Operative safety of orthotopic liver transplant in patients with prior transjugular intrahepatic portosystemic shunts: A 20-year experience

INTRODUCTION AND AIMS

Orthotopic liver transplant (OLT) is the definitive treatment of most types of liver failure. Transjugular intrahepatic portosystemic shunt (TIPS) and portocaval shunt placement procedures reduce the systemic vascular complications of portal hypertension. TIPS placement remains a "bridge" therapy that enables treatment of refractory symptoms until transplantation becomes available. The aim of the present study was to describe the operative impact of TIPS prior to OLT.

MATERIALS AND METHODS

A retrospective review was conducted on patients that underwent liver transplant at the Hospital San José within the timeframe of 1999 and February 2020.

RESULTS

We reviewed a total of 92 patients with OLT. Sixty-six patients were male and 26 were female, with a mean age of 52 years. Nine (9.8%) of the 92 patients had a TIPS, before the OLT. Preoperative Child-Pugh class, MELD score, and sodium and platelet levels were similar between groups. We found no difference in the means of intensive care unit stay, operative time, or blood transfusions for liver transplant, with or without previous TIPS. There was no significant difference between groups regarding vascular and biliary complication rates or the need for early intervention. The overall one-year mortality rate in the TIPS group was 11%.

CONCLUSIONS

TIPS is an appropriate therapeutic bridge towards liver transplant. We found no greater operative or postoperative complications in patients with TIPS before OLT, when compared with OLT patients without TIPS. The need for transfusion, operative time, and ICU stay were similar in both groups.

Catheter directed hepatic artery thrombolysis following liver transplantation. Case report and review of the literature

Hepatic artery thrombosis is the most frequent vascular complication following orthotopic liver transplantation, and often results in biliary complications, early graft loss and death. Surgical revascularization and retransplantation are considered the mainstay of treatment. However, intraarterial endovascular therapy is an alternative that has shown low morbidity and mortality, thereby avoiding the need for retransplantation. We describe a case of orthotopic liver transplantation complicated with hepatic artery thrombosis that was successfully treated with endovascular therapy.

Protective mechanisms of medicinal plants targeting hepatic stellate cell activation and extracellular matrix deposition in liver fibrosis

During chronic liver injury, hepatic stellate cells (HSC) are activated and proliferate, which causes excessive extracellular matrix (ECM) deposition, leading to scar formation and fibrosis. Medicinal plants are gaining popularity as antifibrotic agents, and are often safe, cost-effective, and versatile. This review aims to describe the protective role and mechanisms of medicinal plants in the inhibition of HSC activation and ECM deposition during the pathogenesis of liver fibrosis. A systematic literature review on the anti-fibrotic mechanisms of hepatoprotective plants was performed in PubMed, which yielded articles about twelve relevant plants. Many of these plants act via disruption of the transforming growth factor beta 1 signaling pathway, possibly through reduction in oxidative stress. This reduction could explain the inhibition of HSC activation and reduction in ECM deposition. Medicinal plants could be a source of anti-liver fibrosis compounds.

Liver fibrosis and protection mechanisms action of medicinal plants targeting apoptosis of hepatocytes and hepatic stellate cells

Following chronic liver injury, hepatocytes undergo apoptosis leading to activation of hepatic stellate cells (HSC). Consequently, activated HSC proliferate and produce excessive extracellular matrix, responsible for the scar formation. The pandemic trend of obesity, combined with the high incidence of alcohol intake and viral hepatitis infections, highlights the urgent need to find accessible antifibrotic therapies. Treatment strategies should take into account the versatility of its pathogenesis and act on all the cell lines involved to reduce liver fibrosis. Medicinal plants are achieving popularity as antifibrotic agents, supported by their safety, cost-effectiveness, and versatility. This review will describe the role of hepatocytes and HSC in the pathogenesis of liver fibrosis and detail the mechanisms of modulation of apoptosis of both cell lines by twelve known hepatoprotective plants in order to reduce liver fibrosis.

[Twelve years of liver transplant at the San José-Tec De Monterrey Hospital]

BACKGROUND

Liver transplantation is the only curative alternative for patients with end stage liver disease or acute liver failure.

AIM

To report the experience of a single transplant center in Mexico.

MATERIAL AND METHODS

Fifty-five transplants in 54 adult patients were analyzed between 1999 and 2011 in a single private institution. All grafts were obtained from deceased donor. Surgical technique, donor and recipient demographics, complications, causes of death and overall survival are described. Results were expressed as range and percentages. A Kaplan-Meier survival curve was done to analyze patient and graft survival.

RESULTS

Main cause of cirrhosis was hepatitis C virus infection followed by alcohol intake. A 16% of patients developed biliary complications without graft loss, and vascular complications were observed in 15%. Patient survival at one and five years was 83% and 76%, respectively.

CONCLUSIONS

Complication rates and survival in our center are comparable to those in the United States and Europe.

Cyclosporine and low-dose ketoconazole in renal transplant recipients: a single-center experience

BACKGROUND

The high cost of cyclosporine A (CsA) is an impediment for low-income patients. Previous studies have used ketoconazole at doses between 200 and 400 mg/day to lower CsA consumption.

METHODS

Ketoconazole and CsA were administered prospectively to renal transplant patients. Patients treated historically with CsA were used as a reference group. At different intervals posttransplant, clinical and laboratory data were recorded.

RESULTS

The reference group (n=14) was treated with CsA from 1992 to 1997 and the CsA plus ketoconazole group (n=17) from 1998 to 2002. Follow-up was 76+/-22 and 29+/-14 months, respectively. CsA doses throughout the study were 4.0+/-1.3 and 1.6+/-0.6 mg/kg/day (a 60% reduction, P =0.00). Trough levels of CsA were 194+/-87 and 193+/-69 ng/mL, respectively. The ketoconazole dose was 54+/-17 mg/day. The monthly cost of CsA was reduced by 60%, including the cost of ketoconazole.

CONCLUSIONS

CsA with ketoconazole resulted in a substantial dose and cost reduction that proved safe and effective.

Coadministration of tacrolimus and ketoconazole in renal transplant recipients: cost analysis and review of metabolic effects

BACKGROUND

The high cost of tacrolimus is a major problem in Mexico. Ketoconazole increases tacrolimus bioavailability by inhibiting cytochrome P450 3A4 and glycoprotein-p.

OBJECTIVE

To demonstrate that the coadministration of tacrolimus and ketoconazole allows a significant dose and cost reduction.

PATIENTS AND METHODS

This prospective study administered tacrolimus and ketoconazole to renal transplant recipients with dose adjustment according to tacrolimus blood levels. At 0-1, 1-6, 6-12, and 12-24 months posttransplant demographic, transplant type, immunosuppression, and clinical data were reviewed. The cost of tacrolimus treatment was calculated based on the dose used as compared to the recommended dose (0.15-0.20 mg/kg/d).

RESULTS

Eleven patients with an age of 40 years (range, 13-71) were studied from May 2000 to August 2002. Follow-up was 15 +/- 10 months. Graft source was living donor in six patients and cadaveric in five. All patients received tacrolimus + mycophenolate mofetil + prednisone. The mean ketoconazole dose was 87 mg/d. Since the dose of tacrolimus was 0.04 mg/kg/d versus the recommended dose of 0.15-0.20 mg/kg/d, there was a 78% cost reduction (P =.000). Tacrolimus blood levels remained in the therapeutic range. There were no drug-related side effects.

CONCLUSIONS

The co-administration of tacrolimus and ketoconazole results in a substantial dose and cost reduction while maintaining therapeutic levels. No adverse metabolic consequences were seen with this combination.

[Mediastinal lipoblastoma in a 14-year-old patient]

This is a case report on a 14 year child with a benign mediastinum lipoblastoma examined at the University Hospital "Dr. José E. González", in Monterrey, Nuevo León. This is an infrequent pathology and little has been published especially dealing with patients at this age and the site where it was found. This is a benign tumor which requires complete resection. The patient was submitted to an anterolateral bilateral thoracotomy which allowed for the complete resection of the tumor. It weighed 3.1 kilograms and measured 26 x 21 cm. The patient evolved satisfactorily.