Sistemas de soporte hepático artificial. Revisión de la bibliografía médica / Artificial liver support. Literature review

Se ha realizado una revisión sistemática con el objetivo de describir los instrumentos de soporte hepático artificial utilizados en pacientes con insuficiencia hepática y evaluar su eficacia y seguridad. De las 436 referencias identificadas, sólo 10 ensayos clínicos cumplían los criterios de inclusión y disponían de la información necesaria para incluirse en la revisión. Las intervenciones estudiadas fueron Molecular Adsorbent Recirculating System, sistema Prometheus y Biologic-DT. Estos sistemas disminuyen el valor de bilirrubina, creatinina y otros elementos tóxicos. Asimismo, la eficacia clínica se demuestra con una mejoría de la encefalopatía hepática y un aumento de la supervivencia. La seguridad de la intervención se valora en pocos estudios y las alteraciones en la coagulación son los acontecimientos adversos más notificados. Existe suficiente evidencia científica que respalda que estos sistemas son capaces de mejorar la clínica de los pacientes de una manera segura. Confirmar su impacto sobre la supervivencia de los pacientes es ahora una prioridad (AU)

We performed a systematic review to assess the efficacy and safety of extracorporeal albumin dialysissystems in patients with liver failure. After screening 436 references, 10 controlled trials were detected. The analyzed interventions were MARS, Prometheus and Biologic-DT. Efficacy was proven by a reductionin bilirubin, creatinine and other toxic components after ntervention. Clinical efficacy was measured in fewer studies, some of them showing an improvement in hepatic encephalopathy and survival. Intervention safety was assessed in a reduced number of studies and based on adverse events, being coagulation disorders in most cases. In summary, reviewed evidence showed that albumin dialysis based systems were able to reduce toxic parameters and improve clinical results in these settings. However,more studies are needed to further evaluate survival and adverse events based on standardisednotification (AU)

[Artificial liver support. Literature review]. / Sistemas de soporte hepático artificial. Revisión de la bibliografía médica.

We performed a systematic review to assess the efficacy and safety of extracorporeal albumin dialysis systems in patients with liver failure. After screening 436 references, 10 controlled trials were detected. The analyzed interventions were MARS, Prometheus and Biologic-DT. Efficacy was proven by a reduction in bilirubin, creatinine and other toxic components after intervention. Clinical efficacy was measured in fewer studies, some of them showing an improvement in hepatic encephalopathy and survival. Intervention safety was assessed in a reduced number of studies and based on adverse events, being coagulation disorders in most cases. In summary, reviewed evidence showed that albumin dialysis based systems were able to reduce toxic parameters and improve clinical results in these settings. However, more studies are needed to further evaluate survival and adverse events based on standardised notification.

Multidimensional analysis of treatment adherence in patients with multiple chronic conditions. A cross-sectional study in a tertiary hospital.

OBJECTIVE: Determine treatment adherence in patients with multiple chronic conditions (MCC). METHODS: A random patient sample ≥ 15 years, discharged from hospital with ≥1 chronic conditions (CC) was interviewed after 6-12 months. Analysis included variables in 5 dimensions (WHO): socio-demographics, disease, treatment, patient and health system characteristics. Morisky-Green adherence questionnaire was used. High chronic treatment complexity was defined as: >3 pills/day, >6 inhalations/day, >1 injection/day, pharmacological treatment plus diet or self-monitoring techniques. RESULTS: 301 patients were interviewed (62 ± 15 years, 59% males). Despite good treatment information perception (79%), only 3% followed the patient education programme. Poor adherents (82%) were older (64 ± 14 years vs. 55 ± 16 years), had more CC (3.25 ± 2.02 vs. 2.62 ± 2.72), a higher frequency of hypertension (44% vs. 15%), ischaemic heart diseases: (21% vs. 4%), hyperlipidaemia (19% vs. 6%), more pills/day (5.78 ± 4.14 vs. 3.20 ± 4.70) and more complex treatments (95% vs. 70%) (p<0.05). On multivariate analysis number of CC [3.68 (0.75-18.15)], pills/day [2.23 (1.02-4.84)], treatment complexity [4.00 (1.45-11.04)], and hypertension [2.57 (1.06-6.25)] were predictive of poor adherence (OR 95% CI p<0.05). CONCLUSION: The WHO conceptual framework allows the construction of poor adherence risk profiles in patients with MCC after hospital discharge. PRACTICE IMPLICATIONS: Predictive variables of poor adherence could help clinicians detect patients with MCC most likely to present poor adherence.

[Post-transplantation vaccination of bone-marrow transplant recipients]. / Vacunación de pacientes receptores de trasplante de progenitores hematopoyéticos.

BACKGROUND: Patients subject to bone marrow transplantation (BMT) and other blood stem cell transplantations are severely immunocompromised after transplantation. Some studies have suggested that post-transplantation loss of acquired immunity may play a role. The objective of this study was to determine the susceptibility to vaccine-preventable diseases in people subject to BMT and the serologic response after vaccination. PATIENTS AND METHOD: Study population was people subject to transplantation at least 6 months before initiating vaccination and without immunosuppressive treatment at that time. A prevaccination serologic analysis was carried out, and the hepatitis B, the adult tetanus-diphtheria (Td), the IPV, the influenza and the pneumococccal vaccines were administered in accordance with standard guidelines Depending on the immune status of the patient according to the serologic analysis, the MMR vaccine was administered no sooner than 18 months after transplantation. After vaccination, a serologic analysis was carried out to determine the response. RESULTS: The mean time SD between transplant and the initiation of vaccination was 3.2 2.9 years. Of the 122 recipients of BMT (average age 35.8 13 years; 54.2% male), 51.7% received an allogenic and 48.3% an autologous transplant. Before vaccination, the susceptibility was 48.2% for tetanus, 66.7% for diphtheria, 74.1% for pertussis, 85.9% for hepatitis B, 13.4% for measles, 36.7% for rubella and 9.2% for mumps. The rates of seroconversion with protective titers after vaccination for tetanus, diphtheria and hepatitis B were 94%, 67% and 75% respectively. The response to the MMR vaccine was greater than 70%, with a second dose of the vaccine being needed in 26% of patients. CONCLUSIONS: Susceptibility to vaccine-preventable diseases in transplanted patients is high. The acceptable response to vaccination justifies the development of specific programs. Given the special characteristics of this group of patients, vaccination programs must be simple and flexible.

Vacunación de pacientes receptores de trasplante de progenitores hematopoyéticos / Post-transplantation vaccination of bone-marrow transplant recipients

FUNDAMENTO: Las personas que reciben un trasplante de médula ósea y otros progenitores hematopoyéticos (TPH) están intensamente inmunodeprimidas después del trasplante. Algunos estudios sugieren la pérdida de la inmunidad adquirida antes del trasplante. El objetivo de este trabajo es determinar la susceptibilidad a enfermedades prevenibles por vacunación en receptores de TPH y conocer la respuesta serológica tras la vacunación. PACIENTES Y MÉTODO: La población de estudio estaba constituida por personas que habían sido trasplantadas, como mínimo, 6 meses antes del inicio de la vacunación y sin tratamiento inmunodepresor en el momento de su inicio. Se realizó una determinación serológica prevacunal y se administraron vacunas antihepatitis B, antitétanos-difteria tipo adulto (Td), antipoliomielítica tipo Salk, así como las antigripal y antineumocócica. En función de los resultados serológicos se administró la vacuna triple viral transcurridos al menos 18 meses desde el trasplante. Tras completar la vacunación se realizó una determinación serológica para valorar la respuesta. RESULTADOS: La media (DE) de tiempo transcurrido entre el trasplante y el inicio de la vacunación fue de 3,2 (2,9) años. De los 122 receptores de TPH (edad media, 35,8 [13] años), el 51,7 por ciento había recibido un trasplante alogénico y el 48,3 por ciento, autogénico. El 54,1 por ciento eran varones. Antes de la vacunación, la susceptibilidad era del 48,2 por ciento para tétanos, del 66,7 por ciento para difteria, del 74,1 por ciento para tos ferina y del 85,9 por ciento para hepatitis B. La susceptibilidad a sarampión, rubéola y parotiditis era del 13,4 por ciento, 36,7 por ciento y 9,2 por ciento, respectivamente. Las tasas de seroconversión tras las vacunas de tétanos, difteria y hepatitis B fué de 94 por ciento, 67 por ciento y 75 por ciento respectivamente. La respuesta a la vacuna triple viral fue superior al 70 por ciento, por lo que un 26 por ciento de los pacientes precisó una segunda dosis de vacuna. CONCLUSIONES: La susceptibilidad a varias enfermedades prevenibles mediante vacunación en los pacientes trasplantados es elevada. La respuesta aceptable a la vacunación justifica el desarrollo de programas específicos. Dadas las peculiares características de estos pacientes, los programas de vacunación han de ser sencillos y flexibles. (AU)