Combined Liver-Kidney Transplantation: Survey of a Single Center in Spain

BackgroundRenal dysfunction is a common complication of advanced liver failure and liver transplantation. Since the introduction of the MELD criteria the proportion of patients with advanced chronic kidney disease and need for liver transplantation has increased. One alternative is the combined liver-kidney transplant (CLKT). The aim of this study was to evaluate the outcome of this type of transplant in our center.MethodsWe retrospectively analyzed all combined simultaneous or sequential transplants from 1989 to 2012. We studied demographic and clinical variables. Survival analysis was performed by Kaplan-Meier method.ResultsIn the study period, 1,265 kidney and 1,050 liver transplantations were performed; 34 were CLKT (to 29 adults and 5 children); 13 of these were simultaneous and 12 sequential liver-kidney. We also carried out 4 triple liver-pancreas-kidney transplantations, 3 simultaneous and 1 sequential. The mean age was 44.1 ± 15 years, and 27 were male (93.1%); 9 (37.5%) were diabetic. The main causes of liver disease were viral (n = 11 [41.3%; hepatitis virus B, C, or both] and alcoholism (9 [31%]). The renal disease etiology was unknown in 16 (55.1%), IgA nephropathy in 2 (6.8%), membranoproliferative glomerulonephritis in 2 (6.8%), and calcineurin inhibitor toxicity in 4 (13.6%). Transjugular renal biopsy was performed in 6 sequential transplants. Survival of patients who received a CLKT was excellent: 91%, 51%, and 40%, at 1, 5, and 10 years, respectively. No significant difference was found between sequential and simultaneous transplants (log rank 0.5).ConclusionsOur results of CLKT show results similar or superior to those of other series and are an alternative to consider in candidates for liver transplantation with chronic kidney disease. Transjugular biopsy is an alternative to study the etiology of renal disease in patients with hepatic dysfunction before or after liver transplantation.     

Cytoreductive Surgery and Intraperitoneal Hyperthermic Chemotherapy (HIPEC) by Minimally Invasive Approach,an Initial Experience

Background

The cytoreductive surgery (CRS) associated with hyperthermic intraperitoneal chemotherapy (HIPEC) has become the standard treatment in patients with carcinomatosis peritoneal from different origins. The use of a minimally invasive approach for this high complex procedure might be an alternative that provides them less morbidity and faster recovery with similar oncologic outcomes.

Methods

We describe the initial experience of CRS and HIPEC done via the laparoscopic route in patients with minimal peritoneal metastases in our Unit from March 2016 to January 2018.

Results

A total of eight patients were operated by this minimally invasive approach. The different diagnoses were low-grade pseudomyxoma peritonei (2), benign multicystic mesothelioma (2), primary epithelial ovarian carcinomatosis (2) and locally advanced colon carcinoma T4 (2). The median age was 54 (20–62) years, the median PCI was 3 (2–4), the median operative time was 287 min (240–360), complete cytoreduction CC0 was achieved in all the patients, and no major morbidity was observed. The median length of stay was 4.75 days (4–5). After a median follow-up of 9.5 months, no relapse has been observed.

Conclusion

The results suggest that this minimally invasive approach for CRS and HIPEC is feasible and safe in a highly selected group of patients with peritoneal surface malignancies.

     

Multicentric Study of the Andalusian Experience in Polycystic Liver Disease as Indication for Liver Transplantation

Background

The purpose of this study was to determine the morbidity and survival in patients with polycystic liver disease (PLD) undergoing liver transplantation (LT) in 4 Spanish hospitals.

Colorectal peritoneal metastases: Optimal management review

The peritoneum is a common site of dissemination for colorrectal cancer, with a poorer prognosis than other sites of metastases. In the last two decades, it has been considered as a locoregional disease progression and treated as such with curative intention treatments. Cytoreductive surgery(CRS) and hyperthermic intraperitoneal chemotherapy(HIPEC) is the actual reference treatment for these patients as better survival results have been reached as compared to systemic chemotherapy alone, but its therapeutic efficacy is still under debate. Actual guidelines recommend that the management of colorectal cancer with peritoneal metastases should be led by a multidisciplinary team carried out in experienced centers and consider CRS + HIPEC for selected patients. Accumulative evidence in the last three years suggests that this is a curative treatment that may improve patients disease-free survival, decrease the risk of recurrence, and does not increase the risk of treatment-related mortality. In this review we aim to gather the latest results from referral centers and opinions from experts about the effectiveness and feasibility of CRS + HIPEC for treating peritoneal disease from colorectal malignancies.     

Brassinosteroid signaling and auxin transport are required to establish the periodic pattern of Arabidopsis shoot vascular bundles

The plant vascular system provides transport and support capabilities that are essential for plant growth and development, yet the mechanisms directing the arrangement of vascular bundles within the shoot inflorescence stem remain unknown. We used computational and experimental biology to evaluate the role of auxin and brassinosteroid hormones in vascular patterning in Arabidopsis. We show that periodic auxin maxima controlled by polar transport and not overall auxin levels underlie vascular bundle spacing, whereas brassinosteroids modulate bundle number by promoting early procambial divisions. Overall, this study demonstrates that auxin polar transport coupled to brassinosteroid signaling is required to determine the radial pattern of vascular bundles in shoots.     

What Is the Influence of Both Risk Donor and Risk Receiver on Simultaneous Pancreas-Kidney Transplantation?

Introduction

Some factors affect the pancreas of a marginal donor, and although their influence on graft survival has been determined, there is an increasing consensus to accept marginal organs in a controlled manner to increase the pool of organs. Certain factors related to the recipient have also been proposed as having negative influence on graft prognosis. The objective of this study was to analyze the influence of these factors on the results of our simultaneous pancreas-kidney (SPK) transplantation series.

“Super-rapid” Technique in Donation After Circulatory Death Liver Donors: Advantages and Disadvantages

In recent years, donation after circulatory death (DCD) has increased as an option to overcome the organ donor shortage crisis and to decrease the large number of patients on liver transplant waiting lists. The “super-rapid” technique is now the “gold standard” procurement method because of its availability, reproducibility, low cost, and extensive experience. Recently, extracorporeal support has been implemented, with encouraging results. Strict donor acceptance criteria have proven to be essential to optimize the DCD liver graft outcomes and minimize biliary complication rates. In this study we assessed the state of the art of DCD liver transplantation with regard to its development and the actual strategies to prevent graft complications, with aim of expanding the pool of marginal liver donors.     

Prediction Model to Discard A Priori Liver Allografts

BackgroundThe use of expanded criteria for donors to expand the donor pool has increased the number of discarded liver grafts in situ. The aim of our study was to elaborate a prediction model to reduce the percentage of liver grafts discarded before the procuring team is sent out.MethodsWe analyzed the donor factors of 244 evaluated candidates for liver donation. We performed a multiple logistic regression to evaluate the probability of liver grafts discarded (PD).ResultsThe PD was determined by use of 3 variables: age, pathological ultrasonography, and body mass index >30. The area under curve was 82.7%, and, for a PD of 70%, the false-positive probability was 1.2%.ConclusionsWe have created a useful clinical prediction model that could avoid up to 20% of discarded liver grafts.     

Pancreas Donor Hypernatremia: Is it Really a Risk Factor for Simultaneous Pancreas-kidney Transplantation?

Introduction

Solid organ donor hypernatremia has been classically reported to be a risk factor for cell lysis and graft damage. National criteria for pancreatic donation consider severe hypernatremia (sodium level more than 160 mEq/L) to be relative exclusion criteria. The aim of our study is to review the postoperative outcomes of our simultaneous pancreas-kidney transplantation (SPKT) sample in terms of pancreatic fistula, intra-abdominal abscesses, pancreatitis, pancreas graft thrombosis, early pancreatectomy, and reoperation rates regarding different ranges of donor sodium levels.