Brain death (BD) alters the pathophysiology of patients and may damage the kidneys, the lungs, the heart and the liver. To obtain better quality transplant organs, intensive care physicians in charge of the maintenance of deceased donors should attentively monitor these organs. Careful hemodynamic, ventilatory and bronchial clearance management minimizes the loss of kidneys and lungs. The evaluation of cardiac function and morphology supports the transplant viability assessment of the heart. The monitoring of liver function, the management of the patient's metabolic status and the evaluation of viral serology are fundamental for organ selection by the transplant teams and for the care of the transplant recipient. OBJECTIVEThese guidelines are aimed at contributing to the institutional coordination of organ transplantation and will provide "real world" guidelines that are appropriate in the Brazilian context for the uniform care of the deceased donor. Ultimately, this aim of this guide is to increase the quality and quantity of transplantable organs. METHODOLOGYThe Writing and Planning Committee, comprised of young intensive care physicians and intensive medicine residents, conducted an extensive literature review. From this review, they formulated questions and forwarded the questions to all of the authors of this article. These initial questions served as the starting point for receiving suggestions for the formulation of other questions and definitions.The final questions were revised by the Executive Committee and were returned to the authors to develop the guidelines presented in this article.The questions guided the literature review, which was conducted using the P.I.C.O. methodology where P stands for the target population, I for the intervention, C for the control or comparative group and O for the clinical outcome.The retrieved articles were critically analyzed and categorized according to their grade of recommendation and the strength of the presented evidence in the following manner:

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therapies with loco regional and other modalities are important to stay within the Milan criteria and to prevent dropout. Aim: To evaluate the efficacy of pre transplant bridging therapy on post-transplant outcome. Methods: We revised 70 cases (73% males) with HCC in Hadassah Liver Unit, who underwent liver transplantation along 2001-2015. Results: HCV found in 46%, HBV 37%, NASH 10%, Alcohol 7% and others 7%. CHILD-A 66%, CHILD-B 26% and CHILD-C 9%. Mean aFP at HCC diagnosis was 390 AE 1586. Pre transplant anti-cancer therapy included TACE in 73%, Radiofrequency 20%, Resection 6%, Nexavar 6% and TARE 1%. 79% of cases transplanted within Milan criteria. While 63% underwent liver transplantation in Israel, the rest abroad. The transplant calculated MELD was 12.5 AE 5.9. Mean age at liver transplantation was 56.8 AE 10.9 (84% were >50 years), mean pre transplant HCC diagnosis 1.1 AE 0.7 and mean post-transplant follow up 3.9 AE 3.6 years. Survivors of >3 months after transplantation were divided into dead (12/59, 20%) and alive (47/59, 80%) groups. Pre transplant anti-cancer treatment was significantly more frequent in the dead group, TACE 92 vs. 86% (p = 0.05), Nexavar 17 vs. 2% (p = 0.02. HCC recurred in 11% after transplantation. Conclusion: The overall survival was 79% in a post transplantation follow up of 3.9 AE 3.6 years (up to 14 years). The need for higher use of pre transplant anti-cancer therapy reflects higher malignant potentials that revealed to a higher rate of HCC recurrence and mortality.

Abstract:Objectives: To quantify the frequency of incidental hepatocellular carcinoma (iHCC) and evaluate the reasons for liver transplantation in the study population and the accuracy of imaging tests in diagnosing hepatocellular carcinoma (HCC) in a liver transplant referral center. Methods: Retrospective sectional study conducted based on 426 medical records of patients who underwent liver transplantation at the Hospital Santa Isabel in Blumenau (SC), between January 2016 and December 2019. The pathology reports of the explanted livers, the evolution of the patients, and the reports of the imaging exams performed up to six months before the transplant were evaluated. Patients under 18 years of age, history of retransplantation, fulminant liver failure, metabolic liver disease, autoimmune hepatitis, and other etiologies of liver failure with a lower risk of developing HCC were excluded. Results: Of the 426 transplant patients, 89 were excluded. Among those included, 190 (56.38%) were transplanted for cirrhosis without previously diagnosed HCC and 147 (43.62%) for previously diagnosed HCC. The frequency of iHCC was 7.89% (15/190). Hepatitis C virus was more frequent among patients with previously diagnosed HCC than among those with iHCC (p = 0.033). Magnetic resonance imaging (MRI) was the most sensitive and least specific test (S = 100%; E = 75.76%). Computed tomography (CT) showed high sensitivity and specificity (S = 93.75%; E = 90%), while ultrasonography showed low sensitivity and high specificity (S = 56.76%; E = 97.86%). Conclusion: This study found similar data to the international literature regarding the frequency of iHCC. Ultrasonography was the least sensitive test, while CT and MRI showed higher sensitivity than seen in the literature. The MRI showed lower specificity than most of the references analyzed.

Introdução: Carcinoma hepatocelular (CHC) é a neoplasia hepática de maior prevalência em humanos. Nas últimas décadas houve um aumento na incidência desse tumor, em consequência do número crescente de indivíduos infectados pelo vírus da hepatite C (VHC) e pelo aumento na sobrevida de pacientes cirróticos. Algumas das ferramentas utilizadas na detecção de CHC são: ultrassonografia (US), tomografia computadorizada (TC) e dosagem sérica da alfa-fetoproteína (AFP). O transplante hepático (TH) pode ser empregado como medida terapêutica de CHC em pacientes cirróticos, com tumor restrito ao fígado e em estágio precoce. Objetivos: Quantificar a prevalência pré-operatória de carcinoma hepatocelular, segundo os critérios da EASL (Associação Européia para Estudos das Doenças do Fígado) em receptores de transplante hepático e associar à confirmação diagnóstica por exame anatomopatológico, no Serviço de Transplante Hepático do Hospital Santa Isabel, de Blumenau-SC no ano de 2008. Métodos: Foram analisados retrospectivamente os dados clínicos de 71 receptores de transplante hepático, enfatizando a etiologia da indicação de TH, a dosagem sérica da AFP pré-operatória, e o diagnóstico anatomopatológico dos órgãos explantados. Resultados: A prevalência pré-operatória de CHC foi de 26,76%. Ao considerarmos valores de alfa-fetoproteína ≤ 20 ng/mL como valores normais, encontramos sensibilidade de 63,16% desse método diagnóstico. Em 73,68% dos casos, o diagnóstico pré-operatório de CHC foi confirmado pela análise anatomopatológica dos órgãos explantados. Conclusão: Tanto a prevalência pré-operatória de CHC, segundo os critérios da EASL, como a prevalência anatomopatológica de CHC dos órgãos explantados foram superiores às relatadas por outros estudos, possivelmente devido ao aumento nos casos de infecção pelo vírus da hepatite C ocorrido nos últimos anos, pelo aumento na sobrevida de pacientes com cirrose e pela implantação, desde o ano de 2006, do critério de pontuação do MELD segundo a PORTARIA Nº 1.160, DE 29 DE MAIO DE 2006. A prevalência de tumores incidentais e a sensibilidade diagnóstica do nível sérico da AFP foram similares aos encontrados por outros autores. A confirmação diagnóstica de CHC ocorreu em 73,68% dos casos, devido às limitações dos testes diagnósticos.

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