Estudio comparativo entre enfermos trasplantados de páncreas-riñón simultáneo en diálisis peritoneal frente a hemodiálisis

La Diabetes Mellitus es una enfermedad crónica que agrupa a un conjunto de enfermedades metabólicas caracterizadas por la hiperglucemia y aparece cuando el organismo no puede producir suficiente insulina o no puede usar la insulina eficazmente. Esta enfermedad se asocia con graves complicaciones que aumentan la morbilidad y la mortalidad de los enfermos que la sufren. El riesgo de desarrollar una nefropatía aumenta con los años de evolución de la enfermedad. La progresión de esta complicación se caracteriza por la aparición de uremia, síndrome nefrótico y la necesidad de tratamiento mediante diálisis o la realización de un trasplante renal. Existen diversos métodos de diálisis, actualmente los más utilizados son: la hemodiálisis (HD) y la diálisis peritoneal (DP). Tanto la hemodiálisis como la diálisis peritoneal son tratamientos dirigidos a sustituir la función renal pero no curan la insuficiencia renal. Estos tratamientos aumentan la calidad de vida del paciente y le permiten vivir más tiempo. El único tratamiento que puede curar al paciente es el trasplante renal. Para tratar la diabetes tipo 1 existen tres modalidades terapéuticas, que son la administración exógena de insulina y el restablecimiento de la función de las células β mediante un trasplante de páncreas o un trasplante de islotes pancreáticos. Hoy en día, el trasplante de páncreas es una técnica aceptada en todo el mundo, consiguiéndose con éste el estado euglucémico insulino-independiente con normalización de la HbA1c..

Enfermedad de Hirschsprung, mutación del protooncogén RET y tiroidectomía profiláctica

Depto. de CirugíaFac. de MedicinaTRUEpu

Embolización esplénica completa como tratamiento de la ascitis refractaria postrasplante

RESUMEN La ascitis refractaria es una complicación infrecuente que puede aparecer en el posoperatorio de un trasplante hepático y cuyo diagnóstico y tratamiento suponen un verdadero reto. Presentamos dos casos de pacientes trasplantados por cirrosis criptogénica y que en el posoperatorio inmediato cursaron con ascitis refractaria, una complicación grave que se asocia con una disminución de la supervivencia de hasta un año y afecta la calidad de vida del paciente. Tras descartar las principales causas de ascitis en nuestros pacientes, se propuso como etiología el hiperaflujo portal, una condición que se perpetúa con la circulación esplénica y que condiciona una reducción del flujo arterial hepático. Por tanto, si se consigue disminuir el aflujo arterial al bazo, disminuyen el retorno venoso y la circulación portal, mejorando el flujo arterial. Con la embolización esplénica, procedimiento que surgió hace varios años como tratamiento al fenómeno del robo de la arteria esplénica y en los casos de "small for size" en el trasplante de donante vivo, se pretende disminuir el hiperaflujo portal y, por tanto, la ascitis. En conclusión, la embolización de arteria esplénica es una opción terapéutica como tratamiento de la ascitis refractaria en el postrasplante hepático

Octogenarian liver grafts reaching centennial age after transplantation

Depto. de CirugíaFac. de MedicinaTRUEpu

Management and outcome of liver abscesses after liver transplantation

Background: Liver abscess after orthotopic liver transplantation (OLT) is a rare, life-threatening complication. The aim of this study is to analyze the incidence, risk factors, clinical manifestations, treatment and outcomes of liver abscesses after OLT. Methods: We perform a retrospective review of the patients who developed one or more liver abscesses among a series of 984 patients who underwent OLT between January 2000 and December 2016. Results: Fourteen patients (1.5%) developed 18 episodes of liver abscesses, and the median time from OLT to the diagnosis of liver abscess was 39.7 months. Major predisposing factors were biliary strictures in 11 patients, hepatic artery thrombosis in 8, re-OLT in 3, choledochojejunostomy in 2, living donor OLT in 2, donor after cardiac death in 1, split liver in 1, and liver biopsy in 1. All patients were managed by intravenous antibiotics; percutaneous drainage was performed in 10 patients, while 2 patients underwent re-OLT. The mortality rate related to liver abscesses was 21.4%. The mean hospital stay was 30 ± 19 days, and during a mean follow-up of 93 ± 78 months, three other patients died. Conclusions: Liver abscesses must be managed with antibiotic therapy and percutaneous drainage, but when these conservative measures fail (persistent abscess and sepsis), a re-OLT must be performed in order to prevent the high mortality associated with this severe complication.Depto. de CirugíaFac. de MedicinaTRUEpu

Octogenarian liver grafts: Is their use for transplant currently justified?

Aim: To analyse the impact of octogenarian donors in liver transplantation. Methods: We present a retrospective single-center study, performed between November 1996 and March 2015, that comprises a sample of 153 liver transplants. Recipients were divided into two groups according to liver donor age: recipients of donors ≤ 65 years (group A; n = 102), and recipients of donors ≥ 80 years (group B; n = 51). A comparative analysis between the groups was performed. Quantitative variables were expressed as mean values and SD, and qualitative variables as percentages. Differences in properties between qualitative variables were assessed by χ2 test. Comparison of quantitative variables was made by t-test. Graft and patient survivals were estimated using the Kaplan-Meier method. Results: One, 3 and 5-year overall patient survival was 87.3%, 84% and 75.2%, respectively, in recipients of younger grafts vs 88.2%, 84.1% and 66.4%, respectively, in recipients of octogenarian grafts (P = 0.748). One, 3 and 5-year overall graft survival was 84.3%, 83.1% and 74.2%, respectively, in recipients of younger grafts vs 84.3%, 79.4% and 64.2%, respectively, in recipients of octogenarian grafts (P = 0.524). After excluding the patients with hepatitis C virus cirrhosis (16 in group A and 10 in group B), the 1, 3 and 5-year patient (P = 0.657) and graft (P = 0.419) survivals were practically the same in both groups. Multivariate Cox regression analysis demonstrated that overall patient survival was adversely affected by cerebrovascular donor death, hepatocarcinoma, and recipient preoperative bilirubin, and overall graft survival was adversely influenced by cerebrovascular donor death, and recipient preoperative bilirubin. Conclusion: The standard criteria for utilization of octogenarian liver grafts are: normal gross appearance and consistency, normal or almost normal liver tests, hemodynamic stability with use of 30%.Depto. de CirugíaFac. de MedicinaTRUEpu

Trasplante hepatorrenal simultáneo en pacientes adultos con hiperoxaluria primaria. Experiencia del Hospital Universitario 12 de Octubre

RESUMEN La hiperoxaluria primaria es un trastorno del metabolismo autosómico recesivo que origina una hiperproducción hepática de oxalato, que no puede ser metabolizado por el hígado y se elimina por vía renal formando litiasis, nefrocalcinosis y ocasionando un deterioro progresivo y precoz de la función renal que, generalmente, a pesar del tratamiento médico precisará de una terapia renal sustitutiva. La hiperoxaluria primaria (HOP) tipo 1 es el trastorno más frecuente, se debe a un déficit de la enzima alanina-glicolato aminotransferasa que se encuentra en los peroxisomas hepáticos. Por tanto, el trasplante hepatorrenal simultáneo (THRS) es el tratamiento definitivo para los pacientes con enfermedad renal crónica terminal. Sin embargo, algunos resultados sugieren que la morbimortalidad es mayor al realizar este procedimiento frente al trasplante renal aislado. Se presentan cinco pacientes adultos con hiperoxaluria primaria y un filtrado glomerular medio de 20,2 ± 1,3 ml/min/1,73 m2 a los que se les realizó un THRS entre 1999 y 2015 en el Hospital Universitario 12 de Octubre. No se observó recurrencia de la enfermedad ni pérdida del injerto hepático o renal durante el postoperatorio y únicamente un episodio de rechazo agudo tardío sin pérdida del injerto renal. La supervivencia de los receptores fue del 100% con una mediana de seguimiento de 84 meses. Debido a que el THRS permite la curación de la enfermedad y constituye una técnica segura, con una baja morbimortalidad y elevada supervivencia, debe considerarse como el tratamiento de elección en la hiperoxaluria primaria con enfermedad renal terminal

Liver transplantation as treatment of familial amyloid polyneuropathy in patients older than 60 years

Background and objective: Familial amyloid polyneuropathy (FAP) is the most prevalent type of hereditary systemic amyloidosis. It is an autosomal dominant disease characterized by the deposition of an abnormal variant transthyretin. It has a worldwide distribution, with localized endemic areas in Portugal, Sweden and Japan. In Spain there is an endemic focus, located in Mallorca. Liver transplantation is the only curative option for patients with FAP. The aim of this study was to describe the clinical and demographic characteristics of patients transplanted with a diagnosis of PAF. Material and method: Six patients with PAF underwent liver transplantation between April 1986 and December 2012. Results: The mean age was 57.7+16 years, patients of Spanish origin were older than 60 years. All patients had progressive symptoms as mixed polyneuropathy. In 2 patients, combined heart-liver transplants sequentially were performed. Patient survival and graft was 80% at one, 3 and 5 years. Conclusions: The only effective treatment for etiologic PAF is liver transplantation. Early detection is the key to the treatment and control, avoiding the irreversible organ damage.Depto. de CirugíaFac. de MedicinaTRUEpu

Liver transplantation using uncontrolled donors after circulatory death: A 10-years single-center experience

Background. One method for increasing the donor pool for orthotopic liver transplantations (OLTs) is to use uncontrolled donation after circulation death (uDCDs). Methods. From January 2006 to December 2016, we performed 75 OLTs using uDCD livers. The control group comprised a sample of 265 OLTs using livers of donations after brain death (DBDs). A comparative study was performed. Results. Of 256 potential uDCD donors cannulated, 75 (29.3%) livers were accepted for OLT. The amount of hemoderivatives transfused was significantly higher in the uDCD group. The rate of primary nonfunction was also significantly higher (P = 0.031) in uDCD recipients (8%) than DBD recipients (1.5%). The overall rate of biliary complications was significantly higher (P = 0.001) in uDCD recipients (23 cases, 30.6%) than DBD recipients (28 cases, 10.6%). In the uDCD group, 1-, 3-, and 5-year patient survival rates were 82.7%, 73%, and 71.5%, respectively; in the DBD group, they were 89%, 83.7%, and 78.8%, respectively (P = 0.180). In the uDCD group, 1-, 3-, and 5-year graft survival rates were 73.3%, 65.1%, and 63.6%, respectively; in the DBD group, they were 87.1%, 81.9%, and 76.5%, respectively (P = 0.013). Multivariate analysis showed that independent risk factors for patient and graft survival were intraoperative transfusion of >6 units of packed red blood cell concentrates and recipients who were older than 60 years. Conclusions. Although graft survival is significantly lower using uDCD livers, 5-year patient survival in recipients of DBD and uDCD livers is similar. After careful selection, the livers of uDCD can be selectively used for OLT.Depto. de CirugíaFac. de MedicinaTRUEpu