Alonso Vera

BACKGROUND: Patients with primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD) may have an increased risk of developing colorectal cancer (CRC) after liver transplantation (LT). We evaluated our patients with PSC after LT to identify risk factors for CRC and its impact on survival. PATIENTS AND METHODS: A total of 152 patients (108 men, 100 with IBD) with PSC who underwent 173 LTs between 1986 and May 2000 were analyzed in three groups: (1) PSC without IBD (n=52); (2) PSC with colectomy (pre-LT and at LT) (n=17, colectomy pre-LT in 13 and simultaneous colectomy at LT in four); and (3) PSC with IBD and an intact colon (n=83). The following factors were studied: age, gender, liver, and renal biochemistry, international normalized ratio, Child-Pugh stage, operative time, blood use, hospital stay, immunosuppression, risk of CRC, retransplantation rate, and mortality. RESULTS: The incidence of CRC after LT was 5.3% (8/152) compared with 0.6% (7/1,184) in non-PSC cases (P<0.001). All CRCs in the PSC group were in patients with IBD and an intact colon. The cumulative risk of developing CRC in the 83 patients with an intact colon and IBD was 14% and 17% after 5 and 10 years, respectively (PSC non-IBD group 0% risk after 10 years, P<0.06). The multivariate analysis showed three significant variables related to the risk of developing CRC: colonic dysplasia after LT (P<0.0003), duration of colitis more than 10 years (P<0.002), and pancolitis (P<0.004). The cause of death in patients with CRC was cancer related in 75% of cases with a reduced 5-year survival of 55% versus 75% without CRC (not significant). CONCLUSION: Patients with PSC undergoing LT with a long history of ulcerative colitis and pancolitis have an increased risk of developing CRC with reduced survival. We advocate long-term aggressive colonic surveillance and colectomy in selected high-risk patients with longstanding severe colitis.

It is generally believed that pulmonary hypertension (PHT) adversely affects outcome after liver transplantation (LT). Most transplant units consider severe PHT to be an absolute contraindication to LT. We examined the outcome of 145 patients who underwent LT between 1997 and 1999. Pulmonary artery pressures (PAPs) had been measured before surgery. Pre-LT workup included electrocardiography and echocardiography for the majority of patients. Also, the liver unit database was screened for patients with known PHT who had undergone LT before 1997. Based on pulmonary flotation catheter measurements made after the induction of anesthesia for LT, PHT was defined as mild or moderate to severe if the mean PAP (MPAP) exceeded 25 and 35 mm Hg, respectively. The incidence of PHT was 26% (38 of 145 patients); 31 of 38 patients had mild PHT. Kaplan-Meier survival analysis did not show a significant survival benefit for patients with normal PAPs compared with patients with PHT (all, mild, moderate to severe). For surviving patients, the duration of ventilation and intensive care unit stay was unaffected by PHT. Four of 5 patients (identified from the database 1982 to 1999) with MPAPs greater than 40 mm Hg survived LT by more than 1 year. PHT of this severity was usually associated with specific and suggestive abnormality of the echocardiogram. Mild PHT is common and does not affect patient outcome after LT. Moderate and severe PHT are uncommon. Our analysis suggests that when the cardiac index is preserved, the majority of patients with moderate and severe PHT can survive LT, and they will not die of PHT during long-term follow-up. Echocardiography detects most severe PHT, but not mild and moderate PHT.

The incidence of infections in liver transplant patients is higher compared with recipients of other organs, and infections are one of the major complications after transplantation. The aim of our study was to evaluate the incidence, presentation and risk factors of infections in liver transplant recipients in a Latin-American population, and to compare the results with data worldwide. We performed a retrospective analysis of 94 consecutive patients undergoing liver transplantation between 2004 and 2008 at the University Hospital Fundación Santa Fe de Bogotá, Colombia. The patients contributed a total of 64.4 person years (PY). Fifty-two patients (55.3%) developed one or more infections, in total 83 events (128.9 infections/100 PY). Bacterial infections represented the most frequent event (71.1%), followed by viral (19.3%) and fungal infections (8.4%). In 1%, no causative organism was identified. More than one-third of infections (37%) occurred during the first 30 days, whereas 83% of all events were seen during the first 6 months. The most common site of pathogen localization was the bloodstream (25.3%), followed by the urinary tract (15.7%), liver with bile tract (14.5%), abdomen (10.8%), surgical site (7.2%), and lungs (9.6%). The overall mortality after 1 year was 14.9%, and 57.1% of the deaths were attributed to infections. We found that risk factors significantly associated with increased incidence rate ratio for infection were prolonged stay at the intensive care unit, the need for parenteral nutrition, and blood transfusion requirement. Our data provide additional information about etiology and epidemiology of infections after liver transplantation.

The lack of adequate financial coverage, education, and the organization has been the main limiting factor for the development of transplantation in Latin America. As occurred worldwide, the number of patients on liver waiting lists in Latin America grows disproportionately compared to the number of liver transplantations (LTs) performed. Although many law modifications have been made in the last year, most countries lack social awareness about the importance of donation and the irreversibility of brain death. The mechanisms and norms for organ procurement and infrastructure development, capable of supporting this high demand, are still in slow progress in most countries. Access to LT in the region is very heterogeneous. While some countries have no active LT programs so far, others are an international model of a public transplantation system (Brazil) or a national information system (Argentina). While some countries have only a few LT centers, others have too many LT centers performing an inadequate low number of LTs. Disparity to access transplantation remains the major challenge in the region. Cultural and educational efforts have to be accompanied by transparent public policies that will likely increase organ donation and activity in transplantation. The purpose of this article is to review the trends and current activity in LT within Latin America, based on prior publications and the information available in each country of the region.