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INTRODUCTION: In 1994 our group began its experience with pediatric liver transplantation. The experience gained during this period is the largest in the country, positioning the Hospital Luis Calvo Mackenna and Clinica Las Condes as major referral centers in the public and private sectors. The aim of this study was to report our experience of our pediatric liver transplantation program during this period. METHODS: The liver transplantation database of Hospital Luis Calvo Mackenna and Clinica Las Condes between January 1994 and July 2011 was reviewed recording age, gender, indications for transplantation, surgical technique, complications, and survival. Survival rates were calculated using Kaplan-Meier analysis. RESULTS: During the period described 230 transplantations were performed in 189 pediatric patients. Fifty-five percent were male patients. The average age was 5 years. The main causes of transplantation were biliary atresia (50%), fulminant hepatic failure (25%), and other cholestatic diseases by 10%. Vascular and biliary complications were the leading cause of graft loss and retransplantation. The overall rate of retransplantation at 5 years was 20%. The technique of living donor was used in 28% of the cases. The 1-year patient actuarial survival rate was 80%, 73% at 5 years, and 68% at 10 years. In the last 3 years the survival rate at 1 year exceeds 90%. DISCUSSION: Our program includes more than 90% of the national liver experience. The incorporation of living donor is a milestone that has enabled us to save many patients who previously died while waiting for an organ. Its use in cases of full acute liver failure has allowed us to dramatically reduce mortality on the waiting list. Our results in the last 3 years reflect the experience that results in a significant decrease in mortality, comparing favorably to other series published in the international literature.
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Trasplante de Hígado , Factores de Edad , Preescolar , Chile , Femenino , Supervivencia de Injerto , Humanos , Estimación de Kaplan-Meier , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/mortalidad , Donadores Vivos/provisión & distribución , Masculino , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/cirugía , Evaluación de Programas y Proyectos de Salud , Reoperación , Factores de Riesgo , Tasa de Supervivencia , Factores de Tiempo , Resultado del Tratamiento , Listas de EsperaRESUMEN
BACKGROUND: Orthotopic liver transplantation is the treatment of choice for most terminal liver diseases in children. In small children (≤ 10 kg), this procedure is challenging and has special considerations. The aim of this study is to describe the experience of a Chilean liver transplantation program in this subgroup of patients. METHODS: The liver transplant database of Hospital Luis Calvo Mackenna and Clinica Las Condes was reviewed. All children less than 10 kg undergoing liver transplantation between January 1994 and July 2011 were included. Patient and graft outcomes and main complications were analyzed. RESULTS: We have performed 230 pediatric liver transplantations, 49 of them in 41 patients weighing less than 10 kg. The first indication for transplantation was biliary atresia in 25 patients (61%). A living related donor was used in 23 cases (51%). Actuarial survival was 75.7% at 1 year and 67.1% at 5 years. The main cause of death was infection, and the leading cause of graft loss was vascular complication. DISCUSSION: Our transplant program includes 2 centers that perform more than 90% of pediatric liver transplantations in Chile, including public health pediatric patients from all around the country. Patients weighing less than 10 kg represent the most challenging group in pediatric liver transplantation due to higher rates of vascular and biliary complications and postoperative infections.
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Peso Corporal , Trasplante de Hígado , Factores de Edad , Chile , Enfermedades Transmisibles/etiología , Enfermedades Transmisibles/mortalidad , Estudios Transversales , Femenino , Rechazo de Injerto/etiología , Rechazo de Injerto/mortalidad , Supervivencia de Injerto , Humanos , Lactante , Estimación de Kaplan-Meier , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/mortalidad , Donadores Vivos , Masculino , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: Renal transplantation is the most successful therapy to improve survival and quality of life for patients with end-stage renal disease. Living donors have been used as an alternative to reduce the stay on the waiting list. Laparoscopic living donor nephrectomy has become the standard procedure for renal transplantation. Minimally invasive surgery involves less postoperative pain with less analgesic requirements allowing shorter hospital stay for the donor. MATERIAL AND METHODS: We retrospectively analyzed demographic and intraoperative data and surgical complications for 46 patients who underwent laparoscopic living donor nephrectomy between March 2001 and March 2011. RESULTS: Mean donor age was 41 years. Mean operative time was 170 ± 45 minutes. The average cold ischemic time was 40 minutes and warm ischemic time was 26 minutes. Twenty-one patients were donors for pediatric receptors. Fourty patients underwent left laparoscopic nephrectomy, the other 6 patients underwent right laparoscopic nephrectomy due to vascular anatomic variant. Right laparoscopic nephrectomy was converted in 1 case (2.2%) due to renal vein laceration without donor morbidity and without compromise of graft function. Renal function at the second day post donor nephrectomy was measured using serum creatinine averaged 1.2 mg/dL with a mean increase of 0.4 mg/dL from baseline, with normalization after 30 days. No patient required blood transfusion, and there were no immediate surgical complications, infections, or mortality. One patient developed an incisional hernia in relation to the site of kidney removal. The mean hospital stay was 5 ± 1 days. CONCLUSIONS: Laparoscopic nephrectomy in our experience is a safe technique without postoperative morbidity or mortality. It is associated with low levels of pain, early discharge and early return to physical activity and work, good sense of aesthetic results, and long-term graft function comparable to traditional nephrectomy and cadaveric grafts.
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Trasplante de Riñón/métodos , Laparoscopía , Donadores Vivos , Nefrectomía/métodos , Adulto , Biomarcadores/sangre , Chile , Isquemia Fría , Creatinina/sangre , Femenino , Humanos , Trasplante de Riñón/efectos adversos , Laparoscopía/efectos adversos , Tiempo de Internación , Masculino , Nefrectomía/efectos adversos , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Isquemia TibiaRESUMEN
Cortisol production in adipose tissue is regulated by 11ß-HSD1. Objective. To determine whether there are differences in gene expression, enzyme activity, and protein content of the 11ß-HSD1 enzyme in VAT (visceral adipose tissue) and SAT (subcutaneous adipose tissue) from obese compared to nonobese adults. Methods. VAT and SAT samples were obtained from 32 obese subjects (BMI > 30 Kg/m(2)) who underwent bariatric surgery and 15 samples from controls submitted to elective surgery. Fasting serum glucose, insulin, and lipids were measured. The expression of 11ß-HSD1 was determined by RT-PCR, the enzyme activity by thin-layer chromatography, and the protein content by Western blot. Results. Obese patients had higher cholesterol, insulin, and HOMA-IR compared to nonobese. There were no differences in VAT or SAT expression of 11ß-HSD1 between obese and nonobese patients. However, we found lower 11ß-HSD1 activity and protein content in VAT, in obese women versus nonobese women (P < 0.05). BMI and 11ß-HSD1 enzyme activity and protein content in VAT correlated inversely in women. Conclusions. Regulation of 11ß-HSD1 activity in VAT from obese subjects appears to be gender specific, suggesting the existence of a possible protective mechanism modulating this enzyme activity leading to a decrease in the production of cortisol in this tissue.
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Low-risk renal transplant recipients treated with standard immunosuppressive therapy including interleukin-2 receptor (IL-2R) antagonist show a low incidence of early rejection episodes but few reports have examined the incidence and severity of late rejection processes. This study evaluated retrospectively cellular and antibody-mediated rejection (AMR) among 42 recipients selected because they showed low panel-reactive-antibodies, short cold ischemia time, no delayed graft function, and therapy including basiliximab (Simulect) induction. The mean observation time was 6.6 years. Sixty-seven percent of donors were deceased. Ten-year patient and death-censored graft survivals were 81% and 78%, respectively. Seven patients lost their kidneys due to nonimmunologic events. The seven recipients who experienced cellular rejection episodes during the first posttransplant year had them reversed with steroids. Five patients displayed late acute AMR causing functional deterioration in four cases including 1 graft loss. De novo sensitization occurred in 48% of recipients including patients without clinical rejection. In conclusion, long-term follow-up of kidney transplant recipients selected by a low immunologic risk showed a persistent risk of de novo sensitization evolving to acute AMR in 11% of cases. Although immunologic events were related to late immunosuppressive reduction, most graft losses were due to nonimmunologic factors.
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Anticuerpos Monoclonales/administración & dosificación , Rechazo de Injerto/prevención & control , Supervivencia de Injerto/efectos de los fármacos , Inmunidad Humoral/efectos de los fármacos , Inmunosupresores/administración & dosificación , Trasplante de Riñón , Receptores de Interleucina-2/antagonistas & inhibidores , Proteínas Recombinantes de Fusión/administración & dosificación , Enfermedad Aguda , Adulto , Basiliximab , Chile , Enfermedades Transmisibles/etiología , Femenino , Rechazo de Injerto/inmunología , Rechazo de Injerto/mortalidad , Antígenos HLA/inmunología , Humanos , Isoanticuerpos/sangre , Estimación de Kaplan-Meier , Trasplante de Riñón/efectos adversos , Trasplante de Riñón/inmunología , Trasplante de Riñón/mortalidad , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Acute liver failure (ALF) in children is a life-threatening condition, associated with high mortality, and in almost one third of the cases, with no other therapeutic option than orthotopic liver transplant (OLT). The aim of this study was to present our experience with OLT for ALF in pediatric patients in Chile. Patients fulfilling the criteria for ALF who were transplanted in our centers were prospectively included in an excel Microsoft database. We analyzed demographics, etiology, surgical techniques, complications, and long-term results. PATIENTS AND METHODS: Between 1994 and 2009, we transplanted 52 pediatric patients with ALF. The most frequent known etiology was acute hepatitis A in 9 cases (18%), but in 26 cases (50%) it was impossible to determine the etiology. Thirty- one patients were males (63%). The overall mean age was 7.5 years and the mean weight, 28.1 kg. Thirty-five (67%) received a cadaveric graft. Among them in 18 cases (34%) the liver had to be reduced but 17 (33%) received whole livers. There were 17 (33%) recipients of living-related livers. Twenty-two patients needed reoperation, including 13 due to surgical complications (59%) and 9 (41%) as planned interventions. Ten patients were retransplanted. RESULTS: Actuarial survival of patients at 1 year was 80% and at 5 and 10 years, 72%. Graft survival at 1 year was 79%, at 5 years 69%, and at 10 years 50%. CONCLUSION: We have reported a series of pediatric liver transplant patients due to ALF whose results were comparable to other reported series. Living donor transplantation for ALF should be considered and offers a low morbidity rate without mortality.
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Fallo Hepático Agudo/epidemiología , Trasplante de Hígado/efectos adversos , Cadáver , Niño , Chile , Femenino , Estudios de Seguimiento , Hepatitis A/complicaciones , Hepatitis Viral Humana/complicaciones , Humanos , Fallo Hepático Agudo/cirugía , Fallo Hepático Agudo/virología , Trasplante de Hígado/mortalidad , Donadores Vivos , Masculino , Enfermedades Metabólicas/complicaciones , Tasa de Supervivencia , Donantes de TejidosRESUMEN
Alemtuzumab (ALT), a humanized monoclonal anti-CD52 antibody, was introduced in solid organ transplantation as an induction agent. ALT associated with anticalcineurins has provided a low incidence of acute rejection episodes (ARE) and potential tolerogenic properties. We analyzed the clinical outcomes and effects on peripheral Treg of renal transplant recipients treated with ALT. Six-month data on kidney alone or kidney combined with pancreas or liver patients treated with ALT and tacrolimus (TAC) in standard doses were compared with those on renal transplant recipients of similar demography who were not treated with ALT. We evaluated patient and graft survivals, ARE incidence, hematological parameters, renal function, adverse events, and CD4+CD25+FoxP3+ T cells in peripheral blood. Demographics of recipients, donors, and transplants were similar in both groups. Mean HLA mismatch was slightly greater among ALT-treated patients (3.5 vs 2.5). No combined transplantation was performed in the ALT-untreated group. Patient and graft survivals were 100% without rejection or serious infections in both groups. ALT-treated recipients showed anemia and leukopenia in 3 patients as well as severe lymphopenia in 5 recipients, who partially recovered on day 90. Final mean plasma creatinine was 1.4 mg/dL, while calculated creatinine clearance was approximately 65 mL/min in both groups. Mean Treg cell percentage was higher among ALT-treated recipients than the comparative group or healthy controls (P < .05). In conclusion, renal transplantation results obtained using ALT with rigorous immunosuppressive therapy were excellent; serious adverse events and acute rejection were absent. The effect of the increased proportion of Treg cells must be evaluated with longer observation.
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Anticuerpos Monoclonales/uso terapéutico , Anticuerpos Antineoplásicos/uso terapéutico , Rechazo de Injerto/prevención & control , Inmunosupresores/uso terapéutico , Trasplante de Riñón/inmunología , Linfocitos T Reguladores/inmunología , Adulto , Alemtuzumab , Anticuerpos Monoclonales Humanizados , Antígenos CD/inmunología , Antígenos de Neoplasias/inmunología , Autoanticuerpos/sangre , Recuento de Linfocito CD4 , Antígeno CD52 , Femenino , Glicoproteínas/inmunología , Rechazo de Injerto/epidemiología , Supervivencia de Injerto/efectos de los fármacos , Supervivencia de Injerto/inmunología , Antígenos HLA/inmunología , Humanos , Enfermedades Renales/clasificación , Enfermedades Renales/cirugía , Trasplante de Hígado/inmunología , Masculino , Persona de Mediana Edad , Trasplante de Páncreas/inmunología , Tacrolimus/uso terapéutico , Resultado del TratamientoRESUMEN
Steroids have been a cornerstone in renal transplant immunosuppression despite cardiovascular risk and growth impairment in children. New immunosuppressive drugs have allowed early withdrawal or even complete avoidance of steroids. To evaluate a new immunosuppressive protocol with early withdrawal of steroids in a pediatric renal transplant population, we initiated a prospective study in recipients >1 year old who showed low immunologic risk was started. Group A (n = 12) received decreasing doses of steroids until day posttransplant 7 under a regimen of Tacrolimus (FK) and mycophenolate mofetil (MMF). Group B (n = 11) were controls treated with steroids, cyclosporine and azathioprine. In both groups, induction therapy included basiliximab. We evaluated anthropometric and biochemical variables, acute rejection episodes (ARE), and cytomegalovirus (CMV) infection. Mean values and variations for continuous variables were calculated at months 1 and 3 for comparison at the same time using student's t-test and regresion analysis. We obtained mean values at months 1, 3, and 6 for groups A and B of creatinine clearance (mL/min): 86.2 versus 107.4; 76.9 versus 96.6; 73.3 versus 97.9 (P < .05); hematocrit (%) was 27.4 versus 31.8; 29.3 versus 33.9; 32.9 versus 34.3% (P < .05); total cholesterol (mg/dL), 148 versus 195, 139 versus 85, 142 versus 174 (P < .05); creatinine clearance decreased in both groups during follow-up with a smaller slope among group A (P < .05). No differences were observed between the groups in Z height, diastolic and systolic blood pressures at 6 months of follow-up. Serum total cholesterol mean levels at months 1, 3, and 6 were significantly lower among the group withdrawn from steroids (P < .05). Plasma bicarbonate levels were lower among group A than B; there was no difference in blood glucose levels. No AREs and no difference in CMV infections were observed. In conclusion, early withdrawal of steroids with FK and MMF was not associated with a higher incidence of either ARE or CMV infection. Lower levels of cholesterol could imply a reduced cardiovascular risk. Longer follow-up is needed to evaluate the impact of this therapy on renal function and linear growth.
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Corticoesteroides/uso terapéutico , Trasplante de Riñón/inmunología , Corticoesteroides/administración & dosificación , Anticuerpos Monoclonales/uso terapéutico , Azatioprina/uso terapéutico , Basiliximab , Niño , Creatinina/sangre , Ciclosporina/uso terapéutico , Esquema de Medicación , Quimioterapia Combinada , Supervivencia de Injerto , Humanos , Inmunosupresores/uso terapéutico , Trasplante de Riñón/fisiología , Proteínas Recombinantes de Fusión/uso terapéutico , Tacrolimus/uso terapéutico , Factores de TiempoRESUMEN
UNLABELLED: Living donor liver transplantation (LDLT) for patients with acute liver failure (ALF) is still controversial. To be considered a feasible alternative, this therapeutic option should offer similar results to transplants performed with cadaveric grafts, without significant risks for donors. The aim of this study was to compare the outcomes of pediatric patients with ALF who were transplanted with either cadaveric or living donor grafts. PATIENTS AND METHODS: Between March 1994 and February 2007, 149 patients under 18 years were transplanted, including 43 (28.8%) with ALF. We reviewed the demography, etiology, surgical technique, complications, and long-term results in this group. Patient actuarial survival was determined by Kaplan-Meier analysis. RESULTS: The median age of the recipients was 4.8 years (range 1.2 to 18) including 26 boys and 17 girls. Sixteen (37.2%) underwent LDLT. Three patients in the living donor group needed a second graft (18.7%) versus 7 (26%) among the cadaveric group. No mortality or serious morbidity was observed in living donors. Fifteen patients died. Septic and neurologic complications, and primary graft non-function were the most frequent causes of death. All patients died during the first year after liver transplant. Actuarial 1- and 5-year survivals were 65% without a significant difference between the groups. CONCLUSION: Considering that patients with ALF have no chance of survival without transplantation and that cadaveric grafts remain a limited resource, especially in our country, these results showed that LDLT was a valid option for these patients, as well as a secure procedure for the donors.
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Fallo Hepático Agudo/cirugía , Trasplante de Hígado/métodos , Donadores Vivos , Adolescente , Causas de Muerte , Niño , Femenino , Humanos , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/mortalidad , Donadores Vivos/estadística & datos numéricos , Masculino , Padres , Estudios Retrospectivos , Seguridad , Análisis de Supervivencia , Sobrevivientes , Resultado del TratamientoRESUMEN
New immunosuppressive agents are being actively researched to avoid complications of chronic allograft nephropathy (CAN), calcineurin inhibitor (CNI) nephrotoxicity, and posttransplantation cancer. The family of mTOR inhibitors offers a unique immunosuppressive opportunity to avoid CNI toxicity and reduce the incidence of malignancy. Nevertheless, increasing data have demonstrated that sirolimus (SRL), the first mTOR introduced in the treatment of solid organ transplant recipients, induces proteinuria, an adverse event that could produce deterioration of long-term renal function. In this short-term study of patients followed for 1 to 16 months, we examined changes in renal function and proteinuria among renal transplant recipients converted from a CNI-based regimen to an everolimus (EVL)-based one, a recently introduced mTOR inhibitor. Our data showed that renal function can be optimized after conversion to EVL by up to 42% in recipients showing CAN grade 1 or 2, or CNI nephrotoxicity. Importantly, patients who improved their creatinine clearance did not show increased proteinuria measured in a voided specimen as the ratio of urinary protein and creatinine concentration (P/C). These results, if confirmed with long-term follow-up and a larger number of patients, would allow us to consider EVL as a promising agent for maintenance immunosuppressive regimens in kidney transplantation.
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Inhibidores de la Calcineurina , Inmunosupresores/uso terapéutico , Trasplante de Riñón/fisiología , Proteinuria/prevención & control , Sirolimus/análogos & derivados , Sirolimus/efectos adversos , Anciano , Anticuerpos Monoclonales/uso terapéutico , Suero Antilinfocítico , Azatioprina/uso terapéutico , Basiliximab , Ciclosporina/uso terapéutico , Quimioterapia Combinada , Everolimus , Femenino , Humanos , Inmunosupresores/efectos adversos , Trasplante de Riñón/inmunología , Masculino , Persona de Mediana Edad , Ácido Micofenólico/análogos & derivados , Ácido Micofenólico/uso terapéutico , Proteínas Recombinantes de Fusión/uso terapéutico , Sirolimus/uso terapéuticoRESUMEN
INTRODUCTION: Liver transplantation is the only treatment for end-stage liver disease. Not all patients have a favorable outcome. Graft failure secondary to primary nonfunction, vascular complications, or chronic rejection among other problems may lead to retransplantation. Retransplantation represents 8% to 29% of liver transplantations in the pediatric population. The aim of this study was to present our experience with retransplanted children by analyzing the indications and the results. METHODS: All patients were prospectively included in our database, including 125 children. We included the indications for retransplantation, complications, and mortality. Kaplan-Meier curves were used for survival analysis. RESULTS: Since 1994, 125 patients were transplanted and 25 were retransplanted (20%), including 5 who received a third graft. Primary nonfunction represented 30% of the indications for retransplantation and hepatic artery thrombosis, 20%. Six of 25 patients who received a first retransplantation and 2 of 5 who received a second retransplantation died. The most frequent cause of death was multiorgans failure. The survivals at 1 and 5 years were 82% and 76% for children receiving a first retransplantation, and 60% at 1 and 5 years for those who received a second retransplantation. CONCLUSIONS: Organ failure after liver transplantation was a common event in pediatric transplantation. Survival was similar between patients transplanted once and those who received one retransplantation. Survival decreased among patients who received a third graft but was maintained at 60%, which is better than most published results for first retransplanted patients. Retransplantation is a valid option with good results for selected pediatric cases.
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Trasplante de Hígado/fisiología , Reoperación/estadística & datos numéricos , Adolescente , Niño , Preescolar , Humanos , Trasplante de Hígado/mortalidad , Selección de Paciente , Estudios Retrospectivos , Análisis de Supervivencia , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
Between 1989 and 2003, 100 transplants were performed in 96 patients at the pediatric nephrology unit of the Calvo Mackenna Children's Hospital. Mean age 10.9 +/- 3.9 yr (1-17.6), 30% from LD. Donors were younger than 5 yr in five patients and all recipients received an 'en bloc' graft. Original disease was hypo/dysplasia 27%, reflux nephropathy 22 and 17% chronic glomerulonephritis. The immunosuppressive protocol during the first period (n = 56, 1989-2000): Cyclosporine, steroids and azathioprine, and during the second period (n = 44, 2001-2003): FK, steroids, MMF and anti-CD25 antibody (mAbs). AR was reported in 22 patients, 11% in LD, 31% in DD (p < 0.01). The AR rate decreased from 40 to 8% after anti-CD25 monoclonal induction. Patient actuarial survival rate at 1, 3 and 5 yr was 100% for LD and 96% for DD. The overall actuarial graft survival at 1,3, and 5 yr was 96.7, 96.7 and 71% for LD and 89, 76 and 73% for DD donors. Graft survival rate improved from the first period (1989-2000) to the second period (2001-2003; p = 0.05). No difference in graft survival rate with HLA-A,B,DR matching was found. Graft survival rate was better when cold ischemia time was <24 h (p < 0.01). CMV infections increased from 19 to 40% when MMF and anti-CD25 Ab were introduced (p < 0.01). The height/age Z score at 1, 3 and 5 yr post-transplant was -2.2, -2.1, -2.2, respectively, for children older than 7 yr and -1.8, -1.9, -2.1 for those transplanted younger than 7 yr of age who were switched to alternate day steroids (p < 0.01). The cause of graft lost was: chronic rejection eight, non-adherence four, AR four and vascular thrombosis two. The cause of death in two patients was fungus septicemia and accelerated rejection. Pediatric renal transplantation can be performed in our group with acceptable morbidity, low mortality and graft survival rates similar to other reports in North America and Western Europe. Graft survival rate improved with newer immunosuppression and greater experience at the center. Management of non-adherence and chronic rejection remain the major challenges.
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Trasplante de Riñón , Adolescente , Preescolar , Enfermedad Crónica , Femenino , Glomerulonefritis/cirugía , Supervivencia de Injerto , Humanos , Inmunosupresores/uso terapéutico , Lactante , Masculino , Estudios Retrospectivos , Factores de TiempoRESUMEN
Liver transplantation is the only treatment for patients with terminal acute and chronic diseases. Liver transplantation was started in Chile in 1985; our pediatric program began in 1993. The aim of this paper work was to present our experience from 1993 through 2004. One hundred and thirty two orthotopic liver transplants (OLT) were performed in children of mean age 5 years and median age 4 years (8 months to 15 years). The most frequent indications were biliary atresia, (43.1%) and acute liver failure (ALF; 20.4%), whose frequent cause was unknown but viral hepatitis A was the second one. A complete liver was transplanted in 59 patients, reduced in 39, split in one, and as an auxiliary liver in another one. Living related liver transplantation was performed in 32 cases (24.2%), of which thirty included segments II and III, and two, a right liver. A terminal arterial anastomosis was performed in 102 (77.2%) recipients and a graft interposition in 32 patients (24.2%). In 16 cases, biliary reconstruction was performed through an enterobiliary anastomosis. Immunosuppression included cyclosporine (Neoral), steroids, and azathioprine with conversion to tacrolimus (Prograf) as indicated. Rejection episodes, which were always biopsy-proven, were treated either with methylprednisolone or with antibodies. Biliary complications were the most frequent (21.4%) and the second cause was vascular complications (13%). Sixty-six patients suffered an acute rejection episode. Actuarial graft survival was 81.3% at 1 year and 72% at 5 years, while actuarial graft survival for ALF was 75.9% at 1 year and 67.8% at 5 years. Our results are comparable to those reported by most international groups.
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Trasplante de Hígado/fisiología , Adolescente , Infecciones Bacterianas/epidemiología , Niño , Preescolar , Chile , Infecciones por Citomegalovirus/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Inmunosupresores/uso terapéutico , Lactante , Fallo Hepático , Trasplante de Hígado/inmunología , Trasplante de Hígado/mortalidad , Masculino , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Análisis de SupervivenciaRESUMEN
Living related living transplantation (LRLT) has opened new possibilities for planning transplantation in better conditions for children with emergency situations and chronic liver diseases. Since we began the LRLT program in 1999, we have performed 57 pediatric liver transplants, 17 (29.8%) using living related donors (LRD). The aim of this study was to analyze the reasons why LRD were discarded as a therapeutic option. All pediatric patients were prospectively included in our Microsoft Excel database that was reviewed for obtaining information about causes why the LRLT could not be done. LRLT was proposed in 28 cases and performed in 17 (60.7%). The reasons for LRD rejection were: parent's fear of surgical complications in four cases; drug abuse in two; a mother without family support; medical reasons in two; and only one, due to anatomical reasons and in one case, cadaveric graft transplantation was performed while completing the father's evaluation. From these eleven cases, the indications for liver transplant were acute liver failure (ALF) in seven, biliary atresia in three, and Alagille syndrome in one. Nine were transplanted with cadaveric organs, but two patients with ALF died awaiting a liver. Efforts should be made to clarify the advantages and the disadvantages of LRD in each case, allowing parents to make a free, well-informed decision.
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Trasplante de Hígado/estadística & datos numéricos , Donadores Vivos/provisión & distribución , Actitud Frente a la Salud , Niño , Familia , Rechazo de Injerto/epidemiología , Humanos , Donadores Vivos/psicología , Donadores Vivos/estadística & datos numéricos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Different ways have been suggested to expand donor numbers for liver transplantation. Transplantation using ABO-incompatible hepatic grafts has recently been a controversial issue due to the high risk of hyperacute rejection mediated by preformed anti-ABO antibodies. We report three patients with acute liver failure who were transplanted with ABO-incompatible livers: A to O in two patients and A to B in one case. We used pre- and posttransplant total plasma exchange, splenectomy, and triple immunosuppression. All three patients are alive; one graft was lost, probably secondary to thrombotic microangiopathy with low isohemagglutinin titers of 1:8. One patient developed acute cellular rejection that was reversed with a bolus of methylprednisolone. No antibody-mediated rejection occurred. Financial and infectious considerations have to be considered. In our series, the final liver transplantation cost was higher than average for acute liver failure. Plasmapheresis has the highest cost of all the additional procedures. ABO-incompatible liver transplantation, because of the splenectomy it requires, has been associated with more infections due to encapsulated organisms. However, with splenectomy in our three patients, none had infections due to these bacteria. In our country, we do not consider ABO-incompatible liver transplantation as a first-line option, except for highly selected patients.
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Sistema del Grupo Sanguíneo ABO , Incompatibilidad de Grupos Sanguíneos , Fallo Hepático Agudo/cirugía , Trasplante de Hígado/métodos , Adulto , Preescolar , Chile , Femenino , Humanos , Masculino , Resultado del TratamientoRESUMEN
Between 1989 and 2002, 178 renal transplants were performed in 168 pediatric patients in Chile. The mean age was 10.9 +/- 3.7 years (range 1 to 17.9). End-state renal disease etiologies were: congenital renal hypoplasia/dysplasia, chronic glomerulonephritis, and reflux nephropathy. Seventy received a graft from a living donor (LD), and 108 from a cadaveric donor (CD). Only 9% received antibody induction. Acute rejection episodes were reported in 76 patients: 38% in LD recipients and 48% in CD recipients (P = NS). One-, 3-, and 5-year graft survivals were 88%, 84%, and 76%, respectively, for LD and 86%, 79%, and 68% for CD recipients. Actuarial graft survival was significantly better among those patients with serum creatinine < 1 mg/dL at 1 year posttransplant compared with those with creatinine > 1 mg/dL (P < .05). The graft survival rate has improved from the first period (1989 to 1996) to the second period (1997 to 2002); (P = .05). Patient survival rates at 1, 3, and 5 years were 98%, 98%, and 98%, respectively, for LD, and 95%, 94%, and 94% for CD. Global height/age Z-score decreased from -0.7 at birth to -1.5 when dialysis started, and to -2.4 at the time of transplantation. The Z-score height/age at 1, 3, and 5 years posttransplantation was -2.25, -2.24, and -2.5. No significant differences were observed in transplant outcomes comparing patients younger than 7 years with those older ones. In conclusion, pediatric renal transplant has been performed in Chile with acceptable morbidity. The patient and graft survivals are similar to the reported international experience. In the last period there was a significant improvement in graft survival.
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Trasplante de Hígado/fisiología , Adolescente , Cadáver , Niño , Preescolar , Femenino , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Lactante , Enfermedades Renales/cirugía , Trasplante de Hígado/mortalidad , Donadores Vivos , Masculino , Reoperación , Estudios Retrospectivos , Análisis de Supervivencia , Factores de Tiempo , Donantes de TejidosRESUMEN
Our liver transplant program was started in 1993 in a private clinic and a public hospital. Thereafter, a rapid increase in adults and pediatric candidates for this therapeutic option lead to this analysis of results in 165 orthotopic liver transplants (OLT) in 143 patients between November 1993 and December 2002. Seventy-four OLT were performed in 66 adult patients and 91 in the pediatric group. Liver grafts came from cadaveric donors in 145 cases (74 adults and 71 children). The technique of living-related donor was utilized in 20 pediatric cases. Main indications for OLT in the adult group were HCV cirrhosis, primary biliary cirrhosis; biliary atresia and acute liver failure were the indications in pediatric patients. Retransplantation was needed for 23 patients, including 9 adults and 14 children. The most frequent causes of death were sepsis, graft primary nonfunction, and vascular complications. Actuarial survivals at 1 and 5 years were 80.7% and 72.6% for the adult group and 82% and 74.8% for the pediatric group, respectively. Our results are comparable to those published by large, experienced, international centers, with much better financial support.
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Trasplante de Hígado/estadística & datos numéricos , Adolescente , Adulto , Anciano , Causas de Muerte , Chile , Femenino , Estudios de Seguimiento , Humanos , Trasplante de Hígado/mortalidad , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Listas de EsperaRESUMEN
Acute liver failure (ALF) is a severe, life-threatening condition associated with a high mortality rate. The objective of this study is to present the experience of a Chilean liver transplant program with orthotopic liver transplantation (OLT) for ALF. All patients with the diagnosis of ALF evaluated in our program between January 1995 and May 2003 were included in the analyses of etiology and outcomes. Candidates for OLT activated on a national waiting list were transplanted with cadaveric or living-related donor (LRD) organs. Twenty-seven patients age 1 to 19 years (median, 7.4 years) were transplanted at a median weight of 30.7 kg including 17 cadaveric and 10 with LRD livers. Most frequent etiologies were hepatitis A in 10 cases (37%) and unknown in 12 (48.1%). One donor experienced superficial phlebitis. Four patients were retransplanted (14.8%). Twenty patients are alive with 1- and 5-year survival rates of 74.1% At a median follow up of 34 months (range = 2 to 120). Seven patients died due to sepsis, multiorganic failure, graft primary nonfunction, intracranial hemorrhage, and intraoperative cardiac arrest. This experience revealed results comparable to international reports, allowing survival of patients destined to die.
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Fallo Hepático Agudo/cirugía , Trasplante de Hígado/estadística & datos numéricos , Adolescente , Adulto , Niño , Preescolar , Chile , Femenino , Estudios de Seguimiento , Hepatitis A/cirugía , Humanos , Lactante , Trasplante de Hígado/mortalidad , Masculino , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND/AIMS: The presence of aerobic and/or anaerobic bacteria in the liver parenchyma, gallbladder bile, and common bile duct was investigated. MATERIALS AND METHODS: There were 15 control subjects, 32 cases with symptomatic gallstones, 16 patients with common bile duct stones without acute cholangitis and 8 cases with common bile duct stones with an acute suppurative cholangitis. RESULTS: No bacteria were isolated in controls. The percentage of positive cultures in liver parenchyma increased in proportion to the severity of the biliary tract disease. There was no clear correlation between normal and altered hepatic histology and the presence or absence of bacteria except in patients with acute cholangitis. CONCLUSIONS: When biliary tract obstruction is present, the biliary tract is more vulnerable to invasion of bacteria and therefore increases the chance of spread into the liver parenchyma.
Asunto(s)
Bacterias Aerobias/aislamiento & purificación , Bacterias Anaerobias/aislamiento & purificación , Colangitis/microbiología , Colelitiasis/microbiología , Cálculos Biliares/microbiología , Hígado/microbiología , Enfermedad Aguda , Anciano , Bilis/microbiología , Estudios de Casos y Controles , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Manejo de EspecímenesRESUMEN
Among the 424 serum samples examined, the prevalence of hepatitis virus infection turned out to be 89.6%, with 15.6% of HBsAg positivity. Some of the samples belonged to an afferent population and some other to workers of a West Africa rural hospital (Pop. Rep. of Benin). 27.3% of the positive subjects presented active replication of the virus, shown by the presence of HBcAg. Among the HBcAb positive subjects the anti-delta antibodies showed a positivity frequency of 19.7%. HBsAg presence in 15% of pregnant women suggested the importance of HBV mother-foetal transmission in the district. The examined results can be compared with those obtained in other African areas, with similar socio-economic conditions.