Yellow fever (YF) is a viral hemorrhagic fever that typically involves the liver. Brazil recently experienced its largest recorded YF outbreak, and the disease was fatal in more than a third of affected individuals, mostly because of acute liver failure. Affected individuals are generally treated only supportively, but during the recent Brazilian outbreak, selected patients were treated with liver transplant. We took advantage of this clinical experience to better characterize the clinical and pathological features of YF‐induced liver failure and to examine the mechanism of hepatocellular injury in YF, to identify targets that would be amenable to therapeutic intervention in preventing progression to liver failure and death. Patients with YF liver failure rapidly developed massive transaminase elevations, with jaundice, coagulopathy, thrombocytopenia, and usually hepatic encephalopathy, along with pathological findings that included microvesicular steatosis and lytic necrosis. Hepatocytes began to express the type 3 isoform of the inositol trisphosphate receptor (ITPR3), an intracellular calcium (Ca2+) channel that is not normally expressed in hepatocytes. Experiments in an animal model, isolated hepatocytes, and liver‐derived cell lines showed that this new expression of ITPR3 was associated with increased nuclear Ca2+ signaling and hepatocyte proliferation, and reduced steatosis and cell death induced by the YF virus. Conclusion: Yellow fever often induces liver failure characterized by massive hepatocellular damage plus steatosis. New expression of ITPR3 also occurs in YF‐infected hepatocytes, which may represent an endogenous protective mechanism that could suggest approaches to treat affected individuals before they progress to liver failure, thereby decreasing the mortality of this disease in a way that does not rely on the costly and limited resource of liver transplantation.
Introduction: Biliary complications after hepatic transplantation have a variable incidence of 10 to 25% among all complications after hepatic transplantation and mortality reported up to 10%, have an important impact on the patient's quality of life, since it implies the need for hospitalizations and multiple interventions for treatment. They are more frequent in the first year after transplantation, with progressive reduction of the frequency after 1 year. Objective: To evaluate the risk factors of greater impact in the development of bile duct stenosis in patients after liver transplantation. Methods: One hundred and eighty-eight charts of liver transplant patients were retrospectively evaluated. Inclusion criteria: liver transplanted patients from 2011 to December 2017. Exclusion criteria: deaths that occurred between the first month after transplantation, incomplete medical records and most cases of retransplants, except for patients who retransplanted as a consequence of their own complication. Results: Biliary complications were present in 14% (N=26) of the patients. Of these, 52% (N=21) presented stenosis of the biliary tract, followed by other complications such as cholangitis (20%), fistula calculation (10%), bilioma (3%). Among patients with bile duct stenosis, 19% (N=4) presented non-anastomotic stenosis and 81% (N=17) anastomotic stenosis. The cause of hepatopathy was in 42% of patients (N=9) ethanolic, followed by other causes such as: viral hepatitis, cryptogenic, autoimmune, fulminant hepatitis, NASH, CEP, glycogenosis and 1 case of secondary retransplantation to the bile complication itself. Conclusion: The incidence of biliary complications is comparable with the incidence reported in other institutions. The low incidence of bile duct stenosis reduces the power of the study to identify the most impacting risk factors.
Fundamento: O transplante hepático (TH) é cirurgia de grande porte indicada para tratamento de portadores de cirrose avançada e está associado a diversos riscos. Por esta razão, faz-se necessário estratificar o risco no período prétransplante através da avaliação da função miocárdica e pesquisa de doença coronariana. Objetivo: Demonstrar a aplicabilidade da ressonância miocárdica cardíaca (RMC) na avaliação morfofuncional cardíaca, bem como seu uso na avaliação da isquemia miocárdica no pré-transplante. Método: Realizou-se estudo retrospectivo e descritivo, sendo avaliados dados de pacientes cirróticos encaminhados ao ambulatório de TH no período de Janeiro/2014 a Julho/2016 que se submeteram a RMC para avaliação cardíaca e como teste provocativo de isquemia miocárdica. Resultados: Foram encaminhados 135 pacientes; destes, 39 realizaram RMC. A idade média foi de 60 anos (50 a 71). Cerca de 87% (n = 34) eram do sexo masculino. Prevaleceu etiologia etanólica 56% (n = 22). A maioria era de pacientes CHILD C, MELD ≥ 18, (n = 26). A RMC evidenciou isquemia miocárdica em 03 pacientes (7,6%). A cineangiocoronariografia foi realizada nestes pacientes e a presença de doença arterial coronariana grave (obstrução > 70%) foi confirmada em todos, com consequente revascularização miocárdica. Em um seguimento de até 2 anos e 7 meses, a sobrevida dos transplantados foi de 87%, sem intercorrências cardiológicas. Conclusões: A realização da RMC na avaliação de cirróticos no pré-transplante mostrou-se estratégia segura ao evidenciar a presença de alterações morfofuncionais da cardiomiopatia do cirrótico e a presença de isquemia miocárdica. Entretanto, novos estudos devem ser realizados para padronização de métodos e critérios para avaliação cardiovascular em cirróticos.
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