Teresa Casanovas

Resultados a largo plazo del tratamiento quirúrgico del hepatocarcinoma

Fundamento El tratamiento quirurgico del hepatocarcinoma (HCC) sigue siendo un tema controvertidopor falta de estudios prospectivos aleatorizados. Pacientes y metodo Entre enero de 1990 y diciembre de 2000 se realizaron en nuestro centro121 trasplantes hepaticos (grupo I) y 52 hepatectomias (grupo II) por HCC. La indicacion deuna u otra tecnica dependio de las caracteristicas del paciente y del tumor. Resultados Los pacientes del grupo I presentaron un estadio tumoral mas avanzado, con mayorincidencia de bilobularidad (19 frente a un 4%; p = 0,015) y un mayor numero de nodulos(1,9 DE [2] frente a 1,2 [0,6]; p = 0,001), pero el tamano tumoral medio fue inferior (3 cm[1,5] frente a 4,2 cm [3,2]; p = 0,006). La mortalidad operatoria (4 frente a un 2%; p =0,66), y la supervivencia a los 5 y 10 anos (68 y 42% frente a 63 y 45%; p = 0,23) fueron similarespara los dos grupos. Sin embargo, la incidencia de recidiva a los 5 y 10 anos (10,6 y10,6% frente a 50 y 65,5%; p Conclusiones Con una buena seleccion de los pacientes, tanto el trasplante hepatico como lahepatectomia obtienen excelentes supervivencias a largo plazo en los pacientes con HCC, aunqueel primero permite un mejor control de la enfermedad tumoral. Las causas de mortalidadson diferentes para cada uno de los tratamientos. La prolongacion del tiempo en lista de esperade trasplante que se ha producido en los ultimos anos no ha originado un empeoramiento delos resultados de supervivencia.

Liver transplantation in hepatocellular carcinoma

The initial enthusiasm for orthotopic liver transplantation (OLT) in patients with hepatocellular carcinoma (HCC) soon vanished as early recurrences appeared. OLT in HCC remains a controversial issue. We evaluated the efficacy of preoperative studies to select No-Mo patients and determined whether pT stage and histopathological grade (G) have a prognostic significance. A group of 25 patients, all previously thoroughly studied to rule out extrahepatic disease, underwent OLT for HCC. All patients were pNo after pathological study and none of the six patients who died in the postoperative period showed extrahepatic dissemination at necropsy (pMo). The recurrence rate was 43%. The 2 and 5 years actuarial survival was 62% and 43% respectively. The pT and G were not prognostic factors for long-term survival. We think that HCC is still a good indication for OLT because almost 50% of patients have good survival prospects.

Randomized clinical trial comparing high versus standard dose of ribavirin plus peginterferon alfa-2a in hepatitis C genotype 3 and high viral load. Dargen-3 study

INTRODUCTION Less than half of patients with chronic hepatitis C genotype 3 (G3) and high viral load (HVL) without a rapid virological response (RVR) achieve a sustained virological response (SVR) when treated with peginterferon plus ribavirin (RBV). OBJECTIVES To assess the impact of high doses of RBV on SVR in patients with G3 and HVL. METHODS Ninety-seven patients were randomized to receive peginterferon α-2a+RBV 800 mg/day (A; n=42) or peginterferon α-2a+RBV 1600 mg/day+epoetin β 400 IU/kg/week SC (B; n=55). Patients allocated to group B who achieved RVR continued on RBV (800mg/day) for a further 20 weeks (B1; n=42) while non-RVR patients received a higher dose of RBV (1600 mg/day)+epoetin β (B2; n=13). RESULTS RVR was observed in 64.3% of patients in A and in 76.4% in B (p=0.259). Intention-to-treat (ITT) analysis showed SVR rates of 64.3% (A) and 61.8% (B), with a reduction of -2.5% (-21.8% to 16.9%) (p=0.835). The SVR rate was 61.9% in arm B1 and 61.5% in arm B2. No serious adverse events were reported, and the rate of moderate adverse events was < 5%. CONCLUSIONS G3 patients with high viral load without RVR did not obtain a benefit from a higher dose of RBV. Higher doses of RBV plus epoetin β were safe and well tolerated (Clin Trials Gov NCT00830609).

Programa de uso compasivo con adefovir dipivoxil en España: valoración de su eficacia y estudio de las resistencias

Fundamento y objetivo El tratamiento prolongado con lamivudina de los pacientes con hepatitis B cronica se asocia a la emergencia de resistencias. Los pacientes con resistencia a la lamivudina presentan una perdida de la respuesta tanto bioquimica como virologica y una mayor progression de la enfermedad hepatica. El adefovir dipivoxil, un analogo de los nucleotidos, es eficaz en el tratamiento de los pacientes con resistencia a la lamivudina. El objetivo de este estudio ha sido evaluar la eficacia, la seguridad y las resistencias del adefovir dipivoxil en pacientes con hepatitis B cronica refractarios al tratamiento con lamivudina. Pacientes y metodo Se ha incluido a 120 pacientes afectados de hepatitis B cronica y refractarios al tratamiento con lamivudina que recibieron tratamiento con adefovir dipivoxil. En 74 de ellos se realizo seguimiento durante 2 anos. En todos los casos se determino el ADN del virus de la hepatitis B por reaccion en cadena de la polimerasa, y en los casos sin respuesta al tratamiento se estudio la presencia de resistencias a adefovir dipivoxil y lamivudina. Resultados A los 2 anos de tratamiento se observo respuesta virologica en el 54,1% de los pacientes, respuesta bioquimica en el 62,2% y eliminacion del antigeno e de la hepatitis B en el 21%. Se detectaron resistencias a adefovir dipivoxil en el 20% de los casos, y las mutaciones detectadas con mayor frecuencia fueron A181V, A181T y N236T. La seguridad del farmaco fue excelente, pues se detecto solo un efecto adverso relacionado con el tratamiento. Conclusiones El tratamiento durante 2 anos con adefovir dipivoxil en monoterapia en pacientes previamente refractarios a lamivudina se asocia a una alta tasa de respuesta bioquimica y virologica, con una seguridad excelente. La tasa de resistencias al adefovir dipivoxil a los 2 anos fue del 20%.

The Present Role of Liver Biopsy in Kidney Transplant Candidates in the Management of Hepatitis B and C Patients

This chapter will deal with the present role of Liver Biopsy in determining liver disease prognosis in hepatitis B and C patients on haemodialysis and its role in establishing treatment strategies and in the decision-making process prior to kidney transplant. In recent years, progress has been made in determining the natural history of this disease in renal patients (Espinosa et al., 2004; Jadoul et al., 2004). Chronic hepatitis due to HCV is frequent in renal transplant recipients and in dialysis patients and has a significant impact on their survival (Hanafusa et al., 1998; Orloff et al., 1995; Pouteil-Noble et al., 1995). Mathurin et al., (1999) demonstrated in a case-control study that anti-HCV and HBsAg positive were independently associated with patient and graft survival. This was the first time that a 10 year follow-up was carried out; previous publications are based on shorter follow-ups and fewer patients. It is known that the prevalence of chronic infection with the hepatitis C virus (HCV) in patients with chronic kidney disease is higher than in the general population (Lavanchy, 2009). The estimated prevalence of chronic infection in haemodialysis patients is 13%, ranging from 10 to 65 %, depending on the geographical zone (Hmaied et al., 2006; Huraib et al., 1995; Santos & Souto, 2007; Shamshiraz et al., 2004). When considering patients candidates to kidney transplantation we have to take into account that immunosuppressive therapy after renal transplantation predisposes a reactivation of chronic viral hepatitis B or C, which is usually a mild disease for patients remaining under haemodialysis. It should be noted that HBV and HCV may induce de novo glomerulonephritis and chronic allograft nephropathy which can lead to graft failure (Aouifi & Garcia, 2001). In such cases, patients have to undergo dialysis again and therefore it is beneficial to eradicate HCV RNA before transplantation and to control and maintain HBV DNA negative (Huskey & Wiseman, 2011). A routine liver histological analysis could improve a patient’s chance of being selected for renal transplantation. Liver biopsy has been considered the “gold standard” for many years, because it provides us with information that was otherwise unobtainable (Ghany et al., 2010). Nowadays however, due to progress in non-invasive methods, liver biopsy is only