Resultados a largo plazo del trasplante hepático en pacientes con tratamiento inmunosupresor basado en el uso de novo de tacrolimus de liberación prolongada

176 p.El uso de tratamiento inmunosupresor en el trasplante hepático (TH) tiene como objetivo evitar elrechazo tanto agudo como crónico y la consiguiente pérdida del injerto. Tacrolimus, un fármaco inhibidorde la calcineurina, es el tratamiento de elección en más del 90% de los TH. En 2007, se aprobó una nuevaformulación de tacrolimus de liberación prolongada reduciendo las tomas de una cada 12 horas a unaúnica toma por la mañana.La hipótesis de la presente tesis fue que un protocolo de inmunosupresión basado en tacrolimus deliberación prolongada, usado de novo, podría influir favorablemente en los resultados del trasplantehepático a largo plazo. Esta hipótesis se propuso inicialmente para todos los pacientes trasplantadoshepáticos y, en segundo lugar, para aquellos pacientes con disfunción renal pretrasplante. Finalmente, sepropuso que, bajo una política de minimización de la inmunosupresión, los niveles de tacrolimus en elprimer mes postrasplante no tendrían influencia en los resultados a largo plazo.Los pacientes estudiados se seleccionaron entre aquellos trasplantados en el Hospital UniversitarioCruces entre Abril de 2008 y Mayo de 2012. Todos fueron con un seguidos hasta Diciembre de 2014.Se excluyeron del estudio los pacientes con trasplante combinado, los que no eran un primer trasplante yaquellos que no recibieron tratamiento con tacrolimus de liberación prolongada por cualquier causa.Inicialmente, se utilizó una cohorte de 160 pacientes que presentaban una mediana de seguimiento de57,6 meses. El tratamiento con tacrolimus se inició en el primer día postraplante con intención demantener los niveles en sangre entre 5-10 ng/ml durante las primeras 3 semanas con una reducciónprogresiva hasta mantener niveles 10 ng/ml. Seutilizaron un mínimo de cinco muestras para obtener el nivel medio de tracolimus durante el primer mes.Al finalizar nuestro estudio, hemos podido concluir que el uso de un protocolo de inmnunosupresiónbasado en tacrolimus de liberación prolongada se asoció a una elevada supervivencia a largo plazo tantode los pacientes como de los injertos, con un adecuado cuidado de la función renal y una reducidaincidencia de la recurrencia del hepatocarcinoma sin que ello se acompañara de un aumento de la tasa derechazos agudos biopsiados.Así mismo, comprobamos que este beneficio en la supervivencia a largo plazo y en el mantenimiento dela función renal ocurría también en los pacientes que presentaban disfunción renal pretrasplante, a pesarde ser este, un grupo de pacientes que, históricamente, se ha asociado a una baja supervivencia a largoplazo.Finalmente, pudimos demostrar que un nivel medio de tacrolimus por encima de10 ng/ml durante elprimer mes postrasplante no tiene influencia en los resultados a largo plazo si posteriormente se sigue unapolítica de minimización de la inmunosupresión durante todo el periodo de seguimiento

Surgical treatment for recurrent cholangiocarcinoma: a single-center series

PurposeThe present study aims to assess the results obtained after surgical treatment of cholangiocarcinoma (CC) recurrences.MethodsWe carried out a single-center retrospective study, including all patients with recurrence of CC. The primary outcome was patient survival after surgical treatment compared with chemotherapy or best supportive care. A multivariate analysis of variables affecting mortality after CC recurrence was performed.ResultsEighteen patients were indicated surgery to treat CC recurrence. Severe postoperative complication rate was 27.8% with a 30-day mortality rate of 16.7%. Median survival after surgery was 15 months (range 0-50) with 1- and 3-year patient survival rates of 55.6% and 16.6%, respectively. Patient survival after surgery or CHT alone, was significantly better than receiving supportive care (p< 0.001). We found no significant difference in survival when comparing CHT alone and surgical treatment (p=0.113). Time to recurrence of <1 year, adjuvant CHT after resection of the primary tumor and undergoing surgery or CHT alone versus best supportive care were independent factors affecting mortality after CC recurrence in the multivariate analysis.ConclusionSurgery or CHT alone improved patient survival after CC recurrence compared to best supportive care. Surgical treatment did not improve patient survival compared to CHT alone

Lesión Nerviosa con Aguja en Punta de Lápiz vs. Tuohy

La neuropatía por punción nerviosa es una complicación conocida del bloqueo nervioso periférico. No hay estudios concluyentes que determinen los factores que puedan influir en la lesión nerviosa (tipo de aguja, tamaño de la misma, disposición del bisel, etc.). Los autores nos presentan un estudio experimental que analiza la influencia del tipo de aguja en la lesión nerviosa

Surgical treatment for recurrent cholangiocarcinoma: a single-center series

Purpose: The present study aims to assess the results obtained after surgical treatment of cholangiocarcinoma (CC) recurrences. Methods: We carried out a single-center retrospective study, including all patients with recurrence of CC. The primary outcome was patient survival after surgical treatment compared with chemotherapy or best supportive care. A multivariate analysis of variables affecting mortality after CC recurrence was performed. Results: Eighteen patients were indicated surgery to treat CC recurrence. Severe postoperative complication rate was 27.8% with a 30-day mortality rate of 16.7%. Median survival after surgery was 15 months (range 0-50) with 1- and 3-year patient survival rates of 55.6% and 16.6%, respectively. Patient survival after surgery or CHT alone, was significantly better than receiving supportive care (p< 0.001). We found no significant difference in survival when comparing CHT alone and surgical treatment (p=0.113). Time to recurrence of <1 year, adjuvant CHT after resection of the primary tumor and undergoing surgery or CHT alone versus best supportive care were independent factors affecting mortality after CC recurrence in the multivariate analysis. Conclusion: Surgery or CHT alone improved patient survival after CC recurrence compared to best supportive care. Surgical treatment did not improve patient survival compared to CHT alone

Donation after circulatory death liver transplantation: consensus statements from the Spanish Liver Transplantation Society

Livers from donation after circulatory death (DCD) donors are an increasingly more common source of organs for transplantation. While there are few high-level studies in the field of DCD liver transplantation, clinical practice has undergone progressive changes during the past decade, in particular due to mounting use of postmortem normothermic regional perfusion (NRP). In Spain, uncontrolled DCD has been performed since the late 1980s/early 1990s, while controlled DCD was implemented nationally in 2012. Since 2012, the rise in DCD liver transplant activity in Spain has been considerable, and the great majority of DCD livers transplanted in Spain today are recovered with NRP. A panel of the Spanish Liver Transplantation Society was convened in 2018 to evaluate current evidence and accumulated experience in DCD liver transplantation, in particular addressing issues related to DCD liver evaluation, acceptance criteria, and recovery as well as recipient selection and postoperative management. This panel has created a series of consensus statements for the standard of practice in Spain and has published these statements with the hope they might help guide other groups interested in implementing new forms of DCD liver transplantation and/or introducing NRP into their clinical practices

A case of COVID-19 immediately after liver transplantation: Not only bad news

COVID-19, the illness caused by the SARS-CoV-2 virus originated in December 2019 in Wuhan, China and has caused more 3,3 million cases and more than 230,000 deaths throughout the world, with 25,000 of them only in Spain, where the first case was diagnosed on January 31st, 2020. As COVID-19 is a "new" disease, we still do not have data on prognosis or treatment in transplant patients or on how to manage immunosuppression in this complex scenario. We present a case of COVID-19 diagnosed during the early postoperative period in a recipient whose liver transplantation was performed on late March during the lockdown in Spain, with donor and recipient previously negative rRT-PCR to SARS-CoV-2. In the first post-operative week the patient suffered COVID-19 pneumonia that was treated with immunosuppression minimization, oral Hydroxycloroquine and Azithromycin with favorable outcome. The patient was discharged on POD 21 without complications. To date, few early post-liver transplantation SARS-CoV-2 infected recipients have been published, but only one was an early postoperative infection. In our case the outcome was favorable, even though it was an early post -liver transplantation COVID-19 in a frail patient

Cumulative exposure to tacrolimus and incidence of cancer after liver transplantation

Cancer is the leading cause of death after liver transplantation (LT). This multicenter case–control nested study aimed to evaluate the effect of maintenance immunosuppres sion on post-LT malignancy. The eligible cohort included 2495 LT patacrolimus-based immunosuppression. After 13 922 person/years follow-up, 425 patients (19.7%) developed malignancy (cases) and were matched with 425 controls by propensity score based on age, gender, smoking habit, etiology of liver disease, and hepatocellular carcinoma (HCC) before LT. The independent predictors of post-LT malignancy were older age (HR = 1.06 [95% CI 1.05–1.07]; p < .001), male sex (HR = 1.50 [95% CI 1.14–1.99]), smoking habit (HR = 1.96 [95% CI 1.42–2.66]), and alcoholic liver disease (HR = 1.53 [95% CI 1.19–1.97]). In selected cases and controls (n = 850), the immunosuppression protocol was similar (p = .51). An increased cumulative exposure to tacrolimus (CET), calculated by the area under curve of trough concentrations, was the only immunosuppression-related predictor of post-LT malignancy after controlling for clinical features and baseline HCC (CET at 3 months p = .001 and CET at 12 months p = .004). This effect was consistent for de novo malignancy (after excluding HCC recurrence) and for internal neoplasms (after excluding non-melanoma skin cancer). Therefore, tacrolimus minimization, as monitored by CET, is the key to modulate immunosuppression in order to prevent cancer after LT

Cumulative exposure to tacrolimus and incidence of cancer after liver transplantation

Cancer is the leading cause of death after liver transplantation (LT). This multicenter case–control nested study aimed to evaluate the effect of maintenance immunosuppression on post-LT malignancy. The eligible cohort included 2495 LT patients who received tacrolimus-based immunosuppression. After 13 922 person/years follow-up, 425 patients (19.7%) developed malignancy (cases) and were matched with 425 controls by propensity score based on age, gender, smoking habit, etiology of liver disease, and hepatocellular carcinoma (HCC) before LT. The independent predictors of post-LT malignancy were older age (HR = 1.06 [95% CI 1.05–1.07]; p < .001), male sex (HR = 1.50 [95% CI 1.14–1.99]), smoking habit (HR = 1.96 [95% CI 1.42–2.66]), and alcoholic liver disease (HR = 1.53 [95% CI 1.19–1.97]). In selected cases and controls (n = 850), the immunosuppression protocol was similar (p = .51). An increased cumulative exposure to tacrolimus (CET), calculated by the area under curve of trough concentrations, was the only immunosuppression-related predictor of post-LT malignancy after controlling for clinical features and baseline HCC (CET at 3 months p = .001 and CET at 12 months p = .004). This effect was consistent for de novo malignancy (after excluding HCC recurrence) and for internal neoplasms (after excluding non-melanoma skin cancer). Therefore, tacrolimus minimization, as monitored by CET, is the key to modulate immunosuppression in order to prevent cancer after LT