Switching the use of calcineurin inhibitors (CNIs), as basal immunosuppression in liver transplantation (LT) patients, for that of mycophenolate mofetil monotherapy (MMF-MT) is currently considered a good measure in recipients with chronic kidney disease (CKD) and other CNI-related adverse effects. We analyzed a retrospective cohort series of 324 LT patients who underwent long-term follow-up and were switched from CNI immunosuppression to MMF-MT due to CKD and other CNI-related adverse effects (diabetes, hypertension, infection). The median time on MMF-MT was 78 months. The indication for MMF-MT was CKD alone or associated with CNI-related adverse effects in 215 patients, diabetes in 61, hypertension in 42, and recurrent cholangitis in 6. Twenty-four (7.4%) patients developed non-resistant acute rejection post-MMF-MT, and 48 (14.8%) patients experienced MMF-related adverse effects, with MMF-MT withdrawn in only 8 (2.5%) patients. In the comparison between the pre-MMF-MT period and the last outpatient review, using a repeated measures model and taking each patient as its own comparator, we demonstrated a significant increase in GFR and significant decrease in creatinine and ALT values, remaining the other variables (diabetes, hypertension, and hematological and AST) within similar levels. Five-year survival post-MMF-MT conversion was 75.3%. MMF-MT significantly improved renal function, was well tolerated, and had a low rejection rate.

Liver transplant recipients (LTRs) have been considered a population group that is vulnerable to COVID-19 as they are chronically immunosuppressed patients with frequent comorbidities. This study describes the course of the SARS-CoV-2 disease from February 2020 to December 2023 along seven pandemic “waves”. We carried out an observational study on 307 COVID-19 cases in a cohort of LTRs with the aim of evaluating the changes in the disease characteristics over time and determining the risk factors for severe COVID-19. An older age and serum creatinine level ≥ 2 mg/dL were found to be risk factors for hospital admission and respiratory failure. The use of calcineurin inhibitors was a protective factor for death, hospitalization, and respiratory failure from COVID-19. One hundred percent of patients who died (N = 12) were on mycophenolate mofetil, which was a determinant for respiratory failure. Azathioprine was associated with admission to the intensive care unit (ICU) and with invasive mechanical ventilation (IMV). Vaccination was a protective factor for hospitalization, respiratory failure, and mortality. The severe COVID-19 rate was higher during the first five waves, with a peak of 57.14%, and the highest mortality rate (21.43%) occurred in the fourth wave. The IMV and ICU admission rates did not show significant differences across the periods studied.

BACKGROUND:Several advances in liver transplantation (LT) have provided an increased rate in 1-year patient survival, currently reported between 84.5% and 91.4%. However, this significant improvement is not widely maintained after the 1-year of follow-up. In this study, we analyze short-term and long-term results in LT recipients. METHODS:A retrospective observational cohort study, including patients who underwent LT between 1990 and 2009 and were followed for a minimum 15-year period, analyzing the causes and risk factors of mortality and patient and graft survival from LT up to the last outpatient visit. RESULTS:A total of 594 patients with LT were included (median age, 53-year and 69.7% male). The most common indications for LT were HCV-cirrhosis (267 patients), alcoholic cirrhosis (250 patients), and hepatocellular carcinoma (HCC) (144 patients). Post-LT complications were acute rejection in 44.1%, cardiovascular in 40.6%, chronic kidney disease in 40.1%, hypertension in 22.6%, and de novo tumors in 25.6%. Retransplantation was performed in 40 (6.7%) patients. A total of 388 (65.3%) patients died during a follow-up over 20 years: 106 (17.8%) in the first year post-LT; 76 (12.8%) between 2 and 5 years; 75 (12.6%) between 6 and 10 years; 73 (812.3%) between 11 and 15 years; 30 (5%) between 16 and 20 years; and 28 (4.7%) after 20 years. The overall causes of death were infection in 69 (11.6%) patients, cardiovascular complications in 58 (9.8%) patients, pulmonary complications in 8 (1.3%) patients, liver graft failure in 126 (21.2%) patients, HCC recurrence in 15 (2.6%) patients, de novo tumors in 72 (12.1%) patients, and miscellaneous in 40 (6.7%) patients. Rates of actuarial patient survival at 1-, 3-, 5-, 10-, 15-, and 20-year after LT were 82.7%, 75.6%, 70%, 58.6%, 45.2%, and 37.6%, respectively, and actuarial graft survival were 80%, 72.5%, 67.1%, 54.8%, 42.6%, and 34.6%, respectively. Advanced recipient age, blood transfusion, and infection were the main risk factors for patient mortality. CONCLUSIONS:The highest mortality rate was within the first year of LT, and the most common causes of death were hepatic failure, de novo tumors, infection, cardiovascular disease, and HCC recurrence.

Liver transplant recipients (LTR) have been considered a population group vulnerable to COVID-19 disease as they are chronically immunosuppressed patients with frequent comorbidities. This study describes the course of SARS-CoV-2 disease from February 2020 to December 2023 along seven pandemic “waves". We carried out an observational study on a 307 COVID-19 cases cohort in LTR with the aim of evaluating the changes in the disease characteristics over time and determining the risk factors for severe COVID-19. Older age and serum creatinine ≥ 2 mg/dL were found to be risk factors for hospital admission and respiratory failure. Calcineurin inhibitors was a protective factor for death from COVID-19, hospitalization and respiratory failure. 100% of patients who died (N = 12) were on mycophenolate mofetil, which was a determinant for respiratory failure. Azathioprine was associated with admission to the Intensive Care Unit (ICU) and with invasive mechanical ventilation (IMV). Vaccination was a protective factor for hospitalization, respiratory failure and mortality. Severe COVID-19 rate was higher during the first five waves, with a peak of 57.14% and the highest mortality rate (21.43%), in the 4th wave. IMV and ICU admission rates did not show significant differences across the periods.

BACKGROUND:Preventive management of tuberculosis in liver transplantation (LT) is challenging due to difficulties in detecting and treating latent tuberculosis infection (LTBI). The aim of this study was to analyze the safety and efficacy of a screening strategy for LTBI with the inclusion of moxifloxacin as treatment. METHODS:We performed a retrospective single-center study of all LTs performed between 2016 and 2019 with a minimum 4-year follow-up and a standardized protocol for the evaluation of LTBI. RESULTS:Pretransplant LTBI screening was performed in 191/218 (87.6%) patients, and LTBI was diagnosed in 27.2% of them. Treatment for LTBI was administered to 71.2% of the patients and included moxifloxacin in 75.6% of the cases. After a median follow-up of 1628 days, no cases of active tuberculosis occurred among moxifloxacin-treated patients. The incidence of Clostridioides difficile (0.46 vs. 0.38 episodes/1000 transplant-days; p =  .8) and multidrug-resistant gram-negative bacilli infection (0 vs. 0.7 episodes per 1000 transplant-days; p =  .08) were not significantly higher in comparison to patients who did not receive moxifloxacin. CONCLUSION:A preventive strategy based on systematic LTBI screening and moxifloxacin treatment before LT in positive cases appears safe and effective in preventing the development of tuberculosis in LT recipients. However, our findings are limited by a small sample size; thus, larger studies are required to validate our observations.

Background Percutaneous drainage (PD) and antibiotics are the therapy of choice (non-surgical therapy [non-ST]) for pyogenic liver abscesses (PLA), reserving surgical therapy (ST) for PD failure. The aim of this retrospective study was to identify risk factors that indicate the need for ST. Methods We reviewed the medical charts of all of our institution's adult patients with a diagnosis of PLA between January 2000 and November 2020. A series of 296 patients with PLA was divided into two groups according to the therapy used: ST (n = 41 patients) and non-ST (n = 255). A comparison between groups was performed. Results The overall median age was 68 years. Demographics, clinical history, underlying pathology, and laboratory variables were similar in both groups, except for the duration of PLA symptoms < 10 days and leukocyte count which were significantly higher in the ST group. The in-hospital mortality rate in the ST group was 12.2% vs. 10.2% in the non-ST group (p = 0.783), with biliary sepsis and tumor-related abscesses as the most frequent causes of death. Hospital stay and PLA recurrence were statistically insignificant between groups. One-year actuarial patient survival was 80.2% in the ST group vs. 84.6% in the non-ST (p = 0.625) group. The presence of underlying biliary disease, intra-abdominal tumor, and duration of symptoms for less than 10 days on presentation comprised the risk factors that indicated the need to perform ST. Conclusions There is little evidence regarding the decision to perform ST, but according to this study, the presence of underlying biliary disease or an intra-abdominal tumor and the duration of PLA symptoms < 10 days upon presentation are risk factors that should sway the surgeons to perform ST instead of PD.

Background: Current literature supports the claim that performing a cephalic pancreaticoduodenectomy (CPD) as treatment for pancreatic cancer (PC) is associated with an increase in median survival, both in octogenarian (>80 years) patients as well as younger patients.

BACKGROUND:Massive blood transfusion (MBT) is a common occurrence in liver transplant (LT) patients. Recipient-related risk factors include cirrhosis, history of multiple surgeries and suboptimal donors. Despite advances in surgical techniques, anesthetic management and graft preservation have decreased the need for transfusions, this complication has not been completely eliminated. METHODS:One thousand four hundred and sixty-nine LT were performed at our institution between May 2003 and December 2020, and data was available regarding transfusion for 1198 of them. We divided the patients into two groups, with regards to transfusion of 6 or more units of packed red blood cells in the first 24 h posttransplant, and we analyzed the differences between the groups. RESULTS:Out of the 1198 patients, 607 (50.7%) met criteria for MBT. Survival was statistically lower at 1, 3, and 5 years when comparing the groups that had MBT to those that did not (92.6%, 85.2% and 79.7%, respectively, in the non MBT group, vs. 78.1%, 71.6% y 66.8%, respectively, in the MBT group). MBT was associated with a 1.5 mortality risk as opposed to non-MBT patients. Logistical regression analysis of our variables yielded the following results for a new model, including serum creatinine (OR 1.97), sodium (OR 1.73), hemoglobin (OR 1.99), platelets (OR 1.37), INR (OR 1.4), uDCD (OR 2.13) and split liver donation. CONCLUSION:Massive blood transfusion impacts patient survival in a statistically significant way. The most significant risk factors are preoperative hemoglobin, INR and serum creatinine.

BACKGROUNDThe shortage of liver grafts and subsequent waitlist mortality led us to expand the donor pool using liver grafts from older donors.AIMTo determine the incidence, outcomes, and risk factors for biliary complications (BC) in liver transplantation (LT) using liver grafts from donors aged > 70 years.METHODSBetween January 1994 and December 31, 2019, 297 LTs were performed using donors older than 70 years. After excluding 47 LT for several reasons, we divided 250 LTs into two groups, namely post-LT BC (n = 21) and without BC (n = 229). This retrospective case-control study compared both groups.RESULTSCholedocho-choledochostomy without T-tube was the most frequent technique (76.2% in the BC group vs 92.6% in the non-BC group). Twenty-one patients (8.4%) developed BC (13 anastomotic strictures, 7 biliary leakages, and 1 non-anastomotic biliary stricture). Nine patients underwent percutaneous balloon dilation and nine required a Roux-en-Y hepaticojejunostomy because of dilation failure. The incidence of post-LT complications (graft dysfunction, rejection, renal failure, and non-BC reoperations) was similar in both groups. There were no significant differences in the patient and graft survival between the groups. Moreover, only three deaths were attributed to BC. While female donors were protective factors for BC, donor cardiac arrest was a risk factor.CONCLUSIONThe incidence of BC was relatively low on using liver grafts > 70 years. It could be managed in most cases by percutaneous dilation or Roux-en-Y hepaticojejunostomy, without significant differences in the patient or graft survival between the groups.

Introduction: The upper gastrointestinal anastomoses of a multivisceral graft may suppose a problem sometimes. The trend in recent years has been to preserve a portion of native stomach if possible. Nevertheless, the gastro-gastric anastomoses may also leak. We present one of these cases where the final treatment consisted on endoscopic sponge vacuum aspiration. Material and methods. Case presentation: A 30 years old man who received a multivisceral transplant plus kidney and native spleen preservation with splenocaval venous anastomosis, due to short bowel syndrome after volvulus treatment 11 years before, with home parenteral nutrition since the n. Type I diabetes since 4 years old, badly controlled, with end-stage renal failure in dyalisis since 3 years before. Acute myocardial infarction one year before, with pharmacoactive stent. Liver hematoma after a biopsy, with embolization. Tricuspideal endocarditis with pulmonary septic embolization and pleural effusion. Cerebellar hematoma during hypertensive crisis. Cardiogenic/distributive mixed shock 2 years before without positive culture, with intubation and continuous venovenous hemodiafiltration. Moderate-severe mixed axonal demyelinating peripheral polyneuropthay. He had a prolonged transplant, 15 hours, with 12 packed red cells and 6 fresh frozen plasma units transfusion and 5 fibrinogen grams. Postoperative dyalisis. Extubated after 24 hours. Immunosuppression with thymoglobulin, tacrolimus and steroids. Discharged 8 days after from the ICU. Three days after he presented an acute abdomen due to gastric anastomotic leak, with shock and aspiration, with multiorgan failure. Surgically treated, he was transferred to the ICU. Four days later reoperated for splenic infarction. Fifteen days after gastric leak he showed a new leak. An endoscopic sponge vacuum treatment was decided. Results: Treatment started 2 days after the diagnosis of reperforation. The perforation measured around 1 cm in diameter. A Hanaro type TTS 8 cm prosthesis was placed. But it did not control the situation, with ongoing bile leak shown by the neighbouring abdominal drain, and 56 days after the prosthesis was removed, and a sponge vacuum procedure was initiated. The device was changed every 3 days. The drainage decreased with time and the perforation progressively healed, with the device being removed after 15 days, and nasojejunal tube installed for nutrition. A trophic nutrition was initiated and progressively the flow increased, combined with parenteral nutrition. Discharge from the ICU was on 131st day, due to the severely complicated general condition and the COVID-19 pandemic that affected the hospital management. Conclusion: A sponge vacuum endoscopic device may be an effective treatment in cases of gastro-gastric anastomoses leakage in multivisceral transplantation

Pyogenic liver abscess (PLA) is a life-threatening infection in both liver transplant (LT) and non-LT patients. Several risk factors, such as benign and malignant hepatopancreatobiliary diseases and colorectal tumors have been associated with PLA in the non-LT population, and hepatic artery stricture/thrombosis, biliary stricture, and hepaticojejunostomy in the LT patients. The objective of this study is to compare the outcomes of patients with PLA in LT and non-LT patients and to determine the risk factors associated with patient survival. From January 2000 to November 2020, a total of 296 adult patients were diagnosed of PLA in our institution, of whom 26 patients had previously undergone liver transplantation (LTA group), whereas 263 patients corresponded to the non-LTA population. Seven patients with PLA who had undergone previous kidney transplantation were excluded from this retrospective study. Twenty-six patients out of 1503 LT developed PLA (incidence of 1.7%). Median age was significantly higher in non-LTA patients (p = .001). No significant differences were observed in therapy. PLA recurrence was significantly higher in LTA than in non-LTA (34.6% vs. 14.8%; p = .008). In-hospital mortality was greater in the LT group than in the non-LT group (19.2% vs. 9.1% p = .10) and was identified in multivariable analysis as a risk factor for mortality (p = .027). Mortality rate during follow-up did not show significant differences between the groups: 34.6% in LTA patients versus 26.2% in non-LTA patients (p = .10). The most common causes of mortality during follow-up were malignancies, Covid-19 infection, and neurologic disease. 1-, 3-, and 5-year actuarial patient survival rates were 87.0%, 64.1%, and 50.4%, respectively, in patients of LTA group, and 84.5%, 66.5%, and 51.0%, respectively, in patients with liver abscesses in non-LTA population (p = .53). In conclusion, LT was a risk factor for in hospital mortality, but not during long-term follow-up.