Liver transplantation (LT) is increasingly recognized as a treatment option for various diseases affecting a growing elderly population. However, its use in patients over 70 years of age remains controversial in centers with suboptimal outcomes or high waitlist mortality.
The aim of this study was to evaluate the effectiveness of LT as a treatment option for elderly patients aged 70 years or older, in comparison with younger recipients.
This retrospective study was conducted based on medical record data from 309 liver transplant recipients treated by the same surgical team across three hospitals — two located in São Paulo, São Paulo state (SP) and one in Rio Branco, Acre state (AC). Patients were divided into two groups for comparison: those aged up to 69 years (Group I) and those aged 70 years or older (Group II).
Donor characteristics were similar between the two groups, except for a higher norepinephrine dose in Group I (p<0.05). Group II showed greater transfusion requirements and longer intensive care unit (ICU) stays (p<0.05), as well as higher rates of malnutrition and comorbidities. Notably, 90-day survival was comparable between the groups.
Patients aged 70 years or older can achieve outcomes comparable to those of younger recipients, provided they receive grafts from carefully selected donors. This population should not be excluded from transplant waitlists, and specific allocation policies or scoring adjustments should be considered to ensure equitable access.
A retrospective analysis of liver transplants was performed, comparing patients over and under 70 years of age. The elderly group was transplanted with careful donor selection and obtained results comparable to those of the younger group.
This study aims to show that elderly patients over 70 years of age can have good results after liver transplantation, comparable to patients under 70 years of age, with good donor selection and perhaps additional points to favor their position on the waiting list.
Orthotopic liver transplantation (OLT) is a highly complex procedure, which can be difficult to control intraoperatively in patients with coagulopathies.
The aim of this study was to evaluate the prophylactic administration of epsilon aminocaproic acid (EACA) to reduce the need for transfusion of blood products and its relevance for thrombosis.
Patients were randomized into two groups: one group received EACA (20 mg/kg/h) before surgical incision until the end of OLT and a control group received a similar volume of 0.9% saline solution. Blood was collected to analyze fibrinolysis and coagulation disorders using rotational thromboelastometry (ROTEM®).
A total of 24 patients received EACA and 26 patients received saline solution. In the analysis of the fibrinolytic and hemostatic coagulation profile by ROTEM®, fibrinolysis was significantly less frequent in the group of patients treated with EACA (p<0.001) in the anhepatic phase. There were no significant differences in the other extrinsic pathway thromboelastometry and fibrinogen-specific thromboelastometry analyses. In addition, there were no significant differences between both groups regarding the average and percentage transfusion of blood products, postoperative complications, patients who were discharged from the hospital, and those who died within 3 months after liver transplantation.
Although the administration of EACA did not reduce the transfusion of blood products, this drug effectively treated fibrinolysis and was not associated with any complications with increased risk of vein and hepatic artery thrombosis or mortality within 3 months after liver transplantation.
A total of 105 patients were assessed for eligibility, and 55 were excluded. The remaining 50 patients were randomized, of which 24 patients were allocated to the intervention group and the other 26 to the saline placebo group. In the analysis of the fibrinolytic and hemostatic coagulation profile by rotational thromboelastometry, fibrinolysis was significantly less frequent in patients treated with epsilon aminocaproic acid (p<0.001) compared to those in the placebo group during the anhepatic phase. In the other analyses using thromboelastometry assays such as extrinsic pathway thromboelastometry (EXTEM) (clotting time [CT], clot formation time, alpha angle, amplitude of clot firmness 10 min after CT [A10], and maximum clot firmness [MCF]) and fibrinogen-specific thromboelastometry (FIBTEM) (A10 and MCF), there was no significant difference nor postoperative complications in both groups.
Some studies have shown that epsilon aminocaproic acid (EACA) inhibits the binding of plasminogen to lysine residues on the surface of fibrin and prevents conversion of plasminogen to plasmin and the degradation of glycoprotein Ib receptors, thus preserving platelet function. Although EACA did not reduce blood product transfusion, the drug effectively treated all cases and was not associated with any complications of increased risk of hepatic artery and vein thrombosis or mortality within 3 months after orthotopic liver transplantation (OLT). These results support the safety of EACA as the antifibrinolytic drug of choice in OLT. However, future studies involving larger randomized clinical trials and higher doses are needed to further investigate the results.
Patients listed for liver transplantation and hepatocellular carcinoma are considered priority on the waiting list, and this could overly favor them.
This study aimed to evaluate the impact of this prioritization.
We analyzed the liver transplants performed in adults from 2011 to 2020 and divided into three groups: adjusted Model of End-Stage Liver Disease (MELD) score for hepatocellular carcinoma, other adjusted Model of End-Stage Liver Disease situations, and no adjusted Model of End-Stage Liver Disease.
A total of 1,706 patients were included in the study, of which 70.2% were male. Alcoholism was the main etiology of cirrhosis (29.6%). Of the total, 305 patients were with hepatocellular carcinoma, 86 with other adjusted Model of End-Stage Liver Disease situations, and 1,315 with no adjusted Model of End-Stage Liver Disease. Patients with hepatocellular carcinoma were older (58.9 vs. 53.5 years). The predominant etiology of cirrhosis was viral hepatitis (60%). The findings showed that group with adjusted Model of End-Stage Liver Disease had lower physiological Model of End-Stage Liver Disease (10.9), higher adjusted Model of End-Stage Liver Disease (22.6), and longer waiting list time (131 vs. 110 days), as compared to the group with no adjusted Model of End-Stage Liver Disease. The total number of transplants and the proportion of patients transplanted for hepatocellular carcinoma increased from 2011 to 2020. There was a reduction in the proportion of patients with hepatocellular carcinoma and adjusted Model of End-Stage Liver Disease of 20 and there was an increase on waiting list time in this group. There was an increase in the proportion of those with adjusted Model of End-Stage Liver Disease of 24 and 29, but the waiting list time remained stable.
Over the past decade, prioritization of hepatocellular carcinoma resulted in an increased proportion of transplanted patients in relation to those with no priority. It also increased waiting list time, requiring higher adjusted Model of End-Stage Liver Disease to transplant an organ.
Liver transplantation is a complex and valuable therapy. However, complications that burden postoperative quality of life, such as incisional hernia, are to be better elucidated, such as risk factors and prophylactic measures.
This study aimed to define the rate of incisional hernia in patients who underwent liver transplantation in a population in southern Brazil and to assess the related risk factors in order to establish measures for prior optimization and specific prophylactic care in the future.
Patients undergoing adult Liver transplantation from January 2004 to November 2020 were retrospectively analyzed, assessing demographic features, surgical outcomes, and predisposing factors.
Among 261 liver transplantation patients included, incisional hernia was diagnosed in 71 (27.2%). Of the 71 incisional hernia patients, 28 (39.4%) developed IH during the first post-transplant. Majority of the patients were male (52/71, 73.2%); of the 71 patients, 52 had hepatitis C virus (HCV) and 33 (46.5%) had hepatocellular carcinoma (HCC). Male gender (p=0.044), diabetes mellitus (p=0.008), and acute cellular rejection (p<0.001) were risk factors for IH. In all, 28 (39.4%) patients were submitted for hernia repair with mesh, with a recurrence rate of 17.8%.
Incisional hernia after liver transplantation is a relatively common problem associated with male gender, diabetes, and acute cellular rejection. This is a problem that should not be trivialized in view of the complexity of liver transplantation, as it can lead to a reduction in quality of life as well as jeopardize late liver transplantation results and lead to incarceration and strangulation.
The development of surgical techniques, chemotherapy, biological agents, and multidisciplinary approaches have made patients with unresectable colorectal liver metastases eligible for surgery. Many strategies have been developed to allow patients for surgical resection (percutaneous portal vein embolization, liver venous deprivation, parenchyma-sparing liver surgery, reverse strategy, associating liver partition and portal vein ligation for staged hepatectomy, and liver transplantation), the only form of disease control and curative treatment.
Blood loss during liver transplantation (LT) remains a major concern associated with increased morbidity and reduced patient and graft survival. The high complexity of the procedure associated with the multifaceted origin of the bleeding urges early identification of high-risk patients and proper monitoring of hemostasis disorders in order to improve results. The accuracy of international normalized ratio (INR) and activated partial thromboplastin time (aPTT) to evaluate coagulation status in cirrhotic patients has been doubted.
The aim of this study was to investigate the applicability of these coagulation tests to indicate fresh frozen plasma transfusion in LT.
This retrospective cohort study analyzed 297 cirrhotic patients submitted to LT. INR and aPTT were measured preoperatively and in each surgical phase. Hemostatic blood components were transfused only for coagulopathy indication. Patients were divided according to intraoperative plasma transfusion into transfused and non-transfused groups. The accuracy of INR and aPTT to predict plasma transfusions was investigated. The alert values of INR and aPTT unassociated with coagulopathy in each phase of surgery were identified.
Multivariate analysis showed that preoperative hematocrit (odds ratio [OR]=0.90, p<0.001), preoperative fibrinogen (OR=0.99, p<0.001), and absence of hepatocellular carcinoma (OR=3.57, p=0.004) were significant predictors of plasma transfusions.
INR and aPTT demonstrated poor accuracy in predicting plasma transfusions, irrespective of the cutoff adopted, highlighting the need for a more comprehensive approach to guide hemostatic therapy in LT to improve the outcome.
Intrahepatic cholangiocarcinoma (iCCA) was considered a contraindication for liver transplantation. However, recent studies have shown that highly selected cases of patients with a good response to neoadjuvant therapy may achieve acceptable survival rates when following liver transplantation.
To present two cases of patients with iCCA, without extrahepatic disease, who underwent living donor liver transplantation after receiving neoadjuvant chemotherapy.
Two cases of patients with histopathological diagnosis of locally advanced iCCA, ineligible for resection and without evidence of extrahepatic disease, are presented.
These patients underwent at least nine sessions of neoadjuvant chemotherapy, including Gemcitabine and Cisplatin, with or without the addition of immunobiological agents, resulting in a radiological tumor response. They subsequently underwent living donor liver transplantation. The average follow-up time was 15 months, with no clinical or radiological signs of disease.
In well-selected patients without extrahepatic disease, living donor liver transplantation represents a potential therapeutic option for iCCA.
Hepatic retransplantation is associated with higher morbidity and mortality when compared to primary transplantation. Given the scarcity of organs and the need for efficient allocation, evaluating parameters that can predict post-retransplant survival is crucial.
This study aimed to analyze prognostic scores and outcomes of hepatic retransplantation.
Data on primary transplants and retransplants carried out in the state of Paraná in 2019 and 2020 were analyzed. The two groups were compared based on 30-day survival and the main prognostic scores of the donor and recipient, namely Model for End-Stage Liver Disease (MELD), MELD-albumin (MELD-a), Donor MELD (D-MELD), Survival Outcomes Following Liver Transplantation (SOFT), Preallocation Score to Predict Survival Outcomes Following Liver Transplantation (P-SOFT), and Balance of Risk (BAR).
A total of 425 primary transplants and 30 retransplants were included in the study. The main etiology of hepatopathy in primary transplantation was ethylism (n=140; 31.0%), and the main reasons for retransplantation were primary graft dysfunction (n=10; 33.3%) and hepatic artery thrombosis (n=8; 26.2%). The 30-day survival rate was higher in primary transplants than in retransplants (80.5% vs. 36.7%, p=0.001). Prognostic scores were higher in retransplants than in primary transplants: MELD 30.6 vs. 20.7 (p=0.001); MELD-a 31.5 vs. 23.5 (p=0.001); D-MELD 1234.4 vs. 834.0 (p=0.034); SOFT 22.3 vs. 8.2 (p=0.001); P-SOFT 22.2 vs. 7.8 (p=0.001); and BAR 15.6 vs. 8.3 (p=0.001). No difference was found in terms of Donor Risk Index (DRI).
Retransplants exhibited lower survival rates at 30 days, as predicted by prognostic scores, but unrelated to the donor’s condition.
Liver transplantation (LT) is the only treatment that can provide long-term survival for patients with acute-on-chronic liver failure (ACLF). Although several studies identify prognostic factors for patients in ACLF who do not undergo LT, there is scarce literature about prognostic factors after LT in this population.
Evaluate outcomes of ACLF patients undergoing LT, studying prognostic factors related to 1-year and 90 days post-LT.
Patients with ACLF undergoing LT between January 2005 and April 2021 were included. Variables such as chronic liver failure consortium (CLIF-C) ACLF values and ACLF grades were compared with the outcomes.
The ACLF survival of patients (n=25) post-LT at 90 days, 1, 3, 5 and 7 years, was 80, 76, 59.5, 54.1 and 54.1% versus 86.3, 79.4, 72.6, 66.5 and 61.2% for patients undergoing LT for other indications (n=344), (p=0.525). There was no statistical difference for mortality at 01 year and 90 days among patients with the three ACLF grades (ACLF-1 vs. ACLF-2 vs. ACLF-3) undergoing LT, as well as when compared to non-ACLF patients. CLIF-C ACLF score was not related to death outcomes. None of the other studied variables proved to be independent predictors of mortality at 90 days, 1 year, or overall.
LT conferred long-term survival to most transplant patients. None of the studied variables proved to be a prognostic factor associated with post-LT survival outcomes for patients with ACLF. Additional studies are recommended to clarify the prognostic factors of post-LT survival in patients with ACLF.
The prevalence of primary sclerosing cholangitis (PSC) in the general population has not yet been clearly established. The management of PSC should focus on delaying the progression of the disease and restraining its complications. The only curative therapy for the disease remains liver transplantation (LT). PSC is currently the fifth most common indication for LT and corresponds to 5% of all LT indications in adults.
Our objective is to evaluate the indications and outcomes of PSC patients undergoing LT in three liver transplantation centers in southern Brazil – Hospital Santa Isabel in Blumenau, Santa Catarina state, and Hospital das Clínicas and Hospital Nossa Senhora das Graças, in Curitiba, Parana state).
This is a longitudinal observational study of patients with PSC who underwent LT in three major Brazilian medical centers. Electronic medical records and study protocols of all patients subjected to LT from January 2011 to December 2021 were retrospectively reviewed.
Of the 1,362 transplants performed in the three medical centers, 37 were due to PSC. Recurrence of PSC occurred in three patients (8.1%) in 3.0±2.4 years (range, 1–4 years). The 1-year and 5-year survival rates after the first LT were 83.8 and 80.6%, respectively. The 1-year and 5-year graft survival rates were, respectively, 83.8 and 74.8%.
Our experience with LT in patients with PSC demonstrated good patient and graft survival results. Most deaths were due to common factors in patients undergoing LT.
Desenvolvido por Surya MKT