GOOD QUALITY OF LIFE AFTER MORE THAN A DECADE OF LIVING DONOR LIVER TRANSPLANTATION

BACKGROUND

Receptors of living donor liver transplantation (LDLT) have higher rate of postoperative biliary and vascular complications that may reduce posttransplant quality of life (QOL) due to the need of invasive and repetitive treatments.

OBJECTIVE

The purpose of our study is to assess the various aspects of QOL of receptors undergoing LDLT after 10 years of transplantation and to identify potential factors that might be associated with impaired QOL.

METHODS

Data of all patients with more than 10 years of LDLT were retrospectively evaluated. Patients were interviewed through a quality of life questionnaire (SF-36).

RESULTS

From a total of 440 LT performed in 17 years (from September 1991 through December 2008), 78 patients underwent LDLT, of which 27 were alive and 25 answered completely the questionnaire. There were 17 (68%) men and 8 (32%) women, with a mean age of 38.6±18.5 years at the time of transplantation and mean follow up time of 15.1±1.9 years. The average MELD was 16.4±4.9 and the main indication for LT was hepatic cirrhosis caused by hepatitis B virus (32%). When compared to the general po-pulation, LDLT patients had lower mental health score (66.4 vs 74.5, P=0.0093) and higher vitality score (87.8 vs 71.9, P<0.001), functional aspects (94.6 vs 75.5, P=0.002), social aspects (93 vs 83.9, P=0.005), physical aspects (92 vs 77.5, P=0.006), and emotional aspects (97.33 vs 81.7, P<0.001). General health status (73.28 vs 70.2, P=0.074) and pain (78.72 vs 76.7, P=0.672) scores were similar in both groups.

CONCLUSION

It is concluded that the various aspects LDLT recipients' QOF are similar to those of the general population more than a decade after the transplant, except for the mental health domain which is lower.

Quality of Life after 10 Years of Liver Transplantation

AIM

This study goal was to evaluate the long-term quality of life of patients who underwent cadaveric liver transplants (CLT) in two Brazilian hospitals.

METHODS

Medical records of all patients who underwent CLT and survived over 10 years were revised. The international validated questionnaire Short-Form 36 was employed to assess the quality of life. Patients data were obtained from electronic medical records and study protocols.

RESULTS

A total of 342 patients underwent CLT, of which 129 were alive and 93 fully answered the questionnaire and were included in the study. The group consisted of 62 men (66.6%) and 31 women (33.4%), with average age of 40.1±15.9 years. Follow-up time was 16±4.1 years. The most common indication of CLT was hepatic cirrhosis caused by hepatitis C virus, 24.7%. Transplanted patients had lower scores than the general population in mental health [62.9 (95%CI: 60.1-65.7,) vs. 74.5, p < 0.001]. In all other domains, transplanted patients had similar (emotional aspect limitiation, pain, and general health status) or superior (physical aspect limitation, social aspects, functional capacity, and vitality) scores than the general population. Functional capacity score was lower in patients with long-term complications, who were aged more than 50-years, and unemployed.

CONCLUSIONS

The quality of life in patients with more than 10 years after CLT was similar or superior than the general population, except for the mental health domain.

The influence of end-stage liver disease and liver transplantation on thyroid hormones

BACKGROUND

Thyroid dysfunction has been reported in most chronic illnesses including severe liver disease. These defects in thyroid hormone metabolism result in the sick euthyroid syndrome, also known as low T3 syndrome.

OBJECTIVES

Our objective was to evaluate the thyroid function in patients with end stage liver disease prior and after deceased donor liver transplantation and to correlate thyroid hormonal changes with the MELD score (Model for End stage Liver Disease).

METHODS

In a prospective study, serum levels of thyrotropin (thyroid stimulating hormone TSH), total thyroxine (tT4), free thyroxine (fT4) and triiodothyronine (T3) from 30 male adult patients with end stage liver disease were measured two to four hours before and 6 months after liver transplantation (LT). MELD was determined on the day of transplant. For this analysis, extra points were not added for patients with hepatocellular carcinoma.

RESULTS

The patients had normal TSH and fT4 levels before LT and there was no change after the procedure. Total thyroxine and triiodothyronine were within the normal range before LT, except for four patients (13.3%) whose values were lower. Both hormones increased to normal values in all four patients after LT (P=0.02 and P<0.001, respectively). When the patients were divided into two groups (MELD <18 and MELD >18), it was observed that there was no change in the TSH, freeT4, and total T4 levels in both groups after LT. Although there was no significant variation in the level of T3 in MELD <18 group (P=0.055), there was an increase in the MELD >18 group after LT (P=0.003).

CONCLUSION

Patients with end stage liver disease subjected to liver transplantation had normal TSH and fT4 levels before and after LT. In a few patients with lower tT4 and T3 levels before LT, the level of these hormones increased to normal after LT.

Change in platelet count in patients with hypersplenism subjected to liver transplantation

CONTEXT: Most patients subjected to liver transplantation presents hypersplenism, which is reversed after the operation. However, some patients remain with moderate to intense hypersplenism. OBJECTIVES: To study the effect of liver transplantation on platelet count in patients with hypersplenism. METHOD: Of a total of 233 patients who underwent liver transplantation, 162 were excluded from the present study because of occurrence of steroid-resistant rejection, absence of hypersplenism before the transplantation, absence of follow-up for at least 2 years or incomplete exams data. The electronic study protocols of the remaining 71 patients were reviewed to determine the demographics, etiology of cirrhosis, and results of pathologic examination of the explanted liver. Serial platelet count was obtained from the study protocol on the day before liver transplantation and 1, 2, 4, and 6 months and 1 year after liver transplantation. Statistical analysis was performed using the Student's t-test, chi-square test, and Spearman's correlation test. RESULTS: Posttransplant platelet count at all time intervals was significantly higher than the pretransplant value (P<0.001 for all time intervals). Thrombocytopenia was reversed (platelet count >100,000/mm³) in 58 patients (81.7%) 1 month after liver transplantation. Twelve patients (16.9%) remained with thrombocytopenia 1 year after liver transplantation. Three patients (4.2%) had recurrence of thrombocytopenia within 1 year after liver transplantation. There was no correlation between pretransplant platelet count and the Child-Pugh class or the MELD score. CONCLUSION: Liver transplantation reverses hypersplenism in most patients.

The impact of the model for end-stage liver disease (MELD) on liver transplantation in one center in Brazil

CONTEXT: Presently the MELD score is used as the waiting list criterion for liver transplantation in Brazil. In this method more critical patients are considered priority to transplantation. OBJECTIVE: To compare the results of liver transplantation when the chronologic waiting list was the criterion for organ allocation (pre-MELD era) with MELD score period (MELD era) in one liver transplantation unit in Brazil. METHODS: The charts of the patients subjected to liver transplantation at the Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, PR, Brazil, were reviewed from January of 2001 to August of 2008. Patients were divided into two groups: pre-MELD era and MELD era. They were compared in relation to demographics of donors and receptors, etiology of cirrhosis, cold and warm ischemia time, presence of hepatocellular carcinoma, MELD score and Child-Pugh score and classification at the time of transplantation, units of red blood cells transfused during the transplantation, intensive care unit stay, total hospital stay and 3 month and 1 year survival. RESULTS: Initially, 205 liver transplantations were analyzed. Ninety four were excluded and 111 were included: 71 on the pre-MELD era and 40 on the MELD era. The two groups were comparable in relation to donors and receptors age and sex, etiology of cirrhosis and cold and warm ischemia time. The receptors of the MELD era had more hepatocellular carcinoma than those of the pre-MELD era (37.5% vs 16.9%). Patients with hepatocellular carcinoma had less advanced cirrhosis on both eras. The MELD score was the same on both eras. Excluding the cases of hepatocellular carcinoma, MELD era score was higher than pre-MELD score (18.2 vs 15.8). There were an increased number of transplants on Child-Pugh A and C and a decreased number on Child-Pugh B receptors on MELD era. Both eras had the same need of red blood cells transfusion, intensive care unit stay and hospital stay. Also, 3 month and 1 year survival were the same: 76% and 74.6% on pre-MELD era and 75% and 70.9% on MELD era. CONCLUSION: In our center, after the introduction of MELD score as the priority criterion for liver transplantation there were an increased number of transplants with hepatocellular carcinoma. Excluding these patients, the receptors were operated upon with more advanced cirrhosis. Nevertheless the patients had the same need for red blood cells transfusion, intensive care unit and hospital stay and 3 months and 1 year survival.

[Local therapy for hepatocellular carcinoma as a bridge to liver transplantation]

OBJECTIVE

To analyze the results of pre-operative local therapy for hepatocellular carcinoma in patients who were subjected to liver transplantation.

METHODS

Cadaveric and living-related liver transplants done in cirrotic patients with hepatocellular carcinoma within the Milan criteria were included. The nodules were analyzed according to its number and diameter before and after the institution of the local therapy and on the explant evaluation.

RESULTS

22 patients with 31 nodules that measured 28.8+/-12 mm in diameter were included. They were subjected to 21 sessions of percutaneous ethanol injection and 29 sessions of transarterial chemoembolization. After the local therapy, 29 nodules that measured 24.6+/-12 mm in diameter were detected. All of them were within the Milan criteria and there was no difference compared to the diameter before the treatment. The patients were subjected to 17 cadaveric and 5 living-related liver transplantations. In six cases the tumors exceeded the Milan criteria on the explant evaluation: 4 due to its number and 2 due to its diameter. Sixteen cases were within the criteria and there were 14 neoplastic nodules with 30+/-14 mm in diameter. In these cases no difference was observed compared to the diameter before and after the local therapy.

CONCLUSION

Local therapy for hepatocellular carcinoma with percutaneous ethanol injection and transarterial chemoembolization partially controlled tumor evolution considering the Milan criteria in patients waiting for liver transplantation. Significant differences were observed in terms of the Milan criteria on pre-operative examination compared to the explant evaluation.

[Contraception and pregnancy after liver transplantation: an update overview]

CONTEXT

Successful liver transplantation not only treats the underlying liver disease but also restores libido and fertility in female recipients. Although reports of successful pregnancy after liver transplantation continue to increase, these pregnancies are considered of high-risk because they are associated with increase maternofetal morbidity.

EVIDENCE ACQUISITION

A MEDLINE search (1978-2007) was conducted using the terms 'liver transplantation', 'pregnancy', 'immunosuppressive agents', 'sexual function'. Reviews, retrospective series, long-term clinical follow-up of case series and original articles containing basic scientific observations were included.

RESULTS

Although no formal guidelines have been established there are some 'golden rules' to improve the probability of favorable maternal and fetal outcome. Most transplant centers recommend to delay pregnancy for at least 1-year after transplantation. The recipient should be on a stable immunosuppression regimen, with good graft function and no evidence of renal dysfunction or uncontrolled arterial hypertension. Considering the increased incidence of prematurity, low birth weight, hypertension and preeclampsia reported during pregnancy post-LT, these high-risk patients should be managed by a multidisciplinary team, including an obstetrician specialized in high-risk pregnancies. Carefully monitoring of immunosuppressive drugs serum level is prudent to avoid graft rejection episodes and drugs with teratogenic potential should be discontinued. Breastfeeding is usually not recommended.

CONCLUSIONS

Successful pregnancies are the rule after liver transplantation. A carefully monitoring by an experience multidisciplinary team increases the chances of favorable maternofetal outcome.

[Hepatitis C recurrence after living donor and cadaveric liver transplantation]

OBJECTIVE

To determine the recurrence of hepatitis C in patients subjected to living donor liver transplantation compared to those subjected to cadaveric liver transplantation.

METHODS

Of a total of 333 liver transplantations, 279 (83.8%) were cadaveric liver transplantation and 54 (16.2%) living donor liver transplantation. Hepatic cirrhosis due to hepatitis C virus was the most common indication of both cadaveric liver transplantation (82 patients) and living donor liver transplantation (19 patients). The electronic study protocols of all patients with hepatic cirrhosis due to hepatitis C virus were reviewed. All data, including patients' age and sex, laboratory tests, hepatitis C virus recurrence and acute rejection were evaluated statistically.

RESULTS

A total of 55 cadaveric liver transplantation and 10 living donor liver transplantation performed in patients with liver cirrhosis due to hepatitis C virus was included in the study. Clinical and laboratory characteristics of the two groups before the transplantation were similar, except for the prothrombin time that was higher for the cadaveric liver transplantation than the living donor liver transplantation (P = 0.04). Hepatitis C virus recurrence was similar in the cadaveric liver transplantation (n = 37; 69.3%) and living donor liver transplantation (n = 7; 70%) groups (P = 0.8). The incidence of acute rejection was similar in cadaveric liver transplantation (n = 27; 49%) and living donor liver transplantation (n = 2; 20%) groups (P = 0.08). Hepatitis C virus recurrence in patients of the cadaveric liver transplantation group who received bolus doses of corticosteroids (9 of 11 patients) was similar to the remained patients (28 of 44 patients) (P = 0.25). Recurrence was also similar in patients of the living donor liver transplantation group who received bolus doses of corticosteroids (one of one patient) in relation to those who did not receive them (six of nine patients) (P = 0.7).

CONCLUSION

Hepatitis C recurrence is similar in patients who underwent living donor liver transplantation or cadaveric liver transplantation.

Insuficiência hepática fulminante por intermação induzida por exercício

Intermação induzida por exercício é uma condição potencialmente fatal causada pela elevação extrema da temperatura corporal central. Envolvimento hepático leve a moderado afeta todos os pacientes e manifesta-se pela elevação das enzimas hepáticas. A ocorrência de falência hepática no curso da intermação por exercício é rara e tem prognóstico reservado. Relata-se um caso de insuficiência hepática fulminante em um homem de 36 anos após correr 8km em corrida de rua (corrida rústica) na cidade de Manaus (AM). O paciente desenvolveu insuficiência renal aguda, rabdomiólise e achados compatíveis com insuficiência hepática fulminante (elevação importante das aminotransferases, coagulopatia, letargia e episódios de confusão). As funções hepáticas e renais apresentaram melhora gradual e espontânea sem necessidade de diálise. Três meses após o paciente encontrava-se bem, com enzimas hepáticas normais e com retorno gradual à prática de esportes. Embora rara, a falência hepática aguda deve ser incluída nas complicações da intermação induzida por exercício, a qual pode ter resolução espontânea com medidas conservadoras.

[Hepatocellular carcinoma: impact of waiting list and pre-operative treatment strategies on survival of cadaveric liver transplantation in pre-MELD era in one center in Brazil]

BACKGROUND

Liver transplantation is the main treatment option for hepatocellular carcinoma in patients with cirrhosis.

AIM

Three months and 3 years survival were analysed in patients with cirrhosis and hepatocellular carcinoma and in patients with only cirrhosis.

METHODS

Charts of patients subjected to cadaveric liver transplantation at the Clinical Hospital of the Federal University of Paraná, Curitiba, PR, Brazil, between January 5th of 2001 and February 17th of 2006 were reviewed. Patients were divided into two groups for 3 months and 1 year survival analysis: cirrhosis and hepatocellular carcinoma and cirrhosis only. The two groups were also compared in relation to donor and recipient sex and age, etiology of cirrhosis, Child-Pugh and MELD scores at the time of the transplantation, warm isquemia time, cold isquemia time, units of red blood cells transfused during the transplantation, intensive care unit stay and total hospital stay.

RESULTS

One hundred and forty six liver transplantation patients were analysed: 75 were excluded because of incomplete data and 71 were included. General 3 months and 1 year survivals were 77,4% and 74,6% respectively. Patients with hepatocellular carcinoma (n = 12) presented 3 months and 1 year survivals of 100%. These rates were significantly higher than those of patients without hepatocellular carcinoma (n = 59; 72,8% and 69,4%). Mean MELD score, mean Child-Pugh score and mean number of red blood cells transfused were significantly higher in patients without hepatocellular carcinoma. In this group it was also observed more Child-Pugh B and C patients and the diagnosis of cirrhosis because other causes. The rate of Child-Pugh A and hepatitis C was higher in patients with hepatocellular carcinoma. The two groups were identical in all other parameters analysed.

CONCLUSION

Patients with cirrhosis and hepatocellular carcinoma presented better 3 months and 1 year survival rates than patients with only cirrhosis. This is possibly due to an early stage of cirrhosis at transplantation of patients with hepatocellular carcinoma.

[Prevalence of hepatitis C infection in patients with type 2 diabetes mellitus]

BACKGROUND

Recently, a possible epidemiological association between hepatitis C virus infection and diabetes mellitus has been suggested and a higher prevalence of HCV antibodies has been found among type 2 diabetic when compared with normal controls.

AIM

To evaluate the prevalence of hepatitis C infection in diabetic patients in Curitiba, PR, Brazil.

PATIENTS AND METHODS

A total of 145 type 2 and 104 type 1 diabetic patients attending the outpatient diabetic unit of an university hospital were consecutively tested for anti-HCV, using a fourth-generation enzyme-linked immunosorbent assay (ELISA). The control group was constituted by 16,720 volunteer blood donors attending the blood bank of the same hospital during the period of the study. Diabetic patients were also evaluated for clinical, biochemical (aminotransferase levels) and demographic variables and previous exposure to risk factors for hepatitis C infection.

RESULTS

A higher prevalence of hepatitis C infection was observed in type 2 diabetic patients in comparison with blood donors. Although anti-HCV prevalence in type 2 diabetic patients was higher than found in type 1, it did not reach statistical significance. Both diabetic groups were predominantly female, and as expected, type 2 diabetic were older than type 1. Race distribution, duration of the disease, and previous exposure to hepatitis C risk factors were similar in both groups, but type 2 diabetic subjects had higher median levels of alanine aminotransferase than type 1.

CONCLUSIONS

A higher prevalence of hepatitis C infection was detected in type 2 diabetic patients in comparison with blood donors in our region, in accordance with study data from different populations. If all type 2 diabetic patients should undergo regular screening for hepatitis C infection remains a question.

Doença hepática não-alcoólica: evolução após derivação gastrojejunal em Y-de-Roux pela técnica de fobi-capella

RACIONAL: A doença hepática não-alcoólica apresenta alta prevalência entre pacientes com obesidade mórbida, podendo evoluir de esteatose hepática até esteatohepatite e cirrose. OBJETIVO: Determinar o efeito da derivação gástrica na incidência de doença hepática não-alcoólica e co-morbidades relacionadas em pacientes com obesidade mórbida. MÉTODOS: Os pacientes foram prospectivamente avaliados no pré-operatório e, no mínimo, após 6 meses de pós-operatório. Foram analisados: dados antropométricos, co-morbidades, medicamentos em uso, colesterol, triglicerídeos, provas hepáticas e incidência de doença hepática não-alcoólica. Todos os pacientes com alteração de provas hepáticas foram submetidos a biopsia hepática no peroperatório. RESULTADO: Vinte e oito pacientes com doença hepática não-alcoólica foram incluídos no estudo com índice de massa corpórea médio de 42 ± 4 kg/m². Vinte e cinco pacientes apresentaram 59 co-morbidades, sendo as mais freqüentes: elevação de triglicerídeos (n = 23), elevação de colesterol total (n = 13) e hipertensão arterial (n = 11). Foram submetidos a biopsia 22 pacientes: 10 apresentaram esteatose macrogoticular moderada, 5 esteatose macrogoticular discreta e 7 esteatohepatite. Os doentes foram analisados em média após 230 dias de pós-operatório. Apresentaram perda de 64% do excesso de peso, redução do índice de massa corpórea médio para 29,6 ± 3 kg/m² e 21 co-morbidades em 13 pacientes. Houve diminuição estatisticamente significante do número dos acometidos de elevação de triglicerídeos, elevação de colesterol total, hipertensão arterial e na incidência de doença hepática não-alcoólica. CONCLUSÃO: A perda de peso proporcionada pela derivação gastrojejunal em Y-de-Roux pela técnica de Fobi-Capella em pacientes com doença hepática não-alcoólica está associada à diminuição de sua incidência e de outras co-morbidades.

Resultados do transplante hepático em pacientes com diagnóstico pré-operatório de hepatocarcinoma

RACIONAL: O hepatocarcinoma é o tumor hepático maligno mais freqüente em humanos e sua forte associação com a cirrose torna a abordagem terapêutica ainda um desafio. O transplante hepático é o tratamento de escolha para os pacientes cirróticos com hepatocarcinoma irressecável em estágio precoce OBJETIVO: Avaliar a evolução pós-transplante de 15 pacientes cirróticos com diagnóstico pré-operatório de hepatocarcinoma precoce irressecável que preenchiam os Critérios de Milão e foram submetidos a transplante hepático entre setembro de 1991 e dezembro de 2003 no Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, PR MÉTODOS: Foram analisados retrospectivamente os dados clínicos dos 15 receptores de transplante hepático tendo como parâmetros principais a sobrevida do paciente e a ocorrência de recidiva tumoral após o transplante RESULTADOS: A idade média dos pacientes foi 49,2 ± 14,3 anos, sendo a hepatite crônica C a causa implicada em 60% dos casos. Em 80% dos pacientes realizou-se terapia adjuvante pré-transplante (quimioembolização ou alcoolização). Na análise dos explantes hepáticos constatou-se que 5 dos 12 pacientes (38,5%) submetidos a terapia adjuvante apresentavam necrose completa do tumor, enquanto os demais apresentavam alguma extensão de tecido tumoral viável. Em apenas 4 dos 15 explantes (26,6%) constatou-se invasão microvascular. A mediana do seguimento pós-transplante foi de 33 meses (8_71 meses), tendo ocorrido apenas um óbito precoce, não relacionado à recidiva tumoral (sepse biliar). A sobrevida pós-transplante livre de recurrência em 1 e 3 anos no grupo foi de 93% CONCLUSÕES: O transplante hepático é uma excelente alternativa de tratamento em pacientes cirróticos com hepatocarcinoma irressecável em fase precoce, alcançando elevados índices de sobrevida livre de recurrência tumoral.

Prevalence of new-onset diabetes mellitus in Brazilian liver transplant recipients: association with HCV infection

New-onset diabetes melittus (NODM) is a serious complication following transplantation. Recent studies suggest an association between hepatitis C virus (HCV) infection and DM both in nontransplant settings as well as after liver transplantation (LT). The aim of this study was to assess the prevalence of NODM among Brazilian LT recipients, analyzing possible risk factors including HCV infection. We conducted a cross-sectional study to evaluate the prevalence of NODM in 82 LT recipients with a posttransplant follow-up > or =1 year including 29 HCV-positive patients and 53 with other causes for liver disease. Patients were considered to meet the criteria for DM if they had two consecutive fasting glucose values > or =126 mg/dL or if they were taking insulin or oral hypoglycemic agents at the time of the study. The overall prevalence of NODM was 18.29% with a median interval of 20 months between LT and diagnosis of DM. The age, sex, and race distribution, immunosuppressive regimen, number of rejection episodes treated with pulse therapy, and family history of DM were similar in both groups. However, the frequency of BMI > or = 30 in the pre- and posttransplant periods was higher among patients who developed NODM (P = .02). Upon multivariate analysis of the entire cohort, HCV infection was the only significant predictor of NODM (OR = 4.31, CI = 1.17 to 15.84, P = .02). In conclusion, our study confirmed an association between HCV infection and NODM among Brazilian liver transplant recipients, suggesting that HCV infection may have a potential role in the pathogenesis of posttransplantation DM.

[Cost comparison of cadaveric liver transplantation with living-donor transplantation]

OBJECTIVE

To compare the cost of cadaveric liver transplantation with adult-adult right hepatic lobe living-donor transplantation.

METHOD

Total cost of 25 cadaveric liver transplantations and 22 adult-adult right hepatic lobe living-donor transplantations was considered from the day of hospital admission until the day of discharge. Professional fees and expenses due to post-transplant complications and donor follow-up were not included.

RESULTS

There was no difference in hospital stay between recipients of cadaveric transplantation (13.2+/- 4.1 days) and those of living-donor transplantation (15.4+/- 4.5 days). Costs of living-donor organ acquisition (USD 4,975.08+/- 565.34) were higher than those of cadaveric organ donation (USD 3,081.73+/- 305.57) (p<0.001). Implantation costs were similar for cadaveric and living-donor transplantation. Operating room and material costs were higher for living-donor transplantation and medications, exams and blood components costs were higher for cadaveric transplantation. The most expensive component of both cadaveric and living-donor liver transplantation was the cost of medications. Total cost was higher for living-donor transplantation (USD 22,986.60+/- 1,477.09) than for cadaveric transplantation (USD 21,582.90+/- 1,818.11) (p= 0.0022).

CONCLUSIONS

Total cost of living-donor liver transplantation is higher than that of cadaveric transplantation.

Qualidade de vida do doador após transplante hepático intervivos

RACIONAL: A qualidade de vida do doador após transplante hepático intervivos ainda não foi avaliada em nosso meio. OBJETIVO: Avaliar a qualidade de vida do doador após transplante hepático intervivos. MÉTODOS: De um total de 300 transplantes hepáticos, 51 foram de doadores vivos. Doadores com seguimento menor do que 6 meses e os que não quiseram participar do estudo foram excluídos. Os doadores responderam a um questionário de 28 perguntas abordando os vários aspectos da doação, sendo também avaliados dados demográficos e clínicos dos mesmos. RESULTADOS: Trinta e sete doadores aceitaram participar do estudo. Destes, 32 eram parentes de primeiro ou de segundo grau do receptor. O esclarecimento sobre o caráter voluntário da doação foi adequado para todos pacientes. Apenas um (2%) não doaria novamente. A dor pós-operatória foi pior do que o esperado para 22 doadores (59%). O retorno às atividades normais ocorreu em menos de 3 meses para 21 doadores (57%). Vinte e um doadores (57%) tiveram perda financeira com a doação devido a gastos com medicamentos, exames, transporte ou perda de rendimentos. Trinta e três (89%) não tiveram modificação ou limitação na sua vida após a doação. Os aspectos mais negativos da doação foram a dor pós-operatória e a presença de cicatriz cirúrgica. A maioria das complicações pós-operatória foi resolvida com o tratamento clínico, mas complicações graves ou potencialmente fatais ocorreram em dois pacientes. CONCLUSÕES: A maioria dos doadores apresentou boa recuperação e retornou completamente as suas atividades normais poucos meses após a doação. O aspecto mais negativo da doação foi a dor pós-operatória.

Impact of successful liver transplantation on reproductive function and sexuality in women with advanced liver disease

Abnormalities in the reproductive function and sexuality, which are common among women with advanced liver disease, may reverse after successful liver transplantation (LT). To analyze reproductive function and sexuality in women who underwent successful LT, we interviewed 28 recipients (mean age 44.17 +/- 13.6 years old) at a median posttransplant survival of 36.5 months (range, 6 to 110 months), with good graft function and obeying regular follow-up at our institution. In addition to medical records, all subjects answered a questionnaire on their menstrual pattern, sexual activity, contraceptive practice, pregnancy, and sexuality domain. Nineteen of 22 patients in the child bearing age (86.4%) recovered menstrual function at a median of 1 month after LT (range, 1 to 7 months). Twenty of 28 recipients (71.4%) were sexually active. The most frequent contraceptive practices were barrier methods and tubal ligation. There were four successful pregnancies (one twin) in three patients; five healthy babies were delivered. Overall, 70% of sexually active patients indicated satisfaction with their relationship, 75% had weekly intercourse, and 70% experienced orgasm with intercourse. Eighty percent expressed a desire to receive information concerning sexuality. In conclusion, LT has a positive impact on sexuality and reproductive function in female recipients. It would desirable that LT programs included information regarding these issues for this population.

Prevalence of type 2 diabetes mellitus in Brazilian liver transplant candidates: Negative association with HCV status

Recently, an epidemiological association between hepatitis C virus (HCV) infection and type 2 diabetes mellitus (DM) has been reported in several studies, although many of them did not consider known risk factors in the pathogenesis of type 2 DM. The aim of this study was to assess the prevalence of type 2 DM among Brazilian HCV (+) and HCV (-) liver transplant candidates, analyzing known confounding factors for the development of type 2 DM. We conducted a cross-sectional study to evaluate the prevalence of type 2 DM among 106 liver transplant adult candidates, comparing 36 HCV (+) cirrhotic patients with 70 HCV (-) patients who developed cirrhosis from other causes. Type 2 DM was diagnosed after two consecutive fasting glucose values > or =126 mg/dL. The age, sex, and race distribution, severity of liver disease (Child-Pugh score), and family history of DM were similar in both groups, but the mean body mass index (BMI) was higher in the HCV (-) subjects (26.81 +/- 5.29 vs 24.0 +/- 4.71, P < .01) Most of the patients were Caucasians (70.75%). Type 2 DM was detected in 36.11% of HCV (+) group and in 25.71% of the HCV (-) (P = .27). A multivariate analysis revealed that family history of DM was the only significant independent predictor for DM (odds ratio = 2.55, 95% CI = 1.03 to 6.31, P = .04). In conclusion, our study did not show an association between HCV infection and Type 2 DM in Brazilian liver transplant candidates. It confirmed that the family history of DM was a determinant factor for the development of type 2 DM.

Prevalence of malnutrition in liver transplant candidates

OBJECTIVE

To determine the prevalence of malnutrition among liver transplant (LT) candidates.

MATERIALS AND METHODS

A prospective study evaluated 219 adult LT candidates including 141 men and 78 women. Cholestatic disease was present in 21 (Child: A = 1, B = 11, and C = 9) and noncholestatic disease in 198 (Child: A = 12, B = 93, and C = 93. The mean age was respectively 45.6 and 46.5 years. Anthropometric and biochemical assessments were performed for statistical analysis using Student t test (P <.05).

RESULTS

In the noncholestatic group, 41.5% were obese according to keep a body mass index (BMI); 61.6% were depleted according to adequacy of tricipital skin fold (%TSF); and 71.1% were above normal levels for generalized adipose reserve (%F). In terms of adequacy of mid-upper arm muscle circumference (%MMC), 58% were depleted and 50.5% were depleted for the current body weight/usual body weight (%CBW/UBW). Otherwise 52.2% of current body weight/ideal body weight (%CBW/IBW) values were above normal. Serum albumin was below normal in 64.9% of cases. In the cholestatic group 62% were normal for BMI; 66.7% were depleted for %TSF; 77.8% were above normal for %F. As to %MMC, 47.6% were depleted and 47.6% were depleted for %CBW/UBW. Otherwise 47.6% were above normal weight for %CBW/IBW. Serum albumin was below normal in 53.9% and %MMC values showed statistically significant differences (P =.02) when compared with Child B and C in the noncholestatic group, as well as %F (P =.01) and serum albumin (P =.0002) in the cholestatic and noncholestatic groups. Serum albumin values also showed statistically significant differences (P =.0004) when noncholestatic Child B and C patients were compared.

CONCLUSION

Patients with cholestatic disease were more affected by calorie depletion compared to noncholestatic patients who were more affected by protein depletion.

Donor quality of life after living donor liver transplantation

Living donor liver transplantation (LDLT) for children and adults has gained widespread acceptance due to the severe organ shortage. LDLT provides potential recipients with timely transplantation, but this procedure engenders a potentially significant risk to the donor. This study analyzed medical, functional, and psychological donor outcomes after LDLT. Nineteen donors (mean age 33.9 +/- 12 years), who underwent hepatectomy for LDLT (13 right lobectomy for adult LDLT) from March 1998 to November 2002, were interviewed at a median of 13 months after donation (range, 2 to 58 months). According to the Clavien System classification, major complications occurred in three donors (16%), and minor in four (21%). The mean length of hospital stay was 5.7 +/- 1.6 days. Five patients (27%) needed rehospitalization. Complete recovery was achieved at a mean time of 8.5 +/- 3.5 weeks. All 19 donors were able to return to predonation activities. The donor's relationship to the recipient and to their families was improved after donation in all cases; 12 (63%) cited a positive psychological impact on their lives. About 90% would donate again and 84% would recommend donation to someone contemplating it. In conclusion, all donors are alive and well after donation and were able to return to their predonation occupation. Most of them felt that this experience changed their lives for the better and would donate again. Donor safety and quality of life should remain the priority in all donation processes.

Função sexual e reprodutiva em receptoras de transplante hepático

RACIONAL: Anormalidades na função sexual e reprodutiva são comuns em pacientes com hepatopatia crônica avançada e podem ser revertidas após transplante hepático bem-sucedido. OBJETIVO: Avaliar aspectos da função sexual e reprodutiva em mulheres submetidas a transplante de fígado no Serviço de Transplante Hepático do Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, PR. PACIENTES E MÉTODOS: Entre setembro de 1991 e dezembro de 2001, 94 mulheres foram submetidas a transplante hepático. Vinte e oito delas (idade média 44,17 ± 13,60 anos) preencheram os seguintes critérios de inclusão: idade > 16 anos na época do transplante, sobrevida pós-transplante > 6 meses, estar em acompanhamento regular no Serviço na época do estudo e concordância em participar do mesmo. Os prontuários médicos foram revisados e as pacientes responderam a um questionário abordando padrão dos ciclos menstruais no pré e pós-transplante, gravidez no pós-transplante, métodos contraceptivos no pré e pós-transplante, freqüência de realização de citologia oncótica cervical no pré e pós-transplante, ocorrência de neoplasia ginecológica pós-transplante, além de questionário específico para o domínio da sexualidade no período pós-transplante. RESULTADOS: A mediana do tempo de seguimento pós-transplante das 28 pacientes foi de 36,5 meses (6-110 meses) e a principal indicação para o transplante foi cirrose associada à hepatite C (25%). Todas as pacientes apresentavam função normal do enxerto. Excluindo-se 6 pacientes em menopausa (natural ou cirúrgica), 13 das 22 pacientes (59,1%) com potencial de menstruar apresentavam amenorréia no ano anterior ao transplante. Dezenove dessas 22 pacientes (86,4%) reassumiram os ciclos menstruais após o transplante, com mediana de 1 mês pós-transplante (1 a 7 meses). Todas as pacientes com idade inferior a 45 anos voltaram a menstruar após o transplante. Quatro gestações bem-sucedidas ocorreram em três pacientes, sendo uma gestação gemelar. Cerca de 70% das transplantadas realizavam exame de citologia oncótica cervical pelo menos uma vez ao ano. Um caso de carcinoma adenoescamoso de endométrio foi identificado em uma paciente de 64 anos, 36 meses após o transplante, tratado cirurgicamente com sucesso. Cerca de 71,4% das pacientes referiram vida sexual ativa pós-transplante, sendo que 70% delas consideravam-na satisfatória. CONCLUSÕES: Após transplante hepático bem-sucedido, a maioria das mulheres em idade fértil reassumem os ciclos menstruais poucos meses após o transplante, tornando possível a ocorrência de gestações. Devido ao rápido retorno da libido e da fertilidade, as pacientes devem ser esclarecidas sobre métodos contraceptivos seguros após o transplante. A maioria das pacientes apresenta vida sexual ativa e satisfatória e realiza regularmente citologia oncótica cervical.

Successful twin pregnancy after orthotopic liver transplantation

AIM

Report of a case of successful twin pregnancy following liver transplantation.

PATIENT AND METHOD

A 42-year-old nulliparous-woman was subjected to an orthotopic liver transplantation due to Budd-Chiari syndrome. Sixteen months after the transplantation, an ultrasonography revealed twin pregnancy. Her prenatal course was uneventful, except for mild arterial hypertension. The immunosuppressive agents used during pregnancy were cyclosporine and prednisone.

RESULT

The patient gave birth to two healthy girls at 37 weeks of gestation. The patient's postpartum course was uneventful with normal liver and renal function tests.

CONCLUSION

Following successful pregnancy, women may become pregnant and give birth to normal children, including twins

[Nutritional therapy in liver transplantation]

BACKGROUND

Malnutrition, sometimes severe is common in patients with chronic hepatic diseases who are candidates for liver transplantation. Nutritional therapy can induce partial or total correction of such deficiencies, improving clinical conditions and prognosis of patients who face the great defiance of liver transplantation.

AIMS

Brief revision of hepatic role in the metabolism of several nutrients. Description of available methods of dietary therapy and its application both under different abnormal hepatic conditions and pre and post-transplant periods. The role of nutritional intervention in metabolic side effects due to immunosuppressive drugs.

CONCLUSION

Nutritional therapy is a valuable adjuvant resource to the clinical treatment of candidates and submitted patients to hepatic transplantation providing better prognosis and improved life quality.

[Hepatopulmonary syndrome in liver transplantation candidates]

BACKGROUND

Hepatopulmonary syndrome is an important clinical problem associated with chronic liver disease. Liver transplantation can result in complete resolution of the arterial hypoxemia associated with this syndrome, even in its most severe presentation.

AIM

To determine the prevalence of hepatopulmonary syndrome in adult liver transplant candidates.

PATIENTS AND METHODS

Fifty-four consecutives adult patients (> or = 18 years) with severe liver disease waiting for liver transplant were screened for arterial hypoxemia (PaO2 < 70 mm Hg) while they were seated, at rest, and breathing room air. Patients with arterial hypoxemia underwent contrast-enhanced two-dimensional echocardiography and pulmonary function testing. Hypoxemia (PaO2 < 70 mm Hg) was present in 7 of 54 patients (12.9%), although only 1 of them complained of dyspnea. The Child's classification of the patients were: A = 1, B = 4, and C = 1. All seven hypoxemic patients had positive contrast-enhanced two-dimensional echocardiography, consistent with hepatopulmonary syndrome.

CONCLUSION

The prevalence of hepatopulmonary syndrome in adult liver transplant candidates is elevated. The screening for hepatopulmonary syndrome should be part of the routine evaluation of liver transplant candidates even in the absence of pulmonary symptoms.

[Results of liver transplantation in patients with hepatocellular carcinoma]

BACKGROUND

Hepatocellular carcinoma is one of the most common malignancies worldwide. Liver transplantation has emerged as a good option for early-stage hepatocellular carcinoma yielding survival rates as good as for recipients without this type of tumor.

OBJECTIVE

To assess the outcome of cirrhotic patients with hepatocellular carcinoma undergoing liver transplantation at the Liver Transplantation Service of the "Hospital de Clinicas", Federal University of Paraná, Curitiba, PR, Brazil.

METHODS

Retrospective study of cirrhotic patients with hepatocellular carcinoma undergoing orthotopic liver transplantation at the mentioned Institution between September 1991 and September 2000. The diagnosis of hepatocellular carcinoma was established during the pretransplant workup in five patients and the tumor was an incidental finding in the native liver in three. The indication for liver transplantation was restricted to solitary tumor equal to or less than 5 cm or up to 3 nodules, with each nodule measuring less than 3 cm, and no evidence of vascular invasion or extrahepatic spread. Patient survival and evidence of tumoral recurrence posttransplant were evaluated.

RESULTS

The most common cause for pretransplantation liver disease was hepatitis C virus (50%). On examination of the explanted liver, the majority of patients (6/8, 75%) had a single lesion; one patient had two nodules and one had a multifocal hepatocellular carcinoma found incidentally in the native liver. Tumor size ranged from 0.2 to 5.0 cm. All cases had neither vascular invasion nor linfonodal envolvement. All patients remained alive and free of tumor recurrence at the time of the study with a mean follow-up of 18.5 months (range, 5-29 months).

CONCLUSION

Liver transplantation is a good therapeutic option for early stage hepatocellular carcinoma arising in cirrhotic patients. With proper selection, liver transplantation can offer excellent survival rates free of tumor recurrence.

[Return to work of adults after liver transplantation]

BACKGROUND

Orthotopic liver transplantation is an established therapy for patients with end-stage liver disease. In the last years more attention has been given for the improvement of the quality of life after liver transplantation, and the return to important life pursuits, such as employment, are important goals of this type of therapy.

AIM

To assess the work's return rate in liver transplant recipients and the reasons for inability after liver transplant.

PATIENTS AND METHODS

Forty-one adults (age > or = 18 years) who underwent liver transplantation at our institution, between September 1991 and June 1999, with a post-transplant survival > or = 9 months, good graft function and a regular clinical follow-up were enrolled for the study. A questionnaire that measured aspects of inactivity before and after liver transplantation had been applied.

RESULTS

Thirty-one of 41 patients were unable to work due end-stage liver disease before liver transplantation. Return to work was observed in 28 of 41 patients (68%) in a mean time of 5.9 months after the surgical procedure. Eleven of 28 active patients after liver transplant (39%) contribute significantly to family income. The reasons for inactivity after liver transplantation were: early retirement (n = 5), unemployment (n = 4), and physical disability (n = 4).

CONCLUSION

Successful liver transplantation not only improves the survival rate but allows patients to return to social function and workforce.

[Apoptosis as a mechanism of tissue injury in hepatobiliary diseases]

BACKGROUND

Cell death by apoptosis is a fundamental biologic process involved in many physiologic and pathophysiologic processes in the liver.

OBJECTIVE

To review the process of apoptosis, its cellular mechanisms, its regulation by external factors, and its role in pathophysiologic process and specific diseases of the liver.

CONCLUSION

An understanding of the cellular mechanisms of apoptosis and their dysregulation during pathophysiologic disturbances will help in understanding human liver diseases. The modulation of apoptosis may lead to novel therapeutic strategies for the treatment of a wide range of liver diseases.

Complicações vasculares pós-transplante hepático

OBJETIVO: O objetivo do estudo é apresentar as complicações vasculares arteriais e venosas observadas em um serviço de transplante hepático universitário brasileiro. MÉTODOS: Os prontuários de todos os pacientes submetidos a transplante hepático no período de setembro de 1991 a janeiro de 2000 foram analisados para determinar as complicações vasculares e correlacioná-las a dados clínicos e do procedimento cirúrgico. RESULTADOS: Foram realizados 169 transplantes, sendo quatro inter vivos e nove retransplantes. Um total de 24 complicações vasculares (14,3%) foi identificado em 22 pacientes (13,0%). A complicação vascular mais comum foi a trombose da artéria hepática (15 casos), seguido da trombose da veia porta (quatro casos). Complicações da veia cava inferior infra ou supra-hepática foram incomuns, ocorrendo em um total de três casos (1,8%). As complicações vasculares foram mais freqüentes nas crianças (26,06%) do que em adultos (13,14%) (p<0,05). Dos pacientes com trombose da artéria hepática, um foi submetido à angioplastia, um a trombectomia, oito a retransplante e cinco evoluíram para o óbito enquanto aguardavam retransplante. Dos quatro casos de trombose da veia porta, dois foram a óbito, um foi submetido à colocação percutânea de prótese e um a tratamento conservador. Os pacientes com estenose da veia porta e da veia cava inferior infra e supra-hepática foram submetidos a tratamento conservador, com boa evolução clínica. CONCLUSÕES: que as complicações vasculares são freqüentes após o transplante hepático, principalmente em crianças, e são associadas à elevada morbidade, mortalidade e retransplante.

Fatores de risco e conduta nas complicações do trato biliar no transplante hepático

A reconstrução biliar é um dos pontos vulneráveis do transplante hepático apresentando incidência de complicações biliares, variando de 10 a 35%, nos diversos estudos da literatura. Esse trabalho tem por objetivo apresentar a experiência do nosso serviço em relação à incidência e ao manejo das complicações biliares no transplante de fígado. Foram incluídos no estudo 147 transplantes hepáticos ortotópicos, com idade média de 37,3 anos, correspondendo a 88 procedimentos em pacientes do sexo masculino e 59 do sexo feminino. Complicações biliares ocorreram em 27 transplantes (18,36%) em 25 pacientes (dois retransplantes). A presença de rejeição celular e de complicações vasculares foi identificada como fator de risco para as complicações biliares. A idade, o sexo, a etiologia da cirrose e a técnica utilizada na reconstrução biliar não foram fatores de risco. No total, foram empregados 52 cursos terapêuticos: tratamento cirúrgico em 23 vezes; tratamento endoscópico em 15 vezes; retransplante em sete vezes; drenagem biliar transparieto-hepática em seis vezes e um paciente está em lista de espera para retransplante. Conclui-se deste estudo que as complicações biliares são freqüentes após o transplante hepático e que as vasculares e a rejeição celular são fatores de risco.

[Benign recurrent intrahepatic cholestasis: a seven-year follow-up report]

Benign recurrent intrahepatic cholestasis is a rare autosomal recessive disorder characterized by repeated episodes of intense pruritus and jaundice. Patients are completely asymptomatic for months to years between symptomatic periods. We report a case of a patient with a 7-year history of benign recurrent intrahepatic cholestasis. During the follow-up period the patient has suffered three attacks of cholestasis, confirmed by biochemical tests and histological exam. Liver enzymes were normal between the cholestasis episodes. Despite multiple attacks of cholestasis, no permanent liver damage has occurred. Although the diagnosis of benign recurrent intrahepatic cholestasis is rare, it should be included in the evaluation of a patient with cholestasis. The patients should be reassured of the benign course of this disorder.

[Acute cholestatic hepatitis induced by propylthiouracil. Case report]

Propylthiouracil is widely used to treat patients with hyperthyroidism. However, propylthiouracil-induced hepatitis is an uncommon entity. The case of a 15-year-old boy treated with propylthiouracil for hyperthyroidism who developed a cholestatic acute hepatitis is reported. Viral, metabolic and autoimmune liver diseases were excluded and liver biopsy showed a pattern suggestive of drug-induced cholestatic hepatitis. After discontinuing the drug, there was a progressive resolution of symptoms and normalization of liver biochemical tests. Despite its rarity, patients receiving propylthiouracil are exposed to develop severe hepatotoxicity.

[Normalization of menstrual cycles and pregnancy after liver transplantation]

The objective of the present study is to evaluate the effects of successful liver transplantation on menstrual cycles abnormalities and on reproductive function of women with chronic liver disease. Twelve women with age between 17 and 54 years who underwent liver transplantation were evaluated. The following variables were analyzed: age, etiology of chronic liver disease, pattern of menstrual function and period of amenorrhea before and after transplantation, and occurrence of pregnancy after transplantation. The mean age of patients was 36 +/- 12.6 years. Patients with primary biliary cirrhosis did not have menstrual abnormalities before transplantation. The other patients presented amenorrhea for 3 months to 11 years before the transplantation. Rapid recovery of menstrual function was observed in all patients after the transplantation (3.1 +/- 1.2 months). Two patients became pregnant one and three years after the transplantation. It is concluded from this study that most women who present amenorrhea secondary to chronic liver disease have normal menstrual cycles in approximately three months following liver transplantation and they may become pregnant.

[Multicenter study on the prevalence of hepatitis C virus infection in blood donors in the city of Curitiba, Brazil]

In order to check the presence of anti-HCV in the blood of voluntary blood donors in four of the most active blood banks of Curitiba, PR, Brazil a third generation immunoassay (Murex--version III, ABBOTT AxSYM HCV version 3.0) was used. The study detected 347 positive cases, i.e. a median prevalence of 0.80% (range 0.64%-1.11%). Only 44 from the 347 anti-HCV positive blood donors had elevated values of serum aminotransferases (12.68%). Such low values of ALT suggest that the confirmatory RIBA should be applied to the remnant 303 anti-HCV positive cases (87.32%) which did not show elevation of ALT, with the expectation that 30% to 40% of them might be positive. The prevalence of anti-HCV in blood donors in Curitiba seems similar to published data in the Brazilian medical literature.

[Amantadine-HCL in the treatment of chronic hepatitis C in non-responders to alpha-interferon. Effect on ALT serum levels and viral load]

Due to the limited efficacy of alpha-interferon for chronic hepatitis C amantadine has been proposed as a possible alternative method of treatment. However, few studies about efficacy of amantadine in chronic hepatitis C are available with controversial results. Stimulated by recent data in the literature, we studied the effect of 100 mg of amantadine HCL (alone) PO bid, for a four month period on alanine aminotransferase serum levels and viral load in a cohort of 18 patients (14 males and 4 females) with chronic hepatitis C, non-responders to alpha-interferon. Inclusion criteria were: detectable serum HCV-RNA, alanine aminotransferase above the upper limit of normal, chronic inflammation on liver biopsy, no other associated chronic liver disease and written informed consent. Available biopsies showed initially four cases of cirrhosis, six of chronic persistent hepatitis and eight of chronic active hepatitis. The most prevalent HCV genotypes were 3a (n = 9, 52.94%) and 1b (n = 6, 32.29%). Viral load (Amplicor HCV Monitor, Roche, USA) and alanine aminotransferase levels were obtained at baseline and after four months of treatment. All patients enrolled into the study but one completed the treatment. One patient discontinued amantadine due to severe depression. No significant reduction was observed between baseline and final values of alanine aminotransferase (139.118 +/- 79.789 vs. 99.588 +/- 62.583 U/L, P = 0.059) and viral load (7.154 +/- 1.596 vs. 6.574 +/- 1.584 log copies/mL, P = 0.147). Amantadine alone was not effective neither eradicating viremia nor normalizing alanine aminotransferase levels in chronic hepatitis C non-responders to alpha-interferon patients. It is suggested that only a study with amantadine alone in-patients without previous treatments could determine its efficacy in comparison with alpha-interferon.

Isolated tuberculosis of the pancreas after orthotopic liver transplantation

A patient presented with intermittent high fever, upper abdominal pain, and loss of appetite 9 months after an orthotopic liver transplantation. Computed tomography showed a large mass in the pancreas that was confirmed at laparotomy. Pathological examination of the pancreatic biopsy specimen showed several chronic granulomatous lesions with caseating necrosis. Two and one half months after beginning antituberculous treatment, there was an important reduction of the pancreatic mass.