RESUMEN
Introduction. Hepatitis C virus (HCV) infection continues to represent a poor prognostic factor in kidney transplant (KTx) patients. New direct-acting antiviral agents (DAA) have dramatically changed the therapy management for HCV, showing promising results in terms of sustained virologic response. Timing for DAA therapy in HCV positive kidney waitlist patients continues to be controversial, and caution is recommended due to the potential difficult immunosuppressant dose adjustments, particularly in the early posttransplant period. We report a case of a KTx performed during antiviral DAA therapy. Report of Case. Patient was a 44-year-old man suffering from chronic HCV hepatitis associated with end-stage kidney disease (ESRD), waitlisted for a second KTx as a sensitized patient (panel-reactive antibody peak 85%) in March 2019. Four months later, antiviral DAA therapy was started (glecaprevir/pibrentasvir 300 mg/120 mg daily, for 8 weeks). After 30 days, a left kidney was offered and, given the good compatibility, we decided to proceed with KTx without discontinuing the DAA therapy. A standard straightforward kidney transplant was performed. Immunosuppression included thymoglobulin and prednisone for induction and tacrolimus and mycophenolate for maintenance. After a transient delay graft function, creatinine levels progressively decreased. From postoperative day 3, tacrolimus reached target levels and remained stable. No episodes of acute rejection occurred. The 8-week DAA therapy was carried out without interruption. All HCV-RNA level controls resulted undetectable. On postoperative day 15, the patient was discharged and remains in healthy condition with normal renal function and HCV negative after 18 months of follow-up. Discussion. In this case, DAA therapy during the perioperative KTx period was well tolerated and effective. If confirmed, patients should not necessarily be suspended from the waiting list during DAA therapy for HCV eradication.
RESUMEN
Kidneys with more than 3 arteries are very rare and decision to use or not these organs can be difficult, because there is an increased risk of post-transplant vascular complications, with a higher risk of worse outcome. Here we report a case of a successful transplant a deceased donor left kidney with 5 arteries, using 2 separate wide patches containing 3 and 2 arteries, respectively. These kidneys should be considered as a source for maximize the number of organs available, but a careful selection of the recipient is also crucial for minimize the risk of complications.
Asunto(s)
Trasplante de Riñón/métodos , Riñón/irrigación sanguínea , Obtención de Tejidos y Órganos , Adulto , Arterias/anomalías , Femenino , Humanos , Riñón/anomalíasAsunto(s)
COVID-19/complicaciones , Fallo Renal Crónico/complicaciones , Trasplante de Riñón , SARS-CoV-2/aislamiento & purificación , Adulto , Anticuerpos Antivirales/sangre , Bacteriemia/complicaciones , Basiliximab/efectos adversos , Basiliximab/uso terapéutico , COVID-19/diagnóstico , Prueba de COVID-19 , Terapia Combinada , Infecciones por Escherichia coli/complicaciones , Femenino , Glomerulonefritis Membranosa/complicaciones , Rechazo de Injerto/prevención & control , Humanos , Hipertensión/complicaciones , Huésped Inmunocomprometido , Inmunosupresores/efectos adversos , Inmunosupresores/uso terapéutico , Fallo Renal Crónico/cirugía , Fallo Renal Crónico/terapia , Nasofaringe/virología , Complicaciones Posoperatorias , Prednisona/efectos adversos , Prednisona/uso terapéutico , Diálisis Renal , SARS-CoV-2/inmunología , Factores de TiempoRESUMEN
Kidney transplantation is the gold-standard therapy for select HIV-positive patients with ESRD. Since the Italian Ministry of Health defined the guidelines for organ donation from HIV-positive persons in 2018, we report the first case of renal transplantation from an HIV-positive cadaveric donor in two HIV-positive recipients in Italy. The donor was a 50-year-old male, deceased due to post-anoxic encephalopathy, with a history of HIV infection in HAART, undetectable viral load, and HCV-related chronic hepatitis that had been previously treated. The first recipient was a 59-year-old female with a prior history of drug addiction, and she suffered from ESRD secondary to HIV nephropathy. The patient followed preoperative HAART with a good viral response and undetectable HIV viral load. She also had a history of HCV-related chronic hepatitis that had been successfully treated. The right kidney was uneventfully transplanted. The patient developed an asymptomatic reinfection of endogenous BK virus. The second recipient was a 41-year-old male with ESRD secondary to polycystic kidney disease. The patient was HIV-positive in HAART, with a good viro-immunologic response and an undetectable HIV viral load. He suffered from a severe form of hemophilia A and HCV-related chronic hepatitis, which had been previously treated with undetectable HCV RNA. The left kidney was uneventfully transplanted. At the end of follow-up, both patients had a healthy condition with stable renal function, a persistently good viral response and undetectable HIV and HCV viral loads. These encouraging preliminary results seem to confirm the safety and effectiveness of kidney transplantation from select HIV-positive donors.
Asunto(s)
Nefropatía Asociada a SIDA/cirugía , Fármacos Anti-VIH/administración & dosificación , Fallo Renal Crónico/cirugía , Trasplante de Riñón/métodos , Nefropatía Asociada a SIDA/complicaciones , Adulto , Aloinjertos/virología , Terapia Antirretroviral Altamente Activa/métodos , Selección de Donante/legislación & jurisprudencia , Femenino , Humanos , Italia , Riñón/virología , Fallo Renal Crónico/etiología , Masculino , Persona de Mediana Edad , Cuidados Preoperatorios/métodos , Resultado del Tratamiento , Carga Viral/efectos de los fármacosRESUMEN
BACKGROUND: Carbapenem-resistant Klebsiella pneumoniae (CR-KP) infections in solid organ transplant patients are progressively increasing and are associated with worse outcomes, although potential risk factors and therapeutic strategies are still not well defined. METHODS: We conducted a retrospective matched-pair analysis in which we compared 26 recipients CR-KP-positive after kidney transplantation (KT) with 52 CR-KP-negative patients transplanted in the same period, during a CR-KP outbreak that occurred in our hospital. Twenty-one patients (80%) received a combined antibiotic treatment. At the end of the follow-up, of the 26 CR-KP infected patients, 11 (42.3%) experienced at least one episode of re-infection, 9 (34.6%) remained colonized, and 6 (23.0%) had a symptomatic infection. Two of the 11 patients with re-infection died, while 9 were colonized at the end of the study. RESULTS: A significantly better patient (P = .043) and graft (P < .001) survival was observed in CR-KP-negative patients. Univariate analysis identified the following variables as potential risk factors associated with CR-KP infection after KT: lower body mass index (P = .020); higher creatinine levels at post-transplant days 7 (P = .009), 15 (P = .026), and 30 (P = .019); longer hospital stay (P = .007); longer cold ischemia time (P = .004); delayed graft function (P = .020); and higher Clavien-Dindo score (P = .006). CONCLUSION: The study confirmed that a CR-KP positivity may affect the outcome of a kidney transplant population. In severe CR-KP infections with sepsis, a combined antibiotic treatment seems to be advisable.
Asunto(s)
Antibacterianos/farmacología , Enterobacteriaceae Resistentes a los Carbapenémicos/aislamiento & purificación , Carbapenémicos/farmacología , Trasplante de Riñón/efectos adversos , Infecciones por Klebsiella/epidemiología , Klebsiella pneumoniae/aislamiento & purificación , Adulto , Anciano , Antibacterianos/uso terapéutico , Enterobacteriaceae Resistentes a los Carbapenémicos/fisiología , Carbapenémicos/uso terapéutico , Funcionamiento Retardado del Injerto/epidemiología , Brotes de Enfermedades , Quimioterapia Combinada/métodos , Femenino , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Incidencia , Italia/epidemiología , Estimación de Kaplan-Meier , Infecciones por Klebsiella/complicaciones , Infecciones por Klebsiella/tratamiento farmacológico , Infecciones por Klebsiella/microbiología , Klebsiella pneumoniae/fisiología , Tiempo de Internación/estadística & datos numéricos , Masculino , Análisis por Apareamiento , Persona de Mediana Edad , Estudios Retrospectivos , Sepsis/complicaciones , Sepsis/tratamiento farmacológico , Sepsis/epidemiología , Sepsis/microbiología , Resistencia betalactámicaRESUMEN
Carbapenem-resistant Klebsiella pneumoniae (CR-KP) infections in solid organ transplant recipients are associated with high morbidity and mortality. We report a case of a fatal donor-derived CR-KP infection in a combined kidney-pancreas transplant. Given the short interval of time between donor hospitalization and organ procurement, information concerning the donor CR-KP positivity arrived only 72 hours after transplant. Based on this experience, we believe that knowledge of the donor's CR-KP status should be mandatory before procurement and, if positive, pancreas donation should be contraindicated.
RESUMEN
Rhodococcus equi is a well-recognized pathogen in veterinary medicine that can also affect immuno-compromised human subjects. The most common clinical features in humans include necrotizing pneumonia with subacute pulmonary disease, progressive cough, chest pain and fever. We report a case of a 49-year-old kidney transplant patient who developed a Rhodococcus equi infection characterized by multiple abscesses of the soft tissues and muscles without any respiratory manifestation. Combining specific antibiotic therapy and surgical management of the abscesses without immunosuppression discontinuation led to a complete recovery of both patient and graft.
Asunto(s)
Infecciones por Actinomycetales/complicaciones , Enfermedades Renales/complicaciones , Enfermedades Renales/cirugía , Trasplante de Riñón , Absceso , Infecciones por Actinomycetales/fisiopatología , Supervivencia de Injerto , Humanos , Inmunoterapia , Trasplante de Riñón/efectos adversos , Persona de Mediana Edad , Rhodococcus equi , Infecciones de los Tejidos Blandos/complicaciones , Infecciones de los Tejidos Blandos/fisiopatologíaAsunto(s)
Neoplasias Renales/complicaciones , Trasplante de Riñón/efectos adversos , Trasplante de Riñón/métodos , Nefrectomía/métodos , Nefronas/cirugía , Insuficiencia Renal/cirugía , Adolescente , Adulto , Aloinjertos , Biopsia , Niño , Creatinina/sangre , Femenino , Estudios de Seguimiento , Humanos , Inmunosupresores/uso terapéutico , Neoplasias Renales/cirugía , Laparotomía , Masculino , Persona de Mediana Edad , Recurrencia , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Split liver transplantation for two adults offers a valuable opportunity to expand the donor pool for adult recipients. However, its application is mainly hampered by the physiological limits of these partial grafts. Small for size syndrome is a major concern during transplantation with partial graft and different techniques have been developed in living donor liver transplantation to prevent the graft dysfunction. Herein, we report the first application of synergic approaches to optimise the hepatic hemodynamic in a split liver graft for two adults. A Caucasian woman underwent liver transplantation for alcoholic cirrhosis (MELD 21) with a full right liver graft (S5-S8) without middle hepatic vein. Minor and accessory inferior hepatic veins were preserved by splitting the vena cava; V5 and V8 were anastomosed with a donor venous iliac patch. After implantation, a 16G catheter was advanced in the main portal trunk. Inflow modulation was achieved by splenic artery ligation. Intraportal infusion of PGE1 was started intraoperatively and discontinued after 5 d. Graft function was immediate with normalization of liver test after 7 d. Nineteen months after transplantation, liver function is normal and graft volume is 110% of the recipient standard liver volume. Optimisation of the venous outflow, inflow modulation and intraportal infusion of PGE1 may represent a valuable synergic strategy to prevent the graft dysfunction and it may increase the safety of split liver graft for two adults.
RESUMEN
Two-stage liver transplantation (LT) has been reported for cases of fulminant liver failure that can lead to toxic hepatic syndrome, or massive hemorrhages resulting in uncontrollable bleeding. Technically, the first stage of the procedure consists of a total hepatectomy with preservation of the recipient's inferior vena cava (IVC), followed by the creation of a temporary end-to-side porto-caval shunt (TPCS). The second stage consists of removing the TPCS and implanting a liver graft when one becomes available. We report a case of a two-stage total hepatectomy and LT in which a temporary end-to-end anastomosis between the portal vein and the middle hepatic vein (TPMHV) was performed as an alternative to the classic end-to-end TPCS. The creation of a TPMHV proved technically feasible and showed some advantages compared to the standard TPCS. In cases in which a two-stage LT with side-to-side caval reconstruction is utilized, TPMHV can be considered as a safe and effective alternative to standard TPCS.
RESUMEN
BACKGROUND/AIMS: Patients with hepatocellular carcinoma on the waiting list for liver transplantation are excluded due to causes related to liver failure and tumor progression. We analyze the various factors to suggest a new liver transplant priority. METHODOLOGY: We evaluated the outcome on the list of 309 patients with hepatocellular carcinoma and causes of drop-out from the list were divided as death, "too sick" and tumor progression. The impact of model for end stage liver disease score, tumor stage and waiting time on the causes of drop-outs was evaluated. RESULTS: During the study period, 197 patients had a liver transplantation, 50 were still on the list and the remaining 62 were removed from the list (28 deaths, 30 tumor progressions, and 4 "too sick"). The receiver operating characteristic curves analysis showed that the model for end stage liver disease score predicted the rate of deaths on the list at 1-year (p<0.001). The waiting time and the tumor stage predicted the rate of drop-outs for tumor progression at 1-year on the list (p<0.05). CONCLUSIONS: Patients with hepatocellular carcinoma on the waiting list should have priority based on their model for end stage liver disease score, waiting time with tumor and tumor stage.
Asunto(s)
Carcinoma Hepatocelular/cirugía , Neoplasias Hepáticas/cirugía , Trasplante de Hígado/estadística & datos numéricos , Adulto , Anciano , Carcinoma Hepatocelular/patología , Femenino , Humanos , Fallo Hepático/clasificación , Neoplasias Hepáticas/patología , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Curva ROC , Índice de Severidad de la Enfermedad , Listas de EsperaAsunto(s)
Íleon/irrigación sanguínea , Íleon/trasplante , Intestinos/irrigación sanguínea , Intestinos/trasplante , Neovascularización Fisiológica , Adulto , Anastomosis Quirúrgica , Aorta Abdominal/patología , Femenino , Rechazo de Injerto , Humanos , Enfermedades Intestinales/terapia , Reoperación , Vena Cava Inferior/patologíaRESUMEN
Impact of hepatitis C virus (HCV) recurrence on long-term outcome after orthotopic liver transplantation (OLT) is highly variable, and the role of retransplantation is still debated. From 1996 to 2003, 131 OLT with histologically proven HCV recurrence and 6 months of follow-up were retrospectively reviewed. One and 5-yr overall survivals were 90.7 and 81.3%, respectively. The mean time of HCV recurrence was 10.1 +/- 6.2 months in patients whose donor's age was less than 70 yr old, and 6.6 +/- 4.7 in patients whose donor's age was more than 70 (P < 0.01). The mean time between OLT and HCV recurrence was 10.7 +/- 8.2 months among patients still alive, and 5 +/- 4.2 among the 20 who died (P = 0.02). In 16 (12.2%) patients, retransplantation was required for severe HCV recurrence; 5 are still alive and 11 (68.7%) died. The mean survival time was 16.2 +/- 6 months if re-OLT was performed within 12 months from first OLT, and it was 45.9 +/- 10 months if re-OLT was performed later (P < 0.01). In conclusion, donors older than 70 yr are at high risk of early HCV recurrence; expectancy of life is significantly reduced in case of histologically proven recurrence within 6 months. Outcome is quite dismal in patients with early HCV recurrence requiring retransplantation within 1 yr of first OLT.
Asunto(s)
Hepatitis C/patología , Hepatitis C/cirugía , Trasplante de Hígado , Adulto , Anciano , Femenino , Estudios de Seguimiento , Rechazo de Injerto/patología , Hepacivirus/fisiología , Hepatitis C/virología , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , ARN Viral/genética , Recurrencia , Tasa de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
The effect of ischemic preconditioning (IPC) in orthotopic liver transplantation (OLT) has not yet been clarified. We performed a pilot study to evaluate the effects of IPC in OLT by comparing the outcomes of recipients of grafts from deceased donors randomly assigned to receive (IPC+ group, n = 23) or not (IPC- group, n = 24) IPC (10-min ischemia + 15-min reperfusion). In 10 cases in the IPC+ group and in 12 in the IPC- group, the expression of inducible nitric oxide synthase (iNOS), neutrophil infiltration, and hepatocellular apoptosis were tested by immunohistochemistry in prereperfusion and postreperfusion biopsies. Median aspartate aminotransferase (AST) levels were lower in the IPC+ group vs. the IPC- group on postoperative days 1 and 2 (398 vs. 1,234 U/L, P = 0.002; and 283 vs. 685 U/L, P = 0.009). Alanine aminotransferases were lower in the IPC+ vs. the IPC- group on postoperative days 1, 2, and 3 (333 vs. 934 U/L, P = 0.016; 492 vs. 1,040 U/L, P = 0.008; and 386 vs. 735 U/L, P = 0.022). Bilirubin levels and prothrombin activity throughout the first 3 postoperative weeks, incidence of graft nonfunction and graft and patient survival rates were similar between groups. Prereperfusion and postreperfusion immunohistochemical parameters did not differ between groups. iNOS was higher postreperfusion vs. prereperfusion in the IPC- group (P = 0.008). Neutrophil infiltration was higher postreperfusion vs. prereperfusion in both groups (IPC+, P = 0.007; IPC-, P = 0.003). Prereperfusion and postreperfusion apoptosis was minimal in both groups. In conclusion, IPC reduced ischemia/reperfusion injury through a decrease of hepatocellular necrosis, but it showed no clinical benefits.
Asunto(s)
Precondicionamiento Isquémico , Trasplante de Hígado/fisiología , Donantes de Tejidos , Adulto , Anciano , Apoptosis , Biopsia , Cadáver , Femenino , Humanos , Trasplante de Hígado/mortalidad , Trasplante de Hígado/patología , Masculino , Persona de Mediana Edad , Proyectos Piloto , Estudios Retrospectivos , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: Policies to decrease dropout during waiting time for liver transplantation (LT) are under debate. METHODS: We evaluated the allocation system from 1996 to 2003, when recipients had priority related to Child-Pugh score and donors >60 years were mainly offered to recipients with hepatocellular carcinoma (HCC). The outcomes of 656 patients with chronic liver disease (142 HCC and 514 non-HCC) listed for LT were prospectively evaluated, considering recipient and donor features. RESULTS: Transplantation and dropout rates were similar between HCC and non-HCC patients: 64.1% vs. 70.6% and 26% vs. 22.6%. Multivariate analysis showed the probability of being transplanted within 3 months was related to Child-Pugh score >10 and to HCC, whereas the probability of being removed from the list within 3 months was only related to Child-Pugh score >10. HCC patients had a lower median waiting time (97 vs. 197 days, P<0.001), a higher rate of donors > 60 years (50.5% vs. 33.5%, P<0.005) and with steatosis (31.6% vs. 14.3%, P<0.01), but a lower Child-Pugh score (9.1+/-2.1 vs. 9.6+/-1.7, P<0.05) than non-HCC patients. The 5-year patient survival was comparable since registration on the list and since LT: 56.9% and 77% in the HCC group vs. 61.4% and 79% in the non-HCC patients. Donors > 60 years affected outcome after LT in the non-HCC group, but not in the HCC patients. CONCLUSION: By allocating donors >60 years mainly to HCC patients, we controlled dropout without affecting their survival and the outcome of non-HCC patients.
Asunto(s)
Carcinoma Hepatocelular/cirugía , Hepatopatías/cirugía , Neoplasias Hepáticas/cirugía , Trasplante de Hígado/estadística & datos numéricos , Obtención de Tejidos y Órganos/estadística & datos numéricos , Anciano , Europa (Continente) , Asignación de Recursos para la Atención de Salud , Política de Salud , Humanos , Trasplante de Hígado/mortalidad , Persona de Mediana Edad , Pacientes Desistentes del Tratamiento , Complicaciones Posoperatorias/clasificación , Análisis de Supervivencia , Donantes de Tejidos/estadística & datos numéricos , Resultado del TratamientoRESUMEN
BACKGROUND: Hepatolithiasis is very common in East Asia but infrequent in Western countries, and few reports have been published in European series. In East Asia, the association between cholangiocarcinoma and hepatolithiasis is well recognized, but, on the contrary, hepatolithiasis is uncommon in Europe and the United States, and the relationship with cholangiocarcinoma is not well established. The goal of this study was to analyze the perioperative and longterm results of surgical therapy for hepatolithiasis. STUDY DESIGN: Record review of 22 patients was done to locate immediate (operative morbidity and mortality) and longterm (stone recurrence and survival) results of patients with hepatolithiasis who underwent surgical treatment. RESULTS: There were 19 (86.4%) hepatic resections and 10 (45.5%) hepatico-jejuno-anastomoses. Operative mortality was absent and morbidity rate was 27.3%. Right hepatectomy was predictive of postoperative complications at multivariate analysis (p = 0.04). One (4.5%) patient had an unknown associated cholangiocarcinoma at time of surgical intervention. Mean followup was 67.59 +/- 65.67 (range 12 to 215) months. None presented recurrent cholangitis during the followup period. CONCLUSIONS: Surgical therapy is a safe and effective management for hepatolithiasis. The possibility of developing cholangiocarcinoma in inveterate hepatolithiasis is real, and hepatic resection removes this risk.
Asunto(s)
Cálculos/cirugía , Hepatopatías/cirugía , Anciano , Cálculos/epidemiología , Colecistectomía , Comorbilidad , Femenino , Hepatectomía , Humanos , Hepatopatías/epidemiología , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios RetrospectivosRESUMEN
Biliary reconstruction is one of the most challenging parts of right lobe living donor liver transplantation (RL LDLT), and biliary complications have been reported as the first source of surgical complications of this procedure. We reviewed biliary reconstruction and complications in 27 consecutive RL LDLTs. We compared the first 14 procedures (group 1) to the last 13 (group 2). Seven patients (25.9%) experienced a biliary complication (five leaks and two strictures). The incidence of biliary complications was 11.1% in RL grafts with a single duct and 55.5% in graft presenting multiple bile ducts (P = 0.03). Four of the 18 patients with a duct-to-duct reconstruction (22.2%) and three of the 11 patients with a Roux-en-Y reconstruction (27.3%) developed a biliary complication (P = ns). The incidence of biliary complications significantly decreased from 42.9% (n = 6) in the first group to 7.6% (n = 1) in the second group (P = 0.05). The overall 1-year graft and patient survival were 57.1% and 64.3% in group 1 versus 100.0% and 100% in group 2 (P = 0.01; P = 0.006). Biliary complications remain one of the most important technical complications affecting RL LDLT. Nevertheless, attention and surgical refinement can lead to a significant reduction of the biliary complication rate, improving graft and patient survival.