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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Retransplantation is a therapeutic option when a first liver graft fails&#46; The second operation is technically more complex&#44; and survival is shorter than that of the first graft&#44; but in some cases it is the only treatment option for the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2</span></a> A series in our center showed retransplanted patients to have a 5-year survival rate of 64&#37;&#44; versus over 80&#37; in the case of patients with a single transplant&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> We report two patients subjected to three consecutive liver transplants&#44; and describe the evolution in each case&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The first case corresponded to a 67-year-old male with a history of stage A5 cirrhosis &#40;Child-T-Pugh classification&#41; and a Model End-Stage Liver Disease &#40;MELD&#41; score of 15&#44; secondary to hepatitis C and hepatocarcinoma&#46; The patient received a graft from a brain dead donor &#40;BD&#41;&#44; with a good immediate postoperative course&#46; After 48<span class="elsevierStyleHsp" style=""></span>h hepatic artery thrombosis developed&#44; with multiple infarctions&#44; and the patient was entered on the retransplantation list &#40;emergency 0&#41;&#46; After two days he received a graft from a non-heart beating donor&#44; with a poor intraoperative course &#40;hypovolemic shock with multiple transfusions and prolonged ischemia and clamping times&#44; with secondary intestinal necrosis&#41;&#46; In the immediate postoperative period the patient presented refractory shock and multiorgan failure secondary to primary graft failure&#46; In view of the poor clinical situation&#44; he was again entered on the retransplantation list&#44; with the start of Molecular Adsorbent Recirculating System &#40;MARS&#41; therapy&#46; The patient received a graft from a BD donor&#44; with prolonged surgical times due to technical difficulties in the surgical bed&#46; The postoperative course was poor&#44; with multiorgan failure and a need for respiratory support&#44; prolonged weaning and tracheostomy&#44; and extrarenal replacement support&#46; Hemodynamically&#44; high dose amines were required&#44; and the patient suffered intestinal perforation and ischemia&#44; with associated rhabdomyolysis&#46; The chronic multiorgan failure persisted&#44; with invasive <span class="elsevierStyleItalic">aspergillosis</span> overinfection&#46; The patient died after two months in the Intensive Care Unit &#40;ICU&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The second case corresponded to a 37-year-old male with a first liver transplant at 17 years of age due to Budd-Chiari syndrome secondary to polycythemia vera&#44; in the context of chronic rejection and with a MELD score of 24&#46; The patient received a second graft from a BD donor&#46; Biliary tract complications developed&#44; with intraabdominal abscesses and the isolation of multiresistant bacteria&#44; early renal failure requiring extrarenal replacement therapy&#44; and hepatic artery thrombosis despite attempted surgical recanalization and anticoagulation&#46; The patient developed ischemic hepatitis and was placed on the waiting list for retransplantation&#46; During the waiting period he suffered hemorrhagic shock secondary to gastrointestinal bleeding and partial thrombosis of the portal vein&#46; In view of the impossibility of administering systemic anticoagulation therapy&#44; with secondary graft failure&#44; we decided to enter the patient on the waiting list for retransplantation with regional priority status&#46; The patient entered the operating room with chronic multiorgan failure and a MELD score of 36&#46; He received the third transplant 1&#46;5 months later&#44; with a poor posterior course&#44; and presenting hemorrhagic shock secondary to upper digestive bleeding that required three reoperations and prolonged mechanical ventilation&#46; Absence of flow in the hepatic artery was evidenced&#44; with areas of liver necrosis&#44; intraabdominal infection due to multiresistant organisms&#44; and with the abdomen open and under hypothermia&#46; The patient finally suffered hemorrhagic shock due to gastrointestinal bleeding&#44; not amenable to surgical management&#44; and limitation of therapeutic effort was decided&#46; The patient died after 2&#46;5 months of hospital stay&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Although retransplantation may be the only option for patients of this kind&#44; the published series confirm a decrease in survival with multiple grafting procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> Retransplantation is associated to an increased number of complications and prolonged hospital stays&#44; with long or insufficient recovery periods&#46; In order to avoid futile organ use&#44; attempts have been made to evaluate the factors underlying graft loss and&#47;or mortality risk&#46; Graft quality can be assessed by calculating the Donor Risk Index &#40;DRI&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> though in some cases low indices are not correlated to the poor prognosis predicted by other described variables&#46; These particularly include renal failure and&#47;or a need for renal replacement therapy before retransplantation&#44; prolonged mechanical ventilation times&#44; or a high or rising MELD score&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> as well as the use of vasopressor drugs&#44; preoperative sepsis or urgent retransplantation priority&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> Furthermore&#44; other groups underscore the importance of qualitative variables such as quality of life or mental status before retransplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Both of our patients received a third graft of good quality&#44; with low DRI scores&#44; though they also presented many of the unfavorable clinical variables &#40;need for renal replacement therapy and vasoactive drug support&#44; preoperative sepsis&#44; multiorgan failure and prolonged mechanical ventilation&#41;&#46; The transplant team did not consider the contraindication of retransplantation for a number of reasons&#44; and there was no formal request to the hospital Ethics Committee&#46; In using severity scores such as the APACHE II or SOFA&#44; we probably would not have contemplated surgery other than transplantation&#44; even if representing the only alternative to the limitation of therapeutic effort&#46; Our dilemma as intensivists was whether or not to support the criterion of the surgical team&#44; and the cause of our frustration was the poor outcome of the third organ transplant&#44; leading us to present this letter to the editor&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">How far should we go with patients of this kind&#63; There is probably no evident answer&#46; The data of the Spanish National Transplant Organization &#40;ONT&#41; in Madrid&#44; with survival rates following third transplantation of 55&#37;&#44; 46&#37; and 37&#37; after one&#44; 5 and 10 years&#44; respectively&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> and our own experience&#44; question whether the prognostic indices are enough to avoid futility&#46; We therefore should take into account scales such as the APACHE II and SOFA&#44; and these patients moreover should be considered by the hospital Ethics Committee&#44; either upon request from any of the implicated Departments&#44; or through regional coordination supervision&#46; We have reasonable doubts that the principles of no ill intention and distributive fairness have been adequately observed in these cases&#46; The presentation of these patients aims to draw attention to the need to consider this issue in order to have all the information available in decision making&#44; and thus offer the best possible outcomes for our patients and their families&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have received no funding for the present scientific letter&#46;</p></span></span>"
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Scientific letter
Third liver transplant: How far should we go?
Tercer injerto hepático: ¿hasta dónde deberíamos llegar?
J. Gutiérrez Gutiérrez
Corresponding author
gutierrezgju@gmail.com

Corresponding author.
, J. Czapka Mital, T. Grau Carmona
Servicio de Medicina Intensiva, Hospital 12 de Octubre, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Retransplantation is a therapeutic option when a first liver graft fails&#46; The second operation is technically more complex&#44; and survival is shorter than that of the first graft&#44; but in some cases it is the only treatment option for the patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2</span></a> A series in our center showed retransplanted patients to have a 5-year survival rate of 64&#37;&#44; versus over 80&#37; in the case of patients with a single transplant&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> We report two patients subjected to three consecutive liver transplants&#44; and describe the evolution in each case&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The first case corresponded to a 67-year-old male with a history of stage A5 cirrhosis &#40;Child-T-Pugh classification&#41; and a Model End-Stage Liver Disease &#40;MELD&#41; score of 15&#44; secondary to hepatitis C and hepatocarcinoma&#46; The patient received a graft from a brain dead donor &#40;BD&#41;&#44; with a good immediate postoperative course&#46; After 48<span class="elsevierStyleHsp" style=""></span>h hepatic artery thrombosis developed&#44; with multiple infarctions&#44; and the patient was entered on the retransplantation list &#40;emergency 0&#41;&#46; After two days he received a graft from a non-heart beating donor&#44; with a poor intraoperative course &#40;hypovolemic shock with multiple transfusions and prolonged ischemia and clamping times&#44; with secondary intestinal necrosis&#41;&#46; In the immediate postoperative period the patient presented refractory shock and multiorgan failure secondary to primary graft failure&#46; In view of the poor clinical situation&#44; he was again entered on the retransplantation list&#44; with the start of Molecular Adsorbent Recirculating System &#40;MARS&#41; therapy&#46; The patient received a graft from a BD donor&#44; with prolonged surgical times due to technical difficulties in the surgical bed&#46; The postoperative course was poor&#44; with multiorgan failure and a need for respiratory support&#44; prolonged weaning and tracheostomy&#44; and extrarenal replacement support&#46; Hemodynamically&#44; high dose amines were required&#44; and the patient suffered intestinal perforation and ischemia&#44; with associated rhabdomyolysis&#46; The chronic multiorgan failure persisted&#44; with invasive <span class="elsevierStyleItalic">aspergillosis</span> overinfection&#46; The patient died after two months in the Intensive Care Unit &#40;ICU&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The second case corresponded to a 37-year-old male with a first liver transplant at 17 years of age due to Budd-Chiari syndrome secondary to polycythemia vera&#44; in the context of chronic rejection and with a MELD score of 24&#46; The patient received a second graft from a BD donor&#46; Biliary tract complications developed&#44; with intraabdominal abscesses and the isolation of multiresistant bacteria&#44; early renal failure requiring extrarenal replacement therapy&#44; and hepatic artery thrombosis despite attempted surgical recanalization and anticoagulation&#46; The patient developed ischemic hepatitis and was placed on the waiting list for retransplantation&#46; During the waiting period he suffered hemorrhagic shock secondary to gastrointestinal bleeding and partial thrombosis of the portal vein&#46; In view of the impossibility of administering systemic anticoagulation therapy&#44; with secondary graft failure&#44; we decided to enter the patient on the waiting list for retransplantation with regional priority status&#46; The patient entered the operating room with chronic multiorgan failure and a MELD score of 36&#46; He received the third transplant 1&#46;5 months later&#44; with a poor posterior course&#44; and presenting hemorrhagic shock secondary to upper digestive bleeding that required three reoperations and prolonged mechanical ventilation&#46; Absence of flow in the hepatic artery was evidenced&#44; with areas of liver necrosis&#44; intraabdominal infection due to multiresistant organisms&#44; and with the abdomen open and under hypothermia&#46; The patient finally suffered hemorrhagic shock due to gastrointestinal bleeding&#44; not amenable to surgical management&#44; and limitation of therapeutic effort was decided&#46; The patient died after 2&#46;5 months of hospital stay&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Although retransplantation may be the only option for patients of this kind&#44; the published series confirm a decrease in survival with multiple grafting procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> Retransplantation is associated to an increased number of complications and prolonged hospital stays&#44; with long or insufficient recovery periods&#46; In order to avoid futile organ use&#44; attempts have been made to evaluate the factors underlying graft loss and&#47;or mortality risk&#46; Graft quality can be assessed by calculating the Donor Risk Index &#40;DRI&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> though in some cases low indices are not correlated to the poor prognosis predicted by other described variables&#46; These particularly include renal failure and&#47;or a need for renal replacement therapy before retransplantation&#44; prolonged mechanical ventilation times&#44; or a high or rising MELD score&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> as well as the use of vasopressor drugs&#44; preoperative sepsis or urgent retransplantation priority&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> Furthermore&#44; other groups underscore the importance of qualitative variables such as quality of life or mental status before retransplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Both of our patients received a third graft of good quality&#44; with low DRI scores&#44; though they also presented many of the unfavorable clinical variables &#40;need for renal replacement therapy and vasoactive drug support&#44; preoperative sepsis&#44; multiorgan failure and prolonged mechanical ventilation&#41;&#46; The transplant team did not consider the contraindication of retransplantation for a number of reasons&#44; and there was no formal request to the hospital Ethics Committee&#46; In using severity scores such as the APACHE II or SOFA&#44; we probably would not have contemplated surgery other than transplantation&#44; even if representing the only alternative to the limitation of therapeutic effort&#46; Our dilemma as intensivists was whether or not to support the criterion of the surgical team&#44; and the cause of our frustration was the poor outcome of the third organ transplant&#44; leading us to present this letter to the editor&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">How far should we go with patients of this kind&#63; There is probably no evident answer&#46; The data of the Spanish National Transplant Organization &#40;ONT&#41; in Madrid&#44; with survival rates following third transplantation of 55&#37;&#44; 46&#37; and 37&#37; after one&#44; 5 and 10 years&#44; respectively&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> and our own experience&#44; question whether the prognostic indices are enough to avoid futility&#46; We therefore should take into account scales such as the APACHE II and SOFA&#44; and these patients moreover should be considered by the hospital Ethics Committee&#44; either upon request from any of the implicated Departments&#44; or through regional coordination supervision&#46; We have reasonable doubts that the principles of no ill intention and distributive fairness have been adequately observed in these cases&#46; The presentation of these patients aims to draw attention to the need to consider this issue in order to have all the information available in decision making&#44; and thus offer the best possible outcomes for our patients and their families&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have received no funding for the present scientific letter&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Guti&#233;rrez Guti&#233;rrez J&#44; Czapka Mital J&#44; Grau Carmona T&#46; Tercer injerto hep&#225;tico&#58; &#191;hasta d&#243;nde deber&#237;amos llegar&#63; Med Intensiva&#46; 2020&#59;44&#58;317&#8211;318&#46;</p>"
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