Waiting time dictates impact of frailty: A Spanish multicenter prospective study

Background & aims: Frailty is prevalent in liver transplant (LT) candidates. It is considered an independent predictor of adverse outcomes pre- and post-transplant according to data obtained in the United States. We aimed to externally validate the liver frailty index (LFI) in a multicenter cohort of LT candidates. Methods: Outpatients with cirrhosis were prospectively recruited from five Spanish centers (2018-2020). Patients were defined as "frail" by an optimal cut-off of LFI ≥4.5. Patients were followed for at least 6 months to study associations of pre-LT frailty with pre- and post-transplant mortality, length of hospital and intensive care unit (ICU) stays, risk of early (<30 days) and late (30-90 days) post-transplant complications, retransplantation and cardiovascular events. Results: Of 212 patients included, 45 patients (21%) were frail pre-LT, and the median LFI was 3.9 (IQR 3.5-4.4). After a median waiting time of 78 days, 2% died or were delisted for clinical worsening. The LFI at baseline was not predictive of mortality/delisting in LT candidates in univariable or multivariable analyses after adjusting for age and MELD-Na score (hazard ratio 1.48; p = 0.586). In contrast, compared to non-frail patients, frail LT candidates had a significantly higher length of hospital stay (9 vs. 13 days; p = 0.001) and rate of early (<30 days) post-transplant complications (55% vs. 100%; p = 0.021). Conclusions: In the context of a short LT waiting time, frailty does not impact pretransplant mortality and/or delisting. In contrast, LT frailty is predictive of higher post-transplant complication rates and length of hospital stay. Whether strategies aimed at pre- and/or re-habilitation are beneficial in settings with short waiting times needs to be confirmed in prospective studies. Impact and implications: Literature is scarce on the actual impact of physical frailty on adverse outcomes in the liver transplant scenario outside North America. Evidence-based justification to extend the use of objective frailty tools in the decision-making processes in other liver transplant settings is needed. This study is the first to evaluate the predictive value of the liver frailty index in outpatients in the European liver transplant setting, showing that in a low MELD, high access system, frailty does not impact pretransplant mortality and/or delisting but is predictive of higher complication rates and longer post-transplant length of stay. In practical ways, physicians should consider physical frailty as a vital sign to be measured systematically and routinely during clinic visits; researchers are encouraged to initiate prospective studies to evaluate the benefit of applying strategies aimed at pre- and or re-habilitation in liver transplant settings with short waiting times

Economía verde

En la sección Noticias de este boletín se ha tratado la Cumbre y la Contracumbre Río + 20. Uno de los conceptos que vertebra la Cumbre es el de economía verde y el hecho de que Naciones Unidas lo haya colocado en el centro de la discusión ha hecho que cobre importancia pese a que su origen es anterior. Este término está vinculado al de economía ecológica pero hay diferencias sustanciales entre ambos. La visión de la economía ecológica es integral, transdisciplinar y analiza la realidad física, no sólo la económica. Para profundizar en ella podríamos revisar lo dicho por Aguilera Klink (1996) en «La economía ecológica como un sistema diferente de conocimiento» y por Naredo (2004) «La economía en evolución».Para poder poner ambos términos en relación, era indispensable contar con una recopilación de aquellas reflexiones o consideraciones que se han hecho al respecto de la llamada economía verde, que presentamos a continuación

Burbuja inmobiliaria en América Latina

Índice general2004-2009: algo pasa en el Nuevo Mundo2010: bailemos mientras suene la música2011: déjà v

La privatización del agua en la Comunidad de Madrid

Índice general:El gobierno especula: se cierra el grifo del agua pública.Los expertos opinan: razones contra la privatización.El pueblo habla: consulta social sobre el agua.La derecha ataca: intento de desprestigio público a Ladislao Martínez, promotor de la consulta.La oposición responde: políticos y sindicatos se posicionan

Eurovegas y otras islas

Índice generalEurovegasOtras zonas francas en el mund

Pregnancy outcomes in patients with portal cavernoma: A case series study

Objective: Non-cirrhotic portal vein cavernoma (PVC) is a cause of portal hypertension (PH) frequently affecting women of childbearing age. Cavernous transformation of the portal vein is frequently associated with prothrombotic disorders and often entails multiple hemodynamic changes, porto-collateral shunt development and thrombopenia, all of which can affect the course of pregnancy. Our aim was to evaluate the risk of PH-related complications and pregnancy outcomes in patients with PVC. Methods: Retrospective case series study of patients with PVC undergoing pregnancy in a tertiary care hospital. Results: Eight pregnancies fulfilled the eligibility criteria. All patients had a predisposing factor for PVC. One episode of variceal bleeding was reported at week 28. Six cesarean sections were scheduled to avoid labor while two urgent surgeries were indicated due to fetal distress and intrauterine growth restriction (IUGR). In all but one case, anticoagulation was prescribed after delivery. No hemorrhagic or thrombotic complications were reported. There were four cases of IUGR with no case of miscarriage or stillbirth. Conclusion: Pregnancy in patients with PVC has an overall favorable outcome albeit a higher risk of PH-derived complications, and IUGR may be expected. Hence, PVC must not be considered a contraindication for pregnancy although larger prospective studies are necessary.Depto. de MedicinaFac. de MedicinaTRUEpubAPC financiada por la UC

Clinical utility of a risk‐adapted protocol for the evaluation of coronary artery disease in Liver Transplant recipients

Este estudio, en el cual el solicitante es autor senior (útimo autor), estuvo encaminado a determinar si un protocolo de evaluación de enfermedad coronaria adaptado al riesgo basal en pacientes receptores de trasplante hepático, era capaz de atenuar el riesgo de enfermedad coronaria y en la supervivencia de pacientes trasplantados. El resultado fundamental de este estudio prospectivo fue que este protocolo (que comprende una evaluacion escalonada de la anatomía coronaria con intervenciones terapéuticas adaptadas) iguala la probabilidad de eventos cardiovasculares postrasplante con respecto a los pacientes de bajo riesgo. La aplicabilidad de este estudio es grande puesto que permite de forma protocolizada y adaptada a cada paciente la valoracion precisa del riesgo coronario, evitando exploraciones agresivas.The prevalence and management of coronary artery disease (CAD) in liver transplantation (LT) candidates are not well characterized. The aims of this study were to evaluate the impact on clinical outcomes of a specifically designed protocol for the management of asymptomatic CAD in LT candidates and to investigate noninvasive risk profiles for obstructive and nonobstructive CAD for 202 LT candidates. Those with high baseline cardiovascular risk (CVR; defined by the presence of classic CVR factors and/or decreased ejection fraction) received coronary angiography and significant arterial stenosis and were treated with percutaneous stents. Patients were followed up after LT until death or coronary event (CE). There were 78 patients who received coronary evaluation (62 direct angiography, 14 computed tomography coronary angiography, and 2 both). Of them, 39 (50%) patients had CAD of any severity, and 6 (7.7%) had significant lesions (5 were amenable to be treated with stents, whereas 1 patient had diffuse lesions which contraindicated the LT). Insulin-dependent diabetes was the only factor related to CAD of any severity (odds ratio, 3.44; 95% confidence interval [CI], 1.00-11.97). A total of 69 patients (46 with coronary evaluation) received LT. The incidence of CEs and overall survival after LT were similar between patients with and without coronary evaluation. Furthermore, no differences occurred between these groups in a multivariate competing risk model (subhazard ratio, 0.84; 95% CI, 0.27-2.61; P = 0.76). In conclusion, the application of an angiographic screening protocol of CAD in a selected high-risk Mediterranean population is safe and effective. The short- and medium-term incidence rates of CEs and death after LT in this population are similar to that observed in low-risk patients.Depto. de MedicinaFac. de MedicinaTRUEpu

Frailty Changes After Liver Transplantation. Results From a Spanish Multicenter Prospective Cohort Study

Introduction. Until now, there has been limited evidence, primarily from US cohorts, focusing on frailty as a patient-oriented outcome after liver transplantation (LT). Our study aimed to explore the relationship between pre- and post-LT frailty in a multicenter European cohort of outpatients with cirrhosis undergoing LT. Methods. We conducted a prospective analysis of data from 180 LT recipients recruited between 2018 and 2020 from 5 Spanish centers. Participants underwent objective and subjective frailty assessments using the Liver Frailty Index (LFI) and the Subjective Clinician Assessment (SCA) pretransplant and at 3- and/or 6-mo posttransplant. Results. The median pretransplant LFI was 3.9, showing minimal change at 3 mo (3.8; P = 0.331) and improvement at 6-mo post-LT (3.6; P = 0.001). Conversely, the SCA significantly improved early post-LT: at 3 mo, poor SCA decreased from 11% to 1%, and good SCA increased from 54% to 89% (P < 0.001), remaining stable between 3- and 6-mo post-LT. Multivariable analysis revealed that each 0.1 increase in pretransplant LFI correlated with a reduced probability of being robust at 3-mo (odds ratio [OR] = 0.75; P < 0.001) and 6-mo post-LT (OR = 0.74; P < 0.001). There was poor concordance between SCA and LFI, with SCA underestimating frailty both pre- and post-LT (Kappa < 0.20). Conclusion. In our European cohort, incomplete improvement of physical frailty was observed, with <20% achieving robust physical condition within 6-mo post-LT. The pretransplant LFI strongly predicted posttransplant frailty. As the SCA tends to overestimate physical function, we recommend using both subjective and objective tools for frailty assessment in LT candidates and recipients

Clinical Utility of a Risk-Adapted Protocol for the Evaluation of Coronary Artery Disease in Liver Transplant Recipients

Este estudio, en el cual el solicitante es autor senior (útimo autor), estuvo encaminado a determinar si un protocolo de evaluación de enfermedad coronaria adaptado al riesgo basal en pacientes receptores de trasplante hepático, era capaz de atenuar el riesgo de enfermedad coronaria y en la supervivencia de pacientes trasplantados. El resultado fundamental de este estudio prospectivo fue que este protocolo (que comprende una evaluacion escalonada de la anatomía coronaria con intervenciones terapéuticas adaptadas) iguala la probabilidad de eventos cardiovasculares postrasplante con respecto a los pacientes de bajo riesgo. La aplicabilidad de este estudio es grande puesto que permite de forma protocolizada y adaptada a cada paciente la valoracion precisa del riesgo coronario, evitando exploraciones agresivas.The prevalence and management of coronary artery disease (CAD) in liver transplantation (LT) candidates are not well characterized. The aims of this study were to evaluate the impact on clinical outcomes of a specifically designed protocol for the management of asymptomatic CAD in LT candidates and to investigate noninvasive risk profiles for obstructive and nonobstructive CAD for 202 LT candidates. Those with high baseline cardiovascular risk (CVR; defined by the presence of classic CVR factors and/or decreased ejection fraction) received coronary angiography and significant arterial stenosis and were treated with percutaneous stents. Patients were followed up after LT until death or coronary event (CE). There were 78 patients who received coronary evaluation (62 direct angiography, 14 computed tomography coronary angiography, and 2 both). Of them, 39 (50%) patients had CAD of any severity, and 6 (7.7%) had significant lesions (5 were amenable to be treated with stents, whereas 1 patient had diffuse lesions which contraindicated the LT). Insulin-dependent diabetes was the only factor related to CAD of any severity (odds ratio, 3.44; 95% confidence interval [CI], 1.00-11.97). A total of 69 patients (46 with coronary evaluation) received LT. The incidence of CEs and overall survival after LT were similar between patients with and without coronary evaluation. Furthermore, no differences occurred between these groups in a multivariate competing risk model (subhazard ratio, 0.84; 95% CI, 0.27-2.61; P = 0.76). In conclusion, the application of an angiographic screening protocol of CAD in a selected high-risk Mediterranean population is safe and effective. The short- and medium-term incidence rates of CEs and death after LT in this population are similar to that observed in low-risk patients.Depto. de MedicinaFac. de MedicinaTRUEpu