Search

Cardiovascular (CV) diseases are recognized longterm causes of death after liver transplantation (LT). The objective of this multicenter study was to analyze the prevalence and the evolution of CV risk factors and CV morbidity and mortality in 1819 LT recipients along 5 years after LT. The influence of baseline variables on survival, morbidity, and mortality was studied. There was a continuous and significant increase of the prevalence of all the CV risk factors (except smoking) after LT. CV diseases were the fourth cause of mortality in the 5 years after LT, causing 12% of deaths during the follow-up. Most CV events (39%) occurred in the first year after LT. Preexisting CV risk factors such as age, pre-LT CV events, diabetes, metabolic syndrome, and hyperuricemia, and mycophenolate-free immunosuppressive therapy, increased post-LT CV morbidity and mortality. The development of new-onset CV risk factors after LT, such as dyslipidemia and obesity, independently affected late CV morbidity and mortality. Tacrolimus and steroids increased the risk of posttransplant diabetes, whereas cyclosporine increased the risk of arterial hypertension, dyslipidemia, and metabolic syndrome. In conclusion, CV complications and CV mortality are frequent in LT recipients. Preexisting CV risk factors, immunosuppressive drugs, but also the early new onset of obesity and dyslipidemia after LT play an important role on late CV complications. A strict metabolic control in the immediate post-LT period is advisable for improving CV risk of LT recipients. Liver Transplantation 23 498-509 2017 AASLD., (© 2017 by the American Association for the Study of Liver Diseases.)

Background: The development of metabolic syndrome (MS) after liver transplantation (LT) is a major source of mortality derived from cardiovascular events. The aim of the present study was to determine the prevalence and risk factors of MS after LT., Methods: One-hundred seventy-four consecutive LT patients from January 2004 to June 2010 surviving longer than 1 year after LT were included. Median follow-up after LT was 48 months. Independent predictors of MS were obtained by means of multivariate logistic regression., Results: At 3 years after LT, 25.5% of patients reached a body mass index (BMI) ≥30 kg/m 2 , 35.6% of patients developed arterial hypertension, 54.2% showed impaired fasting glucose, 22.5% had serum cholesterol >200 mg/dL, and 22.5% showed hypertriglyceridemia >150 mg/dL. The prevalence of MS ranged from 49% to 86% depending on the considered period. The pre-LT variables associated with MS were age at LT (odds ratio [OR], 1.08; P = .002), BMI of recipient before LT (OR, 1.23; P = .001), serum glucose (OR, 1.02; P = .005), and non-heart-beating donor (OR, 1.02; P = .046). The post-LT predictors of MS were body weight (OR, 1.04; P = .005), arterial hypertension (OR, 1.02; P = .047), and serum glucose (OR, 1.02; P = .011) at 6 months., Conclusions: LT patients develop MS in a high proportion and progressively despite current efforts (ie, lifestyle modifications and aggressive management of hypertension, diabetes, and hyperlipidemia). The associated risk factors include age, increased BMI, and pre- and post-LT glucose., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background and Aims: MELD allocation system has changed the clinical consequences on waiting list (WL) for LT, but its impact on mortality has been seldom studied. We aimed to assess the ability of MELD and other prognostic scores to predict mortality after LT., Methods: 301 consecutive patients enlisted for LT were included, and prioritized within WL by using the MELD-score according to: hepatic insufficiency (HI), refractory ascites (RA) and hepatocellular carcinoma (HCC). The analysis was performed to predict early mortality after LT (8 weeks)., Results: Patients were enlisted as HI (44.9%), RA (19.3%) and HCC (35.9%). The major aetiologies of liver disease were HCV (45.5%). Ninety-four patients (31.3%) were excluded from WL, with no differences among the three groups (p = 0.23). The remaining 207 patients (68.7%) underwent LT, being HI the most frequent indication (42.5%). HI patients had the shortest length within WL (113.6 days vs 215.8 and 308.9 respectively; p<0.001), but the highest early post-LT mortality rates (18.2% vs 6.8% and 6.7% respectively; p<0.001). The independent predictors of early post-LT mortality in the HI group were higher bilirubin (OR = 1.08; p = 0.038), increased iMELD (OR = 1.06; p = 0.046) and non-alcoholic cirrhosis (OR = 4.13; p = 0.017). Among the prognostic scores the iMELD had the best predictive accuracy (AUC = 0.66), which was strengthened in non-alcoholic cirrhosis (AUC = 0.77)., Conclusion: Patients enlisted due to HI had the highest early post-LT mortality rates despite of the shortest length within WL. The iMELD had the best accuracy to predict early post-LT mortality in patients with HI, and thus it may benefit the WL management.

Background: Biliary complications are a frequent cause of morbidity, graft loss, and death after orthotopic liver transplantation (OLT). The choledochocholedochostomy anastomosis without a T-tube is controversial, as it has been related to more biliary complications., Aims: The aims of this study were to determine the incidence and to identify the risk factors of post-OLT biliary complications after reconstruction with or without a T-tube., Materials and Methods: Ninety-five consecutive adult patients with deceased donor liver transplantations (overall survival rate, 86.3%; mean follow-up, 22.2 months) were analyzed to determine the incidence and type of biliary complications in 2 groups: choledochocholedochostomy with (45 patients, Group I) or without a T-tube (50 patients, Group II). The incidence of biliary complications in Groups I and II was 40% (18/45) and 30% (15/50), respectively (P > .05). In Group I, 49% of the complications were directly related to the T-tube. Biliary anastomosis stricture was more frequent in Group II (28% vs 8.9% in Group I; P = .018). Endoscopic retrograde cholangiopancreatography (ERCP) was the most common therapeutic procedure for the resolution of biliary complications in both groups (Group I, 66.5%; Group II, 58.2%). Arterial thrombosis, high pretransplantation Model for End-Stage Liver Disease (MELD) score, and donor obesity were identified as risk factors for biliary complications after OLT., Conclusion: OLT biliary reconstruction without a T-tube is not related to an increased risk of biliary complications, although stricutre of the anastomosis is more frequent in this group of patients. Donor obesity, arterial thrombosis, and high pretransplantation MELD score are associated with a higher incidence of biliary complications after OLT., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Increased blood pressure (BP) is common after liver transplantation. However, there is scarce information on its control., Methods: In this prospective, cross-sectional, multicenter study, we determined BP according to the recommended international standards in 921 liver transplant patients during one routine outpatient visit to assess their grade of control of BP. At the time of the study, 490 patients had been previously diagnosed with arterial hypertension and were receiving antihypertensive treatment, and 431 were not previously diagnosed as hypertensive., Results: In the hypertensive group, arterial hypertension was uncontrolled (BP >140/90 mm Hg [>130/80 in diabetics]) in 158 (32%) patients and controlled in 332 (68%) patients. In a multivariate analysis, only diabetes was identified as a significant predictor of uncontrolled hypertension. Among patients not previously diagnosed as hypertensive, BP was increased in 106 (25%) and normal in 325 (75%). On multivariate analysis, the only variable independently associated with increased BP in this group was metabolic syndrome., Conclusion: BP is not adequately controlled in a noticeable percentage of liver transplant patients, especially in subjects with diabetes or metabolic syndrome.

Objectives: the postoperative evolution of patients submitted to orthotopic liver transplant (OLT) is frequently associated with the appearance of different types of complications such as renal failure, graft rejection, infections, and neurological disorders. These complications are the most significant causes of early morbidity and mortality in patients undergoing OLT. The purpose of the present study was the identification of factors related to the different postoperative complications after OLT., Experimental Design: a prospective study was carried out., Patients: seventy-eight variables were analyzed in 32 consecutive patients undergoing OLT. The factors independently associated with the appearance of postoperative complications were identified using a stepwise logistic regression analysis., Results: the multivariate analysis showed that malondialdehyde and creatinine pretransplant serum levels were associated with the development of renal dysfunction. The pretransplant levels of haemoglobin and the units of platelets administered during surgery were prognostic factors of infections. Acute graft rejection was predicted by ?-glutamyl transpeptidase and total bilirubin serum levels. The pretransplant sodium and glutaredoxin levels in serum were associated with neurological complications., Conclusions: we propose these markers for the identification of high-risk patients allowing an early surveillance and/or treatment to improve morbidity and survival in patients submitted to OLT.

Objective: The goal of this research has been to evaluate the survival, in long and short term, of the patient receiving liver transplant for hepatocellular carcinoma (HCC), the risk of post-transplant tumor relapse and factors related to this complication., Design: Retrospective study of a consecutive series of patients having had liver transplant for HCC., Patients and Methodology: Transplant patients for HCC from 1989 to November 2003. Patients were selected due to general limitations of nodule size and quantity, which were subsequently published as Milan criteria. Also, criteria agreed in the Conference of Barcelona were followed in the pre-transplant diagnosis., Results: The survival of this 81 patients group was of the 80, 61 and 52% for 1, 5 and 10 years respectively. In the 32% of the cases the HCC was an incidental finding in the explant. In the 12.3%, the tumor relapse was verified. The multivariate research identified the size of the nodule (OR=1,7944) (IC 95%=1,1332-2,8413) and the vascular invasion (OR=6,6346) (IC 95%=1,4624-30,1003) as risk factors of relapse., Conclusions: The liver transplant in selected patients with HCC has good results in medium and long term. The risk of post-transplant tumor relapse becomes notably reduced and is associated with the size of the nodule and the microscopic vascular invasion.

Unlabelled: Pruritus is a common complication of cholestatic liver diseases or liver graft dysfunction. Current medical therapies lack efficacy. The molecular adsorbent recirculating system (MARS) represents an interesting therapeutic option. Our objective was to report our experience in the management of four patients with intractable pruritus with MARS., Patients and Methods: The MARS treatment cycle included three consecutive treatments, each of 8 hours duration. The four patients with intractable pruritus who were treated had primary biliary cirrhosis/autoimmune hepatitis overlap syndrome (n = 1), ductopenic allograft rejection (n = 2), or posttransplant cholestatic HCV recurrence (n = 1). Intensity of pruritus was documented 24 hours before as well as 24 hours, 7 and 30 days after MARS therapy, and at the end of follow-up. We measured complete blood cell counts, glucose, BUN, creatinine, sodium, potassium, AST, ALT, GGT, alkaline phosphatase, bilirubin, prothrombin activity, and activated partial thromboplastin time., Results: MARS therapy was well tolerated. Patient 1 experienced temporal relief of pruritus, but needed another MARS cycle because of relapse. Patient 2 experienced partial and temporary relief of pruritus, was listed for retransplantation, and received a liver graft 2 months later. Patient 3 showed a dramatic reduction in the degree of pruritus with MARS. Pruritus in patient 4 decreased promptly with MARS therapy and conversion of immunosuppression to tacrolimus, thereby avoiding retransplantation., Conclusion: MARS therapy is a promising, safe therapeutic option to treat refractory pruritus caused by cholestatic liver disorders.

Hepatitis B virus (HBV) recurrence and de novo HBV infection are frequent events in liver transplantation recipients. Treatment with lamivudine is initially efficient in both infections but the incidence of lamivudine-resistant HBV emergence increases over time. Adefovir appears to be promising in post-liver transplantation patients with recurrent HBV infection and lamivudine-resistant HBV. This study analyzed adefovir treatment in 42 post-liver transplantation patients who developed recurrent HBV or de novo HBV infection with lamivudine-resistant HBV (54.8% HCV-coinfected). Patients received 10 mg of oral adefovir once daily for a mean period of time of 21.5 months (range from 12 to 31 months). In 62.9% of patients, ALT levels decreased significantly. Serum HBV-DNA was undetectable in 64% of the cases. Twenty percent of patients lost HBeAg marker and 13.3% of them developed anti-HBe. In 9.5% of recipients, HBsAg became negative. There was no significant change in serum creatinine levels. In only one patient was worsening of the renal function detected, making dose adjustment necessary. No other side effects were reported. Our results confirm the efficacy and safety of adefovir treatment in post-liver transplantation patients with lamivudine-resistant HBV, neither were adefovir-resistant mutations identified in patients after 21 months of therapy, nor were there adverse events, especially renal toxicity.

The liver transplantation unit from Córdoba, Spain, performed its first liver transplantation in 1989. Since then, 500 liver transplants have been performed in our institution up to November 2001. Our one-year recipient and graft survival rates are 77% and 76%, respectively. These recipient and graft survival rates are lower when compared with other results in the English language literature, and we present evidence here that the disparity results from 4 especially problematic aspects of our program: 1) the expanded use of donors, 2) the policy of allocation and prioritization in our institution, 3) the recurrence of primary liver disease and 4) de-novo neoplasms. Liver transplantation with unstable, hypernatremic donors or donors with a lengthy hospitalization and grafts with a prolonged cold ischemia time leads to diminished graft survival. When several marginal criteria accumulate in a donor, the results are even poorer. Consequently, the delayed non-function rate is especially high in our series. Attention to severe liver preservation injury as a primary mechanism of graft losses with marginal donors is given. The impact of the policy of the "sickest-first" principle in our center with a long waiting list seems to benefit urgent but not elective patients. Survival in elective patients is poorer than expected considering their clinical condition. The use of the sickest-first or urgency principle in our unit has not been efficient or equitable and may partially explain the poorer survival of our patients. Finally, the recurrence of primary disease and incidence of de-novo tumors after transplantation in our unit are similar those reported in English language literature.

Unlabelled: Homozygous familial hypercholesterolemia is an inherited metabolic disease that leads to decreased catabolism of low-density lipoprotein cholesterol. As a result coronary artery disease ensues by the first or second decade. Because most low-density lipoprotein receptors (50-75%) are located in the liver, liver transplantation has been introduced as a therapeutic option in this disorder., Aims: To report our experience in the treatment of homozygous familial hypercholesterolemia with ortothopic liver transplantation. We evaluated metabolic results and patient survival., Method: We treated two affected siblings. One of them received a sequenced heart-liver transplantation because of cardiac failure due to severe coronary disease., Results: The operative and postoperative course was favourable in both patients, with a decrease in cholesterol levels to normal values. Four years later both were alive and both had normal liver and heart functions. Neither patient needed cholesterol-lowering drugs, and the disease had not progressed., Conclusions: As shown by our results and those reported by others, liver transplantation is the treatment of choice for homozygous familial hypercholesterolemia until gene therapy becomes a viable option. Transplantation should be done before of cardiovascular complications develop.

Background: Recurrence of autoimmune hepatitis after liver transplantation is not rare, but there is little information about its time of onset, risk factors, response to treatment and prognosis. The aim of this study was to evaluate the rate of recurrence and outcome of autoimmune hepatitis after transplantation., Methods: The records of patients transplanted in eight centers in our country between 1984 and 1996 were retrospectively analyzed., Results: Forty-three of the 2331 (1.8%) recipients fulfilled diagnostic criteria of autoimmune hepatitis at the time of transplantation. Sixteen patients were excluded from evaluation. Nine (33%) of the 27 patients evaluated fulfilled criteria for recurrence of autoimmune hepatitis, with a mean time of recurrence after orthotopic liver transplantation of 2.6+/-1.5 years. Patients with recurrence had a longer follow-up time after transplantation (5.1 vs. 2.5 years, P=0.0012) and were receiving less immunosuppressive treatment. The estimated risk of recurrence of autoimmune hepatitis in the graft increased over time: 8% over the first year and 68% 5 years after transplantation. None of the seven patients with liver-kidney microsomal-positive antibodies recurred (P=0.059). Fifty percent of the patients failed to respond or responded only partially to therapy, although none of the patients have deteriorated clinically after 2.4+/-1.06 years of follow-up after recurrence., Conclusions: Recurrence of autoimmune hepatitis in the graft is a common event with an incidence that increases over time as immunosuppression is reduced. Although response to treatment is poor, patient and graft survival do not appear to be decreased.