Browsing by Author "Barroso, E"
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- ABO-Incompatible Liver Transplantation in Acute Liver Failure: A Single Portuguese Center StudyPublication . Mendes, M; Ferreira, AC; Ferreira, A; Remédio, F; Aires, I; Cordeiro, A; Mascarenhas, A; Martins, A; Pereira, P; Glória, H; Perdigoto, R; Veloso, J; Ferreira, P; Oliveira, J; Silva, M; Barroso, E; Nolasco, FINTRODUCTION: ABO-incompatible liver transplantation (ABOi LT) is considered to be a rescue option in emergency transplantation. Herein, we have reported our experience with ABOi LT including long-term survival and major complications in these situations. PATIENT AND METHODS: ABOi LT was performed in cases of severe hepatic failure with imminent death. The standard immunosuppression consisted of basiliximab, corticosteroids, tacrolimus, and mycophenolate mofetil. Pretransplantation patients with anti-ABO titers above 16 underwent plasmapheresis. If the titer was above 128, intravenous immunoglobulin (IVIG) was added at the end of plasmapheresis. The therapeutic approach was based on the clinical situation, hepatic function, and titer evolution. A rapid increase in titer required five consecutive plasmapheresis sessions followed by administration of IVIG, and at the end of the fifth session, rituximab. RESULTS: From January 2009 to July 2012, 10 patients, including 4 men and 6 women of mean age 47.8 years (range, 29 to 64 years), underwent ABOi LT. At a mean follow-up of 19.6 months (range, 2 days to 39 months), 5 patients are alive including 4 with their original grafts. One patient was retransplanted at 9 months. Major complications were infections, which were responsible for 3 deaths due to multiorgan septic failure (2 during the first month); rejection episodes (4 biopsy-proven of humoral rejections in 3 patients and 1 cellular rejection) and biliary. CONCLUSION: The use of ABOi LT as a life-saving procedure is justifiable in emergencies when no other donor is available. With careful recipient selection close monitoring of hemagglutinins and specific immunosuppression we have obtained acceptable outcomes.
- Acute Liver Failure Due to Trazodone and DiazepamPublication . Carvalhana, S; Oliveira, A; Ferreira, P; Resende, M; Perdigoto, R; Barroso, EMost antidepressant agents have the potential to cause liver injury, even at therapeutic doses. Nevertheless, drug-induced liver injury (DILI) from antidepressant agents is a rare event. There is no way to prevent idiopathic DILI, but the severity of the reaction may be minimized with prompt recognition and early withdrawal of the agent. We describe a rare case of a 63-year-old man presenting with acute liver failure after 3 months of trazodone and diazepam administration at normal therapeutic doses, requiring liver transplantation. This report should increase physicians' awareness of this complication and call attention to the regular monitoring of liver tests in patients taking trazodone, in order to prevent life-threatening complications.
- Acute-on-Chronic Liver Failure: A Portuguese Single-Center Reference ReviewPublication . Verdelho, M; Perdigoto, R; Machado, J; Mateus, É; Marcelino, P; Pereira, R; Fortuna, P; Bagulho, L; Bento, L; Ribeiro, F; Nolasco, F; Martins, A; Barroso, EAcute-on-chronic liver failure (ACLF) is a syndrome characterized by an acute deterioration of a patient with cirrhosis, frequently associated with multi-organ failure and a high short-term mortality rate. We present a retrospective study that aims to characterize the presentation, evolution, and outcome of patients diagnosed with ACLF at our center over the last 3 years, with a comparative analysis between the group of patients that had ACLF precipitated by infectious insults of bacterial origin and the group of those with ACLF triggered by a nonbacterial infectious insult; the incidence of acute kidney injury and its impact on the prognosis of ACLF was also analyzed. Twenty-nine patients were enrolled, the majority of them being male (89.6%), and the mean age was 53 years. Fourteen patients (48.3%) developed ACLF due to a bacterial infectious event, and 9 of them died (64.2%, overall mortality rate 31%); however, no statistical significance was found (p < 0.7). Of the remaining 15 patients (51.7%) with noninfectious triggers, 11 died (73.3%, overall mortality rate 37.9%); again there was no statistical significance (p < 0.7). Twenty-four patients (83%) developed acute kidney injury (overall mortality rate 65.5%; p < 0.022) at the 28-day and 90-day follow-up. Twelve patients had acute kidney injury requiring renal replacement therapy (41.37%; overall mortality rate 37.9%; p < 0.043). Hepatic transplant was performed in 3 patients, with a 100% survival at the 28-day and 90-day follow-up (p < 0.023). Higher grades of ACLF were associated with increased mortality (p < 0.02; overall mortality 69%). CONCLUSIONS: ACLF is a heterogeneous syndrome with a variety of precipitant factors and different grades of extrahepatic involvement. Most cases will have some degree of renal dysfunction, with an increased risk of mortality. Hepatic transplant is an efficient form of therapy for this syndrome.
- Adesão nos Doentes TransplantadosPublication . Telles-Correia, D; Barbosa, A; Mega, I; Barroso, E; Monteiro, ECom base na literatura existente abordam-se os principais aspectos psiquiátricos relacionados com a adesão no transplante. Projectam-se vários modelos teóricos que podem ser utilizados no âmbito da adesão, entre os quais se destacam o modelo da hipótese cognitiva da adesão (Ley), o modelo de crenças da saúde (Rosenstock, Becker) e o modelo de autoregulação de Leventhal e propõe-se um modelo que se adequa ao doente transplantado. Não sendo possível uma classificação mono dimensional da adesão, consideraram-se várias características como a temporalidade (inicial, intermédia ou contínua), a frequência (ocasional, intermitente, persistente ou completa), a motivação (acidental, vulnerável ou decidida) e a certeza diagnóstica (definitiva, provável, possível ou pouco provável). Dos métodos para a medição da adesão podemos classificá-los como directos: observação directa da toma dos comprimidos, medição da concentração de fármaco no sangue, uso de marcadores incorporados nos comprimidos e de embalagens electrónicas; e indirectos: autorelato do doente, relato do médico assistente. Sugerese aquele que mais se adequa ao doente transplantado. A não adesão em doentes transplantados é muito frequente sendo a sua prevalência média de 25,28% e pode ser influenciada por diversos factores nomeadamente, demográficos (idade, estado civil, sexo, raça e nível socioeconómico), psiquiátricos e psicológicos (depressão, perturbações de personalidade, atraso mental, alcoolismo, crenças da doença, locus de controlo) e outros (custo da medicação, história de transplante prévio).
- Anastomose Biliar no Transplante Hepático: Com ou Sem Tubo em T?Publication . Carmelino, J; Rodrigues, S; Pinto Marques, H; Ribeiro, V; Virella, D; Alves, M; Martins, A; Barroso, EIntrodução: Complicações biliares ocorrem em 10% - 30% dos transplantes hepáticos. O objetivo deste trabalho é comparar as incidências dessas complicações nos transplantes hepáticos em que foi ou não utilizado tubo em T na anastomose biliar. Material e Métodos: Análise de dois grupos de doentes submetidos a transplante hepático entre 2008 e 2012. Consideraram-se os doentes em que o tubo em T foi utilizado (G1) e em que não o foi (G2). Procuraram-se depois modelos explicativos da ocorrência de complicações biliares por regressão logística, incluindo as variáveis identificadas na análise univariável. Resultados: Estudaram-se 506 doentes consecutivos submetidos a um primeiro transplante hepático (G1 = 363; G2 = 143). A incidência global de complicações biliares foi 24,7% (IC 95% 21,1 - 28,6): 27,0% no G1 e 18,9% no G2 (p = 0,057). As incidências de estenose e de fístula biliar foram tendencialmente mais elevadas em G1: 19,6% (IC 95% 15,7-23,8) vs 15,4% (IC 95% 10,1 - 22,0) (p = 0,275) e 6,6% (IC 95% 4,4 - 9,5) vs 2,8% (IC 95% 0,9 - 6,6) (p = 0,091). Não se encontraram diferenças estatisticamente significativas nas taxas de colangiopancreatografia retrógrada endoscópica, reoperação e retransplante. Verificaram-se dois óbitos no G1. Não se encontrou associação entre a ocorrência de complicações biliares e os diâmetros das vias biliares ou o tempo de isquemia fria. O modelo explicativo ajustado à idade do recetor e do dador, e ao diagnóstico de base identifica o uso do tubo em T como aumentando a possibilidade da ocorrência de complicações biliares (AdjOR 1,71; IC 95% 1,04 - 2,80; p = 0,034). Discussão e Conclusão: A utilização do tubo em T deve ser uma decisão tomada caso a caso e baseada no julgamento intra-operatório de cirurgiões experientes.
- Clinical Outcomes and Genetic Expression Profile in Human Liver Graft Dysfunction During Ischemia/Reperfusion InjuryPublication . Paulino, J; Vigia, E; Marcelino, P; Abade, O; Sobral, J; Ligeiro, D; Carvalho, A; Alves, M; Papoila, AL; Trindade, H; Barroso, EIntroduction. This study aims to compare the molecular gene expression during ischemia reperfusion injury. Several surgical times were considered: in the beginning of the harvesting (T0), at the end of the cold ischemia period (T1), and after reperfusion (T2) and compared with graft dysfunction after liver transplant (OLT). Methods. We studied 54 patients undergoing OLT. Clinical, laboratory data, and histologic data (Suzuki classification) as well as the Survival Outcomes Following Liver Transplantation (SOFT) score were used and compared with the molecular gene expression of the following genes: Interleukin (IL)-1b, IL-6, tumor necrosis factor-a, perforin, E-selectin (SELE), Fas-ligand, granzyme B, heme oxygenase-1, and nitric oxide synthetase. Results. Fifteen patients presented with graft dysfunction according to SOFT criteria. No relevant data were obtained by comparing the variables graft dysfunction and histologic variables. We observed a statistically significant relation between SELE at T0 (P ¼ .013) and IL-1b at T0 (P ¼ .028) and early graft dysfunction. Conclusions. We conclude that several genetically determined proinflammatory expressions may play a critical role in the development of graft dysfunction after OLT.
- Coping nos Doentes TransplantadosPublication . Telles-Correia, D; Mega, I; Barbosa, A; Barroso, E; Monteiro, EO desenvolvimento teórico dos Mecanismos de Coping (MC) tem como base uma dialéctica relacionada com os seus principais factores determinantes: individuais e situacionais (na base das duas abordagens do coping: disposicional e constitucional). Actualmente a classificação dos MC mais utilizada é baseada em duas dimensões: coping focado na emoção, e coping focado na resolução de problemas. Considera-se essencial que os métodos de classificação dos MC tenham em conta a coexistência de elementos disposicionais estáveis com uma variabilidade situacional dos MC. São abordados alguns instrumentos de medição de coping, baseados em diferentes pressupostos teóricos. O coping pode influenciar a saúde através de vários mecanismos (sistema neuroendócrino, comportamentos relacionados com os riscos para a saúde e adesão terapêutica) e é incluído em dois dos principais modelos teóricos de saúde (Moos & Schaefer e modelo de Leventhal). Com base numa revisão da literatura, concluiu-se que os estilos de coping mais prevalentes no pré transplante foram: aceitação, coping activo, e procura de suporte, sendo os menos utilizados: auto culpabilização e evitação. No pós transplante o coping activo e procura de suporte continuam a ser os estilos de coping preferenciais, a par da confrontação, autoconfiança, recurso à religião e coping focado no problema. Os estilos de coping (Evasivo, Emotivo, Fatalistico) estão associados a uma menor capacidade de controlo pessoal sobre a doença, a confrontação a uma maior qualidade de vida, o evitamento à redução da qualidade de vida e ao aumento dos níveis de depressão e a negação ao aumento da não adesão. A compreensibilidade, a sensação de controlo sobre a doença, os estilos de coping «relacionados com a expressão dos afectos» e a negação variam ao longo da evolução do doente transplantado.
- Fulminant Hepatitis E in a Pregnant WomanPublication . Velosa, M; Figueiredo, A; Glória, H; Mateus, E; Neves, Z; Araújo, A; Carvalho, A; Oliveira, J; Barroso, EHepatitis E is an inflammatory liver disease caused by hepatitis E virus (HEV) infection, which is endemic in China, India, Nepal, and in several Asian and African countries, where the prevalence can be as high as 50%. In non-endemic countries, an increasing number of non-travel associated HEV has been reported in recent years, particularly in Europe. The authors describe the clinical case of a puerperal 24-year-old woman from Pakistan admitted to our Tertiary Care Medical Center with acute hepatic failure developed during the third trimester of her pregnancy. She was icteric with grade III encephalopathy and hypothermia. Laboratory values showed significant AST, ALT and LDH elevations of twelve times the upper normal limit, and total bilirubin was significantly elevated (41.20 mg/dL). Prothrombin time was prolonged (4 s) and factor V activity was diminished (15.1%). Extracorporeal albumin dialysis was initiated, but clinical deterioration occurred within 48 h, so she underwent OLT at day 4 post-admission. Severe forms of HEV are known to be more pronounced in pregnant women. Even though most of the described cases of acute hepatic failure associated to HEV during pregnancy had a favorable clinical course, some cases of fulminant liver failure and death are described. It is unknown whether liver transplant outcomes in this setting are different from other causes of acute liver failure. To our knowledge, this is the first case report in Portugal from a pregnant woman who developed hepatic failure due to fulminant hepatitis E that underwent successful liver transplantation.
- Hepatic ActinomycosisPublication . Ávila, F; Santos, V; Massinha, P; Pereira, JR; Quintanilha, R; Figueiredo, A; Lázaro, A; Barroso, E; Duarte, MAActinomycosis is a rare disorder caused by an anaerobic gram-positive bacillus (Actinomyces), predominantly by the Actinomyces israelii species. Only 20% of cases show an abdominal manifestation, the appendix and ileocecal valve being the most frequent locations. Definitive diagnosis is based on microbiological cultures, microscopy or macroscopy examination. Nevertheless, histological examination of the percutaneous biopsy and blood microbiological cultures are rarely positives. Preoperative diagnosis is hampered by the lack of specific clinical and imaging manifestations, which often mimic malignancy. The rate of preoperative diagnosis is less than 10%, however, the outcome is excellent, with a low mortality rate. The authors describe the case of a patient who was diagnosed with primary hepatic actinomycosis only by a histological examination of the surgical specimen of left hepatectomy extended to segments V and VIII, for suspected malignant lesion. This case demonstrates the difficulties in diagnosing hepatic actinomycosis.
- Hepatic Artery Thrombosis in Live Liver Donor Transplantation: How to Solve - a Case ReportPublication . Rodrigues, S; Martins, A; Barroso, EThe decrease in the number of cadaveric donors has proved a limiting factor in the number of liver transplants, leading to the death of many patients on the waiting list. The living donor liver transplantation is an option that allows, in selected cases, increase the number of donors. One of the most serious complications in liver transplantation is hepatic artery thrombosis, in the past considered potentially fatal without urgent re-transplantation. A white male patient, 48 years old, diagnosed with hepatocellular carcinoma in chronic liver failure caused by hepatitis B virus, underwent living donor liver transplantation (right lobe). Doppler echocardiography performed in the immediate postoperative period did not identify arterial flow in the right branch, having been confirmed thrombosis of the right hepatic artery in CT angiography. Urgent re-laparotomy was performed, which consisted of thrombectomy and re-anastomosis of the hepatic artery with segmental splenic artery allograft interposition. The patient started anticoagulation and antiplatelet therapy with acetylsalicylic acid. Serial evaluation with Doppler echocardiography showed hepatic artery patency. At present, the patient is asymptomatic. One of the most devastating complications in liver transplantation, and particularly in living liver donor, is thrombosis of the hepatic artery; thus, early diagnosis and treatment is vital. The rapid intervention for revascularization of the graft avoids irreversible ischemia of the bile ducts and hepatic parenchyma, thus avoiding the need for re-transplantation.