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ABSTRACT COVID-19 is commonly associated with high serum levels of pro-inflammatory cytokines, and the post-infection status can disturb self-tolerance and trigger autoimmune responses. We are reporting a 45-year-old male who was admitted with fatigue, jaundice, elevated liver enzymes (with cholestatic pattern), and acute kidney injury two weeks after recovering from a mild SARS-CoV-2 infection. Serologies for viral hepatitis and anti-mitochondrial antibody were negative, while anti-nuclear and anti-smooth muscle antibodies were positive. There were no signs of chronic liver disease, and a magnetic resonance cholangiography showed no dilatation of biliary ducts. Histologic evaluation of the liver evidenced numerous foci of lobular necrosis without ductopenia or portal biliary reaction. Considering the autoantibody profile and histologic changes, the medical team started oral prednisone, but there was a suboptimal biochemical response in the outpatient follow-up. Two months later, a second liver biopsy was performed and revealed non-suppurative destructive chronic cholangitis, extensive areas of confluent necrosis with hepatocytes regenerating into pseudorosettes, and numerous plasma cells. According to the Paris Criteria, the patient was then diagnosed with an autoimmune hepatitis-primary biliary cholangitis overlap syndrome (AIH-PBC-OS). After adding azathioprine and ursodeoxycholic acid to the treatment, there was a satisfactory response. This is the second worldwide report of an AIH-PBC-OS triggered by COVID-19, but the first case with a negative anti-mitochondrial antibody. In this setting, histologic evaluation of the liver by an experienced pathologist is a hallmark of achieving the diagnosis and correctly treat the patient.
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Abstract With the emergence of new variants of SARS-CoV-2, questions about transmissibility, vaccine efficacy, and impact on mortality are important to support decision-making in public health measures. Modifications related to transmissibility combined with the fact that much of the population has already been partially exposed to infection and/or vaccination, have stimulated recommendations to reduce the isolation period for COVID-19. However, these new guidelines have raised questions about their effectiveness in reducing contamination and minimizing impact in work environments. Therefore, a collaborative task force was developed to review the subject in a non-systematic manner, answering questions about SARS-CoV-2 variants, COVID-19 vaccines, isolation/quarantine periods, testing to end the isolation period, and the use of masks as mitigation procedures. Overall, COVID-19 vaccines are effective in preventing severe illness and death but are less effective in preventing infection in the case of the Omicron variant. Any strategy that is adopted to reduce the isolation period should take into consideration the epidemiological situation of the geographical region, individual clinical characteristics, and mask for source control. The use of tests for isolation withdrawal should be evaluated with caution, due to results depending on various conditions and may not be reliable.
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ABSTRACT Background - In chronic liver disease, trace element levels in plasma are usually low. However, the specific cause and functional implications of this abnormality are yet not well understood. These element levels may decrease as a result of abnormal liver function in patients with cirrhosis and/or malnutrition. Objective - To evaluate the nutritional status and the profile of trace elements in plasma of patients with cirrhosis on a liver transplant list and to correlate them with disease severity. Methods - This cross-sectional study evaluated 31 male patients diagnosed with compensated liver cirrhosis on a waiting list for liver transplant. Nutritional status was objectively evaluated through anthropometry using Mendenhall score and Blackburn classification, subjectively through the Detsky questionnaire and severity of the disease by MELD and CTP score. Trace elements (Zn, Se, Cu, Ca, Fe, Mg and Mn) in plasma were analyzed by inductively coupled plasma mass spectrometry (ICP-MS). Statistical analysis was performed using Mann-Whitney test. Results - According to the nutritional assessment 19 (61.3%) were malnourished and 12 (38.7%) were overweight. Regarding disease severity 12 (39%) were classified as Child A, 17 (55%), Child B and 2 (6%) Child C, with 46.9% of patients with MELD score >17. The trace element analysis indicated that 31 (100%) had Mn levels above the reference range, 23 (74.2%) low levels of Cu, 29 (93.5%) with deficiency of Se, and 31 (100%) low levels of Ca and Mg. Disease severity did not show statistical difference between the studied trace elements, in contrast to the nutritional status, in which the malnourished group showed higher levels of Mn (P=0.01) and Fe (P=0.01) and low levels of Zn (P=0.03) when compared to the overweight group. Conclusion - The results showed that the trace elements in plasma are altered in chronic liver disease; without significant correlation to disease severity, but correlated to nutritional status. Malnutrition is present in the patients studied, nonetheless a new scenario with an increase in the prevalence of overweight was verified regardless of the degree of hepatic decompensation.
RESUMO Contexto - Na doença hepática crônica os níveis plasmáticos de oligoelementos normalmente apresentam-se baixos, mas a causa específica e implicações funcionais desta anormalidade ainda não estão bem esclarecidas. Estes elementos podem estar diminuídos em consequência da função hepática alterada em pacientes com cirrose e/ou desnutrição. Objetivo - Avaliar o estado nutricional e o perfil de oligoelementos plasmáticos dos pacientes com cirrose hepática em lista para transplante e correlacionar com a gravidade da doença. Métodos - Trata-se de um estudo transversal, no qual foram avaliados 31 pacientes do sexo masculino com diagnóstico de cirrose hepática compensada em lista de espera para transplante de fígado. O estado nutricional foi avaliado objetivamente por medidas antropométricas através do escore de Mendenhall e classificado segundo Blackburn, subjetivamente por um questionário sistematizado por Detsky e a gravidade da doença pelo escore MELD e CTP. Os oligoelementos plasmáticos (Zn, Se, Cu, Ca, Fe, Mg e Mn) foram analisados pelo método de espectrometria de massas com fonte de plasma indutivamente acoplado (ICP-MS). Para análise estatística foi utilizado o Teste de Mann-Whitney. Resultados - De acordo com a avaliação nutricional 19 (61,3%) estavam com desnutrição e 12 (38,7%) com sobrepeso. Em relação à gravidade da doença 12 (39%) foram classificados como Child A, 17 (55%), Child B e 2 (6%) Child C, sendo 46,9% dos pacientes com o escore MELD >17. Na análise dos oligoelementos 31 (100%) apresentaram níveis de Mn acima dos valores de referência, 23 (74,2%) níveis baixos de Cu, 29 (93,5%) com deficiência de Se, e 31 (100%) níveis baixos de Ca e Mg. Em relação à gravidade da doença não houve diferença estatística entre os oligoelementos estudados, já em relação ao estado nutricional o grupo desnutrido apresentou níveis maiores de Mn (P=0,01) e Fe (P=0,01) e níveis diminuídos de Zn (P=0,03) quando comparado ao grupo sobrepeso. Conclusão - Os resultados mostraram que os oligoelementos estão alterados na doença hepática crônica, sem associação significativa com a gravidade da doença, mas sim com o estado nutricional. A desnutrição está presente nos pacientes estudados, porém um novo cenário com aumento na prevalência de sobrepeso foi verificado independente do grau de descompensação hepática.
Subject(s)
Humans , Male , Trace Elements/blood , Nutrition Assessment , Liver Transplantation , Malnutrition/blood , Liver Cirrhosis/blood , Severity of Illness Index , Nutritional Status , Cross-Sectional Studies , Waiting Lists , Malnutrition/etiology , Liver Cirrhosis/complications , Middle AgedABSTRACT
RACIONAL: Utiliza-se o escore MELD (Model End-Stage Liver Disease) para o prognóstico da mortalidade em lista de espera para transplante de fígado e, em alguns estudos, para predição da sobrevida pós-operatória a longo prazo. OBJETIVO: Verificar a aplicação do escore MELD como predição da sobrevida após o transplante. MÉTODOS: Por intermédio de dados coletados prospectivamente efetuou-se um estudo de coorte longitudinal retrospectivo em 232 pacientes. Excluíram-se os retransplantes, insuficiência hepática aguda, crianças e enxertos duplos ou reduzidos. Avaliaram-se os dados dos doadores: idade, sexo, peso, creatinina, bilirrubina, sódio, aspartato aminotransferase, antecedentes pessoais, causa da morte, presença de esteatose, número de critérios expandidos do doador e índice de risco do doador. Em relação aos receptores, analisaram-se as variáveis: sexo, idade, peso, doença hepática, pontos de Child-Turcotte-Pugh, escore MELD, depuração de creatinina, sódio, tempos de isquemia e de hospitalização, quantidade de hemoderivados transfundidos, presença e grau de disfunção do enxerto. A análise estatística foi efetuada usando-se a análise de regressão univariada e/ou múltipla, estatística 'c', teste exato de Fisher, método de Kaplan-Meier (teste log-rank) para sobrevida, e análise de regressão de Cox para risco de óbito ajustado para as condições clínicas. RESULTADOS: O ponto de corte MELD para sobrevida foi 20 e de Child-Turcotte-Pugh foi 11,5. Para escore MELD maior ou igual a 20, os fatores preditivos de sobrevida foram: volume de sangue transfundido, disfunção do enxerto e o sódio do doador. Para os hiponatrêmicos os fatores preditivos de sobrevida foram: volume de sangue transfundido, disfunção do enxerto e sódio do doador. A sobrevida estimada para pacientes com escore MELD >25 foi menor ao final de 12 meses (68,86 por cento vs 39,13 por cento). A sobrevida estimada para os pacientes sem hiponatremia foi maior (65,16 por cento vs 44,44...
BACKGROUND: The model for end-stage liver disease (MELD) was developed to predict short-term mortality in patients with cirrhosis. There are few reports studying the correlation between MELD and long-term posttransplantation survival. AIM: To assess the value of pretransplant MELD in the prediction of posttransplant survival. METHODS: The adult patients (age >18 years) who underwent liver transplantation were examined in a retrospective longitudinal cohort of patients, through the prospective data base. We excluded acute liver failure, retransplantation and reduced or split-livers. The liver donors were evaluated according to: age, sex, weight, creatinine, bilirubin, sodium, aspartate aminotransferase, personal antecedents, brain death cause, steatosis, expanded criteria donor number and index donor risk. The recipients' data were: sex, age, weight, chronic hepatic disease, Child-Turcotte-Pugh points, pretransplant and initial MELD score, pretransplant creatinine clearance, sodium, cold and warm ischemia times, hospital length of stay, blood requirements, and alanine aminotransferase (ALT >1,000 UI/L = liver dysfunction). The Kaplan-Meier method with the log-rank test was used for the univariable analyses of posttransplant patient survival. For the multivariable analyses the Cox proportional hazard regression method with the stepwise procedure was used with stratifying sodium and MELD as variables. ROC curve was used to define area under the curve for MELD and Child-Turcotte-Pugh. RESULTS: A total of 232 patients with 10 years follow up were available. The MELD cutoff was 20 and Child-Turcotte-Pugh cutoff was 11.5. For MELD score > 20, the risk factors for death were: red cell requirements, liver dysfunction and donor's sodium. For the patients with hyponatremia the risk factors were: negative delta-MELD score, red cell requirements, liver dysfunction and donor's sodium. The regression univariated analyses came up with the following risk...
Subject(s)
Female , Humans , Male , Middle Aged , Liver Cirrhosis , Liver Transplantation/mortality , Alanine Transaminase/blood , Aspartate Aminotransferases/blood , Bilirubin/blood , Blood Transfusion/statistics & numerical data , Creatinine/blood , Epidemiologic Methods , Hyponatremia/mortality , Liver Cirrhosis/blood , Liver Cirrhosis/surgery , Models, Biological , Patient Selection , Risk Factors , Time Factors , Tissue DonorsABSTRACT
A determinacao dos niveis de alanina aminotransferase (ALT) tem sido util para o diagnostico de hepatopatias. Ultimamente, a elevacao dos niveis sericos de ALT em doadores de sangue, tem sido associada a um maior risco de hepatites pos-tranfusionais. Este estudo busca identificar os fatores associados com elevados niveis de ALT entre doadores voluntarios de sangue e avaliar as relacoes entre estes aumentos de ALT e o desenvolvimento de infeccao pelo virus da hepatite C. Assim, 116 doadores voluntarios de sangue com niveis de ALT elevados, quando da primeira doacao, foram estudados. Todos foram questionados sobre hepatopatias previas, exposicao a hepatites, exposicao a produtos quimicos, uso de drogas ou medicamentos, comportamento sexual, contacto com sangue ou secrecoes e consumo de alcool...