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Yeh H, Chiang CC, Yen TH. Hepatocellular carcinoma in patients with renal dysfunction: Pathophysiology, prognosis, and treatment challenges. World J Gastroenterol 2021; 27:4104-4142. [PMID: 34326614 PMCID: PMC8311541 DOI: 10.3748/wjg.v27.i26.4104] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/17/2021] [Accepted: 06/16/2021] [Indexed: 02/06/2023] Open
Abstract
The population of patients with hepatocellular carcinoma (HCC) overlaps to a high degree with those for chronic kidney disease (CKD) and end-stage renal disease (ESRD). The degrees of renal dysfunction vary, from the various stages of CKD to dialysis-dependent ESRD, which often affects the prognosis and treatment choice of patients with HCC. In addition, renal dysfunction makes treatment more difficult and may negatively affect treatment outcomes. This study summarized the possible causes of the high comorbidity of HCC and renal dysfunction. The possible mechanisms of CKD causing HCC involve uremia itself, long-term dialysis status, immunosuppressive agents for postrenal transplant status, and miscellaneous factors such as hormone alterations and dysbiosis. The possible mechanisms of HCC affecting renal function include direct tumor invasion and hepatorenal syndrome. Finally, we categorized the risk factors that could lead to both HCC and CKD into four categories: Environmental toxins, viral hepatitis, metabolic syndrome, and vasoactive factors. Both CKD and ESRD have been reported to negatively affect HCC prognosis, but more research is warranted to confirm this. Furthermore, ESRD status itself ought not to prevent patients receiving aggressive treatments. This study then adopted the well-known Barcelona Clinic Liver Cancer guidelines as a framework to discuss the indicators for each stage of HCC treatment, treatment-related adverse renal effects, and concerns that are specific to patients with pre-existing renal dysfunction when undergoing aggressive treatments against CKD and ESRD. Such aggressive treatments include liver resection, simultaneous liver kidney transplantation, radiofrequency ablation, and transarterial chemoembolization. Finally, focusing on patients unable to receive active treatment, this study compiled information on the latest systemic pharmacological therapies, including targeted and immunotherapeutic drugs. Based on available clinical studies and Food and Drug Administration labels, this study details the drug indications, side effects, and dose adjustments for patients with renal dysfunction. It also provides a comprehensive review of information on HCC patients with renal dysfunction from disease onset to treatment.
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Affiliation(s)
- Hsuan Yeh
- Department of Nephrology, Chang Gung Memorial Hospital and Chang Gung University, Taipei 105, Taiwan
| | - Chun-Cheng Chiang
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Tzung-Hai Yen
- Department of Nephrology, Chang Gung Memorial Hospital and Chang Gung University, Taipei 105, Taiwan
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Model for End-Stage Liver Disease Score Before Hepatic Transplantation and Root Mean Square of the Diaphragmatic Domes Affect Postoperative Extubation Time. Transplant Proc 2018; 50:776-778. [PMID: 29661436 DOI: 10.1016/j.transproceed.2018.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The liver transplantation procedure, in addition to its prolonged surgical time, also predisposes to complications such as changes in respiratory mechanics, lung volumes, and gas exchange. OBJECTIVE This study aims to verify if clinical factors related to the recipient, namely immediate pretransplant Model for End-Stage Liver Disease (MELD) score, surgical time, and root square metric (RMS) of the diaphragmatic domes, affect the extubation time after liver transplantation. METHOD A prospective study, with a sample collected for convenience, gathered age (years), sex (male or female), MELD score immediately prior to transplantation (without the addition of special situation scores), and surgical time and time for extubation (in minutes). The latter were obtained from the physiotherapy team records, and surface electromyography was performed within 30 minutes after elective extubation, by a single researcher, with supplemental oxygen support, maintaining SpO2 ≥ 95% and following protocol of positioning and acquisition of electromyographic signals based on the study of Oliveira et al (2012). RESULTS For the 21 patients studied, the RMS of the left dome showed a moderate-intensity correlation (-0.56) with the time of extubation, and linear multiple regression model the left dome (P = .013) and preoperative MELD score (P = .048) showed significant correlation with extubation time. CONCLUSION The preoperative MELD score and the RMS values of the left dome significantly correlate with the time for patient extubation after liver transplantation, showing the effect of previously acquired muscle weakness and preoperative MELD score on postoperative outcome.
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Diaphragm Muscle Surface Electromyography in Patients Submitted to Liver Transplant and Eligible for Extubation. Transplant Proc 2017; 49:829-831. [PMID: 28457405 DOI: 10.1016/j.transproceed.2017.01.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Liver disease induces many organic and metabolic changes, leading to malnutrition and weight and muscular function loss. Surface electromyography is an easily applicable, noninvasive study, through which the magnitudes of the peaks on the charts depict voluntary muscle activity. AIM To evaluate the diaphragmatic surface electromyography of postoperative liver transplantation subjects. METHODS Subjects were patients who underwent liver transplantation and extubation in the Clinical Hospital of State University of Campinas. Electromyography data were collected with support pressure of ≤10 cm H2O, Glasgow Coma Scale = 11, and minimum dosages of vasoactive drugs, and data were collected again 30 minutes after extubation. Signal collection was performed with sEMG System Brazil SAS1000V3 electromyograph and electrode stickers. Statistical analysis was performed using R software. RESULTS The average time of surgery was 345.36 ± 125.62 minutes. Time from spontaneous mode until extubation was 417.14 ± 362.97 minutes. The RMS (root mean square) values of the right and left domes in spontaneous mode with minimal ventilation parameters were 26.68 ± 10.92 and 26.55 ± 10.53, respectively, and the RMS values after extubation were 31.93 ± 18.69 to 34.62 ± 13.55, for right and left domes. The last calculated pretransplant Model for End-stage Liver Disease score averaged 19.64 ± 8.41. CONCLUSION There were significant differences between the RMS of the diaphragm domes under mechanical ventilation and after extubation, showing lower effectiveness of the diaphragm muscle against resistance, without the aid of positive pressure and the existing overload of the left dome.
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Moraes ACOD, Oliveira PCD, Fonseca-Neto OCLD. THE IMPACT OF THE MELD SCORE ON LIVER TRANSPLANT ALLOCATION AND RESULTS: AN INTEGRATIVE REVIEW. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2017; 30:65-68. [PMID: 28489174 PMCID: PMC5424692 DOI: 10.1590/0102-6720201700010018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 12/06/2016] [Indexed: 11/21/2022]
Abstract
Introduction 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. Objective To review the literature on the Model for End-stage Liver Disease (MELD) and analyze its correlation with survival after liver transplantation. Method 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. Results 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. Conclusion 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.
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Monte da Silva AG, deA Roza Aguiar B, Chiavegato LD. Association Between Dyspnea and Severity of Liver Disease in Patients in the Pre-transplantation Period-A Pilot Study. Transplant Proc 2016; 48:2328-2332. [PMID: 27742290 DOI: 10.1016/j.transproceed.2016.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Liver transplantation is indicated at the end stage of chronic liver failure, and severity of disease will determine the precocity of this happening. At this stage, the presence of chronic dyspnea is one of several manifestations of progression of the disease, which leads the patient to inactivity. A rehabilitation program can positively influence the evolution of liver transplant recipients. The objective of this study was to establish an association between the perception of dyspnea and the severity of liver disease in patients at a single center of a Brazilian liver pre-transplantation clinic. METHODS Measurements were performed at a liver pre-transplantation clinic. The severity of liver disease was assessed with the use of the Model for End-Stage Liver Disease (MELD) score, and dyspnea was assessed with the use of a modified Medical Research Council scale of dyspnea (mMRC). RESULTS Men had a higher prevalence of viral hepatitis. Dyspnea was reported only during intense exercise. Duration of disease and MELD score showed medians of 49 months and 20, respectively. CONCLUSIONS We found no correlation between mMRC and the MELD score. In addition, no correlation was found between duration of disease and MELD score or mMRC.
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Affiliation(s)
| | | | - L D Chiavegato
- Universidade Federal de São Paulo, São Paulo, Brazil; Master's and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil.
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Eiras FRCD, Barbosa AP, Leão ER, Biancolino CA. Use of a severity indicator as a predictor of the use of hepatic transplantation resources. Rev Esc Enferm USP 2016; 50:579-586. [PMID: 27680042 DOI: 10.1590/s0080-623420160000500006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 05/14/2016] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate the use of a severity indicator for end-stage liver disease as a predictor of resource use in a teaching hospital in São Paulo. METHOD Descriptive, retrospective study, classifying independent variables in seven key dimensions: identification/risk rating; length of stay/use of advanced life support; imaging; clinical analysis; special procedures; blood products in the intensive care unit; and in the operating room. The frequencies were analyzed by linear regression analysis of variance to detect relevance due to the dependent variable (severity indicator) in 76 cases seen in 2013. RESULTS Among the variables studied, those that presented relevance due to the functional risk score were laboratory measurements of bilirubin, amylase, transaminase, blood count, creatine phosphokinase (p<0.05), hemotherapy procedures fresh frozen plasma (FFP) and platelet concentrate (p<0.05), and Doppler echocardiography image (p<0.07). CONCLUSION Given the results/objective of this study, it is concluded that the indicator presents a potential predictive capability in the use of postoperative resources of liver receptors in the size, clinical analysis, images and hemotherapy dimensions. OBJETIVO Avaliar o uso do indicador de gravidade para doenças hepáticas terminais como fator preditivo do uso de recursos em um hospital-escola de São Paulo. MÉTODO Estudo descritivo, retrospectivo, classificando variáveis independentes em sete dimensões principais: identificação/classificação de risco; tempo de permanência/uso de suporte avançado à vida; exames de imagem; análises clínicas; procedimentos especiais; hemoderivados em unidade de terapia intensiva; e em centro cirúrgico. As frequências foram analisadas por regressão linear com análise de variância para detecção de relevâncias face à variável dependente (indicador de gravidade) em 76 casos atendidos em 2013. RESULTADOS Dentre as variáveis estudadas, apresentaram relevância em função do escore de risco funcional as dosagens laboratoriais de bilirrubina, amilase, transaminase, hemograma, creatinofosfoquinase (p<0,05), procedimentos hemoterápicos plasma fresco congelado (PFC) e concentrado de plaquetas (p<0,05), e imagem Ecodoppler (p<0,07). CONCLUSÃO Face aos resultados/propósito do estudo conclui-se que o indicador apresenta potencial capacidade preditiva no uso de recursos pós-operatórios de receptores de fígado nas dimensões, análises clínicas, imagens e hemoterapia.
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Affiliation(s)
| | | | - Eliseth Ribeiro Leão
- Hospital Israelita Albert Einstein, Instituto de Ensino e Pesquisa, São Paulo, SP, Brazil
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Park SW, Lee GJ, Choi ST, Park YH, Lee JN, Kim KK. The Analysis of Prognostic Factors Affecting Survival in Liver Transplantation: A Single Institution Experience. KOREAN JOURNAL OF TRANSPLANTATION 2014. [DOI: 10.4285/jkstn.2014.28.4.211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Sung Won Park
- Department of Surgery, Gachon University Gil Medical Center, Gachon Graduate School of Medicine, Incheon, Korea
| | - Gil Jae Lee
- Department of Surgery, Gachon University Gil Medical Center, Gachon Graduate School of Medicine, Incheon, Korea
| | - Sang Tae Choi
- Department of Surgery, Gachon University Gil Medical Center, Gachon Graduate School of Medicine, Incheon, Korea
| | - Yeon Ho Park
- Department of Surgery, Gachon University Gil Medical Center, Gachon Graduate School of Medicine, Incheon, Korea
| | - Jung Nam Lee
- Department of Surgery, Gachon University Gil Medical Center, Gachon Graduate School of Medicine, Incheon, Korea
| | - Keon Kuk Kim
- Department of Surgery, Gachon University Gil Medical Center, Gachon Graduate School of Medicine, Incheon, Korea
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Hoffmann K, Hinz U, Hillebrand N, Ganten T, Gotthardt D, Longerich T, Schirmacher P, Schemmer P. The MELD score predicts the short-term and overall survival after liver transplantation in patients with primary sclerosing cholangitis or autoimmune liver diseases. Langenbecks Arch Surg 2014; 399:1001-9. [PMID: 25106131 DOI: 10.1007/s00423-014-1237-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 07/28/2014] [Indexed: 12/21/2022]
Abstract
PURPOSE Liver transplantation (LT) is well established in patients with autoimmune liver disease. Despite excellent outcomes, organ scarcity demands careful patients' selection and timing of transplantation. METHODS This retrospective study analyzes data of 79 consecutive patients with primary sclerosing cholangitis (PSC), autoimmune hepatitis (AIH), and overlap syndrome, undergoing LT between 2001 and 2012. Overall survival (OS) and graft survival were assessed using Kaplan-Meier estimate. Multivariate survival analysis was performed to identify prognostic factors by using Cox regression model. RESULTS After 59.6-month median follow-up, the 5-year OS and graft survival were 75.3 and 68.8%, respectively. The 5-year survival rates for patients with PSC (n=57), AIH (n=17), and overlap syndrome (n=5) were 76.3, 76.0, and 60.0%. The 90-day mortality rate of 70.0% was significantly higher in patients with a labMELD score≥20 (n=10) compared to 26.1% in 69 patients with a labMELD<20 (p=0.009). A lab Model for End-Stage Liver Disease (MELD) score≥20 was an independent predictor of impaired OS (p=0.050, hazard ratio 2.5). The 5-year OS was 55.7% in patients with a labMELD score≥20 compared to 84.7% in patients with a labMELD score<20. CONCLUSION The recipients' MELD score is a predictor for the short-term outcome after LT in patients with autoimmune liver disease. Meticulous selection for transplant listing remains necessary to safe scarce donor organs.
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Affiliation(s)
- Katrin Hoffmann
- Department of General and Transplant Surgery, Ruprecht-Karls-University, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
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Bruns H, Lozanovski VJ, Schultze D, Hillebrand N, Hinz U, Büchler MW, Schemmer P. Prediction of postoperative mortality in liver transplantation in the era of MELD-based liver allocation: a multivariate analysis. PLoS One 2014; 9:e98782. [PMID: 24905210 PMCID: PMC4048202 DOI: 10.1371/journal.pone.0098782] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 05/06/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND AIMS Liver transplantation is the only curative treatment for end-stage liver disease. While waiting list mortality can be predicted by the MELD-score, reliable scoring systems for the postoperative period do not exist. This study's objective was to identify risk factors that contribute to postoperative mortality. METHODS Between December 2006 and March 2011, 429 patients underwent liver transplantation in our department. Risk factors for postoperative mortality in 266 consecutive liver transplantations were identified using univariate and multivariate analyses. Patients who were <18 years, HU-listings, and split-, living related, combined or re-transplantations were excluded from the analysis. The correlation between number of risk factors and mortality was analyzed. RESULTS A labMELD ≥20, female sex, coronary heart disease, donor risk index >1.5 and donor Na+>145 mmol/L were identified to be independent predictive factors for postoperative mortality. With increasing number of these risk-factors, postoperative 90-day and 1-year mortality increased (0-1: 0 and 0%; 2: 2.9 and 17.4%; 3: 5.6 and 16.8%; 4: 22.2 and 33.3%; 5-6: 60.9 and 66.2%). CONCLUSIONS In this analysis, a simple score was derived that adequately identified patients at risk after liver transplantation. Opening a discussion on the inclusion of these parameters in the process of organ allocation may be a worthwhile venture.
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Affiliation(s)
- Helge Bruns
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Vladimir J Lozanovski
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Daniel Schultze
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Norbert Hillebrand
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Ulf Hinz
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Markus W Büchler
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
| | - Peter Schemmer
- Department of General and Transplant Surgery, Ruprecht-Karls University, Heidelberg, Germany
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