Dyslipidemia occurs in approximately 70% of all liver transplant (LT) recipients, and no prior control studies have demonstrated any dietary intervention to change it.
To analyze the effects of a dietary intervention on the lipid profile of dyslipidemic LT recipients.
All LT recipients with dyslipidemia on clinical follow-up were enrolled. Anthropometric evaluation, food history, body composition (bioimpedance) and assessment of basal metabolism through indirect calorimetry were performed. Patients met with a dietitian and an individualized diet based on estimate of basal metabolism and consisting of 25% of the total energy value in total fat and <200 mg/day of cholesterol was prescribed. Total cholesterol (TC), HDL-cholesterol (HDL), LDL-cholesterol (LDL), triglycerides (TG) and anthropometric measures were measured at baseline and six months after intervention.
Fifty-thee out of 56 patients concluded follow-up; age was 59±10 years; 29 were men (51.8%). The analysis pre- and post-intervention were, respectively: TC 238.9±30 and 165.1±35, p<0.001; LDL 154±33 and 90±29, p<0.001; and TG 168 (IQR=51-200) and 137 (IQR=94-177), p=<0.001. They were all modified at six months following intervention. At baseline, none of the patients had normal TC, and only 12 (22.7%) had optimal/near optimal LDL. Following dietary intervention, 45 patients (84.9%) reached normal TC and 50 (94.4%) had optimal/near optimal LDL. HDL and anthropometric measures were not modified.
Dietary counseling with prescription of individualized diet based on estimate of basal metabolism through indirect calorimetry was able to manage dyslipidemia in most LT recipients; so, all dyslipidemic LT recipients must be enrolled on a dietary program.
The criterion of Milan (CM) has been used as standard for indication of liver transplantation (LTx) for hepatocellular carcinoma (HCC) worldwide for nearly 20 years. Several centers have adopted criteria expanded in order to increase the number of patients eligible to liver transplantation, while maintaining good survival rates. In Brazil, since 2006, the criterion of Milan/Brazil (CMB), which disregards nodules <2 cm, is adopted, including patients with a higher number of small nodules.
To evaluate the outcome of liver transplantation within the CMB.
The medical records of patients with HCC undergoing liver transplantation in relation to recurrence and survival by comparing CM and CMB, were analyzed.
414 LTx for HCC, the survival at 1 and 5 years was 84.1 and 72.7%. Of these, 7% reached the CMB through downstaging, with survival at 1 and 5 years of 93.1 and 71.9%. The CMB patient group that exceeded the CM (8.6%) had a survival rate of 58.1% at five years. There was no statistical difference in survival between the groups CM, CMB and downstaging. Vascular invasion (p<0.001), higher nodule size (p=0.001) and number of nodules >2 cm (p=0.028) were associated with relapse. The age (p=0.001), female (p<0.001), real MELD (p<0.001), vascular invasion (p=0.045) and number of nodes >2 cm (p<0.014) were associated with worse survival.
CMB increased by 8.6% indications of liver transplantation, and showed survival rates similar to CM.
Surgical strategy to increase the number of liver transplants in the pediatric population is the ex-situ liver transection (reduction or split). However, it is associated with complications such as hemorrhage and leaks. The human fibrinogen and thrombin sponge is useful for improving hemostasis in liver surgery.
Compare pediatric liver transplants with ex-situ liver transection (reduction or split) with or without the human fibrinogen and thrombin sponge.
Was performed a prospective analysis of 21 patients submitted to liver transplantation with ex-situ liver transection with the application of the human fibrinogen and thrombin sponge in the wound area (group A) and retrospective analysis of 59 patients without the sponge (group B).
The characteristics of recipients and donors were similar. There were fewer reoperations due to bleeding in the wound area in group A (14.2%) compared to group B (41.7%, p=0.029). There was no difference in relation to the biliary leak (group A: 17.6%, group B: 5.1%, p=0.14).
There was a lower number of reoperations due to bleeding of the wound area of the hepatic graft when the human fibrinogen and thrombin sponge were used.
Reliable measurement of basal energy expenditure (BEE) in liver transplant (LT) recipients is necessary for adapting energy requirements, improving nutritional status and preventing weight gain. Indirect calorimetry (IC) is the gold standard for measuring BEE. However, BEE may be estimated through alternative methods, including electrical bioimpedance (BI), Harris-Benedict Equation (HBE), and Mifflin-St. Jeor Equation (MSJ) that carry easier applicability and lower cost.
To determine which of the three alternative methods for BEE estimation (HBE, BI and MSJ) would provide most reliable BEE estimation in LT recipients.
Prospective cross-sectional study including dyslipidemic LT recipients in follow-up at a 735-bed tertiary referral university hospital. Comparisons of BEE measured through IC to BEE estimated through each of the three alternative methods (HBE, BI and MSJ) were performed using Bland-Altman method and Wilcoxon Rank Sum test.
Forty-five patients were included, aged 58±10 years. BEE measured using IC was 1664±319 kcal for males, and 1409±221 kcal for females. Average difference between BEE measured by IC (1534±300 kcal) and BI (1584±377 kcal) was +50 kcal (p=0.0384). Average difference between the BEE measured using IC (1534±300 kcal) and MSJ (1479.6±375 kcal) was -55 kcal (p=0.16). Average difference between BEE values measured by IC (1534±300 kcal) and HBE (1521±283 kcal) was -13 kcal (p=0.326). Difference between BEE estimated through IC and HBE was less than 100 kcal for 39 of all 43patients.
Among the three alternative methods, HBE was the most reliable for estimating BEE in LT recipients.
Liver transplantation is the usual treatment for hepatocellular carcinoma.
To analyze the MELD score, waiting time and three month and one year survival for liver transplantation in cirrhotic patients affected by hepatocellular carcinoma or not.
This was a retrospective, observational and analytical study of 93 patients submitted to liver transplantation.
There were 28 hepatocellular carcinoma and 65 non-hepatocellular carcinoma patients with no differences related to age and sex distribution. The main causes of cirrhosis on hepatocellular carcinoma were hepatitis C virus (57.1%) and hepatitis B virus (28.5%), more frequent than non-hepatocellular carcinoma patients, which presented 27.7% and 4.6% respectively. The physiological and exception MELD score on hepatocellular carcinoma were 11.9 and 22.3 points. On non-hepatocellular carcinoma, it was 19.4 points, higher than the physiological MELD and lower than the exception MELD on hepatocellular carcinoma. The waiting time for transplantation was 96.2 days for neoplasia, shorter than the waiting time for non-neoplasia patients, which was 165.6 days. Three month and one year survival were 85.7% and 78.6% for neoplasia patients, similar to non-neoplasia, which were 77% and 75.4%.
Hepatocellular carcinoma patients presented lower physiological MELD score, higher exception MELD score and shorter waiting time for transplantation when compared to non-hepatocellular carcinoma patients. Three month and one year survival were the same between the groups.
Hepatocellular carcinoma is an aggressive malignant tumor with high lethality.
To review diagnosis and management of hepatocellular carcinoma.
Literature review using web databases Medline/PubMed.
Hepatocellular carcinoma is a common complication of hepatic cirrhosis. Chronic viral hepatitis B and C also constitute as risk factors for its development. In patients with cirrhosis, hepatocelular carcinoma usually rises upon malignant transformation of a dysplastic regenerative nodule. Differential diagnosis with other liver tumors is obtained through computed tomography scan with intravenous contrast. Magnetic resonance may be helpful in some instances. The only potentially curative treatment for hepatocellular carcinoma is tumor resection, which may be performed through partial liver resection or liver transplantation. Only 15% of all hepatocellular carcinomas are amenable to operative treatment. Patients with Child C liver cirrhosis are not amenable to partial liver resections. The only curative treatment for hepatocellular carcinomas in patients with Child C cirrhosis is liver transplantation. In most countries, only patients with hepatocellular carcinoma under Milan Criteria are considered candidates to a liver transplant.
Hepatocellular carcinoma is potentially curable if discovered in its initial stages. Medical staff should be familiar with strategies for early diagnosis and treatment of hepatocellular carcinoma as a way to decrease mortality associated with this malignant neoplasm.
Cold ischemia time is related to success of liver transplantation.
To compare the impact of cold ischemia time on allografts locally collected to those collected distantly.
Were evaluated 83 transplantations. The patients were divided in two groups: those who received liver grafts collected from cities out of Curitiba (n=42) and locally (n=41). From the donors were compared: cause of death, days at ICU, cardiac arrest, vasoactive drugs, lab exams, gender, age, and BMI. Were compared the subsequent information of receptors: cold ischemia time, warm ischemia time, length of surgery, lab exams, etiology of cirrhosis, MELD score, age, gender, histology of graft, use of vasoactive drugs, and blood components transfusion. Were evaluated the correlation between cold ischemia time and lab results.
The liver grafts collected from other cities were submitted to a longer cold ischemia time (500±145 min) compared to those locally collected (317,85±105 min). Donors from other cities showed a higher serum sodium level at donation (154±16 mEq/dl) compared to those from Curitiba (144±10 mEq/dl). The length of cold ischemia time was related to serum levels of ALT and total bilirubin.
Liver grafts distantly collected underwent longer cold ischemia times, although it caused neither histologic injuries nor higher transfusion demands. There is a correlation between cold ischemia time and hepatic injury, translated by elevation of serum ALT and total bilirubin levels.
Liver transplantation is intended to increase the survival of patients with chronic liver disease in terminal phase, as well as improved quality of life. Since the first transplant until today many changes have occurred in the organ allocation system.
To review the literature on the Model for End-stage Liver Disease (MELD) and analyze its correlation with survival after liver transplantation.
An integrative literature review in Lilacs, SciELO, and Pubmed in October 2015, was realized. Were included eight studies related to the MELD score and its impact on liver transplant.
There was predominance of transplants in male between 45-55 y. The main indications were hepatitis C, hepatocellular carcinoma and alcoholic cirrhosis. The most important factors post-surgery were related to the MELD score, the recipient age, expanded donor criteria and hemotransfusion.
The MELD system reduced the death rate in patients waiting for a liver transplant. However, this score by itself is not a good predictor of survival after liver transplantation.
Computed tomography volumetry (CTV) is a useful tool for predicting graft weights (GW) for living donor liver transplantation (LDLT). Few studies have examined the correlation between CTV and GW in normal liver parenchyma.
To analyze the correlation between CTV and GW in an adult LDLT population and provide a systematic review of the existing mathematical models to calculate partial liver graft weight.
Between January 2009 and January 2013, 28 consecutive donors undergoing right hepatectomy for LDLT were retrospectively reviewed. All grafts were perfused with HTK solution. Estimated graft volume was estimated by CTV and these values were compared to the actual graft weight, which was measured after liver harvesting and perfusion.
Median actual GW was 782.5 g, averaged 791.43±136 g and ranged from 520-1185 g. Median estimated graft volume was 927.5 ml, averaged 944.86±200.74 ml and ranged from 600-1477 ml. Linear regression of estimated graft volume and actual GW was significantly linear (GW=0.82 estimated graft volume, r2=0.98, slope=0.47, standard deviation of 0.024 and p<0.0001). Spearman Linear correlation was 0.65 with 95% CI of 0.45 - 0.99 (p<0.0001).
The one-to-one rule did not applied in patients with normal liver parenchyma. A better estimation of graft weight could be reached by multiplying estimated graft volume by 0.82.
The incidence of anatomic variations of hepatic artery ranges from 20-50% in different series. Variations are especially important in the context of liver orthotopic transplantation, since, besides being an ideal opportunity for surgical anatomical study, their precise identification is crucial to the success of the procedure.
To identify the anatomical variations in the hepatic arterial system in hepatic transplantation.
479 medical records of transplanted adult patients in the 13-year period were retrospectively analyzed, and collected data on hepatic arterial anatomy of the deceased donor.
It was identified normal hepatic arterial anatomy in 416 donors (86.84%). The other 63 patients (13.15%) showed some variation. According to the Michels classification, the most frequently observed abnormalities were: right hepatic artery branch of superior mesenteric artery (Type III, n=27, 5.63%); left hepatic artery branch of the left gastric artery (Type II, n=13, 2.71%); right hepatic artery arising from the superior mesenteric artery associated with the left hepatic artery arising from the left gastric artery (Type IV, n=4, 0.83%). Similarly, in relation to Hiatt classification, the most prevalent changes were: right hepatic accessory artery or substitute of the superior mesenteric artery (Type III, n=28, 6.05%)), followed by liver ancillary left artery or replacement of gastric artery left (Type II, n=16, 3.34. Fourteen donors (2.92%) showed no anatomical abnormalities defined in classifications, the highest frequency being hepatomesenteric trunk identified in five (01.04%).
Detailed knowledge of the variations of hepatic arterial anatomy is of utmost importance to surgeons who perform approaches in this area, particularly in liver transplantation, since their identification and proper management are critical to the success of the procedure.
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