Centro Hepato-Bilio-Pancreático e de Transplantação
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- Abdominal Perfusion Pressure in Critically Ill Cirrhotic Patients: a Prospective Observational StudyPublication . Antunes Pereira, R; Esteves, A; Sousa Cardoso, F; Perdigoto, R; Marcelino, P; Saliba, FIn critical patients, abdominal perfusion pressure (APP) has been shown to correlate with outcome. However, data from cirrhotic patients is scarce. We aimed to characterize APP in critically ill cirrhotic patients, analyze the prevalence and risk factors of abdominal hypoperfusion (AhP) and outcomes. A prospective cohort study in a general ICU specialized in liver disease at a tertiary hospital center recruited consecutive cirrhotic patients between October 2016 and December 2021. The study included 101 patients, with a mean age of 57.2 (± 10.4) years and a female gender proportion of 23.5%. The most frequent etiology of cirrhosis was alcohol (51.0%), and the precipitant event was infection (37.3%). ACLF grade (1-3) distribution was 8.9%, 26.7% and 52.5%, respectively. A total of 1274 measurements presented a mean APP of 63 (± 15) mmHg. Baseline AhP prevalence was 47%, independently associated with paracentesis (aOR 4.81, CI 95% 1.46-15.8, p = 0.01) and ACLF grade (aOR 2.41, CI 95% 1.20-4.85, p = 0.01). Similarly, AhP during the first week (64%) had baseline ACLF grade (aOR 2.09, CI 95% 1.29-3.39, p = 0.003) as a risk factor. Independent risk factors for 28-day mortality were bilirubin (aOR 1.10, CI 95% 1.04-1.16, p < 0.001) and SAPS II score (aOR 1.07, CI 95% 1.03-1.11, p = 0.001). There was a high prevalence of AhP in critical cirrhotic patients. Abdominal hypoperfusion was independently associated with higher ACLF grade and baseline paracentesis. Risk factors for 28-day mortality included clinical severity and total bilirubin. The prevention and treatment of AhP in the high-risk cirrhotic patient is prudential.
- Abernethy Malformation and Hepatocellular Carcinoma: a Serious Consequence of a Rare DiseasePublication . Jaklitsch, M; Sobral, M; Carvalho, AM; Pinto Marques, HCongenital portosystemic shunts (CPSS) are a rare vascular consequence of embryogenetic vascular alterations or the persistence of the fetal circulation elements, first described by John Abernethy in 1793 and classified by Morgan and Superina, into complete and partial portosystemic shunts. Its prevalence to this day has not been defined. We present a patient series of a 44-year-old and 47-year-old man and woman, with this rare congenital malformation and underlining hepatocellular carcinoma (HCC) treatment strategies. Over half of the individuals with CPSS have benign or malignant liver tumours, ranging from nodular regenerative hyperplasia, focal nodular hyperplasia, adenomas, HCC and hepatoblastomas. Additionally, it is known that half of individuals with Abernethy malformation type Ib will develop one or multiple types of tumours. There seems to be a direct association with tumorigenesis and CPSS, which is the primary consequence of absent portal flow. Surgery is the treatment of choice, either as a curative resection or orthotopic liver transplantation if recommended as per the criteria, in which replacing the hepatic parenchyma in the setting of an Abernathy malformation will correct the underlining hyper-arterialisation.
- 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 Syndrome - Clinical Results from an Intensive Care Unit in a Liver Transplant CenterPublication . Pereira, R; Bagulho, L; Sousa Cardoso, FObjective: To characterize a cohort of acute-on-chronic liver failure patients in Intensive Care and to analyze the all-cause 28-day mortality risk factors assessed at ICU admission and day 3. Methods: This was a retrospective cohort study of consecutive patients admitted to the intensive care unit between March 2013 and December 2016. Results: Seventy-one patients were included. The median age was 59 (51 - 64) years, and 81.7% of patients were male. Alcohol consumption alone (53.5%) was the most frequent etiology of cirrhosis and infection (53.5%) was the most common acute-on-chronic liver failure precipitating event. At intensive care unit admission, the clinical severity scores were APACHE II 21 (16 - 23), CLIF-SOFA 13 (11 - 15), Child-Pugh 12 (10 - 13) and MELD 27 (20 - 32). The acute-on-chronic liver failure scores were no-acute-on-chronic liver failure: 11.3%; one: 14.1%; two: 28.2% and three: 46.5%; and the number of organ failures was one: 4.2%; two: 42.3%; three: 32.4%; four: 16.9%; and five: 4.2%. Liver transplantation was performed in 15.5% of patients. The twenty-eight-day mortality rate was 56.3%, and the in-ICU mortality rate was 49.3%. Organ failure at intensive care unit admission (p = 0.02; OR 2.1; 95%CI 1.2 - 3.9), lactate concentration on day 3 (p = 0.02; OR 6.3; 95%CI 1.4 - 28.6) and the international normalized ratio on day 3 (p = 0.03; OR 10.2; 95%CI 1.3 - 82.8) were independent risk factors. Conclusion: Acute-on-chronic liver failure patients presented with high clinical severity and mortality rates. The number of organ failures at intensive care unit admission and the lactate and international normalized ratio on day 3 were independent risk factors for 28-day mortality. We consider intensive care essential for acute-on-chronic liver failure patients and timely liver transplant was vital for selected patients.
- 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).
- Alcohol Consumption Post-Liver Transplantation: a Cross-Sectional StudyPublication . Chálim Rebelo, C; Félix, C; Sousa Cardoso, F; Bagulho, L; Sousa, M; Mendes, M; Glória, H; Mateus, É; Mega, I; Jara, M; Pinto Marques, H; Nolasco, F; Martins, A; Perdigoto, RBackground: Listing patients with alcohol-associated liver disease (ALD) for liver transplant (LT) remains challenging especially due to the risk of alcohol resumption post-LT. We aimed to evaluate post-LT alcohol consumption at a Portuguese transplant center. Methods: We conducted a cross-sectional study including LT recipients from 2019 at Curry Cabral Hospital, Lisbon, Portugal. A pretested survey and a validated Portuguese translation of the Alcohol Use Disorder Identification Test (AUDIT) were applied via a telephone call. Alcohol consumption was defined by patients' self-reports or a positive AUDIT. Results: In 2019, 122 patients underwent LT, and 99 patients answered the survey (June 2021). The mean (SD) age was 57 (10) years, 70 patients (70.7%) were males, and 49 (49.5%) underwent ALD-related LT. During a median (IQR) follow-up of 24 (20-26) months post-index LT, 22 (22.2%) recipients consumed any amount of alcohol: 14 had a drink monthly or less and 8 drank 2-4 times/month. On drinking days, 18 patients usually consumed 1-2 drinks and the remainder no more than 3-4 drinks. One patient reported having drunk ≥6 drinks on one occasion. All post-LT drinking recipients were considered low risk (score <8) as per the AUDIT score (median [IQR] of 1 [1-2]). No patient reported alcohol-related problems, whether self-inflicted or toward others. Drinking recipients were younger (53 vs. 59 years, p = 0.020), had more non-ALD-related LT (72.7 vs. 44.2%, p = 0.018) and active smoking (31.8 vs. 10.4%, p = 0.037) than abstinent ones. Conclusion: In our cohort, about a quarter of LT recipients consumed alcohol early posttransplant, all with a low-risk pattern according to the AUDIT score.
- Aquaporins Transcripts with Potential Prognostic Value in Pancreatic CancerPublication . Lopes, PA; Fonseca, E; da Silva, IV; Vigia, E; Paulino, J; Soveral, GPancreatic cancer is anticipated to be the second leading cause of cancer-related death by 2030. Aquaporins (AQPs), a family of water channel proteins, have been linked to carcinogenesis. The aim of this study was to determine AQP gene expression in pancreatic cancer tissues and to validate aquaporins as possible diagnosis and/or prognosis genes. The relative gene expression levels of AQP1, AQP3, AQP5, and AQP9 were analyzed using real-time quantitative PCR (RT-qPCR) in 24 paired pancreatic tumors and adjacent healthy tissues according to variables such as age, gender, and tumor invasiveness and aggressiveness. AQPs transcripts were detected in both healthy and tumor tissues. While AQP1 was downregulated in the tumor samples, AQP3 was particularly overexpressed in low-grade invasive tumors. Interestingly, most of the strong positive Pearson correlation coefficients found between AQPs in healthy tissues were lost when analyzing the tumor tissues, suggesting disruption of the coordinated AQP-gene expression in pancreatic cancer.
- 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.