Gabriela Perdomo Coral

Prevalence and risk factors of Hepatitis C virus infection in Brazil, 2005 through 2009: a cross-sectional study

BackgroundHepatitis C chronic liver disease is a major cause of liver transplant in developed countries. This article reports the first nationwide population-based survey conducted to estimate the seroprevalence of HCV antibodies and associated risk factors in the urban population of Brazil.MethodsThe cross sectional study was conducted in all Brazilian macro-regions from 2005 to 2009, as a stratified multistage cluster sample of 19,503 inhabitants aged between 10 and 69 years, representing individuals living in all 26 State capitals and the Federal District. Hepatitis C antibodies were detected by a third-generation enzyme immunoassay. Seropositive individuals were retested by Polymerase Chain Reaction and genotyped. Adjusted prevalence was estimated by macro-regions. Potential risk factors associated with HCV infection were assessed by calculating the crude and adjusted odds ratios, 95% confidence intervals (95% CI) and p values. Population attributable risk was estimated for multiple factors using a case–control approach.ResultsThe overall weighted prevalence of hepatitis C antibodies was 1.38% (95% CI: 1.12%–1.64%). Prevalence of infection increased in older groups but was similar for both sexes. The multivariate model showed the following to be predictors of HCV infection: age, injected drug use (OR = 6.65), sniffed drug use (OR = 2.59), hospitalization (OR = 1.90), groups socially deprived by the lack of sewage disposal (OR = 2.53), and injection with glass syringe (OR = 1.52, with a borderline p value). The genotypes 1 (subtypes 1a, 1b), 2b and 3a were identified. The estimated population attributable risk for the ensemble of risk factors was 40%. Approximately 1.3 million individuals would be expected to be anti-HCV-positive in the country.ConclusionsThe large estimated absolute numbers of infected individuals reveals the burden of the disease in the near future, giving rise to costs for the health care system and society at large. The known risk factors explain less than 50% of the infected cases, limiting the prevention strategies. Our findings regarding risk behaviors associated with HCV infection showed that there is still room for improving strategies for reducing transmission among drug users and nosocomial infection, as well as a need for specific prevention and control strategies targeting individuals living in poverty.

Methodology of a nationwide cross-sectional survey of prevalence and epidemiological patterns of hepatitis A, B and C infection in Brazil

A population-based survey to provide information on the prevalence of hepatitis viral infection and the pattern of risk factors was carried out in the urban population of all Brazilian state capitals and the Federal District, between 2005 and 2009. This paper describes the design and methodology of the study which involved a population aged 5 to 19 for hepatitis A and 10 to 69 for hepatitis B and C. Interviews and blood samples were obtained through household visits. The sample was selected using stratified multi-stage cluster sampling and was drawn with equal probability from each domain of study (region and age-group). Nationwide, 19,280 households and ~31,000 residents were selected. The study is large enough to detect prevalence of viral infection around 0.1% and risk factor assessments within each region. The methodology seems to be a viable way of differentiating between distinct epidemiological patterns of hepatitis A, B and C. These data will be of value for the evaluation of vaccination policies and for the design of control program strategies.

Renal Impairment after Spontaneous Bacterial Peritonitis: Incidence and Prognosis

BACKGROUND/AIMS Spontaneous bacterial peritonitis (SBP) is an important complication in cirrhotic patients. The aim of the present study was to assess the incidence, predictive factors and prognosis for renal impairment (RI) after SBP in cirrhotic patients from southern Brazil. METHODS Of the 1030 hospitalizations evaluated, 114 episodes of SBP were diagnosed in 94 patients (mean age 49 years; 76.59% men). SBP diagnosis was established when the ascitic fluid polymorphonuclear cell count was equal to or greater than 250 cells/mm3. Five cases were excluded. The variables assessed as possible predictors of steady or progressive RI were blood urea nitrogen and creatinine levels before the diagnosis of SBP; type of infection, antibiotic prophylaxis, first episode or recurrent SBP, presence of gastrointestinal bleeding and hepatic encephalopathy during hospitalization, SBP resolution, Child-Pugh classification, levels of blood pressure, ascitic fluid and blood polymorphonuclear cell count, bacteriological data (positive and negative ascitic fluid culture), albumin, bilirubin, sodium and prothrombin time at the moment of diagnosis. RESULTS The incidence of SBP was 11.07%. In 61 (55.96%) episodes, SBP was associated with RI (transient in 57.37%; steady in 19.67%; and progressive in 22.95%). The mortality rate associated with progressive RI was 100%; 58.33% with steady RI; and 2.85% with transient RI. The mortality rate in patients with or without RI was 36.07% and 6.25%, respectively (P<0.001). The level of creatinine (greater than or equal to 1.3mg/dL) before the diagnosis of SBP and the rate of infection resolution were the only predictors of RI in the multivariate analysis. CONCLUSIONS RI after SBP is a common complication, and indicates a poor prognosis for this infection. High levels of creatinine before infection and the rate of infection resolution are independent predictors of RI.BACKGROUND/AIMS: Spontaneous bacterial peritonitis (SBP) is an important complication in cirrhotic patients. The aim of the present study was to assess the incidence, predictive factors and prognosis for renal impairment (RI) after SBP in cirrhotic patients from southern Brazil.

Infecçäo bacteriana no paciente cirrótico

RACIONAL: Em torno de 30% dos pacientes com cirrose hepatica apresentam infeccao bacteriana na admissao hospitalar ou a desenvolvem durante a mesma. As infeccoes bacterianas sao responsaveis por ate 25% das mortes nesta populacao de pacientes. OBJETIVO: Avaliar a prevalencia de infeccao bacteriana em uma populacao de pacientes cirroticos internados em hospital geral, bem como correlacionar sua presenca com a etiologia alcoolica da hepatopatia, com o grau de comprometimento da funcao hepatica e com a presenca de hemorragia digestiva alta. PACIENTES E METODOS: Foram avaliadas retrospectivamente 541 internacoes hospitalares consecutivas em 426 pacientes com cirrose hepatica, internados no periodo de 1992 a 2000. A media de idade destes pacientes foi de 50,5 anos (15-95), sendo 71,2% do sexo masculino. Etiologia alcoolica da hepatopatia esteve presente em 35,4% dos pacientes. Alta ou obito do paciente no periodo da internacao hospitalar foi considerado como principal desfecho. O nivel de significância considerado na analise estatistica foi de 5%. RESULTADOS: As infeccoes bacterianas ocorreram em 25% dos cirroticos (135 episodios). Destas, as mais frequentes foram: a infeccao do trato urinario em 31,1%, a peritonite bacteriana espontânea em 25,9% e a broncopneumonia em 25,2%. Ocorreu associacao de infeccao urinaria e broncopneumonia em 3,7% e infeccao de pele e tecido celular subcutâneo em 11,11%. Bacteremia sem foco definido ocorreu nos quatro casos restantes (2,9%). Houve associacao da presenca de infeccao com a etiologia alcoolica da hepatopatia, com a classificacao de Child-Pugh e com a ocorrencia de hemorragia digestiva alta. A mortalidade hospitalar foi maior nos pacientes infectados (8,9%), estando a mesma associada ao grau de disfuncao hepatocelular. CONCLUSOES: A ocorrencia de infeccao bacteriana no paciente cirrotico hospitalizado e frequente e correlaciona-se com a etiologia alcoolica da hepatopatia, com a reserva funcional hepatica e com a presenca de sangramento digestivo. Alem disso, a presenca de infeccao bacteriana correlaciona-se com mau prognostico.

Occult hepatitis B virus infection in patients with chronic liver disease due to hepatitis C virus and hepatocellular carcinoma in Brazil

BACKGROUND The prevalence and consequences of occult HBV infection in patients with chronic liver disease by HCV remain unknown. AIMS To evaluate the prevalence of occult HBV infection in a population of HCV-infected patients with hepatocellular carcinoma. METHODS The serum samples were tested for HBV DNA by nested PCR and liver tissue analysis was carried out using the immunohistochemical technique of 66 HBsAg-negative patients: 26 patients with chronic hepatitis by HCV (group 1), 20 with hepatocellular carcinoma related to chronic infection by HCV (group 2) and 20 with negative viral markers for hepatitis B and C (control group). RESULTS Occult HBV infection was diagnosed in the liver tissue of 9/46 (19.5%) HCV-infected patients. Prevalence of occult B infection was evaluated in the HCV-infected patients with and without hepatocellular carcinoma, and there were seven (77.7%) of whom from group 2, conferring a 35% prevalence of this group. No serum sample was positive for HBV DNA in the three groups. CONCLUSION Occult infection B is frequently detected in liver tissue of HCV-infected patients, especially in cases of hepatocellular carcinoma. However large studies are needed to confirm that co-infection could determine a worse progress of chronic liver disease in this population.

Prevalência e prognóstico da peritonite bacteriana espontânea: experiência em pacientes internados em um hospital geral de Porto Alegre, RS, Brasil (1991-2000)

BACKGROUND: Spontaneous bacterial peritonitis is a frequent complication that occurs in patients with cirrhosis and ascites and has a recurrence rate of 70% in 1 year. In addition, this infection determines a poor short and long-term prognosis and a shorter survival rate. AIMS: Evaluate the prevalence of spontaneous bacterial peritonitis in cirrhotic patients with ascites and the effect of its occurrence on the survival. PATIENTS/METHODS: One thousand and thirty admissions of patients with cirrhosis and ascites were reviewed and 114 episodes of spontaneous bacterial peritonitis were documented in 94 patients. The ascitic analysis was accomplished in all patients. The diagnosis of this infection was established when the ascitic fluid polymorphonuclear count was equal or above 250 cells mm3. RESULTS: The prevalence of this infection was 11.1% and the mortality rate 21.9%. Spontaneous bacterial peritonitis was community acquired in 61.4% and hospital acquired in 37.7%. The mortality rate was 18.6% and 27.9%, respectively. The infection resolved in 91.1% of the episodes by the analysis of ascitic fluid at 48 hours on antibiotics. The use of prophylactic antibiotics was documented in 22.3% of the episodes, but there are not significant differences on the mortality or type of bacteria isolated when comparing the patients with or without this treatment. CONCLUSIONS: Spontaneous bacterial peritonitis is a common complication in patients with cirrhosis and ascites and determines a worse prognosis, mainly when related with absence of initial response to antibiotics.BACKGROUND Spontaneous bacterial peritonitis is a frequent complication that occurs in patients with cirrhosis and ascites and has a recurrence rate of 70% in 1 year. In addition, this infection determines a poor short and long-term prognosis and a shorter survival rate. AIMS Evaluate the prevalence of spontaneous bacterial peritonitis in cirrhotic patients with ascites and the effect of its occurrence on the survival. PATIENTS/METHODS One thousand and thirty admissions of patients with cirrhosis and ascites were reviewed and 114 episodes of spontaneous bacterial peritonitis were documented in 94 patients. The ascitic analysis was accomplished in all patients. The diagnosis of this infection was established when the ascitic fluid polymorphonuclear count was equal or above 250 cells mm3. RESULTS The prevalence of this infection was 11.1% and the mortality rate 21.9%. Spontaneous bacterial peritonitis was community acquired in 61.4% and hospital acquired in 37.7%. The mortality rate was 18.6% and 27.9%, respectively. The infection resolved in 91.1% of the episodes by the analysis of ascitic fluid at 48 hours on antibiotics. The use of prophylactic antibiotics was documented in 22.3% of the episodes, but there are not significant differences on the mortality or type of bacteria isolated when comparing the patients with or without this treatment. CONCLUSIONS Spontaneous bacterial peritonitis is a common complication in patients with cirrhosis and ascites and determines a worse prognosis, mainly when related with absence of initial response to antibiotics.RACIONAL: A peritonite bacteriana espontânea e complicacao frequente nos pacientes com cirrose e ascite, apresentando taxa de recurrencia em 1 ano proxima de 70%. OBJETIVOS: Avaliar a prevalencia da peritonite bacteriana espontânea em pacientes com ascite por hepatopatia cronica e o impacto da sua presenca na sobrevida dos mesmos. PACIENTES/METODOS: Foram avaliadas 1030 internacoes de pacientes com cirrose e ascite, tendo sido documentados 114 episodios de peritonite bacteriana espontânea em 94 pacientes. Em todos foi realizada paracentese com analise do liquido ascitico. O diagnostico desta complicacao foi estabelecido quando o numero de polimorfonucleares do liquido de ascite fosse superior a 250 celulas por mm³. RESULTADOS: A prevalencia da peritonite bacteriana espontânea foi de 11,1% e sua mortalidade de 21,9%. A infeccao foi adquirida na comunidade em 61,4% e no hospital em 37,7%, sendo as taxas de obito de 18,6% e 27,9%, respectivamente. Houve controle da infeccao, documentado pela analise do liquido de ascite coletado por paracentese realizada 48 horas apos o inicio da antibioticoterapia, em 91,1% dos episodios. Nestes casos a mortalidade foi de 16,7%. Nos casos em que a infeccao nao foi controlada, o obito ocorreu em 80,0%. Em 22,3% da amostra foi documentado o uso do antibiotico profilatico sem, no entanto, demonstrar haver diferenca significativa quanto a mortalidade, quando comparados aos pacientes que nao realizaram profilaxia. CONCLUSOES: A peritonite bacteriana espontânea e infeccao frequente nos pacientes com ascite por hepatopatia cronica, com prognostico reservado, principalmente na ausencia de resposta precoce a antibioticoterapia.

Population-Based Multicentric Survey of Hepatitis B Infection and Risk Factors in the North, South, and Southeast Regions of Brazil, 10-20 Years After the Beginning of Vaccination

A population-based hepatitis survey was carried out to estimate the prevalence of hepatitis B virus (HBV) infection and its predictive factors for the state capitals from the north, south, and southeast regions of Brazil. A multistage cluster sampling was used to select, successively, census tracts, blocks, households, and residents in the age group 10–69 years in each state capital. The prevalence of hepatitis B surface antigen (HBsAg) was lower than 1% in the north, southeast, and south regions. Socioeconomic condition was associated with HBV infection in north and south regions. Variables related to the blood route transmission were associated with HBV infection only in the south whereas those related to sexual behavior were associated with HBV infection in the north and south regions. Drug use was associated in all regions, but the type of drug differed. The findings presented herein highlight the diversity of the potential transmission routes for hepatitis B transmission in Brazil. In one hand, it reinforces the importance of national control strategies of large impact already in course (immunization of infants, adolescents, and adults up to 49 years of age and blood supply screening). On the other hand, it shows that there is still room for further control measures targeted to different groups within each region.

Non-Alcoholic Steatohepatitis (NASH): Risk Factors in Morbidly Obese Patients

The aim was to investigate the prevalence of non-alcoholic steatohepatitis (NASH) and risk factors for hepatic fibrosis in morbidly obese patients submitted to bariatric surgery. This retrospective study recruited all patients submitted to bariatric surgery from January 2007 to December 2012 at a reference attendance center of Southern Brazil. Clinical and biochemical data were studied as a function of the histological findings of liver biopsies done during the surgery. Steatosis was present in 226 (90.4%) and NASH in 176 (70.4%) cases. The diagnosis of cirrhosis was established in four cases (1.6%) and fibrosis in 108 (43.2%). Risk factors associated with NASH at multivariate analysis were alanine aminotransferase (ALT) >1.5 times the upper limit of normal (ULN); glucose ≥ 126 mg/dL and triglycerides ≥ 150 mg/dL. All patients with ALT ≥1.5 times the ULN had NASH. When the presence of fibrosis was analyzed, ALT > 1.5 times the ULN and triglycerides ≥ 150 mg/dL were risk factors, furthermore, there was an increase of 1% in the prevalence of fibrosis for each year of age increase. Not only steatosis, but NASH is a frequent finding in MO patients. In the present study, ALT ≥ 1.5 times the ULN identifies all patients with NASH, this finding needs to be further validated in other studies. Moreover, the presence of fibrosis was associated with ALT, triglycerides and age, identifying a subset of patients with more severe disease.

NONALCOHOLIC FATTY LIVER DISEASE IN SEVERE OBESE PATIENTS, SUBJECTED TO BARIATRIC SURGERY

CONTEXT Nonalcoholic fatty liver disease encompasses a spectrum of histopathological changes that range from simple steatosis to nonalcoholic steatohepatitis. Works suggest that iron (Fe) deposits in the liver are involved in the physiopathology of nonalcoholic steatohepatitis. OBJECTIVE The aim of this study was to determine the prevalence of simple steatosis and nonalcoholic steatohepatitis in patients with morbid obesity, subjected to bariatric surgery and to establish a correlation of the anatomopathological findings with the presence of liver fibrosis. METHODS A total of 250 liver biopsies were conducted in the transoperation of the surgeries. RESULTS Steatosis was present in 226 (90.4%) of the samples, 76 (30.4%) being classified as mild; 71 (28.4%) as moderate and 79 (31.6%) as intense. Nonalcoholic steatohepatitis was diagnosed in 176 (70.4%) cases, where 120 (48.4%) were mild; 50 (20%) were moderate, and 6 (2.4%) cases were intense. Fibrosis was referred to in 108 (43.2%) biopsies, 95 of which (38%) were mild; 2 (0.8%) were moderate; 7 (2.8%) were intense, and cirrhosis was diagnosed in 4 (1.6%) cases. There was a correlation between the degree of steatosis and the level of inflammatory activity (rs = 0.460; P<0.001) and between the degree of this activity and the degree of fibrosis (rs = 0.583; P<0.001). Only 13 (5.2%) samples showed Fe deposits. CONCLUSION There is a high prevalence of nonalcoholic steatohepatitis in these patients and a positive correlation of the degrees of nonalcoholic steatohepatitis with the intensity of fibrosis. The low prevalence of Fe deposits found makes it questionable that the presence of this ion has any participation in the physiopathogeny of nonalcoholic fatty liver disease.

The vitamin E reduces liver lipoperoxidation and fibrosis in a model of nonalcoholic steatohepatitis

CONTEXT No effective treatment is available for nonalcoholic steatohepatitis in nowadays. OBJECTIVES To develop a model of nonalcoholic steatohepatitis induced by a methionine and choline deficient diet, as well as to evaluate the role of metformin, vitamin E and simvastatin in the nonalcoholic steatohepatitis progression. METHODS The study analyzed prospectively 50 Wistar rats for a 90-day period and divided them into five groups of 10 rats. One group was given standard rat diet and the others received the methionine and choline deficient diet. Among the four groups that received this diet, one received saline 0,9% and the others received metformin, vitamin E or simvastatin. After the study period, the animals were sacrificed and their blood was collected for biochemical analysis. The livers were removed for lipoperoxidation analysis and for the histological examinations. RESULTS The methionine and choline deficient diet was able to induce steatosis in 100% of the animals and nonalcoholic steatohepatitis in 27 (69.2%). The alanine aminotransferase levels were significantly higher in the simvastatin group. The aspartate aminotransferase levels were also higher in the simvastatin group, but were statistically significant only in relation to the standard diet group. When lipoperoxidation values were compared, the groups that received standard rat diet and methionine and choline deficient with vitamin E presented significantly lower rates than the others. The presence of fibrosis was significantly smaller in the group receiving vitamin E. CONCLUSIONS The diet used was able to induce steatosis and nonalcoholic steatohepatitis. Besides vitamin E showed to reduce the liver oxidative stress, as well as the fibrosis development.