Publications by authors named "Daniel Reis Waisberg"

69 Publications

COVID-19 Pandemic Impact on Liver Donation in the Largest Brazilian Transplantation Center.

Transplant Proc 2022 Apr 21. Epub 2022 Apr 21.

Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil.

Background: COVID-19 has spread worldwide and has become a public health emergency and a pandemic of international concern. The solid organ donation system was no different. This study aimed to investigate the effect of COVID-19 on the liver transplant (LT) system in Brazilian territory.

Methods: We retrospectively reviewed all liver donor records allocated in São Paulo State, Brazil, 1 year before and 1 year during the COVID-19 pandemic. We defined the pre-COVID-19 (PRE) period as between April 2019 and April 2020 and the post-COVID-19 (POST) period as between April 2020 and April 2021. Moreover, we compared LT performed in our institution during these periods. To evaluate outcomes, we compared 30-day survival after LT.

Results: In the PRE period, 1452 livers were offered for donation in São Paulo State and other Brazilian territories. Of these, 592 were used in LT. In the POST period, 1314 livers were offered for donation, but only 477 were used in LT. Organ refusal was higher in the POST period (P < .05). Our center performed 127 and 156 LTs in these periods, respectively, and an increase above 20% was significant (P = .039). There was no difference in 30-day survival between the periods (87.2% vs 87.9%, P > .5, respectively).

Conclusions: The COVID-19 pandemic harmed potential and allocated donors and LTs performed. However, it is possible to maintain the LT volume of a transplant center without compromising survival outcomes through preventive strategies against COVID-19 propagation.
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http://dx.doi.org/10.1016/j.transproceed.2022.03.045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9021359PMC
April 2022

Prognostic Factors Evaluation for Liver Transplant Mismatching: A New Way of Selecting and Allocating Organs.

Transplant Proc 2022 Jun 26. Epub 2022 Jun 26.

Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil.

Background: Liver transplant (LT) is the standard therapy for end-stage liver disease. Advances in surgical techniques and immunosuppression protocols improved the results of LT by increasing long-term survival. Nevertheless, an adequate match between the donor and recipient is paramount for avoiding futile liver transplants. We aimed to identify the prognostic factors in donor-recipient LT matching.

Methods: Retrospective analysis of adult LT was conducted from January 2006 to December 2018, which included the following transplant modalities: deceased donor LT (DDLT), living donor LT (LDLT), combined liver-kidney transplant (CLKT), and domino LT (DLT).

Results: Among 1101 patients who underwent LT, 958 patients underwent DDLT, 92 patients underwent LDLT, 45 patients underwent CLKT, and 6 patients underwent DLT. The overall survival (OS) in 1, 5, and 10 years were 89%, 83%, and 82%, respectively. For DDLT, OS in 1, 5, and 10 years were 91%, 84%, and 82%, respectively. For LDLT, OS in 1, 5, and 10 years were 89%, 72%, and 69%, respectively. For CKLT, OS in 1, 5, and 10 years were 90%, 71%, and 71%, respectively. None of the DLT patients died. For DDLT, the factors that affected OS were the presence of fulminant liver failure (odds ratio [OR], 2.23; 95% CI, 1.18-4.18; P = .001), hemodialysis before LT (OR, 2.12; 95% CI, 1.27-3.5; P = .004), retransplant (OR, 4.74; 95% CI, 2.75-8.17; P = .000), and recipient age >60 years (OR, 1.86; 95% CI, 1.27-2.73; P = .001). For hospitalization before LT (due to an acute-on-chronic liver failure), the OR was 2.10 (95% CI, 1.29-3.42; P = .003). Donor intensive care unit time >7 days (OR, 1.46; 95% CI, 1.04-2.06; P = .02) was also associated with overall mortality.

Conclusions: We identified prognostic factors in donor-recipient LT matching. Furthermore, we demonstrated that an adequate organ allocation with donor-recipient selection might increase graft survival and reduce waiting list mortality.
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http://dx.doi.org/10.1016/j.transproceed.2022.03.026DOI Listing
June 2022

Experimental Clinical Model of Liver Transplantation in Large White Pigs Without Venovenous Bypass: Pre-, Intra-, and Maintenance Care.

Transplant Proc 2022 Jun 15. Epub 2022 Jun 15.

Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil.

Background: Liver transplantation in an animal model is challenging due to hemodynamics and intraoperative anesthetic care. Several models are described in the literature employing different techniques such as venovenous bypass or aortic cross-clamping to maintain hemodynamic stability, although few groups keep the animal alive in the postoperative period. This study aims to evaluate a liver transplantation clinical model in pigs without venovenous bypass or aortic cross-clamping.

Methods: Male pigs weighing 20 to 35 kg underwent liver transplantation surgery without using venovenous bypass or aorta cross-clamping. Protocols were approved by the Animal Care and Use Committee of the University of São Paulo, Brazil.

Results: Ten LTs were performed. Cold ischemia and warm ischemia were 119 ± 33.28 minutes and 26 ± 9.6 minutes, respectively. Hemodynamic changes were significantly higher after the postrevasculazation phase: heart rate (P < .001), medium arterial pressure (P < .001), and cardiac output (P = .03). Hypotension was treated with intravenous fluids and, in some cases, with vasoactive drugs especially during the post-reperfusion period. No animals died during the procedure and almost survival until the first postoperative day. Serum aspartate aminotransferase and lactate increased their values in the post-reperfusion phase.

Conclusions: Practice-based on laboratory animals improves surgical skills and the development of experimental models aimed at new advances in this field. Perfecting our technique on the swine model, we could move forward to create a small-for-size model, test new therapeutic strategies, and define the boundaries for safely performing an enlarged liver resection or a partial liver graft transplant.
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http://dx.doi.org/10.1016/j.transproceed.2022.04.002DOI Listing
June 2022

Relationship of Anatomic Variations and Arterial Reconstruction of the Hepatic Artery: Prevalence and Effect on Orthotopic Liver Transplantation.

Transplant Proc 2022 Jun 15. Epub 2022 Jun 15.

Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil.

Background: Identifying anatomic variations of the hepatic artery is essential in liver transplantation. The artery supply is crucial for the procedure's success, and, in some cases of anatomic variations, they need reconstruction. Hepatic artery thrombosis is a severe vascular complication. This study evaluated the prevalence of anatomic variations and correlated arterial reconstructions with hepatic artery thrombosis.

Methods: We performed a retrospective analysis of medical records, adult patients undergoing liver transplant, donor's arterial anatomy, arterial reconstructions, and thrombosis after transplant from January 2019 to December 2020.

Results: Among 226 cases, 71% had normal anatomy. All these patients met Michel's classification subtypes, of which 161 (71%) were class I, which is the most common. The second most common variation was class II, with 25 donors (11%), followed by class III, with 17 donors (7.5%). Anatomic artery variations were a risk factor for hepatic artery thrombosis development (odds ratio [OR], 7.2; 95% confidence interval [CI], 2.1-22.5; P = .002). In the same way, the artery reconstruction was associated with hepatic artery thrombosis arising with postoperative time (OR, 18.0; 95% CI, 4.9-57.5; P < .001). Global hepatic artery thrombosis occurred in 11 cases (4.87%).

Conclusion: Anatomic hepatic artery variations are frequent and do not make liver transplant unfeasible. However, variations that require reconstruction may raise the risk of thrombosis.
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http://dx.doi.org/10.1016/j.transproceed.2022.04.012DOI Listing
June 2022

Small-for-Size Syndrome: Systemic Review in a Porcine Experimental Model.

Transplant Proc 2022 Jun 14. Epub 2022 Jun 14.

Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil.

Background: The small-for-size syndrome (SFSS) is characterized by prolonged hyperbilirubinemia, coagulopathy, and/or encephalopathy caused by a small liver graft that cannot sustain the metabolic demands of the recipient after a partial liver transplant (PLT). Models of PLT in pigs are excellent for studying this syndrome. This review aimed to identify the different porcine models of SFSS in the literature and compare their technical aspects and therapeutics methods focused on portal inflow modulation (PIM).

Methods: We performed a systematic review of the porcine experimental model and SFSS. The MEDLINE-PubMed, EMBASE, Cochrane Library, LILACS, and SciELO databases were electronically searched and updated until June 20, 2021. The MeSH terms used were ''ORGAN SIZE'' AND ''LIVER TRANSPLANTATION".

Results: Thirteen SFSS porcine models were reported. Four were performed with portocaval shunt to PIM and 3 with mesocaval shunt to PIM. A few studies focused on clinical therapeutics to PIM; a study described somatostatin infusion to avoid SFSS. Initially, studies on PIM showed its potentially beneficial effects without mentioning the minimum portal flow that permits liver regeneration. However, an excessive portal diversion could be detrimental to this process.

Conclusions: The use of porcine models on SFSS resulted in a better understanding of its pathophysiology and led to the establishment of various types of portal modulation, surgical techniques with different complexities, and pharmaceutical strategies such as somatostatin, making clear that without reducing the portal vein pressure the outcomes are poor. With the improvement of these techniques, SFSS can be avoided.
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http://dx.doi.org/10.1016/j.transproceed.2022.03.024DOI Listing
June 2022

Septuagenarian Donors and Recipients in Deceased Donor Liver Transplantation: A Brazilian Single Center Experience and Literature Review.

Transplant Proc 2022 Jun 8. Epub 2022 Jun 8.

Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil.

Background: The number of elderly patients who have end-stage liver disease and require liver transplantation has dramatically increased. On the other hand, liver grafts from elderly donors have been offered more frequently for transplantation. The present study aims to analyze the results of liver transplants performed with donors and recipients aged ≥70 years.

Methods: We performed a single-center retrospective study of deceased donors liver transplants that involved recipients aged ≥7070 years or recipients who received grafts from donors aged ≥70 years from 2011 to 2021. A literature review on the results of liver transplantation in elderly recipients was also performed.

Results: Thirty septuagenarian recipients were included; their overall 1- and 5-years survival was 80% and 76.6%, respectively. The prevalence of recipients aged ≥70 years in our department was 2.65%. Twenty recipients received grafts form septuagenarian donors; their overall 1- and 5-years survival was 75%. The prevalence of donors aged ≥70 years in our department was 1%. In the literature review, 17 articles were analyzed. The 5-years survival of recipients aged ≥70 years ranged from 47.1% to 78.5%.

Conclusions: Septuagenarian recipients and patients who received grafts from elderly brain-dead donors present adequate overall survival after liver transplantation. Optimized donor-recipient matching is paramount for achieving good outcomes. The combination of high-risk donors with septuagenarian recipients should be avoided as well as using grafts of elderly donors that present others risk factors. Thus, the age of the donor or recipient alone cannot be considered an absolute contraindication for liver transplantation.
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http://dx.doi.org/10.1016/j.transproceed.2022.03.033DOI Listing
June 2022

Duodenal Necrosis and Nonvariceal Digestive Bleeding After Terlipressin Administration for Treatment of Hepatorenal Syndrome: a Case Report of a Novel Side Effect of a Commonly Used Drug.

Transplant Proc 2022 Jun 5. Epub 2022 Jun 5.

Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo; Laboratory of Medica Investigation 37 (LIM-37), Faculdade de Medicina da Universidade de São Paulo.

Background: Terlipressin is widely used for treatment of hepatorenal syndrome and variceal bleeding in cirrhotic patients. However, it may be associated with side effects, especially those related to vasoconstriction, such as myocardial infarction or intestinal ischemia. This is a case report of a cirrhotic patient with nonvariceal upper gastrointestinal bleeding after duodenal necrosis due to the use of terlipressin, a novel side effect not yet described in literature to the best of our knowledge.

Case Report: A 51-year-old male patient, with alcoholic liver cirrhosis and hepatitis C virus infection, was admitted presenting oliguria associated with severe ascites and lower limb edema. His Model for End Stage Liver Disease-Sodium score was 19 and his serum creatine level was 2.12 mg/dL. Albumin infusion was performed for 48 hours, but his serum creatinine level reached 3.46 mg/dL. Terlipressin infusion was started in continuous infusion and serum creatinine levels progressively decreased. However, the patient presented hemorrhagic shock secondary to hematemesis after 7 days. Upper digestive endoscopy showed an extensive ulcerated lesion in the duodenal bulb, reaching 70% of its lumen, with hematic residues and necrotic foci. Terlipressin was suspended and proton pump inhibitors were started. Despite intensive care, the patient developed severe encephalopathy and reentrant seizures. He eventually died 10 days after the bleeding event.

Conclusions: We described a case of nonvariceal upper gastrointestinal bleeding secondary to duodenal necrosis, which was caused by visceral ischemia induced by terlipressin. Given its fatality potential, this novel side effect should be remembered when using this medication in cirrhotic patients.
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http://dx.doi.org/10.1016/j.transproceed.2022.03.023DOI Listing
June 2022

Hepatic Venous Outflow Obstruction in Adult Deceased Donor Liver Transplantation: Classic Piggyback Implantation Versus a Modified Technique that Widens the Ostium of the Recipient's Left and Middle Hepatic Veins.

Transplant Proc 2022 Jun 2. Epub 2022 Jun 2.

Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil; Laboratory of Medical Investigation 37, University of Sao Paulo Medical School, Sao Paulo, Brazil.

Background: The classic piggyback technique uses the union of the 3 hepatic veins to perform the cavo-caval anastomosis. However, due to the lateral localization of the right hepatic vein, the partial clamping of the vena cava in this technique significantly reduces the venous return to the right atrium. To avoid this, we adopted in 2015 a modified piggyback technique, in which we use the common trunk of the middle and left hepatic veins and also perform a lateral incision toward the right in the anterior wall of the vena cava in order to widen the final ostium of the cavo-caval anastomosis. The aim of the study was to analyze the incidence of hepatic venous outflow obstruction between those 2 techniques.

Methods: Retrospective study of liver transplant recipients undergoing venography for suspected hepatic venous outflow obstruction from January 2009 to June 2021. Patients undergoing transplantation with living donors or split grafts and pediatric cases were excluded from the study.

Results: From January 2009 to December 2014 and from January 2015 to June 2021, 587 (group 1) and 730 (group 2) deceased-donor liver transplants were performed with the classic and the modified piggyback techniques, respectively. The incidence of cases with suspected hepatic venous outflow obstruction in groups 1 and 2 were 1.87% (n = 11) and 0.95% (n = 7), respectively (P = 0,15). The number of confirmed patients with outflow blockage that required endovascular treatment during venography in groups 1 and 2 were 4 (0.68%) and 5 (0.68%), respectively (P = 0,31).

Conclusions: This modified piggyback technique did not increase the incidence of hepatic venous outflow obstruction at our service.
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http://dx.doi.org/10.1016/j.transproceed.2022.03.028DOI Listing
June 2022

Incidence of Donor Hepatic Artery Thrombosis in Liver Grafts Recognized During Organ Procurement and Backtable: A Rare but Treacherous Pitfall In Liver Transplantation.

Transplant Proc 2022 May 19. Epub 2022 May 19.

Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Clinics Hospital, University of Sao Paulo Medical School, São Paulo, Brazil; Laboratory of Medical Investigation 37, University of Sao Paulo Medical School, Sao Paulo, Brazil.

Introduction: Donor hepatic artery thrombosis (dHAT) identified during liver procurement and backtable is a rare and little-reported event that can make liver transplants unfeasible.

Methods: This is a retrospective study of dHAT identified during liver grafts procurements or backtable procedures. All grafts were recovered from brain-dead donors. The demographic characteristics of the donors and the incidence of dHAT were analyzed. The data were also compared to a cohort of donors without dHAT.

Results: There was a total of 486 donors during the study period. The incidence of dHAT was 1.85% (n = 9). The diagnosis of dHAT was made during procurement in 5 cases (55.5%) and during the backtable in 4 (44.4%). Most donors were female (n = 5), with an average BMI of 28.14 ± 6.9 kg/m, hypertensive (n = 5), and with stroke as cause of brain death (n = 8). The most prevalent site of dHAT was a left hepatic artery originating from the left gastric artery (n = 4). Of the 9 cases reported, 2 livers were used for transplantation, and 7 were discarded. Comparing those cases to a cohort of 260 donors without dHAT, we found a higher incidence of anatomic variations in the hepatic artery (P = .01) and of stroke as cause of brain death (P = .05).

Conclusion: The occurrence of dHAT before liver procurement is a rare event, however it may become a treacherous pitfall if the diagnosis is late. Grafts with anatomic variations recovered from women with brain death due to stroke and with past history of hypertension seem to be at a higher risk of presenting dHAT.
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http://dx.doi.org/10.1016/j.transproceed.2022.04.003DOI Listing
May 2022

Innovative Technique Avoiding Bleeding After Reperfusion in Living Donor Liver Transplant Using a Modified Right Lobe Graft.

Transplant Proc 2022 May 7. Epub 2022 May 7.

Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil.

Background: Living donor liver transplant (LDLT) is a valuable therapeutic option for overcoming the deceased donor shortage. Modified right lobe graft (MRLG) keeps the middle hepatic vein (MHV) trunk with the remnant liver to improve donor safety. Hemostasis in the MHV tributary reconstruction can be tricky; surgical stitches and energy coagulation are ineffective. Fibrin glues are excellent vascular sealants but are poor in maintaining hemostasis in an active hemorrhage or preventing resection surface-related complications after liver resection. We propose applying fibrin sealant during back table graft preparation to seal the hepatic edge and MHV reconstruction to avoid bleeding after graft revascularization.

Methods: Our retrospective cohort study included all adult patients undergoing LDLT between August 2017 and December 2021. During the back table procedure, we performed the reconstruction of the inferior right hepatic vein and/or MHV tributaries from segment 5 (V5) and segment 8 (V8) using a vein harvested from a nonrelated deceased donor. Before initiating the hepatic graft implantation, we applied fibrin sealant in the resected parenchyma, especially in the V5 and V8 anastomosis, to seal the hepatic edge and hepatic vein reconstruction.

Results: No bleeding was identified in the hepatic edge, and blood product transfusion was unnecessary for any recipients after reperfusion.

Conclusion: In LDLT using MRLG with MHV reconstruction, the fibrin sealant, when applied on the raw hepatic surface, and vascular reconstruction during back table graft preparation avoided bleeding after graft revascularization.
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http://dx.doi.org/10.1016/j.transproceed.2022.04.010DOI Listing
May 2022

Model for establishing a new liver transplantation center through mentorship from a university with transplantation expertise.

PLoS One 2022 30;17(3):e0266361. Epub 2022 Mar 30.

Liver and Digestive Organs Transplantation Division, Gastroenterology Department, Clinical Hospital of São Paulo University - HCFMUSP, São Paulo Faculty of Medicine, Universidade de São Paulo - USP, São Paulo, São Paulo, Brazil.

Background: Setting up new liver transplant (LT) centers is essential for countries with organ shortages. However, good outcomes require experience, because LT learning depends on a high number of surgeries. This study aims to describe how a new center was set up from a partnership between the new center and an experienced one. The step-by-step preparation process, the time needed and the results of the new center are depicted.

Material And Methods: The mentoring process lasted 40 months, in which half of the 52 patients included on the transplant list received LT. After the mentorship, a 22-month period was also analyzed, in which 46 new patients were added to the waiting list and nine were operated on.

Results: The 30-day survival rates during (92.3%) and after (66.7%) the partnership were similar to the other LT centers in the same region, as well as the rates of longer periods. The waiting time on the LT list, the characteristics of the donors and the ischemia times did not differ during or after the mentorship.

Conclusion: The partnership between universities is a suitable way to set up LT centers, achieving good results for the institutions and the patients involved.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0266361PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8967004PMC
March 2022

Pancreas Transplantation in a Single Center: Risk Factors Associated With Pancreatic Allograft Thrombosis.

Transplant Proc 2022 Apr 24;54(3):801-805. Epub 2022 Mar 24.

Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, Brazil; Laboratory of Medical Investigation 37 (LIM-37), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil.

Background: Pancreas transplantation remains a challenging procedure for small and medium-sized transplants teams, despite improvements in graft survival. Data regarding the impact of the procurement team's experience on the outcomes of pancreas transplant are lacking. The objective of this study was to evaluate risk factors that lead to pancreatic allograft thrombosis, especially the experience of the pancreas procurement team.

Methods: A retrospective study of 137 patients who underwent pancreas transplantation between March 2005 and May 2017 was conducted. Donor's and recipient characteristics were evaluated as well as their relationship to pancreatic allograft thrombosis. Cases were divided according to the number of pancreas procurements previously done by the procurement surgeon: group 1 (30 to 40 retrievals) and group 2 (≥40 retrievals).

Results: Simultaneous pancreas-kidney transplants accounted for 89.8% of cases (n = 123). Surgeons from group 2 performed 62.8% (n = 86) of the procurements. The graft was removed in 19 cases (13.8%) due to thrombosis. In univariate analysis, lower experience of the retrieval team was associated with allograft loss (P = .04). In multivariate analysis, donor intensive care unit time ≥5 days (P = .03) and lower experience of the procurement team were associated with increased risk of pancreatic allograft thrombosis (P = .02), whereas recipient's age from 30 to 40 years (P = .018) or ≥40 years (P = .02) was found as a protective factor.

Conclusions: Pancreatic allograft thrombosis remains an important cause of graft loss in pancreas transplantation. Recipient's age, prolonged donor intensive care unit time, and lower experience of the procurement team directly influence pancreatic allograft thrombosis.
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http://dx.doi.org/10.1016/j.transproceed.2022.01.013DOI Listing
April 2022

A challenge for medium and small pancreatic transplant groups: How can the learning curve from the retrieval team affect the pancreas graft thrombosis?

Cir Esp (Engl Ed) 2021 11;99(9):700-701

Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil; Laboratory of Medical Investigation 37 (LIM-37), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil.

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http://dx.doi.org/10.1016/j.cireng.2021.06.020DOI Listing
November 2021

Attitude and knowledge of medical students toward donation after circulatory death.

Rev Assoc Med Bras (1992) 2021 Apr;67(4):602-606

Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Divisão de Transplante de Órgãos Abdominais e Fígado, Departamento de Gastroenterologia - São Paulo (SP), Brazil.

Objective: A survey among medical students in a Brazilian public university was performed to investigate the acceptance of organ donation in Brazil, particularly donation after circulatory death (DCD).

Methods: A questionnaire including 26 objectives and Likert scale questions was validated and sent to all medical students of our institution. The answers were analyzed considering the whole set of individuals as well as by dividing the medical students into two groups: less graduated students and more graduated students.

Results: From 1050 students, 103 spontaneous answers (9.8%) were retrieved after 3 weeks. A total of 89.3% agreed totally with deceased donor organ donation and 8.7% agreed partially. However, only 50.5% of the students agreed totally and 31.1% agreed partially to living donation. Students revealed that 82.6% know the concept of brain death. On the other hand, 71.8% of them declared not knowing the concept of planned withdrawal of life-sustaining therapy, mainly cardiorespiratory support. A total of 85.4% of students agreed totally with donation after brain death and 11.7% agreed partially. However, when questioned about donation in awaiting circulatory death after a planned withdrawal of life-sustaining therapy, only 18.4% agreed totally and 32% agreed partially. Both groups of less and more graduated students showed similar results.

Conclusions: Our study found a clear lack of information and consequently in acceptance of DCD. Education in the field of end-of-life management may improve not only the acceptance of DCD donation but also the whole understanding of planned withdrawal of life-sustaining therapy.
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http://dx.doi.org/10.1590/1806-9282.20210012DOI Listing
April 2021

A challenge for medium and small pancreatic transplant groups: How can the learning curve from the retrieval team affect the pancreas graft thrombosis?

Cir Esp (Engl Ed) 2021 Aug 7. Epub 2021 Aug 7.

Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil; Laboratory of Medical Investigation 37 (LIM-37), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Sao Paulo, Brazil.

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http://dx.doi.org/10.1016/j.ciresp.2021.06.006DOI Listing
August 2021

Living-donor liver transplantation in Budd-Chiari syndrome with inferior vena cava complete thrombosis: A case report and review of the literature.

World J Hepatol 2021 Jan;13(1):151-161

Department of Gastroenterology, Abdominal Organs Transplantation Division, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo (HC-FMUSP), Sao Paulo 05403900, SP, Brazil.

Background: Budd-Chiari syndrome (BCS) is a challenging indication for liver transplantation (LT) due to a combination of massive liver, increased bleeding, retroperitoneal fibrosis and frequently presents with stenosis of the inferior vena cava (IVC). Occasionally, it may be totally thrombosed, increasing the complexity of the procedure, as it should also be resected. The challenge is even greater when performing living-donor LT as the graft does not contain the retrohepatic IVC; thus, it may be necessary to reconstruct it.

Case Summary: A 35-year-old male patient with liver cirrhosis due to BCS and hepatocellular carcinoma beyond the Milan criteria underwent living-donor LT with IVC reconstruction. It was necessary to remove the IVC as its retrohepatic portion was completely thrombosed, up to almost the right atrium. A right-lobe graft was retrieved from his sister, with outflow reconstruction including the right hepatic vein and the branches of segment V and VIII to the middle hepatic vein. Owing to massive subcutaneous collaterals in the abdominal wall, venovenous bypass was implemented before incising the skin. The right atrium was reached a transdiaphragramatic approach. Hepatectomy was performed with the retrohepatic vena cava. It was reconstructed with an infra-hepatic vena cava graft obtained from a deceased donor. The patient remains well on outpatient clinic follow-up 25 mo after the procedure, under an anticoagulation protocol with warfarin.

Conclusion: Living-donor LT in BCS with IVC thrombosis is feasible using a meticulous surgical technique and tailored strategies.
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http://dx.doi.org/10.4254/wjh.v13.i1.151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856862PMC
January 2021

A case report of diffuse hyperplastic gastropathy with multiple polypoid formations in a patient with pernicious anemia, Helicobacter pylori infection, hypergastrinemia and hypoalbuminaemia: Do not forget of Ménétrier's disease.

Int J Surg Case Rep 2020 12;77:498-502. Epub 2020 Nov 12.

Department of Surgery, Hospital de Clínicas Municipal José Alencar, Sao Bernardo do Campo, Brazil.

Introduction: Ménétrier's disease is a rare condition, frequently associated with Helicobacter pylori infection, hypergastrinemia and hypoalbuminaemia.

Presentation Of The Case: A case of a 55 years-old female patient with a previous diagnosis of pernicious anemia complaining of epigastric discomfort, hyporexia, vomiting, and weight loss is reported. Endoscopy showed multiple gastric polyploid formations and Helicobacter pylori infection was detected. Laboratory tests showed elevated gastrin serum levels and presence of antibodies antiparietal cells, as well as microcytic hypochromic anemia compatible with chronic iron deficiency. Albumin serum level was slightly decreased. Full thickness biopsy performed via echoendoscopy reported gastritis cystica/polyposa profunda. Given the association of diffuse involvement of the entire stomach, the possibility of developing malignant disease and the clinical symptoms, the patient underwent laparoscopic total gastrectomy with Roux-en-Y reconstruction. The surgical specimen showed the mucosa hyperemic and swollen, with prominent gastric folds. Hyperplastic elongation of gastric foveolas associated with disappearance of oxyntic glands was compatible with Ménétrier's disease.

Discussion: The Ménétrier's disease diagnosis may be tricky, especially when an unusual endoscopic presentation is associated with other conditions that may mislead the diagnostic evaluation. The differential diagnoses were gastric malignancies, Zollinger-Ellison syndrome, massive gastric polyposis and gastritis cystica/polyposa profunda.

Conclusion: Clinical, laboratory, endoscopic and histopathological findings are paramount for reaching the diagnosis of Ménétrier's disease, but it should be suspected in all cases of upper gastrointestinal symptoms and hypertrophied gastric mucosa.
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http://dx.doi.org/10.1016/j.ijscr.2020.11.055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7700994PMC
November 2020

Enabling liver transplantation during the COVID-19 era: More than screening donors and recipients for SARS-CoV-2.

Clinics (Sao Paulo) 2020 11;75:e2377. Epub 2020 Nov 11.

Departamento de Gastroenterologia, Divisao de Transplantes de Figado e Orgaos do Aparelho Digestivo, Hospital das Clinicas (HCFMUSP), Faculdade de Medicina, Universidade de Sao Paulo, SP, BR.

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http://dx.doi.org/10.6061/clinics/2020/e2377DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7603227PMC
November 2020

Coronavirus Disease 2019 in the Early Postoperative Period of Liver Transplantation: Is the Outcome Really So Positive?

Liver Transpl 2021 09 9;27(9):1357-1359. Epub 2020 Dec 9.

Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo (HC-FMUSP), São Paulo, Brazil.

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http://dx.doi.org/10.1002/lt.25933DOI Listing
September 2021

First case report of spigelian hernia containing the appendix after liver transplantation: Another cause for chronic abdominal pain.

Int J Surg Case Rep 2020 16;72:533-536. Epub 2020 Jun 16.

Digestive Organs Transplant Unit, Department of Gastroenterology, Liver Transplantation Division, University of São Paulo School of Medicine, São Paulo, Brazil.

Introduction: Abdominal ventral hernias are common in chronic liver disease due to increased abdominal pressure and sarcopenia. Following liver transplantation, diagnosis of chronic abdominal pain is challenging because it may relate to immunosuppression, scaring or opportunistic infections.

Presentation Of Case: A 62 years-old male presented with chronic abdominal pain one year following liver transplantation due to hepatocellular carcinoma. After work-up he was diagnosed with a Spigelian hernia containing the appendix. We did hernia repair with mesh but appendectomy was not performed since it showed no signs of inflammation. On follow-up the patient had complete resolution of the pain.

Discussion: This is the first case of spigelian hernia containing the appendix following liver transplantation. Mesh repair can be safely performed in this setting but incidental appendectomy is controversial due to higher morbidity and mortality. In this case report we discuss the relationship between liver transplantation, abdominal hernias and the pitfalls of incidental appendectomy.

Conclusion: Uncommon ventral hernias are a possible cause for chronic abdominal pain after surgery and should be investigated with imaging studies. Mesh repair is safe but incidental appendectomy in the immunosuppressed is not encouraged due to increased morbidity.
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http://dx.doi.org/10.1016/j.ijscr.2020.06.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322101PMC
June 2020

Liver transplant recipients infected with SARS-CoV-2 in the early postoperative period: Lessons from a single center in the epicenter of the pandemic.

Transpl Infect Dis 2021 Feb 4;23(1):e13418. Epub 2020 Aug 4.

Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo (HC-FMUSP), São Paulo, Brazil.

The impact of coronavirus disease-19 (COVID-19) in liver recipients remains largely unknown. Most data derive from small retrospective series of patients transplanted years ago. We aimed to report a single-center case series of five consecutive patients in the early postoperative period of deceased-donor liver transplantation who developed nosocomial COVID-19. Two patients presented important respiratory discomfort and eventually died. One was 69 years old and had severe coronary disease. She rapidly worsened after COVID-19 diagnosis on 9th postoperative day. The other was 67 years old with non-alcoholic steatohepatitis, who experienced prolonged postoperative course, complicated with cytomegalovirus infection and kidney failure. He was diagnosed on 36th postoperative day and remained on mechanical ventilation for 20 days, ultimately succumbing of secondary bacterial infection. The third, fourth, and fifth patients were diagnosed on 10th, 11th, and 18th postoperative day, respectively, and presented satisfactory clinical evolution. These last two patients were severely immunosuppressed, since one underwent steroid bolus for acute cellular rejection and another also used anti-thymocyte globulin for treating steroid-resistant rejection. Our novel experience highlights that COVID-19 may negatively impact the postoperative course, especially in elder and obese patients with comorbidities, and draws attention to COVID-19 nosocomial spread in the early postoperative period.
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http://dx.doi.org/10.1111/tid.13418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7404440PMC
February 2021

Feasibility of Large Liver Grafts in Adults.

Transplant Proc 2020 Jun 8;52(5):1329-1331. Epub 2020 Apr 8.

Liver and Abdominal Organs Transplantation Division, Gastroenterology Department, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, Brazil.

Introduction: Size mismatch between donor and recipients may negatively influence postoperative results of liver transplantation (LT). In deceased donor LT for adults, large grafts are occasionally rejected due to the fear of primary nonfunction. The aim of this study is to assess the feasibility of using large liver grafts in adults undergoing deceased donor LT.

Methods: We performed a retrospective study including adult patients who underwent deceased donor LT at our center between January 2006 and September 2019. Recipients with donors aged less than 18 years and those receiving split-liver grafts were excluded. Graft weight of 1800 grams was the cutoff used to divide patients in 2 groups: group 1 (graft weighing < 1800 g) and group 2 (grafts weighing ≥ 1800 g).

Results: A total of 806 patients were included in the study. group 1 and 2 included 722 and 84 recipients, respectively. A larger proportion of male recipients was obseved in group 2: 64.8% vs 76.2% (P = .0037). Mean graft weight in group 1 and 2 was, respectively, 1348 ± 231.81 g and 1986.57 ± 165.51 g (P < .001), which resulted in significantly higher graft weight/recipient weight ratio and graft weight/standard liver volume ratio in group 2. In group 2, there were 9 (10.71%) patients with portal vein thrombosis as well as 24 patients (28.5%) with bulky ascites and 44 grafts (52.3%) with steatosis. Primary closure of the abdominal wall was not possible in 5 patients (5.9%) from this group. Primary nonfunction was diagnosed in 14 cases (16.6%), with liver retransplantation being performed in 6 of them. Male to female sex combination occurred in 19% of LT in group 2.

Conclusion: The use of large grafts is feasible; however, proper matching between donor and recipient is paramount, especially taking into consideration graft steatosis, portal vein thrombosis and the presence of bulky ascites.
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http://dx.doi.org/10.1016/j.transproceed.2020.02.041DOI Listing
June 2020

Novel Technique in a Sheep Model of Uterine Transplantation.

Transplant Proc 2020 Jun 8;52(5):1399-1401. Epub 2020 Apr 8.

Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil.

Introduction: Uterine transplantation (UTx) is a surgical therapeutic modality designed for the treatment of patients with exclusive uterine factor infertility. Experimental models are paramount to study this transplant modality, and as the ewes' uteri are very similar to that of humans, they are frequently used with this purpose. The aim of this study is to describe a novel technical variation for UTx in sheep.

Methods: This study was conducted at Laboratory of Medical Investigation 37 of the University of São Paulo School of Medicine in São Paulo, Brazil, and was approved by the Ethics Committee of Animal Use of the university. We used 3 adult female sheep that weighed approximately 45 kg and were not pregnant. We performed the technique of uterine autotransplantation with a novel technical variation that we called sequential vascularization: first, we performed the right uterine artery and vein anastomoses, after which the uterine graft was vascularized, and then the contralateral vascular anastomoses were performed.

Conclusion: We described 3 successful uterine autotransplants in sheep models with sequential vascularization. This variation technique will probably allow warm ischemia time in UTx to significantly decrease.
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http://dx.doi.org/10.1016/j.transproceed.2020.02.040DOI Listing
June 2020

Intraoperative Temporary Portocaval Shunt in Liver Transplant.

Transplant Proc 2020 Jun 25;52(5):1314-1317. Epub 2020 Mar 25.

Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, Brazil.

Background: Intraoperative temporary portocaval shunt (TPCS) has been performed during liver transplant to improve hemodynamics and renal function as well as to decrease bleeding during hepatectomy. The aim of this study was to evaluate the impact of TPCS on liver transplant in a long-term single-center study.

Methods: From January 2006 to December 2018, all deceased donor transplants were retrospectively evaluated. Patients were divided in 2 groups: group 1, including those in whom intraoperative TPCS was performed and group 2, including those without TPCS. We analyzed recipient characteristics, survival, mortality, and complication rates in the intraoperative and postoperative periods.

Results: A total of 999 deceased donor liver transplants were studied, with 509 patients in group 1 and 490 in group 2. There were 156 cases (15.61%) of preoperative portal vein thrombosis in the whole series. Postoperative renal function (P = .029) as well as length of hospital and intensive care unit stay (P = .0001) were better in group 1. Surgery time and warm ischemia time was also shorter in group 1 (P = .0001). Complications with Clavien-Dindo score ≥ 3 were higher in group 2 (P = .006). Multivariate analysis showed important risk with fulminant hepatitis (odds ratio, 2.127; 95% CI, 1.408-3.213; P < .0001) and Model for End-Stage Liver Disease > 29 (odds ratio, 2.492; 95% CI, 1.862-3.336; P < .0001). Overall survival in group 1 at 1, 5, and 10 years were 78%, 70%, and 68%, respectively. In group 2, they were 70%, 60%, and 58%, respectively (P = .027).

Conclusions: Patients who underwent intraoperative TPCS presented better postoperative renal function, less intraoperative blending, shorter surgical and warm ischemia time, shorter length of hospital and intensive care unit stay, and better overall survival after transplant. Moreover, TPCS should be used patients with severe conditions, such as fulminant hepatitis and Model for End-Stage Liver Disease score > 29.
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http://dx.doi.org/10.1016/j.transproceed.2020.02.074DOI Listing
June 2020

Adult-to-Adult Living Donor Liver Transplant: Hemodynamic Evaluation, Prognosis, and Recipient Selection.

Transplant Proc 2020 Jun 25;52(5):1299-1302. Epub 2020 Mar 25.

Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil.

Background: Living donor liver transplant (LDLT) is a well-established treatment for end-stage liver disease. A better recipient selection and hemodynamic evaluation may improve transplant outcomes. The aim of this study was to establish recipient parameters that could enhance the results of adult-to-adult LDLT.

Methods: We performed a retrospective study of all adult-to-adult LDLTs from a single center between January 2006 and December 2018. Variables analyzed included demographic and clinical parameters, laboratory tests, performance of intraoperative temporary portocaval shunt (TPCS), graft weight/recipient weight ratio (GW/RW), preoperative portal vein thrombosis (PVT), previous major abdominal surgery, and patient survival. Patients were divided in 2 groups according to GW/RW (0.8% cutoff point).

Results: A total of 92 adult-to-adult LDLTs were analyzed, encompassing 53 male patients (57.6%). Mean Model for End-Stage Liver Disease score was 13.97 (SD, 4.74), and 57 patients (61.95%) had Child-Pugh-Turcotte score B. Mean GW/RW was 1.1% (SD, 0.37%). Group 1 with GW/RW > 0.8% (n = 74) and group 2 with it ≤ 0.8% (n = 13) presented mean GW/RW of 1.14% (SD, 0.24%) and 0.69% (SD, 0.09%) and P < .01, respectively. Eighteen patients (19.56%) presented PVT, with a worse survival than those without PVT (P = .006). Sixteen patients (17.39%) with previous major abdominal or biliary operations also presented higher mortality (P = .341). Forty-six (50%) intraoperative TPCSs were performed with a better 1- and 3-year patient survival. Receiver operating characteristic curve analysis showed PVT area under the curve of 0.701 (95% CI, 0.526-0.876; P = .018), positive predictive value of 0.69, and negative predictive value of 0.62. Multivariate analysis showed important risk regarding PVT (odds ratio, 6.160; 95% CI, 1.566-24.223; P = .004) and retransplant (odds ratio, 4.452; 95% CI, 0.843-23.503; P = .06).

Conclusions: Better recipient selection without PVT or previous major abdominal surgery, an adequate GW/RW, and intraoperative TPCS with hemodynamic modulation significantly improve outcomes of adult-to-adult LDLT.
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http://dx.doi.org/10.1016/j.transproceed.2020.02.073DOI Listing
June 2020

Liver Elastography in Acute Cellular Rejection After Liver Transplantation.

Transplant Proc 2020 Jun 24;52(5):1340-1343. Epub 2020 Mar 24.

Liver and Gastrointestinal Transplant Division. Department of Gastroenterology, University of São Paulo School of Medicine, Brazil.

Background: Transient elastography is a noninvasive method used to estimate the liver stiffness. There are few studies using elastography in acute cellular rejection (ACR). ACR is one of the main complications after liver transplantation. The golden pattern diagnostic is by liver biopsy, which is invasive and subject to complications. Therefore, this paper aims to evaluate the use of elastography in ACR.

Methods: Prospective and comparative study of patients transplanted from January 2017 to March 2019. Comparison group (ACR vs non-ACR) through liver biopsy. The variables analyzed were liver elastography (FibroScan and acoustic radiation force impulse [ARFI]), laboratory tests, liver biopsy, and ultrasound. Mann-Whitney U test was used to compare independent samples, and P < .05 was considered significant. All tests performed with α of 0.05 and a confidence interval of 95%, by IBM SPSS 25 software.

Results: Forty patients, 25 (62.5%) with ACR and 15 (37.5%) without ACR. Five (20%) cases with early acute rejection, late acute rejection in 19 cases (76%), and chronic rejection in 3 (12%). Comparative ACR vs non-ACR showed results of total bilirubin (P = .03), direct bilirubin (P = .015), aspartate aminotransferase (0.001), alanine aminotransaminase (0.001), and gamma-glutamyl transferase (P = .026). The mean elastography (FibroScan) value in ACR was 12.5 ± 8.2 kPa and without was 8.9 ± 3.7 kPa, P = .05. The mean elastography (ARFI) in ACR was 1.9 ± 0.6 m/s and without was 1.6 ± 0.2 m/s, P > .05. The receiver operator characteristic curve analysis shows the FibroScan for ACR with AUC 0.688 (95% CI 0.511-0.865), P = .049, positive predictive value 0.76, and negative predictive value 0.60.

Conclusions: Transient elastography is an important tool for ACR. There is a significant correlation between ACR and the value of hepatic elastography.
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http://dx.doi.org/10.1016/j.transproceed.2020.02.026DOI Listing
June 2020

Histopathologic Evaluation of Acute on Chronic Liver Failure.

Transplant Proc 2020 Jun 21;52(5):1325-1328. Epub 2020 Mar 21.

Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil.

Background: Currently, the diagnosis of acute on chronic liver failure (ACLF) is clinical, and its early identification and proper management are essential for a better prognosis. The aim of this study was to identify histopathologic parameters by analyzing cirrhotic liver explants that could aid in the early recognition of this entity and to determine prognostic factors that would influence ACLF management.

Method: We performed a retrospective analysis of histopathologic material from liver explants from patients transplanted because of chronic hepatitis C virus infection from January 2007 to July 2017. Twenty-nine (n = 29) cases without hepatocellular carcinoma were selected. Histopathologic analysis included the Laennec classification, vascularization, and portal vein thrombosis.

Results: According to the diagnosis of ACLF, patients were divided in 2 groups: group ACLF (n = 10) and group no acute on chronic liver failure (NO-ACLF) (n = 19). Considering the whole series, mean age was 51 ± 11.48 years and prevalence of men was 58.62%. The mean Model of End-Stage Liver Disease (MELD) score at time of transplantation was significantly higher in the ACLF group than in the NO-ACLF group (35 ± 7 vs 22 ± 6, respectively, P < .05) as was the mean total bilirubin (14.38 ± 13.31 vs 8.84 ± 10.46 mg/dl, respectively, P < .05). Histopathologic analysis of explanted livers according to Laennec staging system of cirrhosis was as follows: 1. Group NO-ACLF: 1 case (5.25%) grade 3, 6 cases (31.58%) grade 4B, and 12 cases (63.16%) grade 4C; and 2. Group ACLF: 4 cases (40%) grade 4B and 6 cases (60%) grade 4C. Cholestasis was found in 1 patient in the NO-ACLF group (5%) and in 4 patients in the ACLF group (40%) (P = .03). We studied 30-day and 10-year survival respectively, which were 80% and 60% in the ACLF group and 83% and 70% in the NO-ACLF group (P = .794 and P = .657).

Conclusion: In this preliminary approach, clinical and histologic findings contributed to the differential diagnosis of ACLF. The mean MELD score at time of liver transplantations, total bilirubin levels, and histologically evident cholestasis were significantly higher in patients with ACLF than in those without ACLF.
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http://dx.doi.org/10.1016/j.transproceed.2020.02.036DOI Listing
June 2020

Early Graft Dysfunction Evaluation by Indocyanine Green Plasma Clearance Rate in the Immediate Postoperative Period After Liver Transplantation.

Transplant Proc 2020 Jun 13;52(5):1336-1339. Epub 2020 Mar 13.

Liver and Gastrointestinal Transplant Division, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil.

Background: Liver transplantation (LT) has evolved to improve graft and patient survival. Early graft dysfunction (EGD) and primary nonfunction are an important cause of morbi-mortality. We had formulated the scientific hypothesis that the liver function can be evaluated by the indocyanine green (IG) after LT. The aim was to evaluate the EGD by plasma disappearance rate (PDR) of IG after LT.

Method: Prospective and observational clinical study, from July 2014 to June 2015. IG evaluation by pulse densitometry, Limon system. Degree analysis of ischemia and reperfusion injury in groups as follows: 1 (G0/G1/G2) and 2 (G3/G4). Donor risk index (DRI), Wagener and Olthoff criteria, and prognostic predictors were evaluated. All tests were performed with bidirectional α of 0.05 and a confidence interval of 95% and support by IBM SPSS 25.

Results: A total of 40 patients, mean age 53.3 ± 14.0 years and a majority of men and hepatitis C virus. PDR were more relevant with high degrees of ischemia and reperfusion injury grades G3/G4 (P = .030). The PDR related to the donor risk index showed positive significance at DRI >1.5 (P = .066). The retention rate of IG at 15 minutes demonstrated potential in assessing graft loss or death (P = .063).

Conclusion: EGD can be assessed by PDR with high degrees of ischemia and reperfusion injury (G3/G4) and with marginal donors (DRI >1.5). The retention rate of IG at 15 minutes demonstrated potential in assessing graft loss or death of the patient.
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http://dx.doi.org/10.1016/j.transproceed.2020.02.025DOI Listing
June 2020
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