Introduction. Everolimus is a potent immunosuppressant with several advantages over calcineurin inhibitors, such as good tolerance, preventive effects on cardiovascular morbidity, and mortality and cancer prevention as it inhibits cell proliferation.Patients and Methods. Between April 1986 and December 2010, we performed 1500 liver transplants (OLT) in 1341 recipients, including 57 patients who were prescribed everolimus 24 (42.1%) as monotherapy and 33 (57.9%) as treatments combined with other immunosuppressants. We performed a retrospective analysis of our experience with conversion to everolimus in OLT recipients.Results. The 43 men and 14 women had a mean overall age at transplantation of 59.1 +/- 10 years. The most frequent indication for OLT was hepatocellular carcinoma (HCC; 53.8%). Everolimus was introduced to prevent HCC recurrence (53%), development of de novo tumors (33%), address renal dysfunction (7%), or overcome side effects of other immunosuppressants (7%). We observed a significant improvement in renal function using the estimated glomerular filtration rate (Crockcroft-Gault formula) from 68.5 mL/min before to 74.5 mL/min after switching to everolimus. The 72% of recipients who developed >= 1 adverse event, most frequently showed hyperlipidenaia (34.4%).Conclusion. Both monotherapy and combined everolimus regimens were well-tolerated immunosuppressive regimens in liver transplant recipients with recurrent or de novo malignancies. Everolimus improved renal function. The most common side effects were hyperlipidemia, edema, and mouth ulcerations, which were well controlled with antilipidemic agents or decreased everolimus dosages.

Background. Sexual and reproductive abnormalities affect up to 50% patients with terminal liver failure. However, these functions recover quickly after orthotopic liver transplantation (OLT). Thus, 80%-90% of OLT women of childbearing age recover menstruation within a few months after transplantation. The aim of our study was to analyze the impact of pregnancy among liver transplant recipients at our center, as well as to analyze the effects of immunosuppression on the fetus.Methods. From April 1986 to April 2011, we performed 1500 OLT in 1341 recipients. Among these recipients, 18 patients (1.2%) become pregnant during the follow-up.Results. The most frequent causes of terminal liver failure were as follows: chronic parenchymal disease (n = 9; 50%), cholestatic disease (n = 3; 16.6%), acute liver failure (n = 5; 27.7%), and metabolic disease (n = 1; 5.5%) The average recipient age at the beginning of pregnancy was 21.2 (+/- 7.3) years. Sixteen patients (88%) became pregnant beyond a year after OLT. The 30 pregnancies in our study resulted in the following: newborns alive (NBA; n = 20; 66.6%) abortions (n = 8; 26.6%) or fetal deaths (n = 2; 6%). The most common immunosuppressant used during pregnancy was tacrolimus (75%) followed by cyclosporine (25%). There were no maternal deaths during pregnancy or the postpartum period.Discussion. We did not observe significant differences between immunosuppression type and maternal complications, pregnancy duration, and childbirth type. Although pregnancy is potential risk, the literature and our results suggest that at a year or more after OLT it usually is safe and successful.

Introduction: Primary hyperoxaluria (PHO) type I is an autosomic recessive disease caused by a deficiency of alanine-glyoxylate aminotransferase in the hepatocyte. The deficiency of this enzyme causes an excessive production and excretion by the kidneys of oxalate and glycolate. These substances are precipitated in the kidneys, and renal failure occurs. When only a kidney transplantation is performed, the excess of oxalate deposits in the kidney graft affecting the survival of patients. In these patients, a hepatorenal transplantation is the best option since it treats the disease in its origin and the renal failure is corrected. Patients and methods: Between April 1986 and January 2012, 1498 orthotopic liver transplantations(OLT) were performed, of which 47 were hepatorenal transplants. 3 of these patients had a hepatorenal transplant because of PHO type I. Results: Of the 3 transplanted patients because of PHO type I, 2 were men and 1 woman. The mean recipient age was 38.7±18 years (18-53). All patients were perfused with Wisconsin®, with mean volume of 2.67 liters through porta and 2.67 liters through artery. The mean donor age was 39±22.6 years. The mean warm ischemia time was 71±10 minutes, and mean cold ischemia time 350±60 minutes. The mean transfusional requirements were 12.3 units of red blood cells and 14.67 units of fresh frozen plasma, slightly superior to other transplanted patients. The mean ICU stay was 5.67 days and the mean stay in wards 17 days. The recipient survival rates at 5 years were 100%, with 100% graft survival (both grafts) at the same time with a good function. The mean follow-up was 2119 days(869-4585). Discussion: PHO type I is a rare disease with unknown accurate incidence and prevalence. The mean age at diagnosis is 5 years, and in 82% of the cases the major symptoms are associated to the genitourinary tract. The first symptoms present in a wide range of ages, from the first month after birth, till over 60 years. Nephrocalcinosis develops in a significant number of patients, and at 20 years of age, 90% of these patients have chronic renal failure, requiring hemodialysis. The oxalate crystals, however, are poorly excreted by hemodialysis. Many diseases are treated by an OLT. The main objective of an OLT in metabolic diseases is the correction of the enzyme deficiency or the deficiency of synthesis and is performed when there is a total cure of the disease, functionally and phenotypically. The hepatorenal transplantation permits the correction of the this enzymatic deficiency of the liver and the secondary renal failure. The survival at 2 years is over 80%. In our experience, this combined transplantation for this disease has excellent results. Conclusion: PHO type 1 disease is a rare cause requiring hepatorenal transplantation. In our experience, this combined transplantation for this disease has excellent results.

Introduction: Heat stroke is a situation conditioned by the inability of the body to dissipate excess heat produced by physical exercise. The association of liver damage is not rare, but some patients may progress to fulminant hepatic failure (FHF) requiring liver transplantation. So far, only 5 exertional heat stroke cases requiring liver transplantation have been reported in the literature. Patients and methods: We performed a retrospective review of all patients undergone liver transplantation in our department and we found 2 cases in which the etiology was a heat stroke. Results: The first case is a man of 23 years with no interest past history, who performing military maneuvers, suffers heat stroke, evolving in a few hours with significant clinical deterioration, abnormal liver profile (AST 8945 IU/l, ALT 9322 IU/l), encephalopathy, severe coagulopathy, thrombocytopenia, and acute renal failure. Given the clinical situation and the lack of response to intensive care treatment, liver transplantation from brain death donor was performed 72 hours after the beggining. The postoperative course was torpid, with many complications and the patient was discharged 2 months after transplantation. The second case is another man of 37 years who after heat stroke, secondary to physical exertion, develops a clinical situation compatible with FHF, also undergoing emergency liver transplantation. As in the first case the postoperative course was complicated and the patient was not discharged until the 77th post-transplant day. Currently, after a mean follow-up over 5 years, both patients remain asymptomatic showing normal liver graft function. Conclusions: Heat stroke secondary to stress can trigger liver damage, that in some cases, can progress rapidly to FHF and multiple organ failure with high mortality risk. In these cases, the implementation of an early emergent liver transplantation improves the prognosis of these patients.

Introduction: Children under 5 years are one of the groups with higher mortality on the waiting list for liver transplantation. This has forced the use of differents alternatives to conventional complete graft, such as split-liver or living donor. Primary closure of the abdominal wall in these cases may be impossible by a missmatch between the size of the graft and the recipient. The risk of a compartment syndrome involves the performance of abdominal closures with synthetic meshes increasing the rate of intra-abdominal adhesions and local and systemic infections. The use of biological meshes facilitates a safe abdominal wall closure, thus reducing the risk of complications. Material and methods: Retrospective observational review of our experience with the use of biological meshes in delayed abdominal wall closure after pediatric liver transplantation. Results: In 3 patients, delayed abdominal wall closure after liver transplantation was performed using biological meshes. The 3 children were aged less than 1 year, and in all cases the etiology was extrahepatic biliary atresia after Kasai portoenterostomy dysfunction. In 2 cases we used split-liver grafts, and in the other one a graft from a living donor. The outcome was satisfactory in all cases, with several postoperative complications. We never could perform primary abdominal closure, being necessary the use of synthetic dual meshes, with the development of severe intra-abdominal adhesions and the occurrence of local infections. Delayed abdominal wall closure was perfomed in all cases using a porcine dermis biological mesh attached to the edges of the aponeurotic plane, covered by muscular, subcutaneous layer and skin. The postoperative course was uneventful in all cases. After a mean follow up of 6 months, there have been no complications. Conclusions: Biological porcine dermis meshes are a good treatment option for delayed abdominal wall closure in pediatric liver transplantation, with a lower impact on growth, less risk of complications than synthetic meshes, and excellent short term results.

Introduction: Sarcoidosis is a rare disease characterized by the formation of epitheloid non-caseating granulomas and can affect various organs of the body. The liver is usually affected by the formation of these granulomas (70-90%), but it usually silent, although in rare occasions it can produce complications sucha as jaundice, liver failure, cirrhosis, and portal hypertension. A liver transplantation can be performed in patients with cirrhosis secondary to an intrahepatic cholestasis due to sarcoidosis. We present a case of hepatic sarcoidosis transplated in “12 de Octubre” University Hospital. Patient and methods: A 53-year old woman with diagnosis of pulmonary sarcoidosis in 1999, with personal history of type-2 diabetes melliuas, esophageal varices and hepatic encephalopathy with associated hepatopulmonary syndrome, is admitted for liver transplantation (liver cirrhosis Chil-Pugh B7). An orthotopic liver transplantation is performed with a graft from a brain-dead donor. The pathology of the recipient liver showed micronodular cirrhosis associated with epitheloid non-caseating granulomas and ductopenia compatible with sarcoidosis. The postoperative evolution was uneventful, and the patient was dismissed at tenth postoperative day. Conclusions: Liver transplantation is a valid option in patients with liver cirrosis due to sarcoidosis. The survival after transplantation is similar to patients with liver transplants due to other causes, with good recipient and graft survival at long term. Although liver recurrence in the graft is not well known, it seems to have a little impact in long term results.

Introduction: The scarcity of organs for transplantation from brain-dead donors (BDD), as well as the increased mortality rate in the waiting list, determines us to look for alternatives to achieve more organs, being grafts from non-heart-beating donors (NHBD) the most attractive source. The use of these grafts in the elderly is not well established, and they seem to be bad recipients, since they have less capacity of recovery from the important ischemia reperfusion injury found in theses organs. Patients and methods: Between January 2006 and March 2011, we performed 453 OLT. This comparative study comprises a sample of 45 patients who underwent OLT with NHBD-(Maastricht II) that were divided in 3 groups with respect to their ages: Group A: 22 patients between 18 and 59 years, B: 11 patients between 60-65years, and C: 12 patients >65 years. Results: We compare the 3 groups. The mean age of the recipients in groups A, B & C were 50.27, 62.36,and 68 years respectively (p=0,001), with a mean donor age of 44.5±9, 35.5 ±9, and 37.4±8.7 years respectively(p=0,15). The mean MELD of the recipients were 15.4±4.28, 14±4.69 and 12.2±5.28 (p=0,34) respectively. Mean ischemia times were 6.38±1.54, 7.84±2.43 and 6.79±1.42 hours for cold ischemia (p=0,3); and 1.1, 1.1 and 1.2 hours for warm ischemia (p=0,29). There were no differences with respect to time in ECMO, volume in ECMO, and time before ECMO. The indications for transplant were: in group A: 20% alcoholic cirrhosis (AC), 30% HCV infection, 20% HCV+hepatocarcinoma (HCC) and 20% HCV+AH; in group B: 27% AC, 27% HCV, 20% HCV+AC; in group C: 15% AC, 43% HCV+HCC, 20% AC+HCC. The HCC rate was 26.1%, 36.4% and 78.6% in groups A, B and C respectively; whereas HCV infection rate was 69.9%, 45.5 and 57.1% respectively. Retransplant rates were 26%, 18% and 0% respectively in the three groups. With respect to the intraoperative transfusion we used respectively in the 3 groups: red blood cells 17.86±17, 15.55±12 and 13.02±13 units; fresh frozen plasma 23±14, 18.8±10 and 17.58±15 units; platelets 2.55±1.89; 2.18±1.8 and 3±3(p=ns) The multivariate analysis has not demonstrated statistically significant relationships between variables, except for a tendency with respect to age (p=0.18), and for HCV infection (p=0.14). The actuarial recipient survival for each group at 1, 3 and 5 years was: A: 78%, 55.9%, and 48.1%; group B 81.8%, 71.6%,and 71.6%; group C 58.3%, 25.9%, and 25.9% (p=0.142) The actuarial graft survival was for each group at 1, 3 and 5 years was: A: 64.9%, 48.1%,and 48.1%; group B: 72.7%, 63.6% and 63.6%; group C: 50.6%, 22.1% and 22.1% (p=0.23). Conclusion: There seems to be a worse evolution of older patients who receive liver grafts from NHBD. If this tendency is confirmed, the use of grafts from these kind of donors in the elderly should be reconsidered.

Introduction: The use of NHBD (Maastricht type II) is controversial because they have worse patient and graft survival rates. These results could be poorer in HCV + patients with earlier recurrences. The objective of this study is to evaluate the effect of NHBD grafts over HCV (+) recipients. Patients and methods: Between January 2006 and June 2011, 388 liver transplantations were performed. In 48 recipients grafts from NHBD were used, 29 of which were implanted in patients with HCV-cirrhosis (group A). We compare this group (A) to 139 patients with HCV-cirrhosis who received brain-dead donors (group B). Results: The mean age in group A was 58.7+9 years vs 54.9+9 years in group B (p= 0.735). Mean MELD value of 13.8 vs 15.8 in group A and B respectively (p= 0,135). The percentage of hepatocarcinoma was 51.9% in NHBD vs 36.1% in BBD (p= 0,128). The mean age of donors as well as ischemia times were smaller in NHBD group although these differences were not statistically significant. The recipient mean stay in ICU was 6.8 days in group A vs 5.1 in group B(p= 0,103), whereas the mean stay in the ward was 20 vs 26.2 days (p= 0,487). When comparing the transfusional requirements in both groups: with respect to Red blood cells 13.7 vs 9.6 (p= 0,054), fresh frozen plasma 18.9 vs 12 (p= 0,025), platelets 2.5 vs 1.7 (p=0,539) in group A and B respectively. The first day of pathologic confirmation of HCV recurrence was 79+64 days vs 160+235 (p= 0,011) in group A and B respectively, whereas acute rejection rate was 1.6 vs 1.5 respectively, and the day of rejection was 28.7 vs 45.3 days respectively. Recipient actuarial survival at 1, 3 and 5 years were 66.6%, 55% and 44% in group A, whereas they were 80.2%, 69.3% and 60% in group B (p=0,103)The graft actuarial survival at 1, 3 and 5 years were: 56%, 33%, and 33% in Group A; 76.8%, 66.1%,and 59.2 in Group B (p=0,024). Conclusion: With these results and bearing in mind that NHBD are associated with worse patient and graft results, we need a better patient and donor selection in HCV patients especially if these results are confirmed in a larger sample size and longer follow-up serie.

Introduction: Due to the difficulty of pancreatic transplantation technique, relaparotomies remain being the main cause of graft loss over the years. These reoperations increased patient morbidity. The aim of our study is to analyze the pancreatic transplant recipient relaparotomies in our center as well as the subsequent morbidity and mortality in these patients. Patients and methods: 142 patients underwent pancreatic transplant from March 1995 to December 2010, all of them with more than one year of follow up.132 of these patients were simultaneous pancreas-kidney transplants, 2 pancreas after kidney and 8 retransplants. The mean age of our recipients was 38.20 years (± 7.7 years). The average follow up was 35.96 months (± 24.43). Results: 46 of the 142 recipients needed to be reoperated (33.1%). The most important causes of these relaparotomies were due to: thrombosis (13.4%), hemorrhage (12%), drainage conversion from bladder to bowel (10.4%), peripancreatic abscess (9.9%) and bladder leak (8.3%). 24 of these patients (17.3%) required pancreatectomy. The overall patient and graft survival with any relaparotomy at 1, 3 and 5 years was 91.4, 91.4%, 91.4% and 47.8%, 45.7%, 45.7%, respectively. Conclusions: The reoperations rate in our serie is similar to those refered in the literature, which depend on the serie, is nearly 30%. Graft loss rate is really higher in relaparotomies recipients when we compare them with non relaparotomies recipients, concluding that reoperations increased significantly patient morbidity.

Introduction: The increased number of patients in the waiting list and the donor shortage leads us to consider alternative sources of organs for our liver transplant candidates. One of these organ sources are donors from cardiac death (DCD). An increased incidence of ischemic cholangiopathy (IC) has been reported when these grafts are transplanted on. This complication could lead to severe graft dysfunction or even graft loss. The aim of our study is to analyze the patient and graft outcomes whenever ischemic cholangiopathy is diagnosed and what available treatment options we can offer these patients. Methods: From January 2006 to December 2010, 289 OLT were performed at our hospital. 44 of them (15.2%) were from DCD Maastrich tipe II. The most common cause of end stage liver disease was Hepatitis C, alone or associated with alcohol abuse and/or hepatocellular carcinoma. We defined ischemic cholangiopathy in patients who developed nonanastomotic strictures and dilatations involving the hepatic confluence or the intrahepatic biliary tree, in the absence of arterial thrombosis. The diagnosis was performed on the basis of radiological tests. Liver biopsy was performed in order to confirm it, when necessary. Thus, 14 patients (31.81%) were diagnosed of ischemic cholangiopathy. The average time between transplantation and diagnosis was 6.15 months (± 4.49). Results: The average age of the recipients and donors were 59.14 (± 8.2) and 40.43 (±10.1) years, respectively. 71.4% of our recipients were male. The average MELD value was 14 (± 3.4). Fourteen patients of 44 transplanted with DCD (31.81%) developed IC. Two of these patients (14.28%) did not require any treatment since no symptom or laboratory test deranging was observed, and other 2 patients (14.28%) required retransplant because of sever graft dysfunction. On the other hand most of these patients (12 recipients, 85.7% of those who were found to suffer IC) required radiological treatment by transparietohepatic cholangiography. Seven of the 14 patients (50%) with IC experienced resolution of the biliary complication at the moment, after an average number of procedures performed of 4.75 (± 4.1). We cannot consider cured 4 of the seven patients which have not experienced radiological resolution yet (28.5%) although a minimal impact on graft function has been observed in these cases. The other 3 patients (21.5%) have died (two of them because of HCV recurrence). The overall recipient and graft survival with IC was at 1, 3 and 5 years of follow up was 85.7%, 78.57%, 71.42%, and 85.7%, 64.28%, 57.14%, respectively. Conclusions: The most important complication in DCD transplant is ischemic cholangiopathy. However, a great number of our patients with ischemic cholangiopathy experiments good outcomes with radiologic treatment and even get cured. Not all the patients with ischemic cholangiopathy require retransplant or treatment, but a good multidisciplinary management may be the best solution of this problem in a great percentage of cases.

Introduction: The acceptance of non-heart-beating donors (NHBD) emerges as a consequence of the shortage of organs and increased mortality in the waiting list. The use of these grafts implies a higher risk of primary graft dysfunction (PGD) as well as ischemic cholangiopathy (IC). Classically, liver function tests (LFT) (AST-ALT) and ischemia times, as well as the macroscopic aspect of the liver are used as determining factors in accepting these organs. Patients and methods: Between January 2006 and December 2011, we performed 380 OLT. 48 of these transplants were NHBD (Maastricht type II). We analyzed factors implied in relationship to LFT and the times with ECMO. Results: We present 48 liver recipients from uncontrolled NHBD, with a mean age of 58.1 ± 9.3 (36-71) years, and a male:female ratio of 3.8:1. The mean age of donor was 39 ± 9.3 years. The indications for transplant were: HCV infection + hepatocarcinoma (HCC) 27.1%, alcoholic cirrhosis (AC) 20.8%, HCV alone 20.8% with a total percentage of HCV of 60.4% and HCC of 43.8%. PGD was observed in 5 patients, and IC in 16. In relation to predictive factors for PGD, no statistical differences were found with respect to the mean values of cold ischemia and warm ischemia times in both groups. We also didn't find statistical differences with respect to times in ECMO, fluid flux in ECMO, nor in the transfusion of red blood cells and plasma in ECMO. No statistical differences were seen with respect to time of cardiac arrest, which paradoxically was lower in those with PGD, who also presented shorter time of cardiopulmonary resuscitation (CPR) and out-of-hospital CPR. We observed differences with respect to LFT: AST at start of ECMO: 503 U/l in PGD group vs 150 in non-PGD patients (p=0.000); ALT at the start of ECMO 462 vs 160 (p=0.000). No differences were observed with respect to total bilirrubin levels, prothrombin time (PT), activated partial thromboplastin time (aPTT) and blood pH. Considering the predictive factors for IC, no statistical differences were observed with respect to the mean values of cold ischemia times and warm ischemia times in both groups. Differences were observed with respect to a higher necessity of red blood cells in ECMO in patients with CI, although not statistically significant. No differences were observed with regard to flux parameters in ECMO, in the CPR times, nor in the analytical values. Conclusion: Taking into consideration these results, we should analyse the true value of these classical parameters in decision making, especially that only an association with elevated LFT was observed for dysfunction. Thus new parameters should be considered for the evaluation of these livers.

Introduction: Liver transplantation recipients have an increased risk for developing de novo malignancies, because of the severe immunosuppression necessary to avoid acute and chronic rejections. Neoplasm in transplanted patients is one of the biggest problems recipients could get for the success of the transplant process, so that we must analyze it carefully. A variety of cancers are identified, especially skin cancers and lymphoproliferative disease. But the increased risk for colorectal cancer (CRC) is yet unclear. Methods: We analyze a total of 1500 patients who underwent liver transplantion from April 1986 to April 2011. Of all those patients, 15 of them (1%) were diagnosed of CRC during their evolution. Results: 73.4% of the recipients who has been diagnosed of CRC are men. Enolism is the most common cause of liver transplantation in these patients (26.6%). The mean age at diagnosis was 59.25 years (± 8.5). The average time between transplantation and diagnosis of CRC was 5.3 years (± 5.97). The 69.2% of CRC are located on the left colon, and 26.7% of them were located in the rectum. Surgery was performed in 100% of cases and with curative intention in 86.6%. 54.5% of tumors are well differentiated. 45.6% of CRC are diagnosed in early stages (Stages I and II of the AJCC/TNM). 33.3% of the cases develop colonic polyps during follow-up. Almost 100% oftumors showed microsatellite stability (MS). Recipient's overall survival and recipient's survival without disease recurrence was 70 months (± 40.47) and 55.6 months (± 39.24) respectively. Conclusions: CRC in liver transplant patients has clinical and anatomic characteristics similar to those who appear in general population. The location is also similar. However, they could have an aggressive behavior, probably due to immunosuppression. Prolonged immunosuppression encourages the development of tumors in these patients. However there are patients in our series diagnosed with CRC, only a year after transplantation, which would suggest the need to study more closely pretransplant candidates on the waiting list.

Introduction: Currently, pancreas transplantation is the only treatment option that allows us to keep a diabetic patient in normoglycaemia. It also increases the survival of these patients and improves their quality of life. However, postoperative complications increased their morbidity and mortality which may be considered. One of these complications is the anastomotic leak. The aim of this study is to find out the incidence of anastomotic leak and relaparotomies in our recipients as well as patients and graft survivals. Patients and methods: We analyzed 142 recipients who underwent pancreatic transplant from March 1995 to December 2010, all of them with more than one year of follow up.132 of these patients were simultaneous pancreas-kidney transplants, 2 pancreas after kidney and 8 retransplants. The average follow up was 35.96 months (± 24.43). Results: Twelve of 142 recipients (8.4%) had an anastomotic leak. Enteric drainage was performed in seven of these patients (58.3%) and bladder drainage in five (41.6%). 75% had shunt complications, such as: pancreatitis, lithiasis, abscess and urinary tract infections. Of these 12 patients, 8 (66.6%) required relaparotomy. In two cases (16.7%) a drainage conversion was needed. Three cases (25%) underwent transplantectomy, one of them (8.3%) as a direct result of the anastomotic leak, and the others due to chronic rejection and graft thrombosis. The overall patient and graft survival at 1, 3 and 5 years was 91.7%, 91.7%, 91.7% and 75%, 66.7%, 66.7%, respectively. Conclusions: Anastomotic leak is a severe postoperative complication in pancreas transplant recipients which may be take into account especially during the immediate postoperative period. In our serie the anastomotic leak was the direct cause of graft loss in one case. The anastomotic leak percentage in our serie was higher in those who underwent enteric drainage technique, but this difference was not statistically significant.

Introduction: Patients with diffuse liver hemangiomatosis (DLH) showed symptoms of abdominal pain and a palpable abdominal mass. The natural history and its etiology are uncertain, although in the literature have been cited the role of steroids and metoclopramide. DLH usually occurs in neonates characterized by hemangiomas of the skin and involvement of at least two visceral organs. DLH without extrahepatic lesions is extremely rare in adults. The prognosis is still unclear because it occurs so rarely and has variable clinical courses in affected patients. When patients became symptomatic, liver transplantation is a good choice of treatment if surgical resection can not be performed. Material and methods: We present 2 patients who underwent orthotopic liver transplantation (OLT) for diffuse liver hemangiomatosis. The first one is a 50 years old woman, who showed a 2-year history of progressive abdomen distention and abdominal pain. Firstly, she was diagnosed of a giant liver hemangioma. Left lobe hepatectomy was performed without incidences. Later, the patient developed a DLH with compressive symptoms, so liver transplantation from brain death donor was performed. Postoperative course was uneventful, and after 8 years there has been no incidences. The second case is a 41 year old patient who presented painless hepatomegaly, coagulopathy and thrombocytopenia. DLH with portal vein thrombosis was diagnosed in imaging tests, and the patient is currently on the waiting list for liver transplantation. Conclusions: Difusse liver hemangiomatosis without extrahepatic lesions is extremely rare in adults. The presence of symptoms suggesting extrinsic compression of adjacent structures should be considered for surgical resection. Liver transplantation must be indicated in patients with symptomatic and unresectable disease.

Introduction: The shortage of donor pool forces us to optimize the use of donors. The macrosteatosis of the graft was considered as an exclusion criterion in past times, but nowadays they are no longer rejected only because of this finding. Material and methods: Between March 1990 and December 2009 we performed 1235 OLT. From this period we selected a sample of 490 patients with complete pathological data of the donor. All patients had a minimum 2 year follow-up. They were divided in 3 groups: group A: microsteatosis (158 patients), group B: macrosteatosis (78 patients), and group C: no steatosis (254 patients). We analyze the influence of steatosis over patient and graft survival. Results: We present 3 groups of patients with a mean age of donor: group A: 47.58±20; B 54±17, and C 45.87±20.7 years (p=0.007). The mean recipient age was: group A: 53.65±10, B 52.8±11.4, and C 52.18±11.6 (p=0.425).No statistical significant differences were observed with respect to hemoderivate transfusion, ICU stay, MELD, and MELD-sodium. Also, no differences were observed with respect to VHC infection and hepatocarcinoma (HCC). When comparing biliary complications (leaks and stenosis) between groups, no differences were observed, as well as those related to vascular complications (arterial and venous thrombosis). There were no statistical differences with respect to the number of primary graft dysfunction, nor the number of deaths during hospital stay between the groups. The actuarial recipient survival at 1, 3, 5, and 10 years was 77.8%, 70.2%, 62.6%, and 50.8%, in group A(donor with microsteatosis); 83.3%, 71.6%, 61.2%, and 44.7 % in group B(macrosteatosis); and 86.2%, 81.4%, 76.7%, and 61.6 % in group C (no steatosis) (p=0.002). The actuarial graft survival, with respect to the percentage of macrosteatosis(MS) at 1,3,5 and 10 years: < 30% MS: 84.9%, 71.55, 62.7% and 47.6% respectively. Between 30-40% of MS: 77.8%, 72.2%, 59.1% and 47.3% respectively. When MS>40%: 40%, 20%, 20% and 20% respectively (p=0.038) Conclusion: The grafts used with MS are associated with acceptable survival rates, as compared with the rest of grafts, except for those with MS more than 40%, which have to be rejected.

Introduction: Sexual and reproductive abnormalities are common in patients with terminal liver failure affecting up to 50% of them. However, these functions are recovered quickly after orthotopic liver transplantation (OLT). 80-90% of OLT woman in childbearing age recover menstrual few months after transplantation. The aim of our study is to analyze the impact of pregnancy in liver transplant patients at our center, as well as analyze the effect of immunosuppression on the fetus. Methods: We analyze a total of 1500 liver transplant patients from April 1986 to April 2011. Of these, 18 patients (1.2%) become pregnant during follow-up. Results: The most frequent causes of terminal liver failure in our study were: chronic parenchymal disease in 9 cases (50%), cholestatic disease in 3 cases (16.6%) fulminant hepatitis in 5 cases (27.7%) and metabolic disease in 1 case (5.5%). The average recipient age at the beginning of pregnancy was 21.2 years (±7.3). 88.8% of patients became pregnant over a year after liver trasplant. There was a total of 30 pregnancies in our study: 20 of them (66.6%) were newborn alive (NBA), 8 (26.6%) abortions and 2 (6%) fetal deaths. The most commonly immunosuppressor used during pregnancy was tacrolimus (75%) followed by cyclosporine (25%). There were no maternal deaths during pregnancy and the postpartum period. The most common maternal complications during pregnancy were: preeclampsia (15%), viral reactivation (15%), acute rejection during pregnancy (10%), infections (10%) and high blood pressure (HBP) (0.05%). The relationship between eutocic birth deliveries, assisted deliveries and caesarean were 8 (42%), 3 (16%) and 8 (42%) respectively. Six of 20 NBA (30%) were preterm deliveries, and 5 of them (25%) were attended by caesarean, rate which was significantly higher than term and post-term labor (p = 0.0498). Conclusions: We found no statistically significant differences between immunosuppression type and maternal complications, pregnancy duration and childbirth type. Although pregnancy is an important risk to take into account in liver recipients, according to the literature and our results we can conclude that get pregnant a year or more after liver transplantation is normally safe and has successful results.

Introduction: Since the beginning of non-heart-beating donor (NHBD) (Maastricht II) program in our hospital, the problem to improve these donors in order to get the maximum number of organs, was planned. Thoracic surgeons need a cold donor, whereas liver surgeons need normothermic donors, in order to get the best outcomes. This problem is not yet solved at the moment, and is nowadays an important problem in NHBD transplant program. We aim to calculate the impact of the lungs' cooling on liver transplant. Patients and methods: Between January 2009 and June 2011, 145 liver transplants were performed, 24 of which were NHBD (Maastricht type II). We compared the results of those recipients in which thoracic surgeons perfused in the donor in order to use lung graft (group A), with the others in which thoracic surgeons did not perfuse(group B). Thoracic surgeons select only those with best gasometric results as lung donors. Results: We present 24 transplants from NHBD,11 of which (9M/2F) with thoracic surgeons attempting the lung extraction, and 13 (11M/2F) without them. The mean age of donor was 40.4± 8.5 years in group A vs 38.4±9.58 in group B(p=ns). The mean MELD score was 13 in group A vs 14.4 group B(p=ns). No differences were observed for time in ECMO of the donor, mean flux, and fluids administered in ECMO. There were no differences in ischemia times. The intraoperative transfusional needs during transplant were (group A vs B):Red blood cell concentrates(RBC) 20.55 vs 14.56 (p= 0.019); Fresh frozen plasma(FFP) 26.64 vs 18. 64 (p= 0,000); Platelets 3.8 vs 2.1 (p=0.179). There were the same number of primary graft dysfunction, one case in each group, and we performed 2 re-transplants in each group. We observed 5 cases of ischemic cholangiopathy(IC) in group A vs 3 cases in group B (p=0,34). Graft actuarial survival at 1 and 3 years were: 62.3% and 62.3% in group A; and 76.9% and 69.2% in group B (p=0.65). Conclusion: We need a bigger experience in NHBD type II, but there seems to be a tendency towards worse outcomes of organs from donors where thoracic surgeons perfused attempting a lung extraction. The probable cause is the cool lung ischemia that produces liver damage and consequently increases the necessity of hemoderivates transfusion because of coagulopathy.

BACKGROUND:Hepatitis C (HCV) is among the most common causes of end-stage liver disease worldwide. The donor shortage leads us to consider alternative organ sources such as HCV-positive donors. The outcomes of these transplants must be evaluated thoroughly since there is universal recurrence of disease among HCV-positive liver transplant recipients.METHODS:From January 2005 to April 2011, we performed 143 liver transplants (OLT) to treat end-stage liver disease secondary to HCV infection. Thirteen patients (9,1%) received livers from HCV-positive donors. A control group consisted of 130 HCV-positive patients who underwent OLT during the same period with organs from HCV-negative donors. Donor HCV status was assessed by 2 tests: HCV antibodies and viral load. Not only recipient and graft survivals were analyzed, but also frequency, timing and severity of hepatitis recurrence.RESULTS:Among 143 transplants performed in HCV-positive recipients during a 6-year period from January 1, 2005, to April 30, 2011, 9.1% of patients received an organ from an anti-HCV-positive donor, 72.7% of whom showed a negative viral load. The vast majority (80%) of our patients suffered hepatitis during their follow-up, 22.4% of which were severe cases.CONCLUSIONS:No significant difference in patient or graft survival was observed between the 2 groups. A high percentage of grafts with initial positive serology for HCV showed no viral replication. Grafts from HCV-positive donors can be considered to be a safe, effective source for liver donation.

Background: One of the most common causes of end-stage liver disease worldwide is Hepatitis C (HCV). The donor shortage leads us to consider alternative sources of organs for our liver transplant candidates. One of these organ sources are HCV-positive donors. The outcomes of the recipients transplanted on with these grafts, should be evaluated thoroughly. Considering a universal recurrence in the HCV-positive liver transplant recipient, this source of donation should be accepted. Methods: From January 2005 to April 2011, 143 OLT were performed at our hospital to treat end-stage liver disease secondary to HCV infection. Thirteen patients (9,1%) received livers from HCV-positive donors. A control group was used in this study that consisted of 130 HCV positive patients who underwent OLT during the same period of time with organs from HCV-negative donors. Donor HCV status was assessed by different tests: HCV antibodies, viral load and viral genotype. Recipient's survival, graft survival and hepatitis frequency, timing and severity were compared in both groups. Results: We analyzed retrospectively the serum of the 13 HCV positive donors and 76.9% of them had negative viral load. The vast majority (76.9%) of our patients transplanted with HCV positive donors, suffered from hepatitis during the follow up and 23.1% of those patients developed severe hepatitis. The average time elapsed, from transplant, until recurrent hepatitis and severe recurrent hepatitis documented by biopsy was 196.33 days (± 265.7 days) 245.67 days (± 203.7 days) respectively. In the group of patients of HCV positive donor, the overall recipient and liver graft survival was 91.7 %, 81.5%, 81.5% and 90.9 %, 70.7%, 70.7% at one, three and five years of follow up, respectively. Conclusions: No statistically significant differences in terms of patient and graft survival were found between the two groups. A high percentage of grafts with initial positive serology for HCV, have no real viral replication. Grafts from HCV positive donors can be considered as a safe and effective source of liver donation.