No description available.

Background. Although nutritional deficiency is known to be both common and multifactorial in the post-liver transplant population, a global systematic method of assessing nutritional status has not been widely implemented. The Subjective Global Assessment has been validated in many clinical populations, but to this investigator's knowledge there are no reports on its use in the post-acute liver transplant population. The purpose of this Doctorate of Nursing Practice project was to assess nutritional risk using a Nutritional Assessment Tool, consisting of the Subjective Global Assessment plus additional indicators, for use in the post-acute liver transplant population, defined as one week or less after hospital discharge from liver transplant. The additional indicators consist of age, body mass index, Model for End-Stage Liver Disease score, hospital length of stay for liver transplant, and diagnosis of diabetes mellitus. Methods. This was a practicality study in which a Nutritional Assessment Tool was administered by advanced practice nurses to post-acute liver transplant patients in an outpatient clinic. Each advanced practice nurse completed a practicality survey. Dependence of the additional indicators on the Subjective Global Assessment classification was evaluated using ANOVA and Fisher's exact test. Time to administer the tool was also collected. Results. Seventeen participants were enrolled over a period of three months. Among these, 70.5% were ranked as well-nourished, 23.5% as moderately malnourished, and 5.9% as severely malnourished. No statistically significant dependence of the indicators on the Subjective Global Assessment classification was found. The average time to administer the tool was 9.7+/- 2.4 minutes. Based on the survey from advanced practice nurses, the Nutritional Assessment Tool was found to be practical in this outpatient clinic setting. Conclusions. Implementing a Nutritional Assessment Tool, or the Subjective Global Assessment at minimum, in the post-acute liver transplant population in this setting served to be a practical method of evaluating global nutritional risk.

No description available.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / O transplante hepÃtico à o tratamento padrÃo para os portadores de doenÃa hepÃtica terminal. Com o refinamento da tÃcnica cirÃrgica, melhoria da eficÃcia dos imunossupressores, o entendimento da lesÃo de isquemia-reperfusÃo e o uso de soluÃÃes de preservaÃÃo mais fisiolÃgicas, houve um aumento considerÃvel da sobrevida do enxerto hepÃtico, e consequentemente, da sobrevida do paciente. A soluÃÃo de preservaÃÃo de Collins à a mais simples e a mais econÃmica, sendo utilizada desde 1969 principalmente no transplante renal. A soluÃÃo de Belzer à a mais utilizada mundialmente e preserva o enxerto hepÃtico por um perÃodo maior, entretanto com um custo mais elevado. O presente estudo compara 2 esquemas de perfusÃo hepÃtica utilizando a soluÃÃo de Collins e Belzer. A diferenÃa entre os dois grupos à que a soluÃÃo de Belzer infundida pela veia porta à substituÃda pela soluÃÃo de Collins. Foram avaliados 49 pacientes submetidos a transplante hepÃtico com doador falecido no Hospital UniversitÃrio Walter CantÃdio da Universidade Federal do CearÃ. A funÃÃo hepÃtica apÃs o transplante foi avaliada atravÃs das concentraÃÃes sÃricas de AST, ALT, Bilirrubinas e valores de INR (RelaÃÃo Normatizada Internacional do tempo de protrombina) no primeiro e sÃtimo dia pÃs-operatÃrio. O tempo de isquemia fria foi menor que 10 horas em todos os pacientes. NÃo houve diferenÃa entre os dois grupos nos parÃmetros analisados, exceto no INR do grupo em que foi infundida soluÃÃo de Collins na veia porta, que foi maior no 1 PO. Os dois esquemas de preservaÃÃo hepÃtica podem ser utilizados com seguranÃa, desde que observado um tempo de isquemia fria menor que 10 horas. Houve uma reduÃÃo do custo do transplante no grupo que utilizou um menor volume da soluÃÃo de Belzer / The hepatic transplant is the standard treatment for terminal hepatic illness. With the refinement of the surgical technique, improvement of the effectiveness of the immunosuppressive drugs, the better knowledge of the reperfusion injury and the use of more physiological solutions of preservation, had a considerable increase of the survival of hepatic graft. The Collinsâ preservation solution used since 1969 , in renal transplant, is simplest and most economic preservation solution. The Belzerâs solution is used world wide and preserves hepatic graft for a longer period, although more expensive. The present study it compares 2 projects of hepatic perfusion using the Collins and Belzerâs solution. The difference between the two groups is that the Belzerâs solution perfused for the portal vein is substituted by the solution of Collins. At Walter CantÃdio Hospital of the Federal University of the Cearà 49 patients submitted to hepatic transplant of deceased donors graft were evaluated. The hepatic function after the transplant was evaluated through parameters AST, ALT, INR and Bilirubin in first and the seventh postoperative day. The time of cold ischemia was less than 10 hours in all the patients. There was no difference between the two groups in the analyzed parameters, except in the INR of the group where Collinsâ solution in the portal vein was perfused, which was greater in the 1 postoperative day. The two projects of hepatic preservation can be used with security, as the cold ischemia time is less than 10 hours, however, it had a reduction of the cost of the liver transplant in the group that used a lesser volume of the solution of Belzer.

The purpose of this study was to evaluate liver transplant recipient factors associated with postoperative complications leading to longer intensive care unit (ICU) length of stay which in turn may increase hospital morbidity and mortality. A retrospective, correlational design was developed with a sample of 230 participants. Data were collected for liver transplant recipients over a four-year period (June 2007-December 2011) from the electronic medical record and the transplant database. T test and binary logistic regression were used to assess for the factors predictive of ICU complications, ICU length of stay (LOS), hospital length of stay (HLOS), and overall morbidity and mortality. Data were collected from three time periods: preoperatively, intraoperatively, and postoperatively. The factors identified as statistically significant were cold ischemic time, lowest intraoperative glucose, postoperative four-hour blood urea nitrogen (BUN), Postoperative Day 1 (POD 1) hematocrit, postoperative lowest systolic blood pressure, and fresh frozen plasma (FFP) transfusions. Mortality occurred in 1 recipient in the >9-day ICU stay group, and 7 deaths were noted in the >19-day hospital LOS group. Age of recipients who died was 48-59 (6 males, 2 females), with 7 Caucasian and 1 Other. Comorbidities of these deceased recipients were diabetes and obesity with MELD scores of 18-45. Complications experienced by recipients included: 6 with renal failure, 2 with sepsis, 3 with graft dysfunction, and 1 with cerebral edema. Findings from this study showed factors that impact ICU LOS, HLOS, and mortality, including BUN, glucose, and hematocrit. Implications for practice are that these factors should be closely monitored in the pre-, intra-, and postoperative time periods to reduce risks of complications to transplant recipients. Future research should include further evaluation of the factors associated with poor transplant outcomes, including glucose, continuous renal replacement therapy (CRRT) use, age, and gender. Nurse researchers must continue to strive to understand the pathophysiological mechanism of liver disease to reduce ICU complications ultimately to improve the care and outcomes of liver transplant recipients while reducing ICU LOS and HLOS.

This thesis provides a first description and proof-of-concept of iterative cardiac output measurement (ICO) – a respiratory, carbon-dioxide (CO2) based method of measuring cardiac output (CO). The ICO method continuously tests and refines an estimate of the CO by attempting to maintain the end-tidal CO2 constant. To validate the new method, ICO and bolus thermodilution CO (TDCO) were simultaneously measured in a porcine model of liver transplant. Linear regression analysis revealed the equation ICO = 0.69•TDCO + 0.65 with a Pearson correlation coefficient of 0.89. Analysis by the method of Bland and Altman showed a bias of -0.2 L/min with 95% limits of agreement from -1.1 to 0.7 L/min. The trending ability of ICO was determined using the half-circle polar plot method where the mean radial bias, the standard deviation of the polar angle, and 95% confidence interval of the polar angle were -8º, ±17º, and ±33º, respectively.

This thesis provides a first description and proof-of-concept of iterative cardiac output measurement (ICO) – a respiratory, carbon-dioxide (CO2) based method of measuring cardiac output (CO). The ICO method continuously tests and refines an estimate of the CO by attempting to maintain the end-tidal CO2 constant. To validate the new method, ICO and bolus thermodilution CO (TDCO) were simultaneously measured in a porcine model of liver transplant. Linear regression analysis revealed the equation ICO = 0.69•TDCO + 0.65 with a Pearson correlation coefficient of 0.89. Analysis by the method of Bland and Altman showed a bias of -0.2 L/min with 95% limits of agreement from -1.1 to 0.7 L/min. The trending ability of ICO was determined using the half-circle polar plot method where the mean radial bias, the standard deviation of the polar angle, and 95% confidence interval of the polar angle were -8º, ±17º, and ±33º, respectively.

Orientadores: Ilka de Fatima Santana Ferreira Boin, Raquel Silveira Bello Stucchi / Tese (doutorador) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-24T02:50:29Z (GMT). No. of bitstreams: 1 Silva_AnaCarolinaGuardiada_D.pdf: 4973684 bytes, checksum: b2c754b94b99a119ae7e84ac207a9555 (MD5) Previous issue date: 2013 / Resumo: Introdução: As infecções oportunistas constituem um dos principais problemas para os transplantados de fígado. O Citomegalovírus (CMV) e o Herpesvirus humano 6 (HHV- 6) são patógenos oportunistas freqüentes nesses pacientes, e o HHV-6 tem sido associado a várias desordens tais como a encefalite. A PCR em tempo real (RT-PCR) é o padrão ouro de diagnóstico para os herpesvirus, pois tem melhor precisão, maior rendimento e menos risco de contaminação em comparação com outros testes convencionais. Objetivo: Este estudo teve como objetivo avaliar a cinética viral do HHV-6 e CMV por RT-PCR nos pacientes submetidos ao transplante hepático correlacionando-a com a presença de encefalite e complicações clínicas ocorridas no período pós-transplante. Método: Foram analisadas prospectivamente pela RT- PCR a carga viral do CMV e HHV-6 de 30 pacientes transplantados de fígado. A monitorização dos pacientes foi realizada prospectivamente desde o pré-transplante (imediatamente antes do ato cirúrgico - dia zero) com amostras do doador e receptor, e no pós-transplante: 2ª, 3ª, 4ª, 6ª, 8ª, 10ª e 12ª semanas, somando 270 amostras de soro. O protocolo foi seguido de acordo com os requerimentos para pesquisas e foi aprovado pelo Comitê de Ética em Pesquisada da Faculdade de Ciências Médicas da Universidade Estadual de Campinas (CEP nº 430/2003). Os achados clínicos foram obtidos através dos prontuários. Para a detecção e quantificação do DNA dos vírus CMV e HHV-6 foram usados os Kits comerciais "CMV Real-TM Quant" e "HHV-6 Real-TM Quant". Os testes de Nested-PCR e antigenemia foram realizados rotineiramente para o vírus CMV, pelos laboratórios do HC-Unicamp, e seu resultados obtidos eletronicamente. A análise estatística comparou as variáveis categóricas usando o teste exato de Fisher. Para identificar os fatores associados ao aumento da carga viral foi utilizado o método das Equações de Estimação Generalizadas e medidas de acurácia. Resultados: Treze (43%) dos 30 pacientes apresentaram infecção pelo HHV-6 e 26 (86%) apresentaram infecção pelo CMV. Nove pacientes apresentaram encefalite após o transplante de fígado sendo que sete deles tiveram infecção pelo HHV-6 (p=0,0012), assim com o aumento da carga viral do HHV-6 se constatou a presença de encefalite após o transplante de fígado (p= 0.0226). O RT- PCR (p= 0,0306) para o CMV mostrou aumento significativo na segunda a quarta semana e décima a décima segunda semanas em relação aos outros testes, mostrando-se também mais sensível. Conclusão: concluímos que o aumento da carga viral do HHV-6 foi associado com a presença de encefalite após o transplante de fígado e a técnica de PCR em tempo real se mostrou como o teste mais sensível para detecção e monitorização do CMV nos pacientes transplantados de fígado / Abstract: Introduction: Opportunistic infections are a major problem for liver transplantation patients. Cytomegalovirus (CMV) and human herpesvirus 6 (HHV-6) are opportunistic common pathogens and HHV-6 has been associated with several disorders such as encephalitis. Real-time PCR (RT-PCR) is the gold standard for diagnosis of herpesvirus, as it has better accuracy, higher efficiency and less risk of contamination compared to other conventional tests. Objective: The aim of study was to evaluate the viral kinetics of HHV-6 and CMV by RT-PCR in patients undergoing liver transplantation and correlated with the presence of encephalitis complications occurring in the post-transplant period. Methods: We prospectively analyzed by RT-PCR the viral load of CMV and HHV-6 in 30 liver transplant patients. Monitoring of patients was performed prospectively from pretransplant (immediately before surgery-day zero) with donor and recipient samples and posttransplant: 2nd, 3rd, 4th, 6th, 8th, 10th and 12th weeks with a total of 270 serum samples. The protocol was followed according to the requirements for research and was approved by the Ethics Research Committee of the Faculty of Medical Sciences State University of Campinas (CEP nº 430/2003). The clinical findings were obtained from the medical records. For detection and quantification of DNA of the CMV and HHV-6 virus the commercial kits "Real- CMV Quant TM" and "HHV-6 Real -TM Quant" were used. Nested-PCR and antigenemia tests were performed routinely for CMV virus and their results obtained electronically. Statistical analysis comparing categorical variables was applied using Fisher exact test. To identify associated factors with increased viral load the method of Generalized Estimation Equation (GEE) and the accuracy and precision was used. Results: Thirteen (43 %) of the thirty patients had HHV-6; 26 (86 %) had CMV infection. Nine patients had encephalitis after liver transplantation and seven of them had HHV-6 (p = 0.0012) and with an increasing viral load of HHV-6 the presence of encephalitis after liver transplantation was found (p = 0.0226). RT-PCR (P = 0.0306 ) CMV showed a significant increase at the 2nd to 4th week and 10th to 12th week compared to the other tests, having also more sensibility. Conclusion: We concluded that the increase in viral load of HHV-6 was associated with the presence of encephalitis after liver transplantation and the technique of real-time PCR was shown to be the best sensibility test for the detection and monitoring of CMV in our liver transplant patient / Doutorado / Fisiopatologia Cirúrgica / Doutora em Ciências da Cirurgia

La préservation statique à froid (SCS) est l’étalon-or de la préservation des organes après une greffe. En raison de la pénurie d’organes et de l’augmentation du nombre de patients figurant sur la liste d’attente, le recours aux organes provenant des donneurs à critères élargis, lesquels sont très sensibles au syndrome d’ischémie-reperfusion (IRS), ce qui entraîne une non-fonction primaire (PNF) ou un dysfonctionnement précoce (EAD), est de plus en plus fréquent.Cette recherche avait pour but d’étudier et d’identifier de nouvelles stratégies pour améliorer la qualité de la préservation des organes - d'atténuer les séquelles de l'IRS en utilisant la machine de perfusion hépatique à différentes températures et à différentes périodes d'utilisation après le prélèvement de l'organe ou en ajoutant une hémoglobine extracellulaire en tant que transporteur d'oxygène pendant le SCS.Deux modèles différents ex-vivo ont été analysés : L’un chez le petit animal avec des foies de rats normaux et stéatosiques, pour la perfusion hypothermique (HMP) et SCS avec le transporteur d'oxygène et au niveau préclinique, des foies humains stéatosiques récusés, pour la perfusion normothermique (NMP).Les résultats ont confirmé de manière significative l'intérêt de l’HMP dans la phase pré-ischémique du SCS et celui de l'utilisation de l'hémoglobine extracellulaire en améliorant la fonction hépatique, le maintien de l'anatomie des hépatocytes et en réduisant des marqueurs du stress oxydatif, de l'apoptose et de l'inflammation. Egalement, l'utilisation de NMP a permis d'analyser les foies sévèrement stéatosiques pouvant être récupérés pour une transplantation dans un avenir très proche.Cette recherche met en évidence de nouvelles approches en matière de préservation d'organes susceptibles d'augmenter le pool d'organes et d'améliorer les résultats en transplantation hépatique.Mots-clés : greffe de foie, stockage froid dans le froid, perfusion dans une machine à foie, lésion de reperfusion par ischémie, transporteur d'oxygène. / Static cold storage (SCS) is the gold standard of organ preservation after being procured for transplantation. Due to the organ shortage and the increase of number of patients in the waiting list have pushed the use organs from extended criteria donors which are very susceptible to the ischemia reperfusion syndrome (IRS) leading to primary non-function (PNF) or to early allograft dysfunction (EAD).This research was aimed to study and identify new strategies to improve the quality of organ preservation -liver, to attenuate the IRS sequels by using the liver perfusion machine (LPM) at different temperatures and times of usage after the organ procurement or by adding an extracellular hemoglobin as an oxygen carrier during SCS.Two different ex-vivo models were analyzed: small animal -normal and steatotic rat livers, for hypothermic perfusion (HMP) and SCS with the oxygen carrier and preclinical -steatotic discarded human livers, for normothermic perfusion (NMP).The results significantly confirmed the benefit of the HMP in the preischemic phase of SCS and that of the use of the extracellular hemoglobin by improving the liver function, maintenance of the hepatocytes anatomy and by a reduction of the oxidative stress, apoptosis and inflammation markers. Also, the use of NMP permitted to analyze the severely steatotic livers that can be rescued for transplantation in the very near future.This investigation unveils new approaches in organ preservation that could increase the pool of organs and improve the results in liver transplantation. Key words: liver transplantation, static cold storage, liver machine perfusion, ischemia reperfusion injury, oxygen carrier.

People who need a liver transplant must choose a hospital at which the transplant will be performed. The United Network for Organ Sharing (UNOS) allocates organs to patients based on patient characteristics and assumes all hospitals have equal skill. The question for a patient thus becomes, which hospital to choose? This thesis investigates whether the differences in liver transplant survival rates for hospitals are a result of differences in patients and/or differences in hospital-specific criteria. The findings in this thesis show that most of the differences in hospital survival rates are due to patient characteristics, and that, while not conclusive, hospital characteristics may have an impact on survival rates. However, the variable that is most significant to survival rates is the cold ischemic time, or transportation time of the organ. These results suggest that policies to allocate organs nationally are not optimal. / Master of Arts