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Doctoral Thesis
DOI
https://doi.org/10.11606/T.5.2021.tde-08092021-115359
Document
Author
Full name
Guilherme Marques Andrade
E-mail
Institute/School/College
Knowledge Area
Date of Defense
Published
São Paulo, 2021
Supervisor
Committee
Farias, Alberto Queiroz (President)
Boin, Ilka de Fatima Santana Ferreira
Carrilho, Flair José
Santos, Vinicius Rocha
Title in Portuguese
Elastografia para predizer disfunção primária e perda do enxerto no transplante hepático
Keywords in Portuguese
Disfunção primária do enxerto
Falência hepática
Função retardada do enxerto
Técnicas de imagem por elasticidade
Transplante de fígado
Ultrassonografia.
Abstract in Portuguese
INTRODUÇÃO: A elevada demanda por transplante hepático (TH) frente à escassez de doadores têm levado à maior utilização de órgãos com critérios expandidos de aceitação, com consequente aumento da frequência de disfunção primária do enxerto (DPE), entidade clínica associada à perda precoce do enxerto. Não há na literatura definição consensual para DPE, tampouco ferramenta diagnóstica de elevada acurácia e fácil aplicação à beira do leito. A elastografia hepática (EH) tem sido crescentemente utilizada na avaliação de hepatopatias crônicas, sendo, contudo, subutilizada no período pós-operatório precoce de TH. OBJETIVO: Avaliar o desempenho da EH no pósoperatório precoce do TH como preditor de DPE e perda precoce do enxerto. MÉTODOS: Trata-se de estudo prospectivo observacional de acurácia diagnóstica. Sessenta e um pacientes adultos submetidos a transplante hepático com doador falecido foram incluídos e acompanhados durante 12 meses. As medidas de rigidez hepática (MRH) por point shear wave elastography (pSWE) foram realizadas diariamente durante os primeiros sete dias do período pós-operatório de TH. As medianas das MRH foram correlacionadas ao desenvolvimento de DPE e perda precoce do enxerto (óbito ou retransplante em 180 dias). RESULTADOS: Foram realizadas 412 MRH nos 61 TH incluídos. Vinte e sete (44,2%) deles desenvolveram DPE e 17 (27,8%) evoluíram para óbito ou retransplante. As MRH apresentaram valores ascendentes com pico no quarto dia de pós-operatório (2,12±0,45 m/s) e foram significantemente mais elevadas no grupo de pacientes com DPE (p < 0,001), independentemente do dia em que foram efetuadas. Quanto à DPE, as MRH do 1PO acima de 2,39m/s mostraram sensibilidade de 0,41, especificidade de 0,97, VPP de 0,92, VPN de 0,67, acurácia de 0,83, e LR+ de 13,85 para predizer o desfecho. Por outro lado, valores inferiores a 1,65m/s mostraram sensibilidade de 0,96 especificidade de 0,50, VPP de 0,60, VPN de 0,94, acurácia de 0,83, e LR- de 0,07 para excluir DPE. Quanto à perda precoce do enxerto, MRH do 1PO superiores a 2,25m/s mostraram sensibilidade de 0,76, especificidade de 0,98, VPP de 0,93, VPN de 0,91, acurácia de 0,93, e LR+ de 33,65 para predizer o desfecho. Por outro lado, valores inferiores a 1,75m/s mostraram sensibilidade de 0,94 especificidade de 0,64, VPP de 0,50, VPN de 0,97, acurácia de 0,93, e LR- de 0,09 para excluir o desfecho perda do enxerto. As MRH também se associaram à maior necessidade de reoperação (p=0,004) e hemodiálise (p<0,001), além de maiores períodos de hospitalização (p = 0,007) e em unidade de terapia intensiva (p < 0,001). Não houve variáveis interferentes nas MRH. CONCLUSÃO: a EH é um método capaz de predizer disfunção primária e perda precoce do enxerto no pós-transplante hepático com elevada acurácia e desempenho superior a outras ferramentas previamente citadas na literatura.
Title in English
Elastography as a predictor of primary graft dysfunction and early graft loss in liver transplantation
Keywords in English
Delayed graft function
Elasticity imaging techniques
Liver failure
Liver transplantation
Primary graft dysfunction
Ultrasonography
Abstract in English
INTRODUCTION: The high demand for liver transplantation (LT) and donor paucity has led to a greater acceptance of expanded criteria organs, and a subsequent raise in primary graft dysfunction (PGD) rates, a clinical entity associated with increased early graft losses. There is no consensual definition for PGD within the medical literature, neither a high accuracy and easily applicable bedside diagnostic tool. Liver elastography (LE) has been increasingly used as a chronic liver disease staging tool, but data regarding its use in the early post LT scenario is lacking. OBJECTIVES: To evaluate the performance of LE as a PGD and early graft loss predictor in post-LT. METHODS: This is an observational prospective study of diagnostic accuracy. Sixty-one deceased donor adult liver transplants were included during a 12-month period and followed for another 12 months. Daily liver stiffness measurements (LSM) using point shear wave elastography (pSWE) were taken for the first seven post-operative days. LSM medians were correlated to the development of PGD or early graft loss (death or retransplantation within 180 days). RESULTS: A total of 412 LSM were obtained from 61 included LT. Twenty-seven (44.2%) developed PGD and 17 (27.8%) had early graft loss. LSM showed uprising values peaking on the fourth post-operative day (2.12±0.45m/s), and all values were significantly higher in the PGD group (p < 0.001). C-statistic of each day of LSM showed high accuracy and no significant difference among them. LSM > 2.39m/s performed at day 1 had c-statistics=0.83, sensitivity=0.41, specificity=0.97, positive predictive value=0.92, negative predictive value=0.67, positive likelihood ratio=13.85 to rule in early allograft dysfunction. LSM < 1.65m/s had c-statistics=0.83, sensitivity=0.96, specificity=0.50, positive predictive value=0.60, negative predictive value=0.94, negative likelihood ratio=0.07) to rule out early allograft dysfunction. For early allograft loss, the performance of LSM > 2.25m/s was c-statistics=0.93, sensitivity=0.76, specificity=0.98, positive predictive value=0.93, negative predictive value=0.91, positive likelihood ratio=33.65 to rule in and with the cutoff point < 1.75m/s, c-statistics=0.93, sensitivity=0.94, specificity=0.94, positive predictive value=0.50, negative predictive value=0.97, negative likelihood ratio=0.09 to rule out early allograft loss. LSM were also associated to reoperations (p=0.04) and hemodialysis (p < 0.001), and longer hospital (p=0.007) and intensive care unit stays (p < 0.001). CONCLUSION: LE is a method capable of predicting PGD and early graft losses in post-LT with high accuracy and a superior performance in comparison to other previously described tools.
 
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Publishing Date
2021-09-20
 
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