Time since liver transplant and immunosuppression withdrawal outcomes: Systematic review and individual patient data meta-analysis

BACKGROUND & AIMS

Successful immunosuppression withdrawal (ISW) is possible for a subfraction of liver transplant (LT) recipients but the factors that define the risk of ISW failure are largely unknown. One candidate prognostic factor for ISW success or operational tolerance (OT) is longer time between LT and ISW which we term "pre-withdrawal time". To clarify the impact of pre-withdrawal time span on subsequent ISW success or failure, we conducted a systematic review with meta-analysis.

METHODS

We systematically interrogated the literature for LT recipient ISW studies reporting pre-withdrawal time. Eligible articles from Embase, Medline, and the Cochrane Central Register of Controlled Trials were used for backward and forward citation searching. Pre-withdrawal time individual patient data (IPD) was requested from authors. Pooled mean differences and time-response curves were calculated using random-effects meta-analyses.

RESULTS

We included 17 studies with 691 patients, 15 of which (620 patients) with IPD. Study-level risk of bias was heterogeneous. Mean pre-withdrawal time was greater by 427 days [95% confidence interval (CI) 67-788] in OT compared to non-OT patients. This increase was potentiated to 799 days (95% CI 369-1229) or 1074 days (95% CI 685-1463) when restricting analysis to adult or European study participants. In time-response meta-analysis for adult or European ISW candidates, likelihood of OT increased by 7% (95% CI 4-10%) per year after LT (GRADE low- and moderate-certainty of evidence, respectively).

CONCLUSIONS

Our data support the impact of pre-withdrawal time in ISW decision-making for adult and European LT recipients.

PROSPERO REGISTRATION

CRD42021272995.

Endothelial cell activation mediated by cold ischemia-released mitochondria is partially inhibited by defibrotide and impacts on early allograft function following liver transplantation

DAMPs (danger-associated molecular patterns) are self-molecules of the organism that appear after damage. The endothelium plays several roles in organ rejection, such as presenting alloantigens to T cells and contributing to the development of inflammation and thrombosis. This study aimed to assess whether DAMPs present in the organ preservation solution (OPS) after cold ischemic storage (CIS) contribute to exacerbating the endothelial response to an inflammatory challenge and whether defibrotide treatment could counteract this effect. The activation of cultured human umbilical vein endothelial cells (HUVECs) was analyzed after challenging with end-ischemic OPS (eiOPS) obtained after CIS. Additionally, transwell assays were performed to study the ability of eiOPS to attract lymphocytes across the endothelium. The study revealed that eiOPS upregulated the expression of MCP-1 and IL-6 in HUVECs. Moreover, eiOPS increased the membrane expression of ICAM-1and HLA-DR, which facilitated leukocyte migration toward a chemokine gradient. Furthermore, eiOPS demonstrated its chemoattractant ability. This activation was mediated by free mitochondria. Defibrotide was found to partially inhibit the eiOPS-mediated activation. Moreover, the eiOPS-mediated activation of endothelial cells (ECs) correlated with early allograft dysfunction in liver transplant patients. Our finding provide support for the hypothesis that mitochondria released during cold ischemia could trigger EC activation, leading to complications in graft outcomes. Therefore, the analysis and quantification of free mitochondria in the eiOPS samples obtained after CIS could provide a predictive value for monitoring the progression of transplantation. Moreover, defibrotide emerges as a promising therapeutic agent to mitigate the damage induced by ischemia in donated organs.

Magnetic Dynamo Caused by Axions in Neutron Stars

The coupling between axions and photons modifies Maxwell's equations, introducing a dynamo term in the magnetic induction equation. In neutron stars, for critical values of the axion decay constant and axion mass, the magnetic dynamo mechanism increases the total magnetic energy of the star. We show that this generates substantial internal heating due to enhanced dissipation of crustal electric currents. These mechanisms would lead magnetized neutron stars to increase their magnetic energy and thermal luminosity by several orders of magnitude, in contrast to observations of thermally emitting neutron stars. To prevent the activation of the dynamo, bounds on the allowed axion parameter space can be derived.

Danger signals released during cold ischemia storage activate NLRP3 inflammasome in myeloid cells and influence early allograft function in liver transplantation

BACKGROUND

Innate immunity plays a fundamental role in solid organ transplantation. Myeloid cells can sense danger signals or DAMPs released after tissue or cell damage, such as during ischemia processes. This study aimed to identify DAMPs released during cold ischemia storage of human liver and analyze their ability to activate the inflammasome in myeloid cells and the possible implications in terms of short-term outcomes of liver transplantation.

METHODS

79 samples of organ preservation solution (OPS) from 79 deceased donors were collected after cold static storage. We used different analytical methods to measure DAMPs in these end-ischemic OPS (eiOPS) samples. We also used eiOPS in the human macrophage THP-1 cell line and primary monocyte cultures to study inflammasome activation.

FINDINGS

Different DAMPs were identified in eiOPS, several of which induced both priming and activation of the NLRP3 inflammasome in human myeloid cells. Cold ischemia time and donation after circulatory death negatively influenced the DAMP signature. Moreover, the presence of oligomeric inflammasomes and interleukin-18 in eiOPS correlated with early allograft dysfunction in liver transplant patients.

INTERPRETATION

DAMPs released during cold ischemia storage prime and activate the NLRP3 inflammasome in liver macrophages after transplantation, inducing a pro-inflammatory environment that will complicate the outcome of the graft. The use of pharmacological blockers targeting DAMPs or the NLRP3 inflammasome in liver ischemia during static cold storage or through extracorporeal organ support could be a suitable strategy to increase the success of liver transplantation.

FUNDING

Fundación Mutua Madrileña and Instituto de Salud Carlos III, Madrid, Spain.

Changes in humoral immune response after SARS-CoV-2 infection in liver transplant recipients compared to immunocompetent patients

The protective capacity and duration of humoral immunity after SARS-CoV-2 infection are not yet understood in solid organ transplant recipients. A prospective multicenter study was performed to evaluate the persistence of anti-nucleocapsid IgG antibodies in liver transplant recipients 6 months after coronavirus disease 2019 (COVID-19) resolution. A total of 71 liver transplant recipients were matched with 71 immunocompetent controls by a propensity score including variables with a well-known prognostic impact in COVID-19. Paired case-control serological data were also available in 62 liver transplant patients and 62 controls at month 3 after COVID-19. Liver transplant recipients showed a lower incidence of anti-nucleocapsid IgG antibodies at 3 months (77.4% vs. 100%, p < .001) and at 6 months (63.4% vs. 90.1%, p < .001). Lower levels of antibodies were also observed in liver transplant patients at 3 (p = .001) and 6 months (p < .001) after COVID-19. In transplant patients, female gender (OR = 13.49, 95% CI: 2.17-83.8), a longer interval since transplantation (OR = 1.19, 95% CI: 1.03-1.36), and therapy with renin-angiotensin-aldosterone system inhibitors (OR = 7.11, 95% CI: 1.47-34.50) were independently associated with persistence of antibodies beyond 6 months after COVID-19. Therefore, as compared with immunocompetent patients, liver transplant recipients show a lower prevalence of anti-SARS-CoV-2 antibodies and more pronounced antibody levels decline.

Proteomics in Liver Transplantation: A Systematic Review

Background

Although proteomics has been employed in the study of several models of liver injury, proteomic methods have only recently been applied not only to biomarker discovery and validation but also to improve understanding of the molecular mechanisms involved in transplantation.

Methods

The study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and the guidelines for performing systematic literature reviews in bioinformatics (BiSLR). The PubMed, ScienceDirect, and Scopus databases were searched for publications through April 2020. Proteomics studies designed to understand liver transplant outcomes, including ischemia-reperfusion injury (IRI), rejection, or operational tolerance in human or rat samples that applied methodologies for differential expression analysis were considered.

Results

The analysis included 22 studies after application of the inclusion and exclusion criteria. Among the 497 proteins annotated, 68 were shared between species and 10 were shared between sample sources. Among the types of studies analyzed, IRI and rejection shared a higher number of proteins. The most enriched pathway for liver biopsy samples, IRI, and rejection was metabolism, compared to cytokine-cytokine receptor interactions for tolerance.

Conclusions

Proteomics is a promising technique to detect large numbers of proteins. However, our study shows that several technical issues such as the identification of proteoforms or the dynamic range of protein concentration in clinical samples hinder the successful identification of biomarkers in liver transplantation. In addition, there is a need to minimize the experimental variability between studies, increase the sample size and remove high-abundance plasma proteins.

Impact of Hepatic Artery Thrombosis on the Success of a Liver Transplant Because of Hepatocellular Carcinoma

BACKGROUND

Hepatic artery thrombosis is one of the most serious complications after liver transplant. Our objective is to evaluate the impact of arterial thrombosis on the postoperative evolution of a series of patients who received transplants because of hepatocellular carcinoma.

METHODS

A retrospective study of 100 consecutive hepatocellular carcinoma liver transplants was performed from January 2011 to November 2017.

RESULTS

Of the 100 transplant recipients, we have observed hepatic artery thrombosis in 4 of them, 3 premature and 1 delayed. All of them received retransplants after diagnosis by hepatic artery ultrasonography and arteriography. The descriptive analysis showed a significant relationship between the appearance of hepatic artery thrombosis with variables of postoperative severity, such as arrhythmias, atelectasis, pleural effusion, hemodialysis requirement, acute kidney failure, and respiratory failure. Although patients with hepatic artery thrombosis had a longer mean hospital stay, this was not statistically significant. There was decreased graft survival and overall survival of patients who experienced hepatic artery thrombosis.

CONCLUSION

Although the incidence of hepatic artery thrombosis has been relatively low (4%), the early detection of risk factors, such as arterial anatomic anomalies that condition a complex anastomosis, should draw our attention, thus having at our disposal strict ultrasonography and arteriography surveillance protocols as well as prophylactic anticoagulation guidelines for receptors at risk.

Controlled donation after circulatory death up to 80 years for liver transplantation: Pushing the limit again

Our main objective was to compare liver transplant (LT) results between donation after circulatory death (DCD) and donation after brainstem death (DBD) in our hospital and to analyze, within the DCD group, the influence of age on the results obtained with DCD donors aged >70 years and up to 80 years. All DCD-LTs performed were analyzed prospectively. The results of the DCD group were compared with those of a control group who received a DBD-LT immediately after each DCD-LT. Later, the results obtained within the DCD group were analyzed according to the age of the donors, considering 2 subgroups with a cut-off point at 70 years. Survival results for LT with DCD and super rapid recovery were not inferior to those obtained in a similar group of patients transplanted with DBD livers. However, the cost of DCD was a higher rate of biliary complications, including ischemic cholangiopathy. Donor age was not a negative factor.

Liver Transplantation for Fulminant Hepatic Failure Due to Heat Stroke: A Case Report

Heat stroke is a condition caused by an excessive increase in body temperature in a relatively short period of time, and is clinically characterized by central nervous system dysfunction, including delirium, seizures, coma, and severe hyperthermia. In this context, the resulting fulminant hepatic failure makes liver transplant the best choice when there are no guarantees of better results with conservative treatment. We present our experience in this case, possible alternative choices, and the current role of liver transplantation in the resolution of fulminant liver failure due to heat stroke. CASE REPORT: We report the case of a 32-year-old man with a history of malabsorption syndrome and unconfirmed celiac disease controlled with a gluten-free diet, who, while working on a typical summer midday in southern Spain (approximately 40°C), abruptly presented with loss of consciousness, coma, and a temperature of 42°C, as well as seizures at the initial medical assessment that subsided after the administration of diazepam. On the third day, the patient presented with multiple organ dysfunction syndrome, requiring mechanical ventilation, hemodialysis, and inotropic support. He did not improve with the support of conservative treatment, therefore it was decided to perform an urgent liver transplant, after which he recovered completely. CONCLUSIONS: Liver transplantation should be a main choice of treatment for cases in which, despite intensive medical treatment, there is still clinical and analytical evidence of massive and/or irreversible hepatocellular damage.

Donors Older Than 75 Years Do Not Influence the Appearance of Biliary Complications After Liver Transplantation

BACKGROUND

In recent years, several studies have shown that the age of the donor may be related to an increase in the occurrence of biliary complications (BCs), which remain the main cause of morbidity after liver transplantation. This study analyzed the type and management of these BCs, the impact of BCs on graft and patient survival rates, and the influence of some characteristics of donors and recipients on BC appearance in patients transplanted with donors 75 years of age or older.

PATIENTS AND METHODS

From 2003 to 2016, 100 liver transplantations with donors 75 years of age or older (15.6%) were performed in our hospital. The data were compared with a control group of 400 patients with younger donors (case-control 1:4 per chronology).

RESULTS

The BC rate in the group of patients transplanted with organs from elderly donors was 18%, compared to 21.5% in the control group. Specifically, in the immediate post-transplantation period, 14% of the elderly donor group and 13.8% of the control group presented some BCs, with no statistically significant differences in the incidence, type, and treatment of BCs between the two groups. The occurrence of BCs was not a factor associated with graft and patient survival rates. In the global population, donor death by cerebral vascular accident and male donors have influenced the occurrence of BCs.

CONCLUSIONS

The advanced age of the donor has not influenced BC rates after transplantation.

Orthotopic Liver Transplantation With Elderly Donors (Over 80 Years of Age): A Prospective Evaluation

BACKGROUND

Our main objective was to assess the clinical outcomes obtained in a single orthotopic liver transplant (OLT) hospital with donors ≥80 years of age compared to a control group of patients subjected to OLT during the same period of time with donors who were under 65 years of age.

METHODS

A prospective analysis was carried out on all the OLTs performed using liver grafts from donors in a state of brain death and with an age of ≥80 years (study group) between April 2007 and January 2015. The results of the study group (n = 36) were compared with those of a control group of patients less than 65 years of age receiving transplants with grafts.

RESULTS

A total of 51 potential donors ≥80 years were assessed, with a total of 36 liver transplants being carried out and their results were compared with a control group of 283 patients receiving transplants. The median follow-up time of the patients in the series was 36 months (range: 24-120 months). Graft survival at 1, 2, and 3 years was 77%, 72%, and 62%, respectively, among the patients in the study group and 79%, 73%, and 65% among the patients in the control group, and there were no statistically significant differences. Patient survival at 1, 2, and 3 years was 86%, 82%, and 75%, respectively, among the patients in the study group and 82%, 76%, and 72% among the patients in the control group, also without there being any statistically significant differences.

CONCLUSIONS

There is no age limit for liver transplant donors. The use of octogenarian donors makes it possible to increase the pool of donors while providing enough safety for the recipient.

Extracellular ATP Activates the NLRP3 Inflammasome and Is an Early Danger Signal of Skin Allograft Rejection

Immune cells are equipped with a number of receptors that recognize sterile injury and pathogens. We find that host immune cells release ATP as an inflammatory signal in response to allogeneic transplantation. ATP then acts via a feedback mechanism on the P2X7 channel to activate the NLRP3 inflammasome and subsequently process and release interleukin (IL)-18. This process is a necessary stage in the deleterious Th1 response against allotransplantation via interferon-γ production. Lack of IL-18 resulted in a decrease in graft-infiltrating CD8 cells but an increase in regulatory T cells. In human liver transplant patients undergoing progressive immunosuppressive drug withdrawal, we found that patients experiencing acute rejection had higher levels of the P2X7 receptor in circulating inflammatory monocytes compared to tolerant patients. These data suggest that the pharmacological inhibition of the P2X7 receptor or the NLRP3 inflammasome will aid in inducing transplant tolerance without complete immunoparalysis.

Extracellular adenosine reversibly inhibits the activation of human regulatory T cells and negatively influences the achievement of the operational tolerance in liver transplantation

The artificial induction of tolerance in transplantation is gaining strength. In mice, a differential role of extracellular adenosine (eADO) for regulatory and effector T cells (Tregs and Teffs, respectively) has been proposed: inhibiting Teffs and inducing Tregs. The aim of this study was to analyze the action of extracellular nucleotides in human T cells and, moreover, to examine the influence of CD39 and CD73 ectonucleotidases and subsequent adenosine signaling through adenosine 2 receptor (A₂ R) in the induction of clinical tolerance after liver transplant. The action of extracellular nucleotides in human T cells was analyzed by in vitro experiments with isolated T cells. Additionally, 17 liver transplant patients were enrolled in an immunosuppression withdrawal trial, and the differences in the CD39-CD73-A₂ R axis were compared between tolerant and nontolerant patients. In contrast to the mice, the activation of human Tregs was inhibited similarly to Teffs in the presence of eADO. Moreover, the expression of the enzyme responsible for the degradation of ADO, adenosine deaminase, was higher in tolerant patients with respect to the nontolerant group along the immunosuppression withdrawal. Our data support the idea that eADO signaling and its degradation may play a role in the complex system of regulation of liver transplant tolerance.

Group Psychotherapy Could Improve Depression in Cirrhotic Patients on the Liver Transplant Waiting List

BACKGROUND

It is well-known that there is a high incidence of depression in patients on the liver transplant (LT) waiting list. However, there have been few studies of psychological intervention on these patients.

OBJECTIVES

To determine symptoms of depression in patients on the LT waiting list and the impact of group psychotherapy.

METHODS

Study population: patients on the LT waiting list who received group psychotherapy (n = 15).

CONTROL GROUP

patients who did not receive psychotherapy (n = 10). Measurement instrument: Beck's depression test, which was provided before psychotherapy was initiated and after it was completed (after 6 months). The control group was given the questionnaire at the same 2 points in time as the study group. The psychotherapeutic method consisted of discussing patients' feelings, which dealt with several matters related to transplantation. Different coping strategies were considered.

RESULTS

More than half of those surveyed initially had depressive symptoms. When the second survey was administered to the study population, all the patients improved in their psychopathological assessment. When the survey was administered to the control group, a worse psychopathological assessment was obtained in all cases.

CONCLUSIONS

Our data suggest an improvement in depressive symptoms in patients on the LT waiting list after receiving group psychotherapy.

Quality of Life and Group Psychological Intervention in Patients With Cirrhosis on Liver Transplant Waiting List

BACKGROUND

The patients on the liver transplant (LT) waiting list usually present with deterioration in their quality of life. Previous studies on psychological intervention have shown how the quality of life can be improved.

OBJECTIVE

To analyze preliminary results of the influence of group psychotherapy on the quality of life of patients on the LT waiting list.

METHOD

Fifteen patients on the LT waiting list who accepted receiving group psychotherapy were selected. The development of each 1 of these sessions was carried out at fortnightly periods for 6 months (12 sessions). Those patients who received a transplant and those patients who did not attend more than 6 group psychotherapy sessions were excluded. The Nottingham Health Profile was used to assess the quality of life. It consists of 38 items belonging to 6 health dimensions: energy, pain, physical mobility, emotional reaction, sleep, and social isolation. The study population was given a questionnaire before starting group psychotherapy and after it was finished.

RESULTS

Of the 15 patients selected from the study population, 3 patients were given a transplant before the psychotherapy had finished, and 5 patients were excluded for not having attended more than 50% of the sessions. Therefore, the study was completed on 7 patients (n = 7). Overall, a better assessment can be seen in the second questionnaire.

CONCLUSIONS

Group psychotherapy might favorably influence the quality of life of patients on the LT waiting list; therefore, it might be interesting to carry out studies on a larger scale in order to confirm these results.

Long-term Survival and Evolution of the Kidney Function for Liver Transplant Patients Who Required Postoperative Dialysis

Patients who underwent orthotopic liver transplantation (OLT) frequently develop chronic kidney disease, with those who present postoperative acute kidney failure and require renal replacement therapy (RRT) at higher risk. The objective of the study was to assess the kidney function and long-term survival of patients who underwent OLT and required RRT during or in the immediate postoperative period. Medical records of OLT and postoperative RRT patients with over 6-month survival were reviewed between January 1, 2005, and December 31, 2015. A variance analysis was carried out for repeated measurements to compare the estimate glomerular filtration rate (eGFR) baseline with the different periods (statistical significance level P < .05). Kaplan-Meier estimator was used to estimate the survival rate. Of 539 patients, 20 (3.7%) met the selection criteria. The basal eGFR at 6 months and 1, 3, 5, and 7 years was 93.41 ± 25, 78.28 ± 33, 73.06 ± 29, 65.96 ± 19, 79.81 ± 28, and 59.06 ± 24 mL/min/1.73 m², respectively. The comparison of the eGFR baseline within the different periods was statistically significant at 1 year and at 3 years. Four patients died, 3 of them due to sepsis and 1 due to recurrence of hepatitis C virus infection. The average survival was 28 months. The probability of surviving at 1 year was 100%, at 3 years was 84.21% (95% confidence interval: 58.65-94.62), and at 5 and 10 years was 78.6% (95% confidence interval: 52.49-91.39). In conclusion, we have found a progressive worsening of the kidney function in the long term in patients who required postoperative dialysis. However, actuarial survival of these patients was very successful.

Benefits of Group Psychotherapy in Cirrhotic Patients on the Liver Transplant Waiting List

INTRODUCTION

It is well-known that patients on the liver transplant (LT) waiting list experience a high rate of psychopathologic symptoms. However, few studies have been published about the use of group psychotherapy for these patients. We sought to assess (1) the psychopathologic data in patients on the LT waiting list and (2) the attitude toward a group psychotherapy procedure and its efficacy.

MATERIAL AND METHODS

In the pretransplant consultation phase, group therapy was offered to 20 patients on the LT waiting list. Patients who received psychotherapy were assessed previously using the Beck Depression Inventory.

RESULTS

Fifteen patients were included in the study. Significant differences were found between the psychopathologic assessment and the level of hepatopathy. In the first session, we observed that patients with hepatocarcinoma were much more reluctant to participate in the group therapy. In the second session, the group showed a high level of anxiety connected with a fear of transplantation. In the third session, a transplant physician answered all their questions, and at the end of the session patient anxiety had decreased. During the following sessions, family bonds and sharing experiences with other transplant patients were emphasized.

CONCLUSIONS

Patients were initially reluctant to participate in the group psychotherapy, although this changed as sessions proceeded. It is necessary to provide more information about the transplant procedure itself to decrease anxiety. Group therapy was valued positively by all patients who participated.

PNPLA3 rs738409 causes steatosis according to viral & IL28B genotypes in hepatitis C

BACKGROUND

Hepatitis C virus (HCV) is associated with a higher prevalence of steatosis compared to the general population.

AIM

Our aim was to assess the impact of PNPLA3 rs738409 G-allele on steatosis in HCV patients.

MATERIAL AND METHODS

We included 474 HCV patients treated with peginterferon plus ribavirin. PNPLA3 rs738409 was genotyped and patients were classified according to alleles and genotypes. Steatosis was detected in 46.4% (220/474). Fibrosis was assessed by Scheuer score. Gene expression was analyzed in Huh7.5 and Huh7 cells using Real Time-PCR.

RESULTS

PNPLA3 allele-G was associated with steatosis [54.1% (126/233) vs. 39% (94/241)] (p = 0.0001). In HCV-1, allele-G was related to steatosis [50.6% (82/162) vs. 32.3% (53/164)] (p = 0.001), but did not in HCV-3 [61.9% (26/42) vs. 62% (31/50)] (p = 0.993). PNPLA3 allele-G was associated with steatosis in patients with IL28B-CT/TT [57.7% (82/142) vs. 37.1% (56/151)] (p = 0.0001), but did not in IL28B-CC [47.8% (43/90) vs. 42% (37/88)] (p = 0.442). Independent variables associated with steatosis were: PNPLA3 G-allele [O.R. 1.84 (CI95%: 1.06-3.21); p = 0.007], age [O.R. 1.04 (CI95%: 1.01-1.07); p = 0.017], HCV-genotype 3 [O.R. 2.46 (CI95%: 1.30-4.65); p = 0.006], HOMA > 4 [O.R. 2.72 (CI95%: 1.27-5.82); p = 0.010]. Since PNPLA3 RNA could not be detected on PBMC from HCV patients, an in vitro analysis was performed. Huh7.5 cells infected with JFH1 had a decreased PNPLA3 gene expression (fold inhibition = 3.2 ± 0.2), while Huh7 cells presented increased PNPLA3 gene expression (fold induction = 1.5 ± 0.2).

CONCLUSION

PNPLA3 allele-G modulated the development of steatosis, particularly in patients with HCV-1 and IL28B-CT/TT genotype, but was not associated with SVR. Metabolic but not viral steatosis seems to be PNPLA3 regulated. Gene interaction may result in differential PNPLA3 gene expression levels in HCV infection.

"Very early" intrahepatic cholangiocarcinoma in cirrhotic patients: should liver transplantation be reconsidered in these patients?

A retrospective cohort multicenter study was conducted to analyze the risk factors for tumor recurrence after liver transplantation (LT) in cirrhotic patients found to have an intrahepatic cholangiocarcinoma (iCCA) on pathology examination. We also aimed to ascertain whether there existed a subgroup of patients with single tumors ≤2 cm ("very early") in which results after LT can be acceptable. Twenty-nine patients comprised the study group, eight of whom had a "very early" iCCA (four of them incidentals). The risk of tumor recurrence was significantly associated with larger tumor size as well as larger tumor volume, microscopic vascular invasion and poor degree of differentiation. None of the patients in the "very early" iCCA subgroup presented tumor recurrence compared to 36.4% of those with single tumors >2 cm or multinodular tumors, p = 0.02. The 1-, 3- and 5-year actuarial survival of those in the "very early" iCCA subgroup was 100%, 73% and 73%, respectively. The present is the first multicenter attempt to ascertain the risk factors for tumor recurrence in cirrhotic patients found to have an iCCA on pathology examination. Cirrhotic patients with iCCA ≤2 cm achieved excellent 5-year survival, and validation of these findings by other groups may change the current exclusion of such patients from transplant programs.

Patients with terminal chronic liver pathology faced with this disease

BACKGROUND

"Anxious preoccupation" is a maladaptive coping strategy for patients with terminal chronic liver pathology causing psychopathologic emotional responses. The aim of this study was to identify "anxious preoccupation" as a coping strategy when faced with this disease and to investigate its relationship with emotional-type psychopathologic symptoms in patients awaiting a liver transplant (LT).

METHODS

A total of 63 patients awaiting an LT were evaluated. The instrument used to evaluate coping style was the Mental Adjustment to Cancer questionnaire. One of the coping scales of this questionnaire is "anxious preoccupation" (9 items). An Instrument for psychopathologic assessment was used, the SA-45 questionnaire, which assessed 9 psychopathologic dimensions: somatizations, obsessions-compulsions, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism.

RESULTS

"Anxious preoccupation" was used as an inadequate coping style by 51% of patients when faced with the disease. Five psychopathologic dimensions were associated with this coping strategy: 1) obsessive-compulsivity: 75% of patients with "anxious preoccupation" had obsessive-compulsivity symptoms compared with 29% of patients with other coping strategies (P < .001); 2) interpersonal sensitivity: 25% vs 6%, respectively (P = .044); 3) depression: 59% vs 29% (P = .015); 4) anxiety: 75% vs 32% (P = .001); and 5) phobic anxiety: 19% vs 3% (P = .050).

CONCLUSIONS

More than one-half of the patients on the LT waiting list used "anxious preoccupation" as a coping style for this disease. This strategy was associated with a greater presence of emotional-type psychopathologic symptoms in these patients.

Emotional-type psychopathologic symptoms among patients with terminal chronic alcohol-induced liver cirrhosis

INTRODUCTION

Patients with toxic substance abuse syndrome, such as alcohol abuse, have elevated psychopathologic morbidity and mortality such as mood disorders.

OBJECTIVE

To evaluate the emotional-type psychopathologic symptoms in patients with alcohol-induced hepatic cirrhosis on the liver transplant waiting list.

MATERIALS AND METHODS

Patients with alcoholic liver cirrhosis who were candidates for liver transplant (n = 41) completed the SA-45 questionnaire (González y Cuevas; 88), which assesses nine dimensions: somatizations, obsessive-compulsivity, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. A control group consisted of patients with chronic nonalcoholic terminal hepatopathies (n = 22).

RESULTS

Seventy-six percent of patients had some kind of psychopathologic symptom compared to 68% of the patients in the control group with other nonalcoholic etiologies (P > .05). The emotional-type clinical symptoms were: (1) somatizations: 37% of patients with alcoholic cirrhosis had this type of clinical symptoms compared to 32% of the control group (P > .05); (2) obsessive-compulsivity: 56% versus 46%, respectively (P > .05); (3) interpersonal sensitivity: 19% versus 9%, respectively (P > .05); (4) depression: 54% versus 27%, respectively (P = .045); (5) anxiety: 59% versus 46%, respectively (P > .05); (6) hostility: 29% versus 5%, respectively (P = .021); (7) phobic anxiety: 10% versus 14%, respectively (P > .05); (8) paranoid Ideation: 7% versus 5%, respectively (P > .05); (9) psychoticism: 5% versus 4%, respectively (P > .05).

CONCLUSIONS

The patients with alcoholic liver cirrhosis on the liver transplant waiting list had elevated psychopathologic symptoms. Depressive- and hostile-type emotional alterations were most frequent in this type of patients.

Laparoscopic treatment of biliary peritonitis after removal of T-tube in liver transplant patients

INTRODUCTION

T-tube removal in liver transplant patients can occasionally cause a massive biliary leak and may require surgical treatment for its resolution. We present our experience with a laparoscopic approach to biliary peritonitis in liver transplant patients after the removal of a T-tube.

PATIENTS AND METHODS

From January 2003 until February 2010, we performed 351 liver transplantations in 313 recipients, including 135 with a T-tube. After its removal 31 biliary leaks developed (23%); 12 were massive and required surgery, which utilized a laparoscopic approach.

RESULTS

The mean length of the intervention was 72.9 ± 12.87 minutes (range = 55-95), without any complications during the procedure, and no need to convert to a laparotomy. Mean hospital stay after the intervention was 6.75 ± 3.88 days (range 4-18). There was no mortality from the procedure.

CONCLUSION

The laparoscopic approach for biliary leakage after T-tube removal is indicated when large diffuse acute peritonitis is established a few hours postremoval of the T-tube. This safe procedure treats the complication without the need for another laparotomy.

Protoneutron star cooling with convection: the effect of the symmetry energy

We model neutrino emission from a newly born neutron star subsequent to a supernova explosion to study its sensitivity to the equation of state, neutrino opacities, and convective instabilities at high baryon density. We find the time period and spatial extent over which convection operates is sensitive to the behavior of the nuclear symmetry energy at and above nuclear density. When convection ends within the protoneutron star, there is a break in the predicted neutrino emission that may be clearly observable.

Value of 18-FDG-positron emission tomography/computed tomography before and after transarterial chemoembolization in patients with hepatocellular carcinoma undergoing liver transplantation: initial results

INTRODUCTION

Liver transplantation is the treatment of choice for various types of end-stage liver disease and the most appropriate alternative for the treatment of hepatocellular carcinoma (HCC)-associated liver cirrhosis. The aim of this study was to describe our initial experience with the use of 18-FDG positron emission tomography (PET)/computed tomography CT before and after transarterial chemoembolization (TACE) in HCC patients undergoing liver transplantation, seeking to predict the percentage of tumor necrosis achieved by TACE procedures.

PATIENTS AND METHODS

From January 2007 through December 2009, 39 patients with HCC and liver cirrhosis were included in our liver transplantation program. We selected the 6 subjects who underwent 18-fluorodeoxyglucose PET/CT (18-FDG PET/CT) pre- and post-TACE.

RESULTS

The median SUV (standardized uptake value) in the lesions studied were 4 (range, 2.79-6.95) before TACE with a median post-TACE SUV of 0 (range, 0-4). Among patients whose post-TACE SUV decreased to <3, the percentage of necrosis after studying the hepatectomy was >80%.

CONCLUSION

Performance of an 18-FDG PET/CT before and after TACE and comparison of SUV in patients with HCC awaiting liver transplantation provided valuable information regarding the effectiveness of TACE.

Psychological care: social and family support for patients awaiting a liver transplant

INTRODUCTION

In patients awaiting a transplant, the help received from friends and/or family members is considered to be an important factor in the transplantation process. Our objective was to determine the level of social/family support for patients on the liver transplant waiting list and to determine the relationship between clinical psychopathology and the level of social/family support.

MATERIALS AND METHODS

The study population consisted of 70 patients on the liver transplant waiting list. We used the following instruments: (1) Medical Outcomes Study-Social Support Survey (MOS) Questionnaire. For size of the social network, four support dimensions and a global support index for emotional support, material/instrumental support, leisure/free time activities, and love/care; (2) Family Apgar Questionnaire for personal perception of family function; (3) SA-45 questionnaire of psychopathologic symptoms for somatizations, obsessive-compulsivity, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism.

RESULTS

The MOS showed that the mean size of the social network of these patients was 12 people. In these patients, social/family support was nonfunctional in 20% of the cases. By dimensions, the patients had the following percentage of nonfunctional support: 24% in emotional support; 10% material/instrumental support; 23% social relations of leisure/free-time activities; and 11% compassionate love/care support. The patients with nonfunctional support had the following associated psychopathologic symptoms (SA-45): depression (79% vs 39%; P = .008), anxiety (86% vs 46%; P = .008), hostility (43% vs 12%; P = .009), and psychoticism (14% vs 2%; P = .039) compared to functional patients. The Family Apgar showed that 27% of patients perceived a family dysfunction. These patients had greater interpersonal sensitivity-type emotional symptoms (32% vs 8%; P = .012), depression (79% vs 35%; P = .001), anxiety (79% vs 45%; P = .011), and hostility (42% vs 10%; P = .002) compared to normally functioning patients.

CONCLUSIONS

Nearly a quarter of patients on the liver transplant waiting list have social/family support that is nonfunctional, which leads to greater emotional psychopathologic symptoms that would need to be treated.

Results of liver transplantation from donors over 75 years: case control study

INTRODUCTION

The use of elderly donors can increase the pool of organs available for transplant. The aim of this study was to analyze the outcomes of grafts from donors older than 75 years.

PATIENTS AND METHODS

We selected 29 patients transplanted from January 2003 to January 2010 with livers from donors older than 75 years for comparison with a control group (58 patients), selected among patients transplanted immediately before or after each study case. Data analyzed using SPSS 15.0 were considered statistically significant at P < .05.

RESULTS

Statistically significant differences were evident in the mean age of donors (78.3 ± 2.9 vs 50.4 ± 17.8 years, P < .001), levels of aspartate aminotransferase alanine aminotransferase (30.8 ± 18.13/24.9 ± 14.4 vs 53.81 ± 68.4/39.37 ± 39.94 U/L, P < .05), and waiting list time of (122.4 ± 94.3 vs 169.2 ± 135.5 days, P = .034) of elderly donor versus control graft cohorts. The median follow-up was 32 months (range: 4-88.0) No differences were observed at 1 and 3 years after transplantation: graft survival was 78% and 61% in the older donor group and 83% and 71% in the younger donor group, respectively.

CONCLUSION

The use of expanded donors from elderly subjects can increase the donor pool with good results.

Transhepatic portal venous angioplasty with stenting for bleeding jejunal angiodysplasias in a retrasplant patient: a case report

A 41-year-old man, who had undergone liver retransplantation, was admitted to our institution complaining of rectorraghia. Gastroscopy and colonoscopy failed to detect the source of bleeding. Computed tomographic angiography detected a stenosis at the portal anastomosis. Capsule endoscopy showed the presence of multiple small bowel angiodysplasias. After a surgical failure, direct portography revealed severe stenosis of the extrahepatic portal vein. Subsequent to percutaneous transhepatic portography, we dilated the stenosis using a balloon catheter and placed an expandable metallic stent, stopping the bleeding without further episodes of gastrointestinal bleeding.

Superfluid heat conduction and the cooling of magnetized neutron stars

We report on a new mechanism for heat conduction in the neutron star crust. We find that collective modes of superfluid neutron matter, called superfluid phonons, can influence heat conduction in magnetized neutron stars. They can dominate the heat conduction transverse to the magnetic field when the magnetic field B> approximately 10(13) G. At a density of rho approximately 10(12)-10(14) g/cm3, the conductivity due to superfluid phonons is significantly larger than that due to lattice phonons and is comparable to electron conductivity when the temperature approximately 10(8) K. This new mode of heat conduction can limit the surface anisotropy in highly magnetized neutron stars. Cooling curves of magnetized neutron stars with and without superfluid heat conduction could show observationally discernible differences.

Gastrointestinal complications in liver transplant recipients: MITOS study

INTRODUCTION

Liver transplant recipients frequently suffer gastrointestinal (GI) complications but their prevalence and their influence on quality of life remain unknown.

OBJECTIVE

The objective of this study was to asses the prevalence, impact on quality of life, and management of GI complications in liver transplant recipients.

PATIENTS AND METHODS

This was an epidemiologic, cross-sectional, multicenter study. Four hundred seventeen liver recipients were recruited in 14 centers. A questionnaire was filled for every patient.

RESULTS

The median age of the patients was 55 years. The median time since transplantation was 4.1 +/- 4 years. Whereas 19.2% presented some GI disease before transplantation, 49.4% showed this type of complication after transplantation. Diarrhea was the most prevalent GI complication, and anorexia was the GI disorder that affected patients daily activities the most frequently. GI complications were more frequent among female patients, subjects with pretransplantation hiatal hernia, and those readmitted after transplantation. Of the patients with GI complications, 70.9% received pharmacological treatment (89.7% with gastric protectors). Immunosuppressive therapy was also modified because of GI complications. Immunosuppressive drug dose was reduced in 18.1%, transiently stopped in 3.4%, and definitively stopped in 3.4% of cases. The drug most frequently changed was mycophenolate mofetil: dose reduction, 23.6%; transient withdrawal, 5.7%; and definitive withdrawal, 6.6%.

CONCLUSIONS

The prevalence of GI complications in the liver transplant population was approximately 50%. GI complications showed a significant impact on the quality of life of the patients. They were related to female gender, to pretransplantation GI pathology, and posttransplantation hospital admission. These complications were frequently managed with pharmacological therapy or with changes in immunosuppressive therapy.

Liver transplantation for Klatskin's tumor: contraindicated, palliative, or indicated?

OBJECTIVE

Surgical resection is the only potential curative treatment for Klatskin's tumor. In the cases of Bismuth type IV, some authors have suggested performing liver transplantation (OLT). Our aim was to present our experience in the management of Klatskin's tumor, with special reference to patients undergoing OLT.

PATIENTS AND METHODS

Between May 1988 and December 2006, 66 patients were treated in our department for Klatskin's tumor, including 43 men and 23 women of overall mean age 66 years (range = 38 to 88). Twenty patients (group 1) were in operable and 46 patients underwent resection surgery (group 2), including 13 tumors considered unresectable (group 2a), with OLT contraindicated for disseminated tumor; tumor resection was possible in 23 cases (group 2b) and the remaining 10 patients who were surgically unresectable but with nondisseminated neoplasm (by staging laparotomy) underwent OLT (group 2c). The mean waiting time for OLT was 2 months (range = 1 to 4 months).

RESULTS

The mean survival rates of the group 1 and 2a patients was 6 +/- 2 months and 8 +/- 2 months, respectively. Of the 23 resected patients, the 1-, 3-, and 5-year survivals were 84%, 59%, and 40%. The 1-, 3-, and 5-year survival of OLT was 80%, 60%, and 37%, respectively. Among the 10 transplanted patients, six died due to tumor recurrence at 46, 43, 19, 16, 12, and 12 months. The remaining four patients are alive and tumor-free at 120, 89, 68, and 29 months, respectively.

CONCLUSIONS

A more accurate preoperative staging, perhaps by systematic use of pre-OLT laparotomy, and the use of adjuvant, and most importantly neoadjuvant therapy may improve the results of OLT in Klatskin's tumor.

Hospital Personnel in Surgical Services in a Transplant Hospital Faced With Living Liver Donation: An Attitudinal Survey

Living liver donation is becoming a more widely accepted practice given the decrease in donor morbidity and mortality and the beneficial results in the recipient. Use of this technique is unusual in Spain. There are a number of workers against its use within the health care system. The objective of this study was to analyze attitudes toward and the variables that affect them concerning living liver donation among surgical services in a transplant hospital.

MATERIALS AND METHODS

A random survey was stratified by surgical area and job category in a Spanish third-level hospital with an ongoing solid organ transplant program. Attitudes toward living liver donation were assessed using a questionnaire about organ donation and transplantation that evaluated various psychosocial variables. Student's t test and the chi square test were used.

RESULTS

A total of 263 workers were surveyed (mean age as 40 +/- 9 years). Regarding attitudes toward living liver donation, the level of acceptance was 80% (n = 211) of respondents, whereas 10% were undecided (n = 26), and another 10% were against (n = 26), assuming that the donations were related. When we asked about unrelated living donation, the percentage in favor decreased to 10% (n = 27). No differences were found with respect to job category or type of service. The variables that are related to such an attitude are the following: (1) possibility of respondent needing an organ (P = .001); (2) favorable attitude toward living kidney donation (P < .000); and (3) a belief that medical errors exist (P = .004). An important finding was that attitudes toward living liver donation were not more favorable according to whether the respondent was in favor or against cadaveric organ donation (P = .175).

CONCLUSION

There was a highly favorable attitude toward living liver donation among hospital personnel in surgical services, which is an important factor to take into account if this type of donation is to be encouraged in Spain.

Evidence for heating of neutron stars by magnetic-field decay

We show the existence of a strong trend between neutron star (NS) surface temperature and the dipolar component of the magnetic field extending through three orders of field magnitude, a range that includes magnetars, radio-quiet isolated neutron stars, and many ordinary radio pulsars. We suggest that this trend can be explained by the decay of currents in the crust over a time scale of approximately 10(6) yr. We estimate the minimum temperature that a NS with a given magnetic field can reach in this interpretation.

Prognostic factors for hepatitis C recurrence in patients undergoing orthotopic liver transplantation

End-stage liver disease caused by the hepatitis C virus (HCV) is a major indication for liver transplantation. HCV re-infection after LT is constant, and it significantly impairs patient and graft survival. Factors that may influence histological recurrence in the graft remain unclear. The aim of our study is to analyse the factors that influence the histological recurrence of HCV in a series of 142 patients undergoing orthotopic liver transplantation. In this series, donors age until 1995 were mostly younger than 30 years, however, from 2000 onwards most of the cases had graft implants from elderly donors. Histological recurrence was 92% after a mean follow-up of 60 months (12-120 months), 17% of which had poor-prognostic recurrence. Half of the patients presenting with recurrence did so in the first six months and more than two thirds developing hepatitis in the graft did so in the first year. The accumulated probability of histological recurrence is 40.1%, 51.5%, 70.3%, 83.5% and 92% at 6, 12, 24, 36 and 60 months respectively. In our experience, the variables associated with the development of histological recurrence in the graft, in the multivariate analysis, are donors age > or =31 years and immunosuppressive treatment without mycophenolate mophetil (MMF). Treatment with MMF still acts as a protection factor and is associated with histological non-recurrence.

Risk factors of acute renal failure after liver transplantation

The objective of this study was to determine the risk factors of postoperative acute renal failure (ARF) in orthotopic liver transplantation (OLT). We reviewed 184 consecutive OLT. Postoperative ARF was defined as a persistent rise of 50% increase or more of the S-creatinine (S-Cr). The patients were classified as early postoperative ARF (E-ARF) (first week) and late postoperative ARF (L-ARF) (second to fourth week). Preoperative variables were age, sex, comorbidity, indication for OLT, Child-Pugh stage, united network for organ sharing status, analysis of the blood and urine, and donor's data. Intraoperative variables were systolic arterial pressure, mean arterial pressure, pulmonary capillary wedge pressure, cardiac index, and systemic vascular resistance index. Surgical technique, number of blood products transfused, need for adrenergic agonist drugs, and intraoperative complications were also important. Postoperative variables were duration of stay in the intensive care unit, time on mechanic ventilation, liver graft dysfunction, need for adrenergic agonist drugs, units of blood products infused, episodes of acute rejection, re-operations, and bacterial infections. Firstly we carried out a univariate statistical analysis, and secondly a logistic regression analysis. The risk factors for E-ARF were: pretransplant ARF (odds ratio (OR)=10.2, P=0.025), S-albumin (OR=0.3, P=0.001), duration of treatment with dopamine (OR=1.6, P=0.001), and grade II-IV dysfunction of the liver graft (OR=5.6, P=0.002). The risk factors for L-ARF were: re-operation (OR=3.1, P=0.013) and bacterial infection (OR=2.9, P=0.017). The development of E-ARF is influenced by preoperative factors such as ARF and hypoalbuminemia, as well as postoperative factors such as liver dysfunction and prolonged treatment with dopamine. The predicting factors of L-ARF differ from E-ARF and correspond to postoperative causes such as bacterial infection and surgical re-operation.

Doppler ultrasonographic and scintigraphic assessment of an auxiliary heterotopic liver transplantation with portal vein arterialization in pigs

OBJECTIVE

Our aim was to evaluate liver graft integrity and function using scintigraphy and ultrasonography in a porcine model of auxiliary heterotopic liver transplantation with portal vein arterialization (AHLT-PVA).

MATERIALS AND METHODS

Using Doppler ultrasonography we evaluated eight AHLT-PVA by parenchymal echogenicity, portal and arterial anatomy, and portal and biliary system flow. Two types of scintigraphy were performed: microaggregated human albumin colloid scintigraphy and diisopropyl iminodiacetic acid (DISIDA) scintigraphy, both labeled with 99mTc.

RESULTS

The animals were distributed into two groups. The first group consisted of three animals with clinical suspicion of graft dysfunction, in which the ultrasonographic study revealed areas of parenchymal destructuring. In the scintigraphic study, heterogenous uptake was observed; there was no uptake in one animal. Necropsy of these three animals revealed areas of graft necrosis. The second group consisted of five animals with good clinical evolutions, in which the ultrasonographic study showed portal dilation, portal flow with arterial spiculations, and homogenous echogenicity of the hepatic parenchyma. The scintigraphic study revealed homogenous uptake by the graft and an elimination speed of the hepatobiliary agent similar to that of the native liver.

CONCLUSIONS

An heterogenous echostructure of the graft provided a sign of poor prognosis indicating necrosis in the same way as heterogenous uptake or nonuptake of radioisotope upon scintigraphy. Scintigraphy is a good method to evaluate biliary function and bile elimination. In an AHLT-PVA, the main ultrasound findings derived from arterialization were dilation of the portal system and portal flow with arterial spiculations.

Prevention of hyperacute rejection in a model of orthotopic liver xenotransplantation from pig to baboon using polytransgenic pig livers (CD55, CD59, and H-transferase)

INTRODUCTION

The search for alternative sources for transplant organs leads us to the search for animals as an inexhaustible source of organs. The objective of this study was to analyze whether livers from polytransgenic pigs expressing the human complement regulatory proteins CD55 (hDAF), CD59, and alfa alpha1,2-fucosyltransferase (H-transferase), protected against hyperacute rejection after orthotopic liver xenotransplantation to a baboon and also to study pig liver function in a nonhuman primate.

MATERIALS AND METHODS

Nine liver transplants from pig to baboon were divided into two groups: a control group (n = 4) of genetically unmodified pigs and an experimental group (n = 5) of pigs transgenic for CD55, CD59, and H-transferase as donors. All the donating piglets obtained through hysterectomy were maintained in specific pathogen-free conditions. The selection of transgenic pig donors followed demonstration of transgene expression using monoclonal antibodies (antiCD55, antiCD59) and immunohistological studies on liver biopsies.

RESULTS

All animals in the control group developed hyperacute rejection with survival rates less than 16 hours without function of transplanted livers. In the experimental group none of the animals suffered hyperacute rejection. Survival in this group was between 13 and 24 hours. The livers were functional, producing bile and maintaining above 35% prothrombin activity. Only in one case was there primary dysfunction of the xenograft.

CONCLUSION

Polytransgenic livers for complement regulatory proteins prevent hyperacute rejection when xenotransplanted into a baboon.

Attitudes toward living liver donation among hospital personnel in services not related to transplantation

INTRODUCTION

The deficiency in livers and waiting list mortality have encouraged more living liver donation, although it is not exempt from morbidity and mortality. The enthusiasm of transplant teams for this kind of donation is increasing; however, the attitudes toward it are not so clear among other health professionals. Our objective was to analyze the attitudes toward living liver donation among hospital professionals in services without habitual relations with transplantation.

MATERIALS AND METHODS

A random sample was stratified for service not related to transplantation and job category, in a third level hospital with a transplant program. Attitudes toward living liver donation were evaluated using a psychosocial questionnaire on living donation.

RESULTS

A total of 419 respondents were analyzed (doctors, n = 184; nurses, n = 119; assistant nurses, n = 80; and non-health workers, n = 36), with a mean age of 37 +/- 10 years. The attitude toward living liver donation was favorable in 82% (n = 344). Among the other respondents, half (9%; n = 38) were against and the other half (9%; n = 37) were undecided. No significant differences were found among the doctors, nurses, assistants, and non-health workers. However, when the three categories were grouped in opposition to the non-health workers, there was greater indecision among non-health workers than the others (19% vs 8%; P = .0001). On analyzing the variables that determine this attitude we observed the following: having commented upon and previously discussed donation (P = .016); believing in the possibility of needing an organ oneself (P = .0001); and being in favor of living kidney donation (P = .0001) and cadaveric donation (P = .004).

CONCLUSIONS

Hospital personnel in services not related to transplantation favor living liver donation, especially if it is a related donation, despite its greater risk, except among non-health workers. However, it is important to conduct informative and awareness-raising campaigns in hospitals if such a type of transplantation is to be encouraged.

Pathology findings in a model of auxiliary liver transplantation with portal vein arterialization in pigs

OBJECTIVE

To determine the histological findings and temporal evolution that occur in auxiliary liver grafts as a consequence of arterialization of the portal vein (PVA).

MATERIALS AND METHODS

We evaluated 10 auxiliary heterotopic liver transplants with arterialization of the PVA. The histological study was performed using an optical microscope to process liver samples with staining using hematoxylin and eosin. A biopsy of native liver tissue was used as a control.

RESULTS

Two animals were excluded from the study, one due to ischemic necrosis of the graft and one that died 4 hours after transplant. All of the remaining eight animals underwent a histological study at 1 day, 7 days, and 14 days. The most significant histological findings were: (1) dilation of portal areas and sinusoids, which were detected at 24 hours and persisted; (2) thickening of the interlobular septum, which was observed after day 7 and progressively increased to day 14; (3) bile duct hyperplasia detected at the seventh day.

CONCLUSIONS

The consistent, early findings in a pig liver with PVA included vascular dilation of the portal area and the sinusoids, with bile duct hyperplasia extending progressively and the thickening of interlobular connective tissue septa with a generalized perilobular connective tissue reaction, which did not seem to alter the internal structure of the lobule, which showed histologically normal hepatocytes. The fibrous reaction may be the first stage in chronic hepatopathy. Further long-term studies are required in this model.

Attitude Toward Deceased Organ Donation and Transplantation Among the Workers in the Surgical Services in a Hospital With a Transplant Program

INTRODUCTION

There are data that suggest that the percentage of hospital workers not in favor of donation is relatively high, even in services that are directly related to transplantation. The objective was to analyze attitudes toward decreased organ donation in the surgical services.

MATERIALS AND METHODS

A random sample was stratified by the surgical service and the job category (n = 263) in a third-level hospital with a transplant program assessed attitudes toward the donation of ones own organs after death using a questionnaire including psychosocial factors as validated in our geographic surroundings. Student t test and the chi-square test were used for data analysis.

RESULTS

Favorable attitudes toward donation were observed in 68% (n = 178) as opposed to 32% with an attitude that was undecided or against the act (n = 85). The psychosocial variables that showed significant relationships with this attitude were age (most in favor are younger; P = .021); nonmedical surgical staff (50% against donation; P = .0001); resident physicians (94% in favor; P = .001); discussion and prior consideration of donation (P = .016); knowledge of the concept of brain death (an important factor in nonhealth staff; P = .010); attitude toward manipulation of the deceased (P = .011) and concerns about mutilation (P = .026); partner's opinion toward organ donation (P = .0001); and existence of frequent medical errors (P = .003). No significant differences were found, depending on whether the services were involved in a specific transplant program (P = .853).

CONCLUSIONS

Favorable attitudes toward donation among the hospital staff on surgical services, including those who perform transplants, did not reach more than 70% and was determined by multiple psychosocial factors. Donation promotion activities are necessary for these services, given the importance that this group's negative attitude could have on the attitude of the general population.

Attitude Toward Living Related Donation of Patients on the Waiting List for a Deceased Donor Solid Organ Transplant

INTRODUCTION

Spain is the country with the highest rate of donation from deceased individuals. However, given the deficit in organs, living donation is being encouraged. Our objective was to analyze attitudes toward living donation among patients on the waiting list for a transplant.

MATERIALS AND METHODS

Patients on the waiting list for a kidney or liver transplant (n = 96; 46 kidney and 50 liver) in the last year had their attitudes toward living donation evaluated through a psychosocial survey performed in a direct interview with an independent health professional from the transplant unit and analyzed by Student t test and the chi-square test.

RESULTS

Ninety-one percent were in favor of donating their organs when they die, 6% had doubts, and the remaining 3% were against it. Twenty percent would accept living donation from a family member (32% in liver vs 7% in kidney; P < .05), despite 89% of them accepting that there would be a risk to the family member. Twenty percent reported that a family member had suggested donating, but the patient was opposed. Finally, only 6% considered living donation to be their first choice, 42% did not consider this option. Up to 96% would donate an organ to a family member if they were requested to do so.

CONCLUSION

Patients on the waiting list are not favorable to living related donation for themselves, although members of their family have proposed it to them. However, the liver patient is more prepared to accept it, possibly because that patient has no other alternative as do kidney patients have dialysis. Even so, they are favorable toward donating a living organ if a family member were to request one. In general, living donation is not being proposed to these patients as a real option, partly because of their doctors.

Primary eosinophilic esophagitis

Eosinophilic esophagitis is an uncommon pathology that generally affects children with a history of allergies and intrinsic asthma. We present a clinical case of eosinophilic esophagitis in a 16-year-old boy with upper dysphagia for solids since childhood. The analytical study showed only a repeat serum eosinophilia. Barium transit disclosed a reduction in caliber of the whole esophagus. Functional esophageal tests with pH monitoring and manometry were normal. Endoscopy showed a small-diameter esophagus and fibrosis with a very friable mucosa. The histological study of the esophageal biopsies revealed a full thickness major eosinophil infiltration of the esophagus. These findings suggest a differential diagnosis with a great variety of pathologies that can cause similar lesions in the esophagus, especially between primary eosinophilic esophagitis and eosinophilic esophagitis secondary to gastro-esophageal reflux disease (GERD). We implemented medical treatment with oral corticoids and total suppression of allergens from the diet, and the patient was asymptomatic.

Description of a new auxiliary heterotopic partial liver transplantation technique with portal vein arteriolization of applicability in heterotopic liver xenotransplantation

OBJECTIVE

The aim of this study was to describe a new model of auxiliary heterotopic partial liver transplantation with portal vein arterialization.

MATERIALS AND METHODS

Three standard hepatectomies were performed in pigs. The left lateral lobe was surgically resected and portal vein arteriolization constructed by an end-to-side "Y" anastomoses between the distal to the celiac axis aorta and the portal vein.

RESULTS

The graft was placed in the left iliaca fossa using anastomoses of the donor infrahepatic inferior cava vein end-to-side to the host infrarenal inferior vein and the donor aortic stump with portal vein arteriolization end-to-side to the left iliac artery. After graft reperfusion, the 3 recipients showed intraoperative hypotension, which was treated with fluid administration and vasoactive drugs. At the end of the operation, the graft displayed normal arterial blood flow and good venous drainage. The donor liver graft appeared more red than the host liver, which was due to the increased arterial blood flow. One pig of 3 died at 24 hours after surgery, probably due to hypothermia. However, the other 2 pigs survived the procedure and remained stable. Echographic monitoring showed intrahepatic arterial expansion, which may be the result of high blood pressure due to the arteriolization procedure.

CONCLUSIONS

We have developed a novel and easy to perform technique that diminishes the number of anastomoses and does not involve vessels from other organs.

Does the standard vs piggyback surgical technique affect the development of early acute renal failure after orthotopic liver transplantation?

The objective of this study was to evaluate the effect of the surgical technique on postoperative renal function during the first week after liver transplantation (OLT). We performed a retrospective study of 184 consecutive OLT. Criteria for acute renal failure were: serum creatinine >1.5 mg/dL, an increase by 50% in the baseline serum creatinine, or oliguria requiring renal replacement therapy. The distribution of patients according to the surgical technique was: standard (n=84), venovenous bypass (n=20), and piggyback (n=80). Other variables analyzed were: intraoperative requirement for blood products, treatment with adrenergic agonists, intraoperative complications, and postreperfusion syndrome. Univariate analysis showed the following parameters to be significantly related to postoperative renal failure: intraoperative fresh frozen plasma and cryoprecipitate requirements, intraoperative complications, postreperfusion syndrome, need for noradrenaline or dobutamine, standard surgical technique versus piggyback (39% vs 18%, P<.01) and venovenous vs piggyback (50% vs 18%, P<.01). Logistic regression analysis identified the following variables as having independent prognostic value: (1) Standard surgical technique vs piggyback (OR=3.3, P=.01); (2) venovenous vs piggyback (OR=4.7, P=.02); and (3) >20 U cryoprecipitate requirement (OR=1.04, P=.01). In conclusion, compared with the piggyback technique, the standard surgical technique appears to be an independent risk factor for postoperative acute renal failure. When venovenous bypass is used in patients who do not tolerate trial clamping of inferior vena cava, it does not reduce the incidence of postoperative renal failure. Finally, the piggyback technique significantly reduces the probability of acute renal failure after liver transplantation.

Immunopathology of an hDAF transgenic pig model liver xenotransplant into a primate

BACKGROUND

hDAF transgenic pigs do not display the inherent hyperacute rejection reactions of pig-to-primate xenotransplants. The purpose of this study was to determine the immunopathologic phenomena following an hDAF transgenic pig hepatic orthotopic xenotransplant into a baboon.

METHODS

Donor animals were unmodified pigs (n=4) and hDAF transgenic pigs (n=2). Recipient animals were baboons (Papio anubis). Liver biopsies were immunostained using monoclonal antibodies to C3, C5b-9, IgG, IgM, CD2, CD4, CD8, CD68, CD20, Bric 216, CD31, and fibrin, and polyclonal antibody to C4.

RESULTS

hDAF transgenic grafts showed IgG, IgM, and C4 endothelial deposits. However, no fibrin, C3, or C5b9 deposits were observed after reperfusion. hDAF xenografts displayed CD31 staining in the portal spaces, perilobular areas, and at hepatic sinuisoidal levels. The baboon that lived for 4 days displayed either CD4 or CD8 T-cells periportal infiltrate.

CONCLUSIONS

Future studies will seek to determine the physiologic role of CD31 hepatic sinusoidal expression in transgenic xenotransplants, and will also study the role of T-cell infiltrates in xenograft rejection.