Miquel Torres

Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis

It has recently been shown that repeated large-volume paracentesis associated with intravenous albumin infusion is a rapid, effective, and safe therapy of ascites in cirrhosis. To investigate whether intravenous albumin infusion is necessary in the treatment of cirrhotics with large-volume paracentesis, 105 patients with tense ascites were randomly allocated into two groups. Fifty-two patients (group 1) were treated with paracentesis (4-6 L/day until disappearance of ascites) plus intravenous albumin infusion (40 g after each tap), and 53 (group 2) with paracentesis without albumin infusion. After disappearance of ascites, patients were discharged from the hospital with diuretics. Patients developing tense ascites during follow-up were treated according to their initial schedule. Paracentesis was effective in eliminating the ascites in 50 patients from group 1 and in 48 from group 2, with the duration of the hospital stay being approximately 11 days in both groups. Paracentesis plus intravenous albumin did not induce significant changes in standard renal function tests, plasma renin activity, and plasma aldosterone. In contrast, paracentesis without albumin was associated with a significant increase in blood urea nitrogen, a marked elevation in plasma renin activity and plasma aldosterone concentration, and a significant reduction in serum sodium concentration. One patient from group 1 and 11 from group 2 developed renal impairment or severe hyponatremia after treatment, or both (chi 2 = 9.19; p less than 0.01). The development of these complications could not be predicted by clinical and laboratory data before treatment. Although the probability of survival after entry into the study was similar in patients from both groups, a multivariate analysis identified the development of hyponatremia or renal impairment, or both, following the first paracentesis treatment and the occurrence of other complications during the first hospitalization (encephalopathy, gastrointestinal bleeding, and severe infection) as being the only independent predictors of mortality. These results indicate that intravenous albumin infusion is important in avoiding renal and electrolyte complications and activation of endogenous vasoactive systems in cirrhotics with ascites who are treated with repeated large-volume paracentesis. The development of such complications may impair survival in these patients.

Histological course of alcoholic hepatitis. Influence of abstinence, sex and extent of hepatic damage.

The factors influencing the histological evolution of alcoholic hepatitis without cirrhosis have been evaluated in 26 patients (14 males and 12 females) submitted to repeated liver biopsies over a mean period of 1.7 years (1-3). Drinking habits during follow-up were checked by inquiries to patients and relatives and by serial determination of ethanol in urine. At the end of the follow-up, 9 patients (34.6%) had progressed to cirrhosis, 5 (19.2%) still had alcoholic hepatitis and 12 (46.1%) had normal liver or only minimal changes. Nine patients continued drinking heavily, 4 reduced their daily intake markedly and 13 stopped drinking. Improvement of liver lesions was observed in 9 of the abstainers and in 3 non-abstainers that had markedly reduced their alcohol consumption. Among the 9 patients with persistent heavy alcohol consumption, 5 developed cirrhosis and 4 still showed alcoholic hepatitis in their last biopsy. Cirrhosis also developed over 1-2 years in 4 females who had stopped drinking, indicating a marked influence of sex on the course of alcoholic hepatitis. Progression of the disease to cirrhosis despite abstinence occurred in a high proportion of women (4/7) but not in men (0/6). These observations indicate that discontinuation of heavy alcohol consumption often results in improvement of liver lesion in patients with alcoholic hepatitis. However, the risk of progression to cirrhosis remains elevated in women.

Liver dysfunction related to hepatitis B and C in patients with inflammatory bowel disease treated with immunosuppressive therapy

Background There is no information about the frequency of liver dysfunction in patients with inflammatory bowel disease (IBD) treated with immunosuppressants and infected with hepatitis B (HBV) and/or C virus (HCV). Aim To assess the influence of immunosuppressants on the course of HBV and HCV infection in IBD. Methods Patients with IBD with HBV and/or HCV infection from 19 Spanish hospitals were included. Clinical records were reviewed for the type of immunosuppressant used, treatment duration, liver function tests and viral markers before, during and after each immunosuppressant. Logistic and Cox regression analysis were used to identify predictors of outcome. Results 162 patients were included; 104 had HBV markers (25 HBsAg positive) and 74 had HCV markers (51 HCV-RNA positive), and 16 patients had markers of both infections. Liver dysfunction was observed in 9 of 25 HBsAg positive patients (36%), 6 of whom developed hepatic failure. Liver dysfunction in HCV was observed in 8 of 51 HCV-RNA positive patients (15.7%), and only one developed hepatic failure. The frequency and severity of liver dysfunction was significantly higher in HBV-infected patients than in HCV-infected patients (p=0.045 and p=0.049, respectively). Treatment with ≥2 immunosuppressants was an independent predictor of HBV reactivation (OR 8.75; 95% CI 1.16 to 65.66). The majority of patients without reactivation received only one immunosuppressant for a short period and/or prophylactic antiviral treatment. No definite HBV reactivations were found in anti-HBc positive patients lacking HBsAg. Conclusion Liver dysfunction in patients with IBD treated with immunosuppressants is more frequent and severe in those with HBV than in HCV carriers and is associated with combined immunosuppression.

Terapia de inducción con interferón alfa-2a en la cirrosis por el virus de la hepatitis C compensada. Estudio multicéntrico aleatorizado

Fundamento Aunque el tratamiento con interferon (IFN) a las dosis estandar solo consigue unarespuesta persistente en el 5% de los pacientes con cirrosis debida al virus de la hepatitis C(CVHC), se ha planteado que podria disminuir el riesgo de complicaciones y la incidencia dehepatocarcinoma. Teniendo en cuenta los estudios cineticos del virus de la hepatitis C (VHC),la terapia de induccion con IFN podria aumentar las tasas de respuesta al tratamiento. Pacientes y metodo Cuarenta pacientes con CVHC compensada fueron distribuidos al azar pararecibir (grupo I = 19) o no (grupo II = 21) tratamiento con IFN (4,5 MU/dia durante 6 meses,seguidos de 4,5 MU/dias alternos durante 6 meses mas, solo si la ALT se habia normalizado). Resultados El tratamiento con IFN hubo de reducirse o interrumpirse por efectos adversos en11 (58%) y seis (31,5%) casos, respectivamente. La respuesta al final del tratamiento se observoen 4 pacientes del grupo I (21%), que fue persistente en dos (10,5%), y en ninguno delgrupo II (p = 0,04 y NS, respectivamente). La probabilidad global de presentar ascitis, hepatocarcinomay/o muerte o trasplante hepatico fue menor en el grupo I que en el II (el 6 frenteal 27% a los tres anos; p = 0,05). Conclusiones Aunque la terapia de induccion con IFN en la CVHC compensada se asocia a frecuentesefectos adversos e induce una respuesta persistente en una proporcion baja de pacientes,podria mejorar el pronostico a medio plazo de los pacientes.

Susceptibilidad a la varicela en personal sanitario. Aceptación y respuesta a la vacunación

BACKGROUND AND OBJECTIVE To determine the prevalence of health care workers (HCW) susceptibility to varicella zoster virus (VZV). As a secondary objective, we describe the immunogenicity and reactogenicity of the vaccine. SUBJECTS AND METHODS A multicenter analytic cross-sectional study was conducted in 5 hospitals in Catalonia, Spain, in a total of 1,111 HCW, aged between 18-60 years. We studied the prevalence of anti-VZV antibodies (IgG) and obtained demographic, occupational and health related variables that were expected to be associated with immunogenicity, as well as past history of varicella. All susceptible HCW were vaccinated and we studied the immunogenicity (antibody detection) and reactogenicity of the 1st and 2nd doses of the vaccine. Detection of antibodies against VZV was obtained by ELISA. All negative results were confirmed with FAMA. RESULTS Forty two subjects (3.8%) were negative. Susceptibility to VZV was associated (p<0.05) with decreased age (29.6 years ± 8.5 vs. 32,5 ± 9,3 in non-susceptible individuals), having fewer siblings and having no previous clinical history of varicella. Postvaccination detection tests with ELISA showed a seroconversion rate of 52 and 86% after the 1st and 2nd doses of the vaccine respectively, and 100% when using FAMA. There were no significant adverse events. CONCLUSIONS Susceptibility to varicella among HCW is low. Positive past history of varicella is a good predictor of previous exposure to VZV, since 99% (687/696) of the individuals that declared having experienced the disease were immune. This would avoid prevaccination screening in nearly two thirds of HCW.

Tratamiento quirúrgico de la poliquistosis hepática sintomática un problema infrecuente sin protocolizar

5. Moudgil SS, Riggs JE. Fulminant peripheral neuropathy with severe quadriparesis associated with vincristine therapy. Ann Pharmacother. 2000;34: 1136–8. 6. Martino MA, Miller E, Grendys EC. The administration of chemotherapy in a patient with Charcot-Marie-Tooth and ovarian cancer. Gynecol Oncol. 2005; 97:71. 7. Ameyaw MM, Regateiro F, Li T, Liu X, Tariq M, Mobarek A, et al. MDR1 pharmacogenetics: frequency of the C3435 T mutation in exon 26 is significantly influenced by ethnicity. Pharmacogenetics. 2001;11:217–21. Juan R. de la HABA-RODRÍGUEZ, Marı́a José Ortiz-Morales*, Marı́a Auxiliadora Gómez-España y Enrique Aranda Aguilar

Asistencia urgente a los pacientes con hemorragia digestiva alta en los hospitales comarcales catalanes

OBJECTIVE To evaluate the resources available in Catalan regional hospitals for the emergency care of upper gastrointestinal hemorrhage. METHODS We analyzed a survey sent to 32 hospitals on the availability, composition and resources of a duty endoscopy service for the year 2009. RESULTS Responses were obtained from 24 centers, covering 3,954,000 inhabitants. Duty endoscopists were available in 12 hospitals. A total of 1,483,000 inhabitants were unable to access a duty endoscopist in the referral center. Centers with duty endoscopists had more beds and had a larger catchment area. Duty services were composed of 4.5 endoscopists (range 2-11), covering 82.1 (33.2-182.5) duty shifts/year. Seventeen centers reported 1,571 episodes (51%, range: 3-280, 39.68/100,000 inhabitants). Centers with a duty service reported a greater number of cases (76 vs. 43, p=0.047). Centers without this service referred a greater number of patients (147 vs. 17, p=0.001). Patients in the emergency department were under the care of the internal medicine department in four centers, the surgery department in 14 centers and under the care of both departments in six. Admitted patients were under the care of the gastroenterology department in only six hospitals. The most widely used procedures were ligation of varicose bleeding and injection therapies in non-varicose bleeding. Twenty-one percent of centers did not perform combined treatment. CONCLUSIONS A significant proportion of the population does not have access to a duty endoscopist in referral centers. Duty shifts represent significant workload in regional hospitals. Coordination among health professionals and centers would allow the efficient application of therapeutic resources and a duty endoscopy service to be established in centers lacking this resource.

Carta al EditorTratamiento quirúrgico de la poliquistosis hepática sintomática, un problema infrecuente sin protocolizarSurgical treatment of symptomatic polycystic liver disease, an uncommon problem without systematic approach

5. Moudgil SS, Riggs JE. Fulminant peripheral neuropathy with severe quadriparesis associated with vincristine therapy. Ann Pharmacother. 2000;34: 1136–8. 6. Martino MA, Miller E, Grendys EC. The administration of chemotherapy in a patient with Charcot-Marie-Tooth and ovarian cancer. Gynecol Oncol. 2005; 97:71. 7. Ameyaw MM, Regateiro F, Li T, Liu X, Tariq M, Mobarek A, et al. MDR1 pharmacogenetics: frequency of the C3435 T mutation in exon 26 is significantly influenced by ethnicity. Pharmacogenetics. 2001;11:217–21. Juan R. de la HABA-RODRÍGUEZ, Marı́a José Ortiz-Morales*, Marı́a Auxiliadora Gómez-España y Enrique Aranda Aguilar

ESTUDIO MULTICÉNTRICO ESPAÑOL PARA EVALUAR LA INFLUENCIA DEL TRATAMIENTO IMMUNOSUPRESOR EN LA EVOLUCIÓN DE LA INFECCIÓN POR EL VIRUS DE LA HEPATITIS B Y C EN LA ENFERMEDAD INFLAMATORIA INTESTINAL

Introduccion Los inmunosupresores pueden aumentar la replicacion viral con exacerbacion de la hepatitis B (VHB) y C (VHC). Existe escasa informacion con respecto a la influencia del tratamiento inmunosupresor en pacientes con enfermedad inflamatoria intestinal (EII) e infeccion viral simultanea. En pacientes hematologicos sometidos a terapia antineoplasica, se demuestra reactivacion por el VHB que oscila del 14–78%, con un alto porcentaje de hepatitis fulminante (50% mortalidad), siendo la reactivacion por el VHC menos frecuente. Objetivo Evaluar la influencia del tratamiento inmunosupresor en la evolucion de la infeccion por el VHB y C en pacientes con EII. Metodos Estudio multicentrico retrospectivo que incluye todos los pacientes con EII e infeccion por el VHB y/o VHC actual o pasada y que hayan recibido tratamiento inmunosupresor en 18 hospitales espanoles. Se recopila informacion sobre el tipo y periodo de uso de los inmunosupresores utilizados y se evalua la funcion hepatica y marcadores virales pre, durante y postratamiento. Los datos se introducen en una base electronica ( www.repentina.com ), finalizando el reclutamiento el 31 marzo 2009. Resultados En el momento del envio del resumen, disponemos de datos de los marcadores virales de 77 pacientes; 43 de los cuales con serologia positiva para el VHB y 39 para el VHC. Cinco de estos tenian marcadores de ambas infecciones (antiHBc+AcVHC). En la tabla se muestra la evolucion de la infeccion de los pacientes HBsAg y RNA-VHC positivos, en relacion con la inmunosupresion. Casos Reactivacion No reactivacion Datos incompletos VHB (HBsAg) 13 53,8% (7/13) 46,1% (6/13) 0% (0/13) VHC (RNA) 23 8,7% (2/23) 52,2% (12/23) 39,1% (9/23) La reactivacion del VHB se observo en la mayoria de los casos con la utilizacion simultanea de 2 inmunosupresores (azatioprina+infliximab o esteroides), y se acompano de insuficiencia hepatica grave en 5 de 7 casos (71%). En 1 paciente con marcadores de infeccion pasada por VHB (antiHBc+antiHBs) y tratado con infliximab+azatioprina se detecto DNAVHB en dos ocasiones sin evidencia de reactivacion. Conclusiones 1) Igual como se ha descrito en otras situaciones de inmunosupresion, la reactivacion del VHB (HBsAg positivo) es mucho mas frecuente y grave que con el VHC. 2) La mayoria de las reactivaciones del VHB se producen con la administracion de 2 inmunosupresores simultaneos. 3) Los pacientes con marcadores de infeccion pasada por VHB deben ser controlados de forma estricta por la posibilidad de infeccion oculta.