Uso de tacrolimus na terapia de resgate de rejeições agudas e crônicas no transplante de fígado

OBJETIVO: Estudar os critérios de indicação e o resultado do uso de tacrolimus na terapia de resgate de rejeições agudas ou crônicas no transplante de fígado. CASUÍSTICA E MÉTODO: Foram estudados 18 pacientes transplantados de fígado, submetidos a terapia de resgate com tacrolimus entre março de 1995 e agosto de 1999. Foram registradas a indicação do tratamento e a situação de pacientes e enxertos em 31/10/1999. Considerou-se "respondendores" pacientes vivos, com enxerto funcionante e regressão histológica da terapia de resgate de rejeições agudas, ou com bilirrubina até 2 vezes o valor normal, no caso de terapia de resgate de rejeições crônicas. RESULTADO: Observou-se resposta em 14 casos (77,8%). A taxa de resposta nas diferentes indicações foi: (1) terapia de resgate de rejeições agudas + sepse bacteriana - 0/1 caso; (2) terapia de resgate de rejeições agudas recorrente - 1/1 caso; (3) terapia de resgate de rejeições agudas resistente a OKT3 - 2/2 casos; (4) terapia de resgate de rejeições agudas resistente a corticóide + doença viral ativa - 3/3 casos; (5) terapia de resgate de rejeições crônicas - 8/11 casos (72,7% de resposta). Os quatro casos sem resposta (22,2%) evoluíram para óbito. CONCLUSÃO: O tacrolimus é eficaz na terapia de resgate da maioria dos casos de rejeição celular aguda e crônica no transplante de fígado.PURPOSE: To study the indications and results of tacrolimus as rescue therapy for acute cellular or chronic rejection in liver transplantation. PATIENTS AND METHODS: Eighteen liver transplant recipients who underwent rescue therapy with tacrolimus between March 1995 and August 1999 were retrospectively studied. The treatment indication, patients, and graft situation were recorded as of October 31st, 1999. The response to tacrolimus was defined as patient survival with a functional graft and histological reversal of acute cellular, or for chronic rejection, bilirubin serum levels decreasing to up to twice the upper normal limit. RESULTS: Fourteen cases (77.8%) presented a good response. The response rate for the different indications was: (1) acute cellular + sepsis - 0/1 case; (2) recurrent acute cellular - 1/1 case; (3) OKT3-resistant acute cellular - 2/2 cases; (4) steroid-resistant acute cellular + active viral infection - 3/3 cases; (5) chronic rejection - 8/11 cases (72.7% response rate). The 4 patients who did not respond died. CONCLUSION: Tacrolimus rescue therapy was successful in most cases of acute cellular and chronic rejection in liver transplantation

Efeito da escala MELD na mortalidade após transplante de fígado

The high mortality rate on the waiting list for liver transplantation (Tx) has stimulated the use of criteria ofdisease severity for graft allocation. The aim of this study is to asses the effect of MELD (Model for End-Stage LiverDisease) on the post Tx mortality rate. We have reviewed 237 cases of cadaveric donor elective Tx performed between1st/Nov/95 and 30th/Jul/01. In logistic regression it was found a significant interaction between MELD score and 6-monthmortality after Tx (odds ratio = 1.052; 95%CI = 1.015 a 1.090; p = 0.02). In order to study the effect of the MELD score on the actuarial survival, the patients have been divided into two groups: Group A (n = 126), constituted by patients with MELD below the global mean score (14.4); and Group B (n = 111), constituted by patients with MELD score above thisvalue. There is a statistically significant difference between the survival rate in the two groups (p = 0.0374). Cox proportionalregression analysis indicated that group B patients are 1.65 times more likely to die (risk ratio = 1.6523; 95% CI = 1.0240 a 2.6662).A alta mortalidade na lista de espera por transplante de fígado (Tx) tem estimulado a adoção de critérios degravidade para alocação de órgãos. O objetivo desse trabalho é investigar qual o efeito da classificação MELD (Modelfor End-Stage Liver Disease) na mortalidade após o Tx. Foram revisados 237 casos de Tx eletivo com doador cadáverrealizados entre 1º/11/1995 e 30/7/2001. Na análise de regressão logística, foi encontrada uma interação significanteentre a pontuação MELD e a mortalidade nos primeiros 6 meses após o transplante (odds ratio = 1,052; IC95% = 1,015 a 1,090; p = 0,02). Para estudar o efeito da escala MELD na sobrevida atuarial, os pacientes foram divididos em dois grupos: Grupo A (n = 126) com valores de MELD abaixo da média da casuística global (14,4) e Grupo B (n = 111) compontuação MELD acima desse valor. Existe uma diferença significante entre a sobrevida ao longo do tempo nos doisgrupos (p = 0,0374). A análise de regressão proporcional de Cox indicou risco 1,65 vezes maior no grupo B (riscorelativo = 1,6523; IC95% = 1,0240 a 2,6662).

A imunoglobulina policlonal humana anti-antígeno de superfície da hepatite B reduz a freqüência da rejeição aguda após transplante de fígado

BACKGROUND: Use of polyclonal anti-hepatitis B surface antigen immunoglobulin (HBIg) has been shown to reduce hepatitis B virus (HBV) recurrence after liver transplantation (LT) and to decrease the frequency of acute cellular rejection (ACR). However, the protective role of HBIg against ACR remains controversial, since HBV infection has been also associated with a lower incidence of ACR. AIM: To assess the relationship between HBIg immunoprophylaxis and the incidence of rejection after LT. METHODS: 260 patients (158 males, 43 ± 14 years old) submitted to LT were retrospectively evaluated and divided into three groups, according to the presence of HBsAg and the use of HBIg. Group I was comprised of HBsAg-positive patients (n = 12) that received HBIg for more than 6 months. Group II was comprised of HBsAg-positive patients that historically have not received HBIg or have been treated irregularly for less than 3 months (n = 10). Group III was composed of 238 HBsAg-negative subjects that have not received HBIg. RESULTS: HBIg-treated patients (group I) had significantly less ACR episodes, when compared to group II and III. No differences between groups II and III were observed. CONCLUSIONS: Long-term HBIg administration contributes independently to reduce the number of ACR episodes after LT.INTRODUÇÃO: O emprego da imunoglobulina policlonal anti-antígeno de superfície da hepatite B (HBIg) tem reduzido a recorrência da hepatite B após transplante hepático (TH), assim como também a freqüência de rejeição celular aguda (RCA). No entanto, o papel protetor da HBIg contra a RCA permanece controverso, pois a própria infecção por vírus B foi também associada a menor incidência de RCA. OBJETIVOS: Verificar a relação entre HBIg e a freqüência de RCA após TH. MÉTODOS: 260 pacientes (158 do sexo masculino, com 43 ± 14 anos) submetidos a TH foram avaliados, retrospectivamente, e divididos em três grupos de acordo com a presença de AgHBs e uso de HBIg. O grupo I foi constituído por 12 pacientes com AgHBs que receberam HBIg por mais de 6 meses; o grupo II foi formado por 10 pacientes com AgHBs que não receberam HBIg regularmente; o grupo III foi composto por 238 indivíduos sem AgHBs que não receberam HBIg. RESULTADOS: Nos pacientes do grupo I houve freqüência significantemente menor de episódios de RCA, em comparação ao que se observou nos grupos II e III. Nenhuma diferença ocorreu entre os grupos II e III. CONCLUSÕES: A administração profilática de HBIg contribui independentemente para reduzir a freqüência dos episódios de RCA após a realização de TH

Model for End-Stage Liver Disease, Model for Liver Transplantation Survival and Donor Risk Index as predictive models of survival after liver transplantation in 1,006 patients

OBJECTIVES: Liver transplantation has not increased with the number of patients requiring this treatment, increasing deaths among those on the waiting list. Models predicting post-transplantation survival, including the Model for Liver Transplantation Survival and the Donor Risk Index, have been created. Our aim was to compare the performance of the Model for End-Stage Liver Disease, the Model for Liver Transplantation Survival and the Donor Risk Index as prognostic models for survival after liver transplantation. METHOD: We retrospectively analyzed the data from 1,270 patients who received a liver transplant from a deceased donor in the state of São Paulo, Brazil, between July 2006 and July 2009. All data obtained from the Health Department of the State of São Paulo at the 15 registered transplant centers were analyzed. Patients younger than 13 years of age or with acute liver failure were excluded. RESULTS: The majority of the recipients had Child-Pugh class B or C cirrhosis (63.5%). Among the 1,006 patients included, 274 (27%) died. Univariate survival analysis using a Cox proportional hazards model showed hazard ratios of 1.02 and 1.43 for the Model for End-Stage Liver Disease and the Model for Liver Transplantation Survival, respectively (

Comparative study of etiological diagnosis of nosocomial pneumonia

Nosocomial pneumonia is a common complication in patients on mechanical ventilation and results in significant mortality. Diagnosis of pneumonia in patients who are intubated and under mechanical ventilation is difficult, even with the aid of clinical, laboratorial, and endoscopic tests. The objective of this study was to compare three methods of tracheal sputum collection in patients with a clinical and radiological diagnosis of pneumonia. Twenty-two patients with a clinical diagnosis of liver disease were enrolled, 18 years of age or older, 13 males and nine females, who had been mechanically ventilated over an intubation period of 5.86 ± 4.62 days. These patients were being treated in intensive care unit (ICU) of the Liver Transplantdepartment. Secretion collection was carried out according to a protocol with three distinct methods: endotracheal aspiration with a closed aspiration system, Bal cath and bronchoalveolar lavage. Of the 22 patients analyzed, 21 (95.4%) showed one or more infectious agent when the closed aspiration system was used. With the Bal cathâ collection, 19 patients (86.3%) had one or more infectious agents; in the collection by bronchoalveolar lavage, 10 patients (45.4%) presented one or more infectious agent. According to the laboratorial analysis, 14 different microorganisms were isolated, the most frequent of which were Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pneumoniae. We concluded that aspiration with the closed system produced the most effective results in comparison with those of bronchoalveolar lavage and the Bal cathâ, and may be an acceptable method for diagnosing hospital-acquired pneumonia when no fiberoptic technique is available

Inhalation anesthesia and hepatoprotection in patients undergoing right hepatectomy for living donor liver transplantation

Objective: To verify if inhalation anesthesia administered duringright lobe hepatectomy for living donor transplantation, asperformed at Hospital Israelita Albert Einstein, could attenuatepostoperative liver dysfunction in these patients. Methods: Weretrospectively reviewed perioperative data of 56 patients whounderwent right lobe hepatectomy for living donortransplantation. Patients were separated into two groups: onegroup received inhalation anesthesia, and another received totalintravenous anesthesia. Results: Standard liver function tests:prothrombin time, platelet count, ALT/AST were not statisticallydifferent in patients who received inhalation anesthesia comparedto total intravenous anesthesia in the early postoperative period.Conclusion: Hepatoprotective properties of inhalation anesthesiacould not be demonstrated in this retrospective study whencompared to intravenous anesthesia in patients submitted to rightlobe hepatectomy. Increased safety of this procedure for the donoris mandatory. Therefore, strategies resulting in preservation ofliver function, like preconditioning, deserve further studies

Data from: Prospective randomized trial comparing hepatic venous outflow and renal function after conventional versus piggyback liver transplantation

Background: This randomized prospective clinical trial compared the hepatic venous outflow drainage and renal function after conventional with venovenous bypass (n = 15) or piggyback (n = 17) liver transplantation. Methods: Free hepatic vein pressure (FHVP) and central venous pressure (CVP) measurements were performed after graft reperfusion. Postoperative serum creatinine (Cr) was measured daily on the first week and on the 14th, 21st and 28th postoperative days (PO). The prevalence of acute renal failure (ARF) up to the 28th PO was analyzed by RIFLE-AKIN criteria. A Generalized Estimating Equation (GEE) approach was used for comparison of longitudinal measurements of renal function. Results: FHVP-CVP gradient > 3 mm Hg was observed in 26.7% (4/15) of the patients in the conventional group and in 17.6% (3/17) in the piggyback group (p = 0.68). Median FHVP-CVP gradient was 2 mm Hg (0–8 mmHg) vs. 3 mm Hg (0–7 mm Hg) in conventional and piggyback groups, respectively (p = 0.73). There is no statistically significant difference between the conventional (1/15) and the piggyback (2/17) groups regarding massive ascites development (p = 1.00). GEE estimated marginal mean for Cr was significantly higher in conventional than in piggyback group (2.14 ± 0.26 vs. 1.47 ± 0.15 mg/dL; p = 0.02). The conventional method presented a higher prevalence of severe ARF during the first 28 PO days (OR = 3.207; 95% CI, 1.010 to 10.179; p = 0.048). Conclusion: Patients submitted to liver transplantation using conventional or piggyback methods present similar results regarding venous outflow drainage of the graft. Conventional with venovenous bypass technique significantly increases the harm of postoperative renal dysfunction