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- ItemAcesso aberto (Open Access)Análise multivariada dos fatores de sobrevida e recidiva em 414 pacientes portadores de carcinoma hepatocelular transplantados em São Paulo.(Universidade Federal de São Paulo (UNIFESP), 2020-01-30) Takamatsu, Fernanda Yuri [UNIFESP]; Netto, Alcides Augusto Salzedas [UNIFESP]; Gonzalez, Adriano Miziara [UNIFESP]; http://lattes.cnpq.br/6234829429056217; http://lattes.cnpq.br/2580534578039797; http://lattes.cnpq.br/1700430753091220; Universidade Federal de São PauloObjective: To identify the risk factors involved in the survival and recurrence of patients with hepatocellular carcinoma (HCC) undergoing liver transplantation (LTx). Methods: Retrospective observational study that analyzed the medical records of 414 patients with HCC undergoing deceased donor LTx in São Paulo between January 2007 and December 2011. Multifactorial analysis of survival and recurrence was performed using clinical, laboratory and pathology data. Results: The mortality rate was 27.5%, with a mean survival time of 68.1 months (95% CI) and estimated 1-, 3- and 5-year survival probabilities of 83.8%, 75.8% and 71.5%, respectively. Altered donor blood glucose, female sex, vascular invasion, advanced age, high Model for End‐Stage Liver Disease (MELD) score and tumor size were the main risk factors determining survival in LTx recipients. Recurrence occurred in 7.2% of patients during the study period and was more frequent in women (hazard ratio [RR] 2.6). Vascular invasion increased the chance of recurrence 5.4×. Each additional 1-year increase in recipient age increased the chance of recurrence by 5.6%, and each 1-mm increase in tumor size increased the chance of recurrence by 3%. Conclusion: Risk factors for reduced survival are donor blood glucose, female recipient, older age, increased MELD score and nodule size. Tumor recurrence risk factors are vascular invasion, female sex, recipient age and nodule size.
- ItemAcesso aberto (Open Access)Análise qualitativa da adesão ao tratamento pós-transplante hepático em adultos(Universidade Federal de São Paulo (UNIFESP), 2019-11-28) Silva, Juliana Dutra De Araujo [UNIFESP]; Roza, Bartira De Aguiar [UNIFESP]; http://lattes.cnpq.br/9049493842666015; http://lattes.cnpq.br/1589752854243094; Universidade Federal de São Paulo (UNIFESP)Objective: To understand the experience of adherence to treatment after liver transplantation in adults. Method: An exploratory, descriptive, qualitative study with Laurence Bardin's Content Analysis as a reference for organizing and analyzing data collected in semi-structured interviews. Results: We interviewed 18 adult patients with deceased donor liver transplant, followed in a transplant center in São Paulo. The results emerged from two themes: 1) Illness: patients reported the experience of discovering a silent disease, the severe limitations of illness and the transplant acceptance process, the latter being crossed by coping with illness, waiting for the compatible organ at the ideal time, the information that has no way to cure the disease and finally, the acceptance; 2) Life after transplantation: Patients reflected on whether life after transplantation is normal, evaluating what have improved, which aspects of the health are still recovering, what are the limitations, complications and emotional responses in this new phase. They reported the coping strategies used - such as seeking information, support network, spirituality, and gratitude - and conclude that this is a life of care involving healthy living habits, continuous use of medication, and outpatient followup, to which they will respond adhering or not. Going through all these moments of life after transplantation, the fear of death was a central finding of the study associated with treatment adherence. Patients who adhere to health care team guidelines may be mobilized by the fear of dying that persist even after transplantation with the threat of graft loss. Non-adherence to treatment was associated with the absence of fear of death, either by the absence of symptoms that would approach them to this reality or by the denial of their own finitude. Conclusion: Behaviors of adherence or nonadherence to treatment after transplantation were associated with emotional responses to illness and fear of death. Thus, interventions to promote adherence should alert patients about the risks (sometimes silent risks) that remain after transplantation and take care of those who are suffering feeling their life continually under threat.
- ItemSomente MetadadadosAnastomose biliar com ou sem tubo em t durante transplante hepático em adultos: revisão sistemática e metanálise(Universidade Federal de São Paulo (UNIFESP), 2021) Oliveira Filho, Jose Jeova de [UNIFESP]; Linhares, Marcelo Moura [UNIFESP]; Universidade Federal de São PauloIntroduction: In liver transplantation, biliary complications, especially leaks/fistulas and stenosis, remain the main causes of surgical morbidity (5% to 35%) and mortality (10% to 60%). The end-to-end choledochocholedocostomy is the most commonly adopted biliary anastomosis technique, be it associated or not with the use of a T-tube. There is no consensus regarding the use of the T-tube as a drainage technique during biliary reconstruction. Objectives: Analyzing the results of biliary anastomosis, with or without the use of a T-tube in adults undergone liver transplantation. Methods: Systematic review of randomized clinical trials. The research was conducted on the Cochrane Hepato-Biliary Group Controlled Trials Register (Cochrane Hepato-Biliary Group Module) databases, Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, MEDLINE Ovid, Embase Ovid, Latin American and Caribbean Health Sciences Database (LILACS; Virtual Health Library - BVS), Science Citation Index Expanded (Web of Science), Conference Proceedings Citation Index - Science (Web of Science) (Royle 2003), Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO), ClinicalTrial.gov (clinicaltrials.gov/), and WHO International Clinical Trial Registry Platform (www.who.int/ictrp). There were no restrictions on language and publication date. Randomized clinical trials comparing choledochocholedocostomy with or without the use of a T-tube were included. The primary outcomes studied were mortality, serious adverse events (anastomotic and non-anastomotic stenosis, anastomotic and non-anastomotic biliary leakage, complications related to the T-tube, retransplantation and non- biliary complications) and quality of life. Secondary outcomes were non-serious adverse events (systemic and other biliary complications) and pain. We used the standard methodological procedures expected by Cochrane and Cochrane Hepato-Biliary Group Module and performed the analyzes using Review Manager 5.4. We used a random-effects model meta-analysis and presented the results of the review incorporating the methodological quality of the studies using GRADE. In our review, we used dichotomous results and expressed the results as hazard ratio (HR) with a 95% confidence interval (CI). Results: The review included seven randomized controlled trials, with a total of 881 adult participants, averaged 50.4 years old and with an average follow-up period from 8 to 35 months. Has been demonstrated the occurrence of a greater number of anastomotic stenosis in the control group (without T-tube) just as it was observed greater number of complications related to the T-tube and greater overall risk of serious adverse events in this same group, being these differences were statistically significant. There was no evidence of an overall significant difference between T-tube and non-T-tube groups, regarding the other outcomes. Heterogeneity between studies was variable. All studies presented a high risk of biases and we classified the evidence from low-quality to very low-quality. Conclusions: There was low-quality to very low-quality evidence showing that biliary anastomosis without a T-tube may be associated with an increased risk of anastomotic stenosis and that biliary anastomosis with a T-tube may be associated with an increased risk of complications related to its use, such as leakage and cholangitis and the increased overall risk of serious adverse events. We suggest more randomized controlled trials, especially with a longer observation period and better evidence quality.
- ItemAcesso aberto (Open Access)Estudo da bioquímica salivar de crianças e adolescentes com atresia de vias biliares pré e pós transplante hepático(Universidade Federal de São Paulo (UNIFESP), 2019-08-29) Buosi, Debora Fernandes [UNIFESP]; Salzedas Netto, Alcides Augusto [UNIFESP]; Macedo, Adriana Furtado de; http://lattes.cnpq.br/0954447386352811; http://lattes.cnpq.br/2580534578039797; http://lattes.cnpq.br/8992396165332437; Universidade Federal de São Paulo (UNIFESP)Objective: This study aimed to evaluate some salivary parameters of children and adolescents with biliary atresia before and after liver transplantation. Methods: The sample consisted of 69 children and adolescents, both sexes, edentulous, deciduous, mixed and permanent dentures, attended at the Pediatric Gastroenterology and Liver Transplantation outpatient clinics of Unifesp. They were divided into three distinct groups: bile duct atresia group (AVB=29), hepatic post-transplant group (TxH=20) and without systemic diseases Control group (C=20). Saliva was collected by the non-stimulated aspiration method and the salivary amylase, sialic acid, total protein, calcium and phosphate concentration were analyzed and the readings were performed by the spectrophotometer. Results: Salivary amylase and sialic acid in the group (AVB) are significantly reduced in relation to the other groups. The total protein was elevated in the AVB group in relation to the TxH group. Calcium showed no difference between the AVB, TxH and C groups. Phosphate was decreased in patients with mixed dentition in the AVB and TxH groups. In patients with deciduous dentition the phosphate was higher in the AVB and TxH group when compared to the control group. Conclusion: Sialic acid and amylase in patients with AVB are reduced in relation to the other groups (TxH and control). The total protein in the AVB group is increased in relation to the TxH group. There was no difference between the groups regarding salivary calcium. Salivary phosphate presented alterations: higher in the AVB group in relation to the control. Decreased in patients with mixed dentition in AVB and TxH groups. In patients with deciduous dentition the phosphate was higher in the AVB and TxH group when compared to the control group.
- ItemSomente MetadadadosNão adesão ao tratamento no transplante de fígado(Universidade Federal de São Paulo (UNIFESP), 2019-04-25) Oliveira, Priscilla Caroliny De [UNIFESP]; Roza, Bartira De Aguiar [UNIFESP]; Schirmer, Janine [UNIFESP]; http://lattes.cnpq.br/3721636964139813; http://lattes.cnpq.br/9255434835123749; http://lattes.cnpq.br/3558901850783019; Universidade Federal de São Paulo (UNIFESP)Objectives: To evaluate the interventions of the multiprofessional team that provide improved adherence to treatment after liver transplantation; to assess levels of non-adherence to immunosuppressive therapy in a sample of liver transplant recipients using the Basel Assessment of Adherence with immunosuppressive medication Scalee to correlate sociodemographic characteristics and clinical factors to non-adherence to medication; to develop a model of evaluation of nonadherence to the treatment in the context of liver transplantation capable of covering several dimensions of the phenomenon, correlating the levels of non adherence to the different methods of measurement applied in liver transplant patients; to reflect on the theoretical and practical aspects related to non-adherence to treatment in the context of liver transplantation and to correlate with the concepts of normality established by Michael Foucault and The Power as Knowing Participation in Change Theory. Methods: This study adopted a mixed method design, in which elements of qualitative and quantitative research were combined. The work was divided into four subprojects: 1- adherence to treatment in liver transplantation: an integrative review; 2- evaluation of adherence to treatment in patients submitted to liver transplantation; 3 - New perspectives of analysis in nonadherence research in liver transplantation by means of data association: pilot study. 4 - subjectivity, adherence in transplantation and biopolitics - possible reflections of power as normative practice in health. The study was and approved by the Ethics and Research Committee under the opinion 623.082 and Certificate of Presentation for Ethical Appreciation nº1643201470005505. Results: The integrative review, which aimed to evaluate the interventions of the multiprofessional team that provides the improvement of adherence to treatment after liver transplantation, initially selected 84 publications. After applying the exclusion criteria, 10 studies were selected. Four significant categories were found: educational interventions; adoption of an individual therapeutic plan; change in immunosuppressive regimen; emotional support, psychological support and strengthening of the support network. The level of nonadherence in liver transplantation was 49% and was directly related to the use of mycophenolic acid (p = 0.007) and administration of multiple doses of immunosuppressants daily (p = 0.004). No statistically significant correlations were found between non-adherence to immunosuppressive therapy and sociodemographic characteristics and other clinical variables analyzed. It was proposed a data triangulation model that evaluated the non adherence to liver transplantation under different aspects: a) direct evaluation of non adherence - through the application of a self-report instrument, associated to the perspective of the patient himself and the specialist responsible for follow-up; b) clinical evaluation, considering the serum immunosuppressive level in use, alterations of the aminotransferases, histological analysis of the graft and previous treatment for rejection; c) behavioral evaluation, which analyzed the existence of reports of therapeutic failure and absences on outpatient return. These indicators were analyzed individually and together. The theoretical essay aimed to develop a systematic reflection on adherence to treatment in the context of transplantation, based on the historicity of its concept of adherence through the construction of parallels between the concepts of adherence and health. The problem of non-adherence questions the team about its role, which requires listening to the demands that come in to everyday praxis. In this perspective, the theory of power as knowledge and participation for change of Elizabeth Barrett is emphasized, for emphasizing the subjective aspect present in health care, emphasizing the role of a dialogue and supported action in the establishment of solidarity and socio- and fostering the social role of users of transplantation actions and services. Conclusion: In view of the gaps highlighted and the results pointed out through the integrative review, it is understood that it is necessary to intensify efforts for the development of research with designs that produce strong evidences regarding the interventions adopted by the multiprofessional team capable of improving the adherence. This study showed that nearly half of the patients stopped adhering to immunosuppressive therapy after liver transplantation. Since unfavorable outcomes in transplantation are closely related to adherence failures, it is important that nurses assess this behavior during outpatient follow-up of liver transplant recipients. The application of triangulation methods to qualitatively assess noncompliance in an adult liver transplant program included 10 indicators in the analysis and identified a non-adherence level of 14.3%. At the end of the reflective study, it was possible to conclude that the phenomenon of adherence is more complex than we have traditionally described, because it depends on the subjective process that involves many questions that are not yet addressed by nurses in general. The threshold between adhesion and nonadherence is unique, even if it is influenced by plans that transcend the strictly individual, such as social, economic, political, historical and cultural.
- ItemSomente MetadadadosPerfil Inflamatório Dos Doadores De Órgãos Em Morte Encefálica E Sua Correlação Com A Falência Dos Enxertos Renal, Hepático E Pancreático(Universidade Federal de São Paulo (UNIFESP), 2017-11-30) Soutinho, Leonardo Wanderley [UNIFESP]; Linhares, Marcelo Moura [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)Introduction: Organ transplantation is an established therapy since it improves survival and quality of life of renal, hepatic and pancreatic terminal patients, but many are not performed due to a shortage of organs for donation. This imbalance between the supply and demand for organs causes a high mortality in the transplant waiting list worldwide. The rationalization of the use of organs is imposed and begins with the best evaluation of potential brain-dead donors and the inclusion of marginal criteria donors. These donors are increasingly used and the decision on the viability of their organs is a difficult task and specific risk scores for each organ are currently applied. In this study, we investigated whether cytokines and chemokines in the blood of multiple organ in brain-dead donors may influence the results of each specific transplanted organ including kidney, liver and pancreas. We also sought to clarify the relationship of these proteins to the routinely collected health data from donors. Methods: A prospective, non-interventional cohort study was conducted between 2013 and 2016. Of the 99 multiple organs donors in encephalic death offered to our institution (mean age 40.2 years), were performed 172 renal transplants, 54 Hepatic and 15 pancreatic. From each donor, serum samples were collected from which the concentrations of 41 cytokines and chemokines were measured through the Luminex® xMAP® technology MILLIPLEX MAP kits #HCYTMAG-60K-X41 (Millipore Corporation). Clinical data from donors and recipients were collected and, through the Mann-Whitney statistical test, their correlations with the cytokine results of the collected plasma samples were investigated. Results: The cytokine eotaxin elevation demonstrated a significant correlation with the loss of twelve transplanted kidneys. Five hepatic and one pancreatic grafts were lost and none of the 41 cytokines evaluated showed a significant correlation with these losses. Significant correlations were detected between the presence of Infection in the Donors and the mean values of the macrophage-derived chemokine (MDC); Serum sodium and interleukin 10; The number of days of Orotracheal Intubation and interleukins 5 and 8; The number of days in intensive care with the concentrations of interleukin 5, and inversely with interferon gamma, interleukin 8 and with interleukin 1 antagonist receptor; leukocytosis in donors and the interleukins: granulocyte colony-stimulating factor (GCSF), granulocyte/macrophage colony-stimulating factor (GM-CSF), macrophagederived chemokine (MDC), IL-6 and IL-8. Conclusions: The elevation in the Eotaxin chemokine concentration in the donors demonstrated a significant correlation with the loss of renal grafts in the recipients. No significant difference was detected between the mean values of any of the cytokines among donors whose recipients lost or not the pancreas or liver grafts. There were important correlations between data from the donor information sheet (serum sodium, leukocytosis, infection, number of days of intubation and hospitalization in ICU) and the inflammatory profile of the donors at the time of organ harvesting.
- ItemSomente MetadadadosProcesso De Ensino Aprendizagem De Pacientes Hepatopatas Com E Sem Encefalopatia No Transplante Hepático(Universidade Federal de São Paulo (UNIFESP), 2017-12-20) Cavalcante, Tatiana De Medeiros Colletti [UNIFESP]; Diccini, Solange [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)To evaluate the impact of the teaching-learning process during the preoperative period on the retention of knowledge after one month of liver transplantation, to compare the knowledge of patients with and without encephalopathy after one month of liver transplantation regarding the information received in the preoperative period, to identify complications up to the third month after hepatic transplantation between the group of patients with and without encephalopathy, and to assess the degree of patient satisfaction regarding the guidelines provided in the preoperative period of liver transplantation. Methods: Prospective cohort study, performed at a transplant center in Fortaleza, Brazil, with 55 patients in the first phase and 36 patients in the second phase. In the first phase, patients were selected and answered a questionnaire regarding the transplant (pre-test). Shortly afterwards, they received information based on the protocol (intervention) and then answered the same questionnaire (post-test). In the second phase, patients who participated in the first phase answered the same questionnaire one month after the transplantation. Results: The patients’ average age was 50.8 years, mostly male (74.5%) with low level of education and medical diagnosis of alcoholic cirrhosis (49.1%). Before the educational intervention, we obtained a median of 8 correct answers to the questionnaire; afterwards, the median grew to 34 correct answers (p < 0.001). After hepatic transplantation, we stratified the patients into groups with and without encephalopathy. Before the intervention, the groups with and without encephalopathy scored 9.9 and 9.0 correct answers, respectively. After the intervention, the mean number of correct answers was 32.8 in the encephalopathy group and 33.4 in the non-encephalopathy group. After one month of transplantation, the mean was 31.2 questions in the group with encephalopathy and 33.6 questions in the group without encephalopathy. There was no statistically significant difference between measurements of effects amongst successful answers given before the intervention and soon after it (p = 0.548) compared to before the intervention and a month later (p = 0.104) between the two groups. Complications occurred in 61.1% of patients up to three postoperative months. Infection was more frequent in patients with encephalopathy. Patients were satisfied with the information received and the private moment of orientation. Conclusions: A level of correctness above 80% after one month of transplantation in 94.4% of patients demonstrates the positive impact of the individualized educational intervention in the preoperative period with respect to retention of knowledge after hepatic transplantation. Patients with and without encephalopathy had a good retention of knowledge after one month of transplantation, with no difference between the two groups, which demonstrates that the individualized educational intervention is effective for the patient with encephalopathy. The most frequent complication was infection, found to be higher in the group with encephalopathy. Patient satisfaction about the educational intervention was positive with respect to the information received and the individualized moment of the nursing consultation.