S. Coll

Prevalencia de las hepatitis B y C en diversas comarcas de Cataluña: estudio transversal

Fundamento Existen pocos estudios sobre la prevalencia de las infecciones por los virus de la hepatitis B (VHB) y C (VHC) en nuestro medio Material y metodo Para conocer la prevalencia y las caracteristicas serologicas del VHB y el VHC se han determinado HBsAg y anti-VHC en alicuotas de suero de una muestra aleatoria, estratificada a partir de las listas censales, de 2.194 individuos de diversas comarcas de Cataluna. En los casos en que resulto positivo alguno de los marcadores se determinaron transaminasas sericas, ADN-VHB (PCR) (en HBsAg+) y genotipos (DIA @) y ARN-VHC (PCR) (en anti-VHC+). Los sujetos positivos fueron entrevistados con el fin de conocer los factores deriesgo Resultados La prevalencia del VHB fue del 1,69% (IC del 95%, 1,62–1,76), y del VHC del 2,64% (IC del 95%, 2,53–2,75). La prevalencia del VHC aumento con la edad (1,7% y 3,6% en los menores y mayores de 50 anos, respectivamente; p Conclusiones La prevalencia del VHC en las poblaciones estudiadas de Cataluna es del 2,64%, y en la mayoria de los casos cursa con ARN-VHC serico positivo. Por el contrario, en la mayoria de los portadores del VHB (1,69%) el ADN-VHB serico es negativo

Total paracentesis with dextran 40 vs diuretics in the treatment of ascites in cirrhosis: a randomized controlled study.

The aim of the current study was to compare total paracentesis associated with dextran-40 infusion with diuretics in the treatment of tense ascites in patients with cirrhosis. Eighty patients were randomly allocated to two groups: 40 patients were treated with paracentesis plus dextran-40 infusion (8 g per liter of ascitic fluid removed), and 40 patients with diuretics. After treatment patients were discharged with diuretics, and patients developing tense ascites during follow up (54 +/- 4 weeks) were treated according to their initial schedule. Paracentesis was more effective than diuretics in mobilizing the ascitic fluid. The incidence of complications was significantly higher (p < 0.05) in the diuretic group (38%) than in the paracentesis group (15%). This difference was mainly due to a higher incidence of hepatic encephalopathy in the former group (30% vs. 2.5%). A significantly higher incidence of hepatic encephalopathy was also observed in the diuretic group during the follow-up readmissions for ascites recurrence. There were no significant differences between the two treatment groups in the probability of survival after inclusion. Plasma renin activity and plasma aldosterone concentration measured before and 2 and 6 days after paracentesis in 20 randomly selected patients increased significantly (p < 0.05) (baseline values: 5.3 +/- 1.4 ng.ml-1.h-1 and 63 +/- 21 ng/dl; 48 h after paracentesis: 11.7 +/- 3.9 ng.ml-1.h-1 and 99 +/- 31 ng/dl; 6 days after paracentesis: 10.9 +/- 3 ng.ml-1.h-1 and 110 +/- 27 ng/dl).(ABSTRACT TRUNCATED AT 250 WORDS)

Incidence and Prognosis of Different Types of Functional Renal Failure in Cirrhotic Patients With Ascites

BACKGROUND & AIMS Hepatorenal syndrome is a well-characterized type of terminal renal failure that occurs in patients with cirrhosis with ascites. Information about other types of functional renal failure in these patients is scarce. We assessed the incidence and prognosis of different types of functional renal failure in cirrhotic patients with ascites and investigated prognostic factors for these disorders. METHODS Consecutive cirrhotic patients (n = 263) were followed for 41 +/- 3 months after their first incidence of ascites. Three types of functional renal failure were considered: pre-renal failure (when renal failure was associated with a depletion of intravascular volume), renal failure induced by infection that did not result in hepatorenal syndrome, and hepatorenal syndrome. RESULTS During the follow-up period, 129 (49%) patients developed some type of functional renal failure. The most frequent was pre-renal failure (27.4%), followed by renal failure induced by infection (14.1%), and then hepatorenal syndrome (7.6%). The 1-year probability of developing the first episode of any functional renal failure was 23.6%. The independent predictors of functional renal failure development were baseline age, Child-Pugh score, and serum creatinine. Although the 1-year probability of survival was 91% in patients without renal failure, it decreased to 46.9% in those patients who developed any functional renal failure (P = .0001). CONCLUSIONS Approximately 50% of the cirrhotic patients with ascites developed some type of functional renal failure during the follow-up period; renal failure was associated with worse prognosis. Efforts should be made to prevent renal failure in cirrhotic patients with ascites.

Probability of liver cancer and survival in HCV-related or alcoholic-decompensated cirrhosis. A study of 377 patients

Abstract: Background: Although chronic alcohol intake and chronic hepatitis C may progress to cirrhosis and hepatocellular carcinoma (HCC), few data are available about survival and probability of developing HCC in decompensated cirrhosis of both aetiologies.

A multidisciplinary support programme increases the efficiency of pegylated interferon alfa-2a and ribavirin in hepatitis C

BACKGROUND & AIMS Adherence to antiviral treatment is important to achieve sustained virological response (SVR) in chronic hepatitis C (CHC). We evaluated the efficiency of a multidisciplinary support programme (MSP), based on published HIV treatment experience, to increase patient adherence and the efficacy of pegylated interferon alfa-2a and ribavirin in CHC. METHODS 447 patients receiving antiviral treatment were distributed into 3 groups: control group (2003-2004, n=147), MSP group (2005-2006, n=131), and MSP-validation group (2007-2009, n=169). The MSP group included two hepatologists, two nurses, one pharmacist, one psychologist, one administrative assistant, and one psychiatrist. Cost-effectiveness analysis was performed using a Markov model. RESULTS Adherence and SVR rates were higher in the MSP (94.6% and 77.1%) and MSP-validation (91.7% and 74.6%) groups compared to controls (78.9% and 61.9%) (p<0.05 in all cases). SVR was higher in genotypes 1 or 4 followed by the MSP group vs. controls (67.7% vs. 48.9%, p=0.02) compared with genotypes 2 or 3 (87.7% vs. 81.4%, p=n.s.). The MSP was the main predictive factor of SVR in patients with genotype 1. The rate of adherence in patients with psychiatric disorders was higher in the MSP groups (n=95, 90.5%) compared to controls (n=28, 75.7%) (p=0.02). The cost per patient was € 13,319 in the MSP group and € 16,184 in the control group. The MSP group achieved more quality-adjusted life years (QALYs) (16.317 QALYs) than controls (15.814 QALYs) and was dominant in all genotypes. CONCLUSIONS MSP improves patient compliance and increases the efficiency of antiviral treatment in CHC, being cost-effective.

Total paracentesis in cirrhotic patients with tense ascites and dilutional hyponatremia

OBJECTIVE:The safety of large-volume paracentesis with plasma expander infusion in ascitic cirrhotic patients with advanced liver disease, hyponatremia, or renal failure has not been elucidated. Our aim was to investigate the safety of total paracentesis in cirrhotic patients with ascites and severe hyponatremia.METHODS:Forty-five cirrhotic patients with tense ascites were treated with total paracentesis and infusion of plasma expanders. At inclusion, 20 patients showed severe hyponatremia (serum sodium <130 mEq/L). In the remaining 25 patients, serum sodium was >130 mEq/L (range, 133–146 mEq/L).RESULTS:Plasma renin activity (PRA) and plasma aldosterone concentration (PAC) were significantly higher in patients with hyponatremia (PRA: 19.7 ± 5.8 ng/mL/h; PAC: 217 ± 35 ng/dL) than in those patients without hyponatremia (PRA: 4.9 ± 1.1 ng/mL/h; PAC: 95 ± 31 ng/dL), indicating a more severe systemic hemodynamic deterioration. After paracentesis, PRA and PAC increased similarly in both groups of patients. Serum sodium levels remained unchanged after paracentesis in patients with hyponatremia (127 ± 0.5 to 128 ± 1.5 mEq/L) and decreased slightly in patients without hyponatremia (137 ± 1 to 135 ± 1 mEq/L; p < 0.005). The incidence of complications during the first hospitalization, the probability of readmission for complications of cirrhosis, and the probability of survival at 1 yr were similar in both groups of patients.CONCLUSIONS:These results indicate that therapeutic paracentesis is a safe treatment for tense ascites in cirrhotic patients with severe hyponatremia.

Mechanisms of early decrease in systemic vascular resistance after total paracentesis: influence of flow rate of ascites extraction.

Background An early decrease in systemic vascular resistance (SVR) after total paracentesis has been observed in ascitic patients who developed paracentesis-induced circulatory dysfunction. Aims To investigate the mechanisms of early changes in SVR after total paracentesis and the influence of intra-abdominal pressure and the flow rate of ascites extraction on the development of an early decrease in SVR. Methods Twenty-two cirrhotic patients with tense ascites were treated by total paracentesis (7 ± 0.4 l). Measurements of intra-abdominal pressure and the volume of ascites removed were recorded every 10 min. Hormonal and haemodynamic measurements were performed at baseline and 3 h after total paracentesis. Results SVR decreased 3 h after paracentesis in 17 patients and remained stable in five patients. Patients with a decrease in SVR showed a significant increase in nitrite/nitrate serum values (4.4 ± 0.9 to 7.4 ± 1 nmol/ml; P < 0.05). A significant correlation was observed between the decrease in SVR and nitrite/nitrate serum values (r = 0.566; P < 0.05). The volume of ascites removed was similar in patients with and without a decrease in SVR. Patients with a decrease in SVR showed higher baseline intra-abdominal pressure, shorter duration of paracentesis (60 ± 4.9 vs 88 ± 0.4 min; P < 0.01) and higher flow rate of ascites extraction (1.18 ± 0.08 vs 0.81 ± 0.12 l/min; P < 0.05). Conclusions Our results confirm that an early decrease in SVR after total paracentesis is due to an increase in arterial vasodilation that may be related to an abrupt decrease in intra-abdominal pressure after fast paracentesis. Haemodynamic disturbances after total paracentesis could be prevented by reducing the flow rate of ascites extraction.

Applicability and accuracy improvement of transient elastography using the M and XL probes by experienced operators

Transient elastography (TE) is the reference method to obtain liver stiffness measurements (LSM), but no results are obtained in 3.1% and unreliable in 15.8%. We assessed the applicability and diagnostic accuracy of TE re‐evaluation using M and XL probes. From March 2011 to April 2012 868 LSM were performed with the M probe by trained operators (50–500 studies) (LSM1). Measurements were categorized as inadequate (no values or ratio <60% and/or IQR/LSM >30%) or adequate. Inadequate LSM1 were re‐evaluated by experienced operators (>500 explorations) (LSM2) and inadequate LSM2 using XL probe (LSMXL). Inadequate LSM1 were obtained in 187 (21.5%) patients, IQR/LSM >30% in 97 (51%), ratio <60% in 24 (13%) and TE failed to obtain a measurement in 67 (36%). LSM2 achieved adequate registers in 123 (70%) of 175 registers previously considered as inadequate. Independent variables (OR, 95%CI) related to inadequate LSM1 were body mass index (1.11, 1.04–1.18), abdominal circumference (1.03, 1.01–1.06) and age (1.03, 1.01–1.04) and to inadequate LSM2 were skin‐capsule distance (1.21, 1.09–1.34) and abdominal circumference (1.05, 1.01–1.10). The diagnostic accuracy (AUROC) to identify significant fibrosis improved from 0.89 (LSM1) to 0.91 (LSM2) (P = 0.046) in 334 patients with liver biopsy or clinically significant portal hypertension. A third evaluation (LSMXL) obtained adequate registers in 41 (93%) of 44 patients with inadequate LSM2. Operator experience increases the applicability and diagnostic accuracy of TE. The XL probe may be recommended for patients with inadequate values obtained by experienced operators using the M probe. http://clinicaltrials.gov (NCT01900808).

Impact of Anthropometric Features on the Applicability and Accuracy of FibroScan® (M and XL) in Overweight/Obese Patients.

Transient elastography is the reference method for liver stiffness measurement (LSM) in the general population, having lower applicability in obese patients. We evaluated the applicability and diagnostic accuracy of the M and XL probes in overweight/obese patients to establish the most appropriate approach.

Drug-drug interactions of telaprevir and boceprevir in HCV-monoinfected and HIV/HCV-coinfected patients can modify the adherence.

The first generation protease inhibitors, boceprevir (BOC) and telaprevir (TVR), are both CYP3A4 inhibitors, which predispose drug–drug interactions (DDIs). The aim of this study was to evaluate the prevalence of potential DDIs, the management of outpatient medication and its impact on adherence and efficacy to antiviral treatment in hepatitis C virus (HCV)‐monoinfected and human immunodeficiency virus (HIV)/HCV‐coinfected patients receiving BOC and TVR.