Selección de candidatos para trasplante hepático

Inadequate social support decreases survival in decompensated liver cirrhosis patients

INTRODUCTION

Inadequate social support is associated with higher mortality both in the general population and in patients with chronic diseases. There are no studies that have described social support in liver cirrhosis and its impact on prognosis.

OBJECTIVES

To analyze the impact social support has in the survival of patients with decompensated cirrhosis.

METHODS

Prospective multicentric cohort study (2016-2019). Patients with decompensated liver cirrhosis were included. Epidemiological, clinical and social variables were collected, using the validated Medical Outcomes Study Social Support Survey, with a 12-month follow-up.

RESULTS

A total of 127 patients were included, of which 79.5% were men. The most common etiology of cirrhosis was alcohol (74.8%), mean age was 60 years (SD 10.29), mean MELD was 15.6 (SD 6.3) and most of the patients had a Child-Pugh B (53.5%) or C (35.4%). In the assessment of social support, we observed that most of the patients (92.2%) had adequate global support. At the end of the follow-up (median 314 days), 70.1% of the patients survived. The 1-year survival rate in patients with inadequate global social support was 30%, compared to 73.5% in the presence of social support. In multivariate Cox regression analysis, inadequate social support predicted survival with an adjusted HR of 5.5 (95% CI 2,3-13,4) independently of MELD (HR 1.1, 95% CI 1-1.2), age (HR 1, 95% CI 1-1.1) and hepatocarcinoma (HR 10.6, 95% CI 4.1-27.4).

CONCLUSION

Adequate social support improves survival in liver cirrhosis, independently of clinical variables. Social intervention strategies should be considered for their management.

[Blood coagulation factor levels in candidates for liver transplantation: correlation with disease severity]

OBJECTIVE

To correlate blood coagulation factor levels with disease severity in cirrhotic patients evaluated as candidates for liver transplantation.

MATERIAL AND METHOD

We included 87 patients (75.9% men) with a mean age of 54+/-9.4 years. Etiology and Child-Turcotte-Pugh (CTP) class were as follows: alcohol-related (36.8%), hepatitis C virus infection (35.6%), hepatitis B virus infection (11.5%) and other (16.1%); class A (13.8%), class B (40.2%) and class C (46%), respectively. The mean value of the Model for End-Stage Liver Disease (MELD) score was 14.5+/-5.9. Levels of factors II, V, VII, VIII, IX and X were compared between each CTP grade and with the MELD score.

RESULTS

Except for factor VIII, all the clotting factors were reduced in our series (in particular factors II, V and VII) and deficiencies in these factors were closely related to CTP grade with statistical significance for stage C (p <0.05). We also found a marked inverse correlation between the MELD score and factors II, V, VII, IX and X values (p <0.05).

CONCLUSIONS

A correlation was found between reduced levels of factors II, V, VII, IX and X in liver cirrhosis and the severity of liver disease.

Interregional allocation models for liver transplantation

In light of the persistent donor scarcity, it has been advocated to shift the current region-based allocation model for liver transplantation (OLT) to an interregional one, so as to allow sicker patients on the wait list to obtain timely transplantations. Being convinced that tackling the challenge of organ donor scarcity requires appropriate measures, we have suggested some initiatives to be taken at different levels. First, definition of the real need for OLT, since it is largely unknown to transplant physicians and still represents the starting line for any initiative in the field. Second, we recommend creation of liver transplant care processes organized around the concept of smooth, seamless, and prompt referral of liver disease patients. Third, we suggest continued efforts in the field of deceased donation, so as to reduce the chasm between organ donation and demand and limit the persistent variability among regions. Fourth, we favor patient mobility, so as to expand the opportunity for transplantation for sicker patients. Finally, we seek to improve the efficiency of interregional coordination by prompt referral of extended criteria donors, sicker patients, or patients with rare diseases, so as to expand the opportunity for better donor-to-recipient matching at a national level.

[Results of colonoscopic examination in the evaluation of cirrhotic candidates for liver transplantation]

AIM

To assess the presence of preneoplastic and neoplastic colonic lesions, as well as those related to portal hypertensive vasculopathy, and their association with liver disease in cirrhotic patients who are candidates for orthotopic liver transplantation (LT).

METHODS

Between October 2004 and December 2005, colonoscopy was performed in 92 patients who were LT candidates, aged >50 years old or aged <50 years old but with clinical indications.

RESULTS

Eighty-eight percent of the patients were > 50 years old, the mean age was 55.3 years (29-69) and 81.5% were males. The main etiology of cirrhosis was alcoholic (46.7%), and 21% were Child-Pugh class A. No abnormalities were detected in 20.7%. Polyps were discovered in 38% (35/92) of patients (adenomatous 65.2%; tubular type 86.7%). Six patients with adenomatous polyps had mild dysplasia, and one asymptomatic patient had a well-differentiated adenocarcinoma. An association was found between polyps and male sex (44% males vs 17.6% females; p=0.044) and Child-Pugh grade (63.2% Child A vs 32.9% Child B/C, p=0.016) but not with serum levels of carcinoembryonic antigen (CEA), age or etiology of liver disease. Portal hypertensive colopathy was found in 23.9%, rectal varices in 7.6% and internal or mixed hemorrhoids in 52.3%.

CONCLUSION

The prevalence of preneoplastic and neoplastic colonic lesions may support the use of colonoscopy in LT candidates aged >50 years-old or with a history suggesting lower gastrointestinal bleeding or other abnormalities.

Intrasplenic or subperitoneal hepatocyte transplantation to increase survival after surgically induced hepatic failure?

BACKGROUND

As a basis for future clinical questions, we evaluated the efficacy of hepatocyte transplantation in a surgical model using a subperitoneal or intrasplenic approach for cell implantation.

METHODS

In rats, acute liver failure was induced by subtotal hepatectomy. Series of allogenic hepatocyte transplantations were performed by varying cell number, site, and sequence of cell transplantation.

RESULTS

Following subperitoneal or intrasplenic cell implantation subsequent to liver surgery, no survival benefit was achieved when compared to the control groups. However, intrasplenic cell implantation 24 h prior to liver surgery revealed a statistically significantly higher animal survival (72 vs. 29%).

CONCLUSION

According to our experience, both timing and site of cell implantation played an important role in hepatocyte transplantation. Intrasplenic hepatocyte transplantation 1 day before liver surgery showed the best results in terms of survival. Consequently, we were able to establish a model of hepatocyte transplantation which may be the basis for further investigations evaluating potential treatment modalities to overcome deleterious postoperative liver insufficiency.