Liver transplantation:Fifty years of experience

Since 1963,when the first human liver transplantation(LT)was performed by Thomas Starzl,the world has witnessed 50 years of development in surgical techniques,immunosuppression,organ allocation,donor selection,and the indications and contraindications for LT.This has led to the mainstream,wellestablished procedure that has saved innumerable lives worldwide.Today,there are hundreds of liver transplant centres in over 80 countries.This review aims to describe the main aspects of LT regarding the progressive changes that have occurred over the years.We herein review historical aspects since the first experimental studies and the first attempts at human transplantation.We also provide an overview of immunosuppressive agents and their potential side effects,the evolution of the indications and contraindications of LT,the evolution of survival according to different time periods,and the evolution of methods of organ allocation.

Predictive factors for survival and score application in liver retransplantation for hepatitis C recurrence

AIM: To identify risk factors associated with survival in patients retransplanted for hepatitis C virus(HCV) recurrence and to apply a survival score to this population.METHODS: We retrospectively identified 108 patients retransplanted for HCV recurrence in eight European liver transplantation centers(seven in France, one in Spain). Data collection comprised clinical and laboratory variables, including virological and antiviral treatment data. We then analyzed the factors associated with survival in this population. A recently published score that predicts survival in retransplantation in patients with hepatitis C was applied. Because there are currently no uniform recommendations regarding selection of the best candidates for retransplantation in this setting, we also described the clinical characteristics of 164 patients not retransplanted, with F3, F4, or fibrosing cholestatic hepatitis(FCH) post-first graft presenting with hepatic decompensation. RESULTS: Overall retransplantation patient survival rates were 55%, 47%, and 43% at 3, 5, and 10 years, respectively. Patients who were retransplanted for advanced cirrhosis had survival rates of 59%, 52%, and 49% at 3, 5, and 10 years, while those retransplanted for FCH had survival rates of 34%, 29%, and 11%, respectively. Under multivariate analysis, and adjusting for the center effect and the occurrence of FCH, factors associated with better survival after retransplantation were: negative HCV viremia before retransplantation, antiviral therapy after retransplantation, non-genotype 1, a Model for End-stage Liver Disease(MELD) score < 25 when replaced on the waiting list, and a retransplantation donor age < 60 years. Although the numbers were small, in the context of the new antivirals era, we showed that outcomes in patientswho underwent retransplantation with undetectable HCV viremia did not depend on donor age and MELD score. The Andrés score was applied to 102 patients for whom all score variables were available, producing a mean score of 43.4(SD = 6.6). Survival rates after the date of the first decompensation post-first liver transplantation(LT1) in the liver retransplantation(re LT) group(94 patients decompensated) at 3, 5, and 10 years were 62%, 59%, and 51%, respectively, among 78 retransplanted individuals with advanced cirrhosis, and 42%, 32%, and 16% among 16 retransplanted individuals with FCH. In the non-re LT group with hepatic decompensation, survival rates were 27%, 18%, and 9% at 3, 5, and 10 years, respectively(P < 0.0001). Compared with non-retransplanted patients, retransplanted patients were younger at LT1(mean age 48 ± 8 years compared to 53 ± 9 years in the no re LT group, P < 0.0001), less likely to have human immunodeficiency virus(HIV) co-infection(4% vs 14% among no re LT patients, P = 0.005), more likely to have received corticosteroid bolus therapy after LT1(25% in re LT vs 12% in the no re LT group, P = 0.01), and more likely to have presented with sustained virological response(SVR) after the first transplantation(20% in the re LT group vs 7% in the no re LT group, P = 0.028).CONCLUSION: Antiviral therapy before and after retransplantation had a substantial impact on survival in the context of retransplantation for HCV recurrence, and with the new direct-acting antivirals now available, outcomes should be even better in the future.

Immune thrombocytopenic purpura induced by intestinal tuberculosis in a liver transplant recipient

A variety of clinical manifestations are associated directly or indirectly with tuberculosis. Among them, haematological abnormalities can be found in both the pulmonary and extrapulmonary forms of the disease. We report a case of immune thrombocytopenic purpura(ITP) associated with intestinal tuberculosis in a liver transplant recipient. The initial management of thrombocytopenia, with steroids and intravenous immunoglobulin, was not successful, and the lack oftuberculosis symptoms hampered a proper diagnostic evaluation. After the diagnosis of intestinal tuberculosis and the initiation of specific treatment, a progressive increase in the platelet count was observed. The mechanism of ITP associated with tuberculosis has not yet been well elucidated, but this condition should be considered in cases of ITP that are unresponsive to steroids and intravenous immunoglobulin, especially in immunocompromised patients and those from endemic areas.

Seroprevalence of hepatitis E in adults in Brazil:a systematic review and metaanalysis

Background:Hepatitis E virus(HEV)is a member of the Hepeviridae family;it has four main genotypes and one serotype.While genotypes 1 and 2 cause epidemic hepatitis and are transmitted via water and the fecal-oral route,genotypes 3 and 4 are zoonotic In the various seroprevalence studies of hepatitis E in Brazil,the numbers reported vary widely and are difficult to interpret.The aim of this study was to analyze existing seroprevalence studies of hepatitis E in adults in Brazil.Main text:We searched the PubMed,Latin American and Caribbean Health Sciences and Embase databases for studies published from inception to May 12,2018 concerning infection by HEV in Brazil without time period or language restrictions.We included studies that presented data concerning hepatitis E seroprevalence in adults in Brazil,had a sample size>50 patients and whose method used for the detection of anti-HEV was standardized and commercialized.We also evaluated the quality of the articles using a list of criteria that totalized 9 items.Of the 20 studies ultimately analyzed,10(50%)were from the southeast region of Brazil,3(15%)were from the central-west region,3(15%)were from the northern region,2(10%)were from the northeast region and 2(10%)were from the southern region.Regarding the quality evaluation of the studies,the mean score was 5.6(range:4-8).The estimated overall seroprevalence of HEV infection in the adult population was 6.0%(95%CI:5.0-7.0);in subgroup analyses,we observed that the prevalence of anti-HEV antibodies in blood donors was 7.0%(95%CI:5.0-8.0),whereas in the general population,it was 3.0%(95%CI:2.0-4.0).Conclusions:The results of this systematic review indicate that there should be national investment in the prevention of hepatitis E virus infection in Brazil,including the implementation of improvements in basic sanitation and guidance regarding the appropriate handling of animal waste and the optimal cooking of vegetables,meat and their derivatives.