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BACKGROUND: Cirrhotic patients are highly exposed to healthcare services and antibiotics. Although pre-liver transplantation (LT) infections are directly related to the worsening of liver function, the impact of these infections on LT outcomes is still unclear. This study aimed to identify the effect of multidrug-resistant microorganism (MDRO) infections before LT on survival after LT. METHODS: Retrospective study that included patients who underwent LT between 2010 and 2019. Variables analyzed were related to patients' comorbidities, underlying diseases, time on the waiting list, antibiotic use, LT surgery, and occurrences post-LT. Multivariate analyses were performed using logistic regression, and Cox regression for survival analysis. RESULTS: A total of 865 patients were included; 351 infections were identified in 259 (30%) patients, of whom 75 (29%) had ≥1 pre-LT MDRO infection. The most common infection was spontaneous bacterial peritonitis (34%). The agent was identified in 249(71%), 53(15%) were polymicrobial. The most common microorganism was Klebsiella pneumoniae (18%); the most common MDRO was ESBL-producing Enterobacterales (16%), and carbapenem-resistant (CR) Enterobacterales (10%). Factors associated with MDRO infections before LT were previous use of therapeutic cephalosporin (p = .001) and fluoroquinolone (p = .001), SBP prophylaxis (p = .03), ACLF before LT (p = .03), and days of hospital stay pre-LT (p < .001); HCC diagnosis was protective (p = .01). Factors associated with 90-day mortality after LT were higher MELD on inclusion to the waiting list (p = .02), pre-LT MDRO infection (p = .04), dialysis after LT (p < .001), prolonged duration of LT surgery (p < .001), post-LT CR-Gram-negative bacteria infection (p < .001), and early retransplantation (p = .004). CONCLUSION: MDRO infections before LT have an important impact on survival after LT.

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La hipertensión arterial pulmonar (HAP) representa el 2,6% de los trasplantes pulmonares (TP), con una mediana de supervivencia condi cional (desde los 30 días del TP) de 9,8 años. Son frecuentes, el rechazo celular agudo (ACR) y la disfunción crónica del injerto (CLAD), mientras que es infrecuente el rechazo mediado por anticuerpos (AMR). El retrasplante pulmonar (RTP) constituye el 4% del TP mundial, debido a complicaciones en la vía aérea, disfunción primaria del injerto, ACR y CLAD. Mujer de 22 años, portadora de HAP idiopática (HAPI) desde el año 2013, trasplantada bipulmonar (TBP) en enero de 2018. A los 16 meses presentó neumonía adquirida en la comuni dad. En una internación posterior, presentó ACR y a pesar de pulsos de metilprednisolona, progresó a requerimientos de cánula de alto flujo y ventilación mecánica no invasiva hospitalaria, caída del VEF1, y tomografía de tórax con vidrio esmerilado difuso y engrosamiento irregular reticular del intersticio subpleural; interpretándose como CLAD a predominio de síndrome de bronquiolitis obliterante (BOS), con presencia de anticuerpos específicos contra el donante (DSA). En enero de 2020 se realizó nuevo TP y ante cross-match positivo, se realizó plasmaféresis y reposición de IgG. Al mes del egreso, no se observaron signos de rechazo en control de biopsias transbronquiales. Entre 2 y 10% de los pacientes con indicación primaria de TP por HAPI son sometidos a retrasplante pulmonar (RTP). La presencia de DSA y el miss-match de HLA, no son contraindicaciones para el RTP.

Pulmonary arterial hypertension (PAH) represents 2.6% of lung transplantations (LT), with a conditional median survival (from 30 days after LT) of 9.8 years. Acute cellular rejection (ACR) and chronic lung allograft dysfunction (CLAD) are common; whereas the antibody-mediated rejection (AMR) is not. Lung retransplantation (LR) accounts for 4% of global LTs for complications in the airways, primary allograft dys function, ACR and CLAD. 22-year-old woman with idiopathic PAH (IPAH) since 2013, who underwent a double-lung transplantation (DLT) in January 2018. 16 months after transplantation she presented community-acquired pneumonia. During a subsequent hospitalization, she presented ACR. Despite the fact that she received pulse methylprednisolone, she required high-flow cannula therapy and hospital non-invasive mechanical ventilation; the FEV1 was reduced and she underwent a chest tomography with diffuse ground glass opacities and irregular reticular thickening of the subpleural interstitium; interpreting the predominance of BOS (bronchiolitis obliterans syndrome) as CLAD, with presence of donor-specific antibodies (DSA). In January 2020, she received a new DLT and due to a positive crossmatch, she was treated with plasmapheresis and IgG replacement. One month after hospital discharge, no signs of rejection were observed at the BTB (bone-patellar tendon-bone) control. Between 2 to 10% of patients with primary indication of LT for IPAH are subjected to lung retransplantation (LR). The presence of DSA and HLA (human leucocyte antigen) mismatch aren't contraindications to LR.

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RESUMEN: El Trasplante cardíaco es la mejor alternativa para la insuficiencia cardíaca terminal, logrando buenos resultados de sobrevida y calidad de vida a largo plazo. Una de las causas más importantes de morbimortalidad es la falla del injerto, la que puede ser secundaria, entre otros, a rechazo agudo y/o vasculopatía y su presencia requiere considerar todas las alternativas terapéuticas, dentro de las cuales está el retrasplante. Los resultados de sobrevida en retrasplante cardíaco son buenos. No obstante, los pacientes presentan los riesgos de una terapia inmunosupresora más intensa, así como el desarrollo recurrente de vasculopatía del injerto. Por lo que se considera una opción en pacientes cuidadosamente seleccionados, dado que la experiencia internacional demuestra que la sobrevida del retrasplante es menor que en el primer trasplante. Presentamos el caso de un paciente trasplantado a los 42 años, quien desarrolla una enfermedad vascular del injerto e insuficiencia cardíaca con capacidad funcional IV, por lo cual se decidió realizar un retrasplante cardíaco.

ABSTRACT: Cardiac transplantation is the best alternative for terminal heart failure, achieving good long-term survival and life quality. One of the most important causes of morbidity and mortality is graft failure, which may be secondary, among others, to acute rejection and / or vasculopathy and its presence requires the consideration of all therapeutic alternatives, re transplantation being one of them. The results of survival in cardiac retransplantation are good; however, they present the risks of a more intense immunosuppressive therapy as well as the recurrent development of graft vasculopathy. Therefore, it is considered an option in carefully selected patients given that international experience shows that the survival of retransplantation is lower than in primary cases. We present the case of a 42 year old transplanted patient , who developed graft vascular disease with progressive deterioration of his ventricular function leading to functional class IV. for which a cardiaccardiac retransplantation was performed.

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Resumen Objetivo: el trasplante hepático es el tratamiento de elección para la falla hepática aguda y crónica. Los resultados en el trasplante hepático han mejorado en los últimos años, así que el objetivo de nuestro trabajo es comparar la experiencia de un centro en Colombia en dos períodos de tiempo diferentes. Pacientes y métodos: estudio descriptivo retrospectivo donde se analizaron pacientes adultos con primer trasplante hepático en dos períodos; serie 1, entre 2004-2010 (241 pacientes); y serie 2, entre 2011-2016 (142 pacientes). Resultados: la edad promedio fue de 54 años, el 57 % eran hombres y con un puntaje Model for End-stage Liver Disease (MELD) promedio de 20, sin cambios significativos en las características del donante y del receptor en los dos períodos. Las principales indicaciones de trasplante hepático fueron cirrosis por alcohol, cirrosis criptogénica y cirrosis por hepatitis autoinmune, con una disminución de los casos de hepatitis B y C en la serie 2. El 30 % de los pacientes tenía hepatocarcinoma. La supervivencia de los pacientes a 1 año fue de 81 % frente a 91 % y a 5 años fue de 71 % frente a 80 %, respectivamente. Las principales causas de muerte fueron: cáncer, enfermedad cardiovascular y sepsis. Existió un incremento significativo en las complicaciones biliares, sin diferencias en las complicaciones infecciosas, vasculares y el rechazo celular entre los dos períodos. Conclusión: el trasplante hepático en este centro en Colombia se relaciona con excelentes resultados a corto y mediano plazo, con una mejoría significativa en la supervivencia de los pacientes en los últimos años y con resultados similares a los reportados en otros centros del mundo.

Abstract Objective: Liver transplantation is the treatment of choice for acute and chronic liver failure. Liver transplantation results have improved in recent years, so the objective of our work was to compare results from two different periods of time at a center in Colombia. Patients and Methods: This is a retrospective descriptive study comparing first time adult liver transplant patients from 2004-2010 (Series 1: 241 patients) and from 2011-2016 (Series 2: 142 patients). Results: The average patient age was 54 years, 57% were men, and the average MELD score was 20. There were no significant differences between the characteristics of donors and recipients from one period to the next. The main indications for liver transplantation were alcoholic cirrhosis and cryptogenic and autoimmune hepatitis. Series 2 contained fewer hepatitis B and C cases than did Series 1. Thirty percent of the patients had hepatocellular carcinoma. The one-year survival rates were 81% in Series 1 and 91% in Series 2, whereas five-year survival rates were 71% and 80%, respectively. The main causes of death were cancer, cardiovascular disease and sepsis. From the first period to the second period, there was a significant increase in biliary complications but no differences in infectious complications, vascular complications or cellular rejection. Conclusion: Short and medium term liver transplantation results at this center in Colombia have been excellent, but there have been significant improvements in patient survival rates in recent years that are similar to those reported elsewhere in the world.

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Orthotopic cardiac retransplantation is used to treat transplanted cardiac graft end-stage failure. We present the first case of successful elective cardiac retransplantation in Mexico. It was a 25-year old male with heart transplantation who developed graft-resistant chronic vasculopathy. He underwent elective retransplantation in September 2017; complications during postoperative evolution were treated with favorable response. He was discharged owing to improvement at four weeks postoperatively. It is concluded that in adequately selected cases and comprehensively assessed, cardiac retransplantation is an appropriate option to treat cardiac graft failure.

El retrasplante cardiaco ortotópico se utiliza para tratar la falla cardiaca terminal del injerto cardiaco trasplantado. Presentamos el primer caso exitoso de retrasplante cardiaco electivo en México. Se trató de un varón de 25 años con trasplante de corazón, quien presentó vasculopatía crónica resistente del injerto. Fue retrasplantado electivamente en septiembre de 2017; las complicaciones durante la evolución posoperatoria fueron tratadas con respuesta favorable. Egresó por mejoría a las cuatro semanas del posoperatorio. Se concluye que en los casos apropiadamente seleccionados y valorados integralmente, el retrasplante cardiaco es una opción adecuada para el manejo de la falla cardiaca del injerto.

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The treatment of biliary stenosis after pediatric LDLT is challenging. We describe an innovative technique of peripheral IHCJ for the treatment of patients with complex biliary stenosis after pediatric LDLT in whom percutaneous treatment failed. During surgery, the percutaneous biliary drainage is removed and a flexible metal stylet is introduced trough the tract. Subsequently, the most superficial aspect of the biliary tree is recognized by palpation of the stylet's round tip in the liver surface. The liver parenchyma is then transected until the bile duct is reached. A side-to-side anastomosis to the previous Roux-en-Y limb is performed over a silicone stent. Among 328 pediatric liver transplants performed between 1988 and 2015, 26 patients developed biliary stenosis. From nine patients requiring surgery, three patients who had received left lateral grafts from living-related donors due to biliary atresia were successfully treated with IHCJ. After a mean of 45.6 months, all patients are alive with normal liver morphological and function tests. The presented technique was a feasible and safe surgical option to treat selected pediatric recipients with complex biliary stenosis in whom percutaneous procedures or rehepaticojejunostomy were not possible, allowing complete resolution of cholestasis and thus avoiding liver retransplantation.

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Abstract: The torsion of vessels after liver transplantation rarely occurs. Likewise, calcification of a liver graft has seldom been reported. This report details a case which had torsion of the left hepatic vein on the seventh day after living-related donor liver transplantation. The torsion was reduced soon after re-exploration; however, congestion with partial necrosis of the graft occurred. On the follow-up imaging studies, some resolution of necrosis and graft regeneration were found, yet geographic calcification of the liver graft appeared. The patient died of pneumonia after 13 weeks, post-operation. The avoidance such torsion of vessels is necessary and important.(AU)

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Outcomes of retransplantation after initial living donor liver transplantation (LDLT) are poorly understood. The aim of this study is to better understand the indications, timing, and outcomes of retransplantation after initial LDLT when compared to after initial deceased donor transplantation (DDLT). From 2002 to 2013, 209 retransplant recipients after initial LDLT and 2893 after initial DDLT were identified in Organ Procurement and Transplantation Network/United Network for Organ Sharing. Multivariable logistic models evaluated the association between initial transplant type and 1-year mortality. The most frequent reason for early graft failure (≤14 days) in LDLT recipients was vascular thrombosis (63.6%) versus primary graft failure in initial DDLT recipients (59.1%). LDLT recipients were more often acutely and/or critically ill with a greater proportion of Status 1 (42.6% vs. 27.3%; p < 0.001) and intensive care unit (52.2% vs. 39.9%; p = 0.001) recipients at the time of retransplantation. There was no difference in adjusted 1-year mortality between retransplant recipients after initial LDLT versus DDLT (odds ratio 0.74; 95% confidence interval 0.51-1.08). The proportion of recipients who ultimately required retransplantation for a third time was not different between the two groups (4.8%). Retransplantation outcomes after LDLT are not different from other retransplant procedures, despite recipients having greater acuity of illness and different indications.

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Survival benefit (SB) for first liver transplantation (LT) is favorable at Model for End-Stage Liver Disease (MELD)≥15. Herein, we identify the MELD threshold for SB from repeat liver transplantation (ReLT) by recipient hepatitis C virus (HCV) status and donor risk index (DRI). We analyzed lab MELD scores in new United Network for Organ Sharing registrants for ReLT from March 2002 to January 2010. Risk of ReLT graft failure≤1 year versus waitlist mortality was calculated using Cox regression, adjusting for recipient characteristics. Of 3057 ReLT candidates, 54% had HCV and 606 died while listed. There were 1985 ReLT recipients, 52% had HCV and 567 ReLT graft failures by 1 year. Unadjusted waitlist mortality and post-ReLT graft failure rates were 416 (95% confidence interval [CI] 384-450) and 375 (95% CI 345-407) per 1000 patient-years, respectively. Waitlist mortality was higher with increasing waitlist MELD (p<0.001). The MELD for SB from ReLT overall was 21 (21 in non-HCV and 24 in HCV patients). MELD for SB varied by DRI in HCV patients (MELD 21, 24 and 27 for low, medium and high DRI, respectively) but did not vary for non-HCV patients. Compared to first LT, ReLT requires a higher MELD threshold to achieve an SB resulting in a narrower therapeutic window to optimize the utility of scarce liver grafts.

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Objetivos: El retrasplante hepático es la única opción terapéutica para el fracaso del injerto hepático, corresponde al 5% a 23% de todos los trasplantes y está relacionado con menor sobrevida, con aumento de las complicaciones y costos. Los objetivos son evaluar la incidencia, describir las complicaciones y la sobrevida de los pacientes de retrasplante hepático de un centro en Colombia. Materiales y métodos: Estudio descriptivo retrospectivo de pacientes retrasplantados en el Hospital Pablo Tobón Uribe entre el 2004 y el 2010. Resultados: Se realizaron 305 trasplantes ortotópicos de hígado en adultos y niños. El retrasplante hepático se realizó en 21 pacientes adultos (7,7%). La principal indicación fue trombosis de la arteria hepática. La supervivencia de pacientes a 1 año fue de 81%, y a 5 años fue 76%. La supervivencia del injerto hepático fue a 1 y 5 años del 76% y 72%, respectivamente. Se encontraron complicaciones vasculares en 4 pacientes (19%) y complicaciones biliares en el 19%. Se documentaron infecciones en 11 pacientes (52%). La principal causa de muerte fue la disfunción primaria del injerto hepático. Conclusión: El retrasplante hepático es un procedimiento complejo que requiere gran destreza técnica y la apropiada selección de los pacientes, con resultados, a mediano plazo en el Hospital Pablo Tobón Uribe en Medellín, que son similares a lo reportado en la literatura mundial.

Objectives: Liver retransplantation is the only therapeutic option for liver graft failure which occurs in 5% to 23 % of all transplants. Graft failure is associated with poorer survival rates and increased complications and costs. The objectives of this study were to assess the incidence of liver retransplantation and describe complications and survival of liver retransplantation patients at a center in Colombia. Materials and Methods: This was a retrospective descriptive study of patients retransplanted at the Hospital Pablo Tobón Uribe between 2004 and 2010. Results: Three hundred five adults and children underwent orthotopic liver transplants between 2004 and 2010. Liver retransplantation was performed on 21 adult patients (7.7 %). The main indication was thrombosis of the hepatic artery. Patient survival at 1 year was 81 %, and at 5 years it was 76 %. Liver graft survival was at one year was 76 % and at five years was 72%. Vascular complications were found in 4 patients (19%), and biliary complications were found in 4 patients (19%). Infections were documented in 11 patients (52 %). The main cause of death was primary liver graft dysfunction. Conclusion: Liver retransplantation is a complex procedure requiring great technical skill and appropriate patient selection. Medium term results in the Hospital Pablo Tobón Uribe in Medellin are similar to those reported in the literature.

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Introducción: el retrasplante constituye la mejor opción terapéutica para los enfermos que pierden un primer trasplante renal y vuelven a diálisis, existen disímiles criterios en cuanto a sus resultados al compararlos con los trasplantes renales primarios. Objetivo: analizar el porcentaje de retrasplantes, revisar la supervivencia del injerto y del enfermo, el comportamiento de variables que pueden incidir en los resultados y compararlos con los de los enfermos que reciben un primer trasplante renal. Métodos: se realizó un estudio analítico, descriptivo, retrospectivo, de los trasplante renales realizados en el Hospital Hermanos Ameijeiras desde 1984 hasta diciembre de 2012; quedaron excluidos, los terceros trasplante, dobles (2 riñones a un mismo receptor), combinados (páncreas-riñón e hígado-riñón) y aquellos en los que no fue posible obtener la información requerida para la investigación. Se compararon (entre los grupos retrasplantes y primeros trasplantes) variables de índole general: edad de los receptores y donantes, sexo del receptor, enfermedad que ocasionó la insuficiencia renal, porcentaje de reactividad ante un panel de linfocito (PRA), compatibilidades HLA, tipo de donante (vivo o cadáver), tiempos de isquemia, presencia y duración de necrosis tubular aguda (donante cadáver), rechazo y supervivencia del injerto y el paciente. Resultados: los retrasplantes constituyeron el 5,4 por ciento de la muestra. No existieron diferencias entre edades, sexo, PRA, compatibilidades ni tipo de donante entre los segundos y primeros injertos. Los enfermos que llegaron a la insuficiencia renal por riñones poliquísticos nunca han recibido en nuestro centro un segundo trasplante. Resultó significativamente estadístico el uso de terapia cuádruple secuencial como inmunosupresión de inducción en los retrasplantes (55,9 por ciento vs. 9,7 por ciento de los primarios...

Introduction: retransplant constitutes the best therapeutic choice for patients who lose a first renal transplant and return to dialysis, existing dissimilar criteria as to its results when ranking them with renal primary transplant. Objective: to analyze the percentage of retransplantation, to revise graft and patient survival, to review the behavior of variables that can affect the results and to compare them with patients receiving a first renal transplant. Methods: an analytic, descriptive, retrospective study was accomplished, including all renal transplant performed at the Hermanos Ameijeiras Hospital from 1984 to December of 2012. Third transplants, double transplants (two kidneys to the same receptor), combined transplants (pancreas-kidney and liver-kidney) and those where it was not possible to obtain the information required for this research were excluded. Variables of general nature were compared between retransplantation groups and first transplants, such as: age of recipient and donor, sex of the recipient, a disease that caused kidney failure, percentage of reactivity to a lymphocyte panel (PRA), HLA compatibility, donor type (living or dead), ischemia time, presence and duration of acute tubular necrosis (dead donor), rejection and graft and patient survival. Results:rRetransplant constituted only 5.4 percent of the sample (34 patients). There were no differences in age, sex, PRA, donor type or compatibilities between the second and first grafts. Patients who reached the renal failure due to polycystic kidneys have never had a second transplant in our institution. The use of sequential quadruple therapy as induction immunosuppression, retransplantation (55.9 percent vs. 9.7 percent of primary) was statistically significant...

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La enfermedad vascular del injerto es el principal factor limitante de la sobrevida de los pacientes sometidos a trasplante cardíaco, siendo el retrasplante la única alternativa de tratamiento de la enfermedad vascular del injerto severa.El objetivo de esta comunicación es analizar el caso clínico del primer paciente sometido a retrasplante cardíaco en Uruguay, así como una serie de consideraciones respecto a las indicaciones del procedimiento y sus resultados. Se trata de un paciente de 21 años, de sexo masculino, que fue sometido a procedimiento de trasplante cardíaco en julio de 1997. Buena evolución hasta marzo de 2004, en que comienza con elementos de insuficiencia cardíaca congestiva. El ecocardiograma demostró disminución severa de la fracción de eyección del ventrículo izquierdo (FEVI). Estudiado con cineangiocoronariografía se comprobó lesión severa de sector medio de arteria descendente anterior; se realiza angioplastia con stent con sirolimus. Buena evolución inicial con mejoría de la clase funcional y reaparición de elementos funcionales de insuficiencia cardíaca congestiva a los cinco meses de ese procedimiento. Una nueva cineangiocoronariografía confirmó lesión severa de tres vasos con aspecto de enfermedad vascular del injerto. El ecocardiograma demostró persistencia de severa disminución de la función ventricular izquierda. Evoluciona en clase funcional III-IV. Se trata de una enfermedad vascular del injerto grave y rápidamente progresiva (seis meses) en fase dilatada con severa disminución de la FEVI. Se descartaron otras opciones de revascularización, por lo que se incluyó en lista de espera para retrasplante en carácter de urgente.En octubre de 2004 se realiza procedimiento de retrasplante cardíaco, sin incidentes...

Graft vascular disease represents the main restrictive factor in the survival of heart transplantation patients. Cardiac retransplantation remains the sole alternative for the treatment of severe graft vascular disease. We analyze the first clinical case of cardiac retransplantation in Uruguay, as well as to provide some considerations regarding the indication for the procedure and its results. We consider a 21 year old male patient, who underwent cardiac transplantation in July 1997 and showed a good evolution until March 2004, when symptoms of cardiac congestive insufficiency became evident. Through echocardiography, we noticed a severe decrease in the ejection fraction for the left ventricle. Through cineagiography, we remarked severe injury in the middle section of the descending anterior artery. We performed an angioplasty with sirolimus stent, followed by an intially positive evolution of the patient and function improvement, later followed by functional symptoms of congestive cardiac insufficiency 5 months after the procedure. New cineagiography studies confirmed the presence of a severe wound in three vessels, similarly to graft vascular disease signs. The echocardiographic studies showed the persistence of a severe decrease in the left ventricular function, with an function evolution class III-IV. It represents a case of severe and rapidly progressive graft vascular disease, (6 months) with a dilated phase presenting serious decrease in left ventricular ejection fraction. We discarted other options regarding revascularization, therefore included the patient in the waiting list for urgent retransplantation. In october 2004 the retransplantation procedure was performed without complications and with a positive evolution...

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