p=NS), presence of hepatocellular carcinoma (HCC) (22,3% vs 19,8% p=NS) or hepatitis C virus (HCV) infection (47,0% vs 44,2% p=NS). Statistically significant differences were found concerning transfusion requirements, as Ab (+) patients were shown to have received a higher number of red blood cell transfusions (9± 9,0 vs 6± 5,1, p=0,001). No statistically significant differences were found regarding vascular complications, that is pretransplantation portal vein thrombosis (PVT) (15,8% vs 10,5%, p=0,46), post-transplant hepatic artery thrombosis (4,2% vs 2,3%, p=0,5), and post-transplant PVT (1,4% vs 0%, p=0,27). Patient survival rate at 1, 3, and 5 years was 82,9%, 76% and 68,9% respectively in group A, vs 84,9%, 72,1% y 66,3% in group B; no significant differences were found (p=0,370.) Conclusion The presence of AbIGA (+) in OLT patients is not associated with a higher incidence of vascular complications compared to those OLT patients with AbIGA (-).
Background Malnutrition and inmunological status are associated with worse survival in many cancers. Preoperative nutritional index (PNI) is calculated according to the serum albumin concentration and total lymphocyte count (ALC) in the peripheral blood. This index was originally proposed to assess the perioperative inmunonutritional status and surgical risk in patients undergoing gastrointestinal surgery and later in patients with hepatocellular carcinoma (HCC) undergoing liver resection. The aim of this study is to evaluate the prognostic value in terms of overall survival of PNI in patients with HCC after liver transplantation (LT). Material and methods We performed a retrospective study during the period between 2006-2016. Excluding HIV positive recipients, split grafts, simultaneos liver-kidney transplantation, donors older than 70 years, we analyzed 404 patients. There were 144 recipients transplantated for HCC. The preoperative PNI was calculated using albumin and ALC on admission for liver transplant,following this formula: serum albumin (g/dL)x10+0,005xALC (mm3). Results A total of 144 patients with HCC were included in the study. There were 120 men (83%), with a median age of 58+-7 years. Hundred patients (69,4%) were HCV+, 41 received a DCD (donation after cardiac death) donor type II graft and 103 received a BDD donor. HCC recurred in 10 patients (7%). Of these patients, 116 fulfilled the Milan criteria, 35 the UCSF criteria and 3 were beyond UCSF. Regarding the PNI, the median value was 40,9+-8,3. The AUC was 0,753 (p=0,08), and the Younden index was highest when PNI was 45: the S was 75% and E, 75% also. One,3 and 5 years overall survival were 99%, 84% and 79% in patients with PNI>45 higher than 85%, 70% and 64% in PNI<45. Comparing in both groups the clinical characteristics like age, gender, HCV proportion or listing AFP, we did not find significant differences. Patients with PNI<45 showed significantly higher number of nodules before LT (p<0,05) and microvascular invasion than those with PNI >45 (p<0,05). During the surgery patients with PNI<45 requiered more platelets, plasma or red blood cell transfussion than those with PNI>45 (p<0,001), being 1,4 the median McCluskey index in PNI>45 group and 2,6 in PNI<45 (p<0,05) . Discussion PNI is the result of low hipoalbuminemia and lymphocytopenia. As we all know, albuminemia has been already used in several staging systems to asess the liver function. But behind its correlation with malnutrition, it is thought to be also an indirect meassure of the level of inflamation and tumour progression. In our study, PNI grade was also a good indicator of transfusional requirements. Conclusion Though we need a larger sample size and a longer follow up, PNI before LT for HCC seems to be useful as prognostic factor for overall survival and for transfusional requirements.
Introduction Although donors after cardiac death (DCD) Maastricht type IIA have been established as an acceptable source of grafts in the current setting of organ shortage, biliary complications, especially ischemic cholangiopathy (IC), remain a considerable difficulty in the management of these patients, with a significant impact in long term results and quality of life. Objectives To study the incidence and impact of ischemic cholangiopathy among DCD IIA liver transplant recipients, and identify risk factors related to this complication. Materials and Methods Retrospective analysis of the DCD Maastricht type IIA liver transplantation series in University Hospital 12 de Octubre, registered from January 2006 to December 2016. Results 75 LT from DCD type IIA were performed during the study period, with 23 cases of IC diagnosed (30.7%). Comparing patients who suffered this complication (IC) with those who did not (no-IC), there were no significant differences found in recipient age (no-IC 58.4+7.7, IC 59.5+7.7 years), MELD score (no-IC 13.9+4.8 vs IC 15.6+4.8), donor age, HCV infection or hepatocellular carcinoma prevalence. Mean MELD-Na was 19+7 in those patients who developed IC, and 15.9+5.8 in those who did not, although the difference was not significant. Ischemia times and ECMO flow rates were similar in both groups. Retransplantation rate was higher in the no-IC group (11.5% vs. 13%, NS). No differences were achieved comparing liver function tests. Median time from transplantation to development of ischemic cholangiopathy was 5.8 months (range 1.2-70.3). Multivariate analysis shows an increased risk of IC in those grafts with AST levels over four times the upper limit of the normal range in the last blood sample obtained during NECMO (OR, 5.93; 95% CI, 1.001-35.208; p 0.05). No other statistically relevant risk factors were identified in this analysis. Differences found when comparing actuarial survival at 1, 3 and 5 years in recipients who did not develop IC (76.5%, 70.3% and 70.3%) with those who did (91.3%, 69.6% and 65.2%) were not statistically significant (p 0.915). Similar results were obtained when studying graft survival (no IC 70.6%, 64.3%, 64.3% vs. IC 78.3%, 60.9%, 56.5%; p 0.958). Conclusions AST levels 4 times above the usual laboratory range have been identified as a significant risk factor in the developement of ischemic cholangiopathy, suggesting that grafts with this characteristic should be discarded to minimize said complication.
Introduction Ten years after the beginning of the donation after cardic death (DCD) programme in the University Hospital 12 de Octubre, we study the evolution of the results of said programme over time. Objectives To compare the results of liver transplantation (LT) using grafts obtained from donors after cardiac death (DCD type Maastricht IIA) performed during the first period (A) of the programme (January 2006 to December 2010) versus those performed during a later period defined from January 2011 to December 2016 (B). Materials and Methods Retrospective analysis of the DCD liver transplantation series in the University Hospital 12 de Octubre. Results 75 LT from DCD type IIA have been reviewed, 44 performed during period A and 31 during period B. Mean recipient ages were 59+8 y 58+6 (NS) respectively, with a similar number of male patients (79,5% vs. 71% NS). There were no statistically significant differences found regarding other recipient characteristics such as MELD score, hepatocellular carcinoma or HCV infection. Mean donor age was 38+9 years in group A and 46+7 in group B (p 0.000). When reviewing ischemia times (IT), cold IT was shorter in group B (A 7:00 vs. B 6:05; p 0.046) as was warm IT (A 1:08 vs. B 0:58, p 0.025). However NECMO time was significantly shorter during the first period (3:16 vs. 3:37 min, p 0.027). Recipient survival during period A at 1, 3 and 5 years was 77.3%, 61.4% and 59.1% while during period B it was 87.1%, 83.7% and 83.7% (p 0.039). Graft survival after period A was significantly lower as well (63.6%, 50% and 47.7% vs. 83.9%, 80.5% and 80.5% in group B; p 0.008). The incidence of ischemic cholangiopathy was higher in group A (43.2% vs. 13.3%; p 0.006), as well as the retransplantation rate (A 18.2% vs. B 3.2%; p 0.05). There were non-statistically significant differences found regarding the incidence of primary graft non-function (A 11.4% vs. 3.3% in group B; p 0.214). Conclusions The study shows a significant improvement in the results of DCD liver transplantation through time, possibly related to graft ischemia time optimization.
Introduction Portal vein thrombosis is a late consequence of advanced cirrhosis. Its development has been associated with worse long term patient and graft survival, as well as a higher risk of vascular complications after liver transplantation. Material and Methods We reviewed all patients over 18 years old who underwent liver transplantation (LT) at University Hospital “12 de Octubre” between January 2002 and January 2017. Pediatric recipients and cases of retransplantation were excluded. Patients were divided according to the presence of preoperative portal thrombosis (PT, 126 patients) or no PT (N-PT, 724 patients). Results Mean recipient age was 55.5±9 in PT vs 53.7±11 in N-PT (p 0.085), with a similar number of male patients in both groups (76.2% en PT vs 72.8% in N-PT; p 0.431). There was a 59,2% rate of HCV infection in the PT group (52.4% in N-PT; p 0.157), and 22.2% of patients in the same group had a diagnosis of hepatocellular carcinoma (vs 29,9% in N-PT group; p 0.080). Mean preoperative MELD score was 14.7 en TP vs 15.6 in N-PT (p 0.067). There were no significant differences found regarding preoperative BMI, haemoglobin, MELD-Na score and Child-Pugh score.16.7 % of patients in the PT group received a subobtimal graft for LT, vs 21.7% in the N-PT group (p 0.204). In relation to blood products transfusion, an average of 12.3 units of RBC was administered in the the PT group and 9.2 in the N-PT (p 0.084), with an average of 14.6 and 12.8 FFP units respectively (p 0.093) and no differences found when reviewing platelets and fibrinogen. Mean ICU stay was 9.2 days in PT vs 6.7 in N-PT (p 0.075), while mean ward stay was 17.7 days in PT vs 19.4 in N-PT (p 0.429). Portal thrombosis recurrence rate was 4% in patients with a previous diagnosis of PT, significantly higher than in those without said previous history (1.1% in N-PT; p 0.015). However, the rate of arterial thrombosis was 4.8% in the PT group vs 3.8% in the N-PT group with no statistical significance (p 0.890). Retransplantation rate was 4% in PT and 6.2% in N-PT (p 0.326). Actuarial survival at 1, 3 and 5 years was 86.5%, 79.1% and 76.2% respectively in the PT group, vs 84.5%, 78.3% y 74.3% in the N-PT group (p=0.489). Conclusion Pretransplant portal thrombosis is a diagnosis that has not been associated with a decreased survival after LT in our series; but seems to determine an increase in transfusion requirements and a higher risk of postoperative vascular complications.
Introduction Steatotic liver grafts represent the most common type of extended criteria of liver grafts organ that have been introduced in the last decade due to the disparity between liver transplant candidates and the number of available organs. The aim of this study was to determine the effect of donor graft steatosis on the outcomes of liver transplantation (LT). Material and Methods We performed a retrospective study during the period between 2006-2016. Excluding HIV positive recipients, split grafts, simultaneos liver-kidney transplantation, donors eldier than 70 years, we analyzed 172 patients. The sample divided into 3 groups: normal histology (steatosis<10%), mild steatosis (10-30%), and moderate steatosis (30-60%). Factors such as mortality, overall survival, graft surgical complications, graft rejection were analyzed following the degrees of steatosis. Results Among the existing pathology reports of the 172 cases we found 94 (54%) with normal pathology (steatosis less than 10%), 74 (43%) with mild steatosis (10-30%) and 4 (3%) patients with moderate steatosis (30-60%). If we compare the MELD score before transplantation or the transfusional requierements using the McCluskey index, no differences were seen among the three groups. Mean ICU stay were also similar: 6.7 days in the non steatosis group, 7.6 days in mild steatosis and 3,5 in moderate steatosis (p=0.6). No difference was observed between the three groups for the incidence of complications such as acute graft rejection (p=0,1), ischemic cholangiopathy (p=0,1), hepatic artery thrombosis or chronic rejection (p=0,2). Regarding the early allograft disfunction (EAD) and primary non function (PNF), no differences were observed: 8 EAD (8,5%) in no steatosis group and 6 (8,1%) in the mild steatosis. No difference was found on the actuarial survival (AS) at 1,3 and 5 years, being for each group: steatosis<10%, the AS was 87%, 82% and respectively 81%. In mild steatosis group the AS was 85%, 83% and respectively 82% (p=0,5). If we take a look to the early mortality, during the hospitalization stay, 3 (3%) died in the non steatosis group and 6 (8%) in the mild steatosis. Conclusion Though we need a larger sample size, we did not find differences in terms of overall survival or complications after LT using grafts with middle to moderate steatosis (<60%).
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