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Living donor kidney transplantation (LDKT) offers superior outcomes for most patients with end-stage kidney disease (ESKD), yet its uptake across Europe remains highly variable. This proceedings article summarizes key themes from a pan-European symposium held in November 2025 in Prague, organized by the European Kidney Transplant Association (EKITA) in collaboration with the DESCaRTES Working Group. Discussions highlighted substantial heterogeneity in LDKT activity across Europe, driven by differences in healthcare capacity, legal frameworks, donor evaluation practices, and access to kidney exchange programmes. Marked inequities persist between regions, particularly in the Balkans and Western Balkans, for women those who are socioeconomically disadvantaged, ethnic minority populations, paediatric and elderly patients and individuals with obesity. The symposium identified wide variation in donor selection criteria, risk assessment, informed consent practices, and long-term donor follow-up, despite existing international guidelines. Emerging strategies to address these challenges include harmonisation of donor evaluation and consent, expansion of paired and cross-border kidney exchange programmes, increased use of unspecified kidney donation, and adoption of innovative surgical and immunological approaches to safely broaden donor eligibility. Advances in outcome measurement, including validated surrogate endpoints, machine learning methods, and integrated, harmonised transplant registries, were discussed as critical tools to improve quality, transparency, and research efficiency. Collectively, the proceedings underscore the need for coordinated clinical, policy, and data-driven solutions to reduce inequities and unlock the full potential of LDKT across Europe, with implications for international transplant practice.
Kidney transplantation is the optimal renal replacement therapy, offering superior survival and quality of life compared with dialysis. Although outcomes after repeat transplantation may be inferior to those of first transplantation, retransplantation provides a survival benefit compared with remaining on dialysis. Living donor kidney transplantation (LDKT) offers advantages such as improved HLA matching and reduced cold ischemia time, potentially mitigating retransplantation-related risks. We performed a retrospective single-center study including all LDKT performed at ULS Coimbra between 2009-2020, with a mean follow-up of 9 years. Clinical and immunological donor-recipient variables were collected. Death-censored graft survival was assessed using Kaplan-Meier analysis and univariable Cox regression was used to explore predictors of graft loss. Acute rejection was defined according to Banff 2019 criteria. Seventy-six patients were included: 63 underwent a first LDKT and 13 a second LDKT. Baseline characteristics were similar regarding gender, dialysis vintage, HLA mismatches, and cold ischemia time. Second LDKT recipients were older (42 vs 33 years, p = 0.025), had higher historical panel reactive antibody levels, and more frequently received thymoglobulin induction (69.2% vs 16.7%, p < 0.001). Serum creatinine at 1 year was associated with graft loss (p = 0.007). Acute rejection was rare (4% vs 0%). Five- and 10-year death-censored graft survival was comparable between first and second LDKT (88.9% and 87.3% vs 100% and 92.3%, respectively). Second living donor kidney transplantation achieved excellent long-term graft survival comparable to first transplantation, supporting its safety and efficacy.
Chronic portal vein thrombosis and cavernomatosis are a complex challenge for liver transplantation. This study aims to analyze the results of portomesenteric reconstruction with a jump graft using the cadaveric iliac vein in liver transplantation. Non-concurrent cohort study from 2001 to 2023. All patients who underwent portal vein reconstruction with a mesenteric jump graft for liver transplantation were included. Nineteen patients were included. Pretransplant diagnosis of portal vein thrombosis was in 13 patients (68,4%), with 7 of them (36.8%) receiving anticoagulation. A preoperative decision to perform the venous jump graft was made in 8 patients (42.1%). Intraoperatively, 11 patients were classified as grade III according to the Yerdel classification, and eight were found to have cavernomatosis. Eleven patients (57.9%) experienced major complications, with 7 patients requiring reoperation. None of the complications were related to the portomesenteric jump graft. Two patients (10,5%) died in the first 30 days. The 5-year overall and graft survival rates were identical at 63.2%, as no retransplantations occurred. The median follow-up for venous bridge patency was 18 months, identifying only 2 thrombosed bridges (13.3%). Portomesenteric reconstruction with a jump graft using a cadaveric iliac vein yields favorable outcomes in this cohort of liver transplantations. This technique represents a vital surgical strategy, enabling transplantation for patients who would otherwise not be considered transplant candidates.
Hepatic ischemia-reperfusion injury (HIRI) is a major complication in liver surgery and transplantation, with mitochondrial dysfunction playing a central role. Mitochondrial transplantation has shown promise in other organ systems, but its effects and mechanisms in HIRI remain incompletely understood. This study aimed to investigate the protective effects of mitochondrial transplantation on HIRI and explore the underlying molecular mechanisms. HIRI was induced in male C57BL/6 mice by 60 minutes of partial hepatic ischemia followed by 3 hours of reperfusion. Autologous liver mitochondria (0.5 mg/kg) or vehicle were administered intravenously at the onset of reperfusion. In parallel, human THLE-2 hepatocytes were subjected to oxygen-glucose deprivation/reoxygenation (OGD/R) with or without mitochondrial supplementation (50 μg/mL). Liver injury (serum ALT/AST, measured as mass concentrations by ELISA), histopathology, cytokine profiles (TNF-α, IL-6, IL-10), apoptosis (Bax, Bcl-2, Cleaved Caspase-3, Annexin V), mitochondrial function (membrane potential, ROS production), and cell viability were assessed. Mitochondrial transplantation was associated with significantly reduced serum ALT and AST levels and attenuated histopathological liver damage in vivo (**p < .01). These changes correlated with a shift in cytokine balance, characterized by lower TNF-α and IL-6 and higher IL-10 levels, and with reduced expression of pro-apoptotic markers. In vitro, mitochondrial supplementation was associated with improved hepatocyte viability, reduced enzyme leakage, modulated cytokine secretion, and decreased apoptosis following OGD/R. These protective effects correlated with preserved mitochondrial membrane potential and reduced mitochondrial superoxide production. Our findings suggest that mitochondrial transplantation is associated with mitigation of HIRI in a murine model and with improved mitochondrial parameters in stressed hepatocytes. These correlative data support the potential of this approach as a therapeutic strategy for HIRI.
Heart transplantation represents the standard of care for pediatric patients with advanced heart failure. While outcomes have significantly improved in recent decades, adolescence remains a high-risk period marked by increased rejection rates and mortality, largely due to treatment non-adherence. This study aimed to analyze morbidity and mortality in adolescents undergoing heart transplantation at a single Brazilian center, focusing on the role of non-adherence. We conducted a retrospective review of medical records of 41 patients who underwent heart transplantation at our institution between 2002 and 2022. Patients transplanted during adolescence or who became adolescents after transplantation were included. We assessed episodes of rejection, major complications, and mortality, correlating outcomes with treatment adherence. Adolescents represented 54.5% of transplant recipients. This group exhibited higher rejection rates, with an average of 2.3 episodes per patient. Late mortality (>1 year after transplant) was predominantly rejection-related, with 61.5% of deaths directly linked to non-adherence to immunosuppressive therapy. Our findings reinforce that adolescents constitute a vulnerable group within pediatric heart transplantation, mainly due to the high rate of non-adherence to immunosuppressive treatment. Multidisciplinary strategies, such as psychological support, continuing education, and transition programs to adulthood, are essential to mitigate this risk and improve outcomes in this population.
Internal iliac vein dissection (IIVD) can be used for optimal venous anastomosis during renal transplantation; however, it poses a massive bleeding risk. No method has been established yet to identify the need for IIVD during renal transplantation. To develop a preoperative predictive nomogram that assesses IIVD necessity for safe living-donor renal transplantation. Data were retrieved from electronic medical records for 523 consecutive living-donor renal transplant cases at 4 institutions between 2009 and 2024. The key preoperative variables included recipient anatomical factors and donor kidney characteristics. Correlations among variables were examined to avoid multicollinearity. Variables were selected using the step-down method of multiple logistic regression. Eight pediatric transplant patients and 15 patients with renal vein venoplasty were excluded; hence, 500 patients were included in the final analysis. Caudal branch of the internal iliac vein, shallowness of the iliopsoas muscle, laterality of the transplanted pelvis, kidney thickness, and laterality of the transplanted kidney were incorporated into a nomogram. The model demonstrated good accuracy (C-index: 0.79). Internal validation via bootstrap resampling yielded an optimism-corrected C-index of 0.79 and a calibration plot with an intercept of 0.03 and a slope of 0.95, indicating no major overfitting. Our nomogram can assess IIVD necessity and facilitate surgical planning and intraoperative decision-making to ensure safe living-donor kidney transplantation.
Surgical site infection (SSI) after lung transplantation is an under-reported complication, despite its potential impact on postoperative morbidity and clinical outcomes. This study aims to evaluate the clinical impact and identify predictors of SSI in lung transplant recipients. A retrospective observational study was conducted including patients who underwent lung transplantation at the Portuguese Lung Transplantation Center between January 2016 and December 2024, with follow-up until June 2025. Univariate and multivariate analyses were performed to identify independent predictors. Among 316 transplanted patients, 25 (7.9%) developed SSI. Deep infections represented 80% of cases, including 5 with sternal osteomyelitis, occurring at a median of 25 days post-transplant (IQR: 17-43). Gram-negative bacteria were most frequently isolated, particularly Enterobacteriaceae. Negative-pressure wound therapy was used in 17 (68%) patients, and 8 (32%) required surgical debridement. Patients with SSI were older, predominantly female and had a higher body mass index (BMI). Moreover, they presented significantly longer ICU stay, drainage duration and hospital stay (all p < .05). No significant differences were observed regarding primary graft dysfunction, acute or chronic rejection, or mortality. In multivariate analysis, female sex (OR 3.15; 95% CI: 1.33-7.48) and higher BMI (OR 1.21; 95% CI: 1.05-1.32) were risk factors for SSI. SSI after lung transplantation is associated with significant postoperative morbidity, underscoring that this complication, although underestimated, remains clinically relevant. The incidence observed in our center (7.9%) is comparable to that reported in the literature. Early identification of high-risk patients may support the implementation of tailored strategies and optimize perioperative management.
Tumors involving the hepatic venous confluence and the retrohepatic inferior vena cava (IVC) remain among the most formidable challenges in hepatobiliary surgery. Conventional in situ resection is often unfeasible due to limited vascular control and the high risk of massive bleeding or incomplete oncologic margins. Liver autotransplantation with ex situ hepatectomyhas emerged as an advanced surgical strategy that allows total vascular exclusion, hypothermic perfusion, and complex vascular reconstruction on the back table. Recurrent pheochromocytoma with major vascular invasion is rare, but when present, demands aggressive management in highly specialized centers to achieve radical resection and long-term disease control. A 64-year-old woman presented with recurrent pheochromocytoma infiltrating the retrohepatic IVC. She had undergone right adrenalectomy 4 years earlier. Due to the impossibility of achieving an R0 resection with standard techniques, liver autotransplantation was performed. The procedure consisted of total hepatectomy under veno-venous bypass, hypothermic perfusion with preservation solution, ex situ caudate lobe resection, and en bloc resection of the retrohepatic inferior vena cava (IVC). On the back table, the hepatic venous outflow was reconstructed, and a neocava was created using deceased-donor iliac vein allografts before liver autotransplantation. Total ischemia time was 191 minutes, and operative time reached 770 minutes. Postoperative complications-hypernatremia, bronchopneumonia, and catheter-related jugular vein thrombosis-were successfully managed in the intensive care unit. Postoperative liver function was preserved, and the patient was discharged home on postoperative day 24. In experienced transplant centers, liver autotransplantation with ex situ hepatectomy is a feasible and effective strategy for selected patients with complex vascular tumor recurrence, facilitating radical resection, vascular reconstruction, and favorable postoperative outcomes.
In ABO-incompatible (ABOi) liver transplantation, antibody-mediated rejection (AMR) is a challenging post-transplant complication. In Japan, rituximab was approved in 2016 to prevent AMR in ABOi kidney and liver transplantation and in 2023 to prevent and treat AMR in kidney, liver, heart, lung, pancreas, and intestine transplantation. We conducted an all-case postmarketing surveillance to assess the safety and effectiveness of rituximab in ABOi liver transplant recipients, with a registration period between February 29, 2016 and May 9, 2021. The safety endpoint was the occurrence of adverse drug reactions (ADRs). The effectiveness endpoints were the AMR-free rates at weeks 4 and 24 post-transplant. Graft survival rates, rejection-free rates (excluding AMR), and survival rates at weeks 24 and 48 were also assessed. In the safety analysis set, 50.3% (91/181) were male, 8.8% (16/181) were aged ≥ 65 years, 12.8% (23/180) were considered at high risk for cytomegalovirus (CMV) infection, and 95.0% (171/180) received a single infusion preoperatively. ADRs and serious ADRs occurred in 65.7% (119/181) and 27.6% (50/181), respectively. ADRs associated with infection occurred in 57.5% (104/181), with CMV infection being the most frequent event. Twenty-four adverse events leading to death occurred in 16 patients, 7 of whom died from 11 ADRs. In the effectiveness analysis set of 183 patients, the AMR-free rate was 93.4% at weeks 4 and 24. At week 48, the graft survival rate was 94.8%, and the survival rate was 90.6%. Rituximab had an acceptable safety profile in real-world settings in ABOi liver transplantation.
Kidney transplantation from Hepatitis C virus (HCV) positive donors to HCV-negative recipients has emerged as a viable strategy to expand the donor pool, made possible by advances in antiviral therapy and post-transplant management. Notably, access to the necessary drug regimen in this study was guaranteed through a public-private partnership with the Washington D.C. municipal government. In this retrospective cohort study, we analyzed 58 kidney transplant recipients, including 29 HCV-negative patients who received organs from HCV-positive donors and 29 matched controls who received kidneys from HCV-negative donors. Variables collected included metrics detailing time to transplant, donor graft function, and transplant outcomes. Given the small sample size, non-parametric statistical methods were used. Recipients from HCV-positive donors demonstrated a trend toward shorter waiting times compared to controls (median, 1402 vs. 2276 days; p = .053), with no difference in listing times (p = .785). Donor kidney quality was similar between groups in terms of allograft eGFR (94 vs. 113 mL/min/1.73m², p = .715), cold ischemia time (18.9 vs. 15.7 hours, p = .142), and donor age (32 vs. 34 years, p = .432). Acute rejection rates were similar (34.5% vs. 31.0%; p = .78) as were IFTA scores (0.1 vs. 0.05; p = .37). Allograft loss occurred in 0% of recipients from HCV-positive donors compared to 3.4% in the control group. At one year, patient survival was 100% in both groups. A novel public-private collaboration allowed us to increase kidney transplantation access in an underserved community through transplantation of kidneys from HCV-positive donors into HCV-negative recipients with trending decreases in wait times, and without differences in graft function and clinical outcomes. Prophylactic direct-acting antiviral therapy (DAAT) allows our patients to never experience hepatitis C viremia. These findings support adoption of innovative healthcare partnerships to broaden access to life-saving therapies, especially as poor patients and marginalized communities continue to have significant obstacles to organ transplantation.
Locally advanced hepatic tumors involving the hepatic veins and inferior vena cava (IVC) represent a major surgical challenge and are often considered unresectable using conventional in situ techniques. In such settings, ex situ hepatectomy with liver autotransplantation emerges as an extreme yet potentially curative strategy that combines oncologic liver surgery and transplant principles. By enabling total vascular exclusion, hypothermic perfusion, and ex situ vascular reconstruction on the bench, this technique allows radical resections with controlled management of complex vascular invasion. Although rarely indicated, it may offer a salvage option for carefully selected patients with recurrent disease and otherwise limited therapeutic alternatives. A 64-year-old woman with a history of left hepatectomy for intraductal papillary neoplasm of the bile duct (IPNB) with cystic degeneration developed recurrent disease in the caudate lobe, with intimate proximity to the major vascular structures of the right hemiliver. Curative-intent salvage ex situ hepatectomy with liver autotransplantation was performed without venovenous bypass, using a temporary portocaval shunt for hemodynamic stability. The liver was perfused with Custodiol solution under hypothermic conditions, followed by ex situ caudate lobe resection with meticulous dissection of the lesion from the right hepatic vein, right portal vein, and right hepatic duct. A large V5 hepatic vein branch was reconstructed using iliac vein allograft. Total ischemia time was 229 minutes and operative time was 625 minutes. After revascularization, the graft showed good aspect without reperfusion syndrome. Histopathology revealed recurrent IPNB with high-grade dysplasia and negative margins. The patient recovered well and was discharged home on postoperative day 15. Ex situ hepatectomy with liver autotransplantation is a feasible salvage therapy for recurrent hepatic tumors in anatomically complex locations,enabling radical resections and favorable functional outcomes in specialized centers.
Primary graft dysfunction (PGD) is one of the most common and severe complications after lung transplantation. However, beyond the ratio of partial pressure of oxygen to fraction of inspired oxygen, there is a lack of objective clinical or laboratory indicators to guide real-time decision-making during the first 24 hours after surgery. We retrospectively examined 74 patients who underwent lung transplantation at our center between September 2022 and December 2024. The patients were classified into 2 groups based on the presence or absence of PGD. We analyzed their clinical data and lactate dynamic changes within 24 hours. The PGD group showed significantly higher lactate values at 0 hours (L0, P = .011), 3 hours (L3, P = .001), and 6 hours (L6, P = .001) after intensive care unit admission than the group without PGD. The largest difference occurred at 6 hours. There was no statistically significant difference in lactate levels at 24 hours (L24, P = .139) between the 2 groups. Delta lactate values between 0 and 24 hours (L0-L24) showed no statistically significant difference (P = .096), while the values of L3-L24 and L6-L24 showed statistically significant differences between the 2 groups (P = .015 and P = .002, respectively). Multivariate Cox regression analysis showed that L6-L24 was independently a protective factor for PGD (Wald = 4.227, P = .04). After lung transplantation, a significant increase in 6-hour lactate levels and untimely clearance from 6 to 24 hours are powerful warning signs for the development of PGD.
Polycystic liver disease (PLD) is an autosomal dominant disorder, frequently associated with polycystic kidney disease. Although often asymptomatic, progressive hepatomegaly may cause debilitating compressive symptoms, recurrent infections, and significant impairment in quality of life. Liver transplantation (LT) remains the only curative option for highly symptomatic patients. The objective was to evaluate the evolution and outcomes of patients undergoing LT for PLD between January 1994 and December 2024 at a tertiary university hospital. This retrospective observational study analyzed preoperative variables, including symptom burden, indication for transplantation, and waiting time, as well as postoperative data such as operative time, ischemia times, complications, length of hospital stay, survival, morbidity, and mortality. Data were obtained from medical record review and analyzed using descriptive statistics. Among 1,188 liver transplants performed during the study period, 9 (0.75%) were indicated for PLD. Most patients were female (88.8%), with a mean age of 47.3 years. The main indication for LT was severe impairment in quality of life due to compressive symptoms. Mean warm ischemia time was 45.6 minutes, and cold ischemia 6.3 hours. Mean waiting time was 7.1 months, and mean hospital stay was 12.4 days. Three patients required retransplantation due to hepatic artery thrombosis. Survival rates were 66.6% at 30 days and 55.5% at 5 years. It was observed that LT is an effective option for symptom relief and quality-of-life improvement in PLD. Given its technical complexity and associated morbidity, careful patient selection remains essential.
Budd-Chiari syndrome (BCS) is a rare vascular liver disorder characterized by obstruction of the hepatic venous outflow, involving the hepatic veins and/or the inferior vena cava (IVC). Etiology varies geographically, with thrombophilic conditions and myeloproliferative disorders predominating in Western countries, and membranous IVC obstruction being more frequent in Eastern countries. Liver transplantation (LT) remains the definitive treatment for patients with acute liver failure or advanced disease refractory to medical and interventional therapies, but it presents unique surgical challenges due to hepatomegaly, retroperitoneal fibrosis, and potential IVC stenosis or thrombosis. We report a 33-year-old male with BCS who underwent deceased-donor LT using the piggyback technique. Intraoperatively, the retrohepatic IVC was fibrotic and narrowed; a diamond-shaped side-to-side cavocaval anastomosis was performed to optimize venous outflow. Despite an initially well-perfused graft, the patient developed primary graft nonfunction on the first postoperative day. Urgent retransplantation revealed severe venous outflow obstruction caused by an unrecognized stenosis of the native suprahepatic IVC near the right atrium. The first graft exhibited extensive congestion and coagulative necrosis. Retransplantation was successfully performed using conventional technique without veno-venous bypass, completely removing the recipient's IVC. This case illustrates the potential for subtle anatomical anomalies, such as suprahepatic IVC stenosis, to cause acute post-transplant hepatic venous outflow obstruction in BCS. Awareness of these "Budd-Chiari pitfalls" is critical for surgical planning and intraoperative decision-making. LT remains a safe and effective therapy for carefully selected BCS patients, provided that meticulous attention is paid to venous anatomy and possible intraoperative challenges.
Identifying patients at high risk of mortality following liver transplantation and implementing timely interventions are essential to reducing fatality rates. This study aimed to develop a prognostic model to predict mortality after liver transplantation, using a nomogram based on specific risk factors. The study included 1951 liver transplant recipients, divided into a training group (n = 1366) and a validation group (n=585) through stratified cluster sampling. Nine key factors were considered for the prognostic model: Child-Pugh score, MELD score, extended Intensive Care Unit stays over seven days, catheter-related bloodstream infections, delayed graft function, intraperitoneal hemorrhages, pulmonary infections, renal failure, and vascular complications. Lasso regression and Boruta feature selection were applied to identify the most important predictors. The model's effectiveness was evaluated using ROC curves, calibration plots, decision curve analysis, and internal validation. The model achieved an area under the curve of 0.824 in the training group and 0.774 in the validation group. Calibration plots showed good alignment with the ideal diagonal line, indicating robust predictive accuracy. Decision curve analysis demonstrated various levels of clinical benefit across a range of risk thresholds (3%-81%). This nomogram, despite its limitations from the retrospective cohort, proves to be a valuable tool for predicting mortality outcomes in liver transplant recipients. It helps healthcare professionals identify high-risk patients who require urgent interventions following transplantation.
Fulminant hepatitis is a rare but highly lethal complication associated with various drugs, including antithyroid thionamides used for hyperthyroidism. While propylthiouracil (PTU) is more commonly linked to severe hepatotoxicity, methimazole can also cause acute liver failure and, rarely, bone marrow suppression such as aplastic anemia or agranulocytosis. Drug-induced liver injury accounts for a significant proportion of acute liver failure cases requiring transplantation, with antithyroid drugs occasionally implicated. The pathogenesis is thought to be immune-mediated and potentially dose-dependent, with cross-reactivity between thionamides. Simultaneous occurrence of severe hepatotoxicity and aplastic anemia is exceptionally rare, particularly with methimazole. A 37-year-old man with Graves' disease, on methimazole for 4 years without recent follow-up, presented in February 2024 with jaundice, choluria, and acholic stools. Investigations revealed hyperbilirubinemia, elevated transaminases, negative viral/autoimmune serologies, and normal imaging. Liver biopsy confirmed drug-induced injury with ductopenia, portal fibrosis, inflammation, and bilirubinostasis. Methimazole was discontinued. One month later, progressive pancytopenia developed, unresponsive to corticosteroids. Bone marrow biopsy showed hypocellularity consistent with aplastic anemia, requiring transfusions. Liver failure progressed to grade II encephalopathy, bilirubin 30.23 mg/dL (516.93 µmol/L), MELD 29, meeting King's College Criteria. He underwent urgent cadaveric orthotopic liver transplantation on June 13, 2024. Post-transplant, aplastic anemia was managed with erythropoietin, G-CSF, eltrombopag, and transfusions. An opportunistic CMV infection was treated with ganciclovir. Hematopoietic support was eventually discontinued without further transfusions, and the patient was discharged with stable graft and hematological recovery. This case illustrates the rare simultaneous occurrence of methimazole-induced fulminant hepatitis and aplastic anemia necessitating liver transplantation. It underscores the challenges in perioperative management of profound pancytopenia and posttransplant complications in such patients. Multidisciplinary care was key to successful outcome, highlighting the need for vigilant monitoring of antithyroid drug therapy and avoidance of cross-use in cases of severe adverse reactions.
Liver transplantation (LT) has emerged as a potential therapeutic option for selected patients with unresectable liver-confined metastatic neuroendocrine tumors (NETs), although evidence remains limited, particularly in low- and middle-income countries. To describe the experience of a Brazilian referral center with orthotopic LT for metastatic NETs and to evaluate post-transplant outcomes. A retrospective descriptive cohort study was conducted, including patients who underwent deceased-donor LT between 2002 and 2025 at a tertiary referral center in Brazil. Among 2312 liver transplants, six patients transplanted for unresectable hepatic metastases from well-differentiated NETs were identified. Demographic, clinical, oncological, and transplant-related variables were analyzed, with outcomes assessed over a 5-year follow-up period. The cohort consisted predominantly of middle-aged men, with a median age of 47.5 years. All patients had preserved liver function at transplantation, reflected by low MELD-Na scores. The median Ki-67 index was 10% (range: 1%-20%). Overall survival was 100%, and tumor recurrence occurred in two patients (33.3%). Acute rejection was infrequent and successfully managed, with no cases of chronic rejection. Post-transplant complications were limited, mainly involving biliary events. Immunosuppressive regimens were predominantly tacrolimus-based, with selective use of mycophenolate and everolimus. LT for metastatic NETs was associated with excellent survival and low morbidity in this highly selected cohort. Despite the small sample size, these findings support LT as a feasible therapeutic option in carefully selected patients treated at specialized referral centers.
Ischemia-reperfusion injury is a relevant complication in liver transplantation. Sequential (SeqR) and simultaneous reperfusion (SimR) techniques are the most commonly used strategies to reduce this injury; however, there is still no consensus regarding which technique provides better outcomes. This study compares these techniques in terms of graft recovery, complications, and patient survival. This retrospective study included 872 patients who underwent liver transplantation, divided into 2 groups according to the reperfusion technique used. Patient characteristics, intraoperative and postoperative outcomes, as well as recipient and graft mortality and survival, were analyzed. Continuous variables were analyzed using Student's t-test, and categorical variables using Pearson's chi-square test, with a significance level of 5%. A total of 520 transplants were performed using SimR and 352 using SeqR. SimR was associated with shorter operative time (P < .001) and longer total ischemia time (P < .001). It was also associated with a higher incidence of biliary stricture (P = .032) and a lower rate of graft rejection (95% CI: 0.342-0.754; OR: 0.508; P < .001). Overall recipient survival was significantly higher in the SimR group (P = .002). In this study, the SimR technique was significantly associated with improved overall recipient survival, despite being associated with longer total ischemia time. SimR was also correlated with a higher incidence of biliary strictures but demonstrated a protective effect against graft rejection. These findings should be confirmed in prospective, randomized studies.
Surgical resection is the standard treatment for combined hepatocellular carcinoma-cholangiocarcinoma (cHCC-CC). However, recent studies suggest that liver transplantation (LT) may be a viable alternative for selected patients, with encouraging survival outcomes. The objective of this study is to report the outcomes of LT in patients with incidental cHCC-CC. This single-center retrospective study included adult patients who underwent LT for hepatocellular carcinoma (HCC) and were found to have an incidental histopathological diagnosis of cHCC-CC between January 2015 and December 2024. During the study period, 1321 LT were performed, of which 24 patients (2.57%) had a histopathological diagnosis of cHCC-CC. The mean age was 58.5 years (range: 31-71), and 75% of patients were male. Regarding radiological findings, 16 patients had a LI-RADS 5 classification. On explant analysis, 3 patients (12.5%) had a single nodule confirmed as cHCC-CC on histopathology. In the remaining cases, the disease was multifocal (ranging from 2 to 25 nodules), with HCC as the predominant lesion and at least one nodule identified as cHCC-CC. During follow-up, 2 patients developed pulmonary recurrence of HCC, with a mean time between LT and recurrence of 314 days. Liver transplantation may represent a therapeutic option for selected patients with cHCC-CC. However, these results should be interpreted with caution due to the retrospective design of the study and the limited number of cases analyzed.