Is hepatitis B immunoglobulin prophylaxis needed for liver transplantation in the era of new antivirals?

Chronic infection with hepatitis B virus (HBV) is one of the most common causes of cirrhosis of the liver and hepatocellular carcinoma worldwide, frequently requiring liver transplantation. Other nonliver organ transplants get infected de novo or through reactivation from previous active or inactive infections. With significant improvements in the surgical techniques and immunosuppressive regimens over the last 20 years, organ transplantation has become the most effective and lifesaving therapy for patients with chronic renal failure, cirrhosis, hepatocarcinoma, and heart failure. Until recently chronic HBV infection was considered a formal contraindication for liver transplantation, since recurrence of infection without prophylaxis occurs in 75% to 90% of the patients, with significant morbidity and mortality and few therapeutic alternatives. However, the introduction of hepatitis B immunoglobulin (HBIG) a decade ago to reduce the risk of reinfection of liver grafts, and more recently the availability of nucleoside analogues with few side effects and easy administration, have led to a dramatic improvement in patient outcomes with a risk of long-term HBV reinfection of less than 10% with combined HBIG and lamivudine prophylaxis. Chronic HBV infection in kidney, heart, and other organs has become a serious long-term problem and one of the most frequent and important comorbidities affecting graft and patient survival. Fortunately the introduction of nucleoside analogues allows significant control of viral replication and prevents progression of liver disease and other organ damage. In the present article we discuss the current indications for HBV prophylaxis and treatment prior to and after organ transplantation, as well as the most cost-effective way to apply different regimens to reduce side effects and improve survival and quality of life after transplantation.

Should patients with chronic hepatitis C infection be transplanted?

Chronic hepatitis C (HCV) infection affects more than 170 million people throughout the world and 2 to 3 million Americans. End-stage liver disease secondary to chronic HCV infection is the most frequent indication for liver transplantation in this country. Currently, the gold standard for treatment for immunocompetent patients is a combination of peginterferon (PEG-IFN) and ribavirin for 6 to 12 months depending on the genotype. This treatment achieves a sustained virological response (SVR) in 54% to 61% of patients overall. Almost 50% of patients do not respond or have recurrences posttreatment and progress in over 10 to 20 years into chronic liver disease and its complications. Liver transplantation is the only therapeutic modality that impacts on quality of life and survival of these patients. However, recurrence of HCV in the new allograft is universal with accelerated progression to cirrhosis in 5 to 10 years. Response to treatment is usually low (20% to 30%), and associated with significant side effects and depression. A significant percentage of patients with recurrent HCV after transplantation require retransplantation to control the complications of end-stage liver disease. Other solid organ transplants recipients already HCV-positive, or infected at the time of transplantation from blood transfusions or an infected graft, develop accelerated, progressive liver disease facilitated by the adverse effects of immunosuppression in addition to HCV replication. To prevent morbidity, mortality, and high costs related to the consequences of HCV infection, all solid organ transplant candidates should be tested for HCV infection and treated appropriately with PEG-IFN and ribavirin prior to transplantation.

Gastrostomía endoscópica percutánea: Una experiencia multicéntrica

El objetivo fue presentar la experiencia con dos variantes técnicas de la Gastrostomía Endoscópica Percutánea (GEP). Fueron practicadas 78 GEP, 63 por ciento por la técnica de deslizamiento y 37 por ciento por tracción, 44 mujeres (57 por ciento) y 34 hombres (43 por ciento) de 6 a 94 años, con enfermedades del sistema nervioso central en 89.6 por ciento de los casos. No fueron observadas diferencias estadísticas en los resultados dependientes de la institución ni el uso o no de antibióticos. Las complicaciones fueron más frecuentes durante las primeras 24 horas y después del séptimo día con la técnica por tracción, durante su estandarización. Los pacientes desnutridos tuvieron más complicaciones asociadas al procedimiento. Se concluye que la GEP es una técnica practicable en cualquier servicio de endoscopia, de bajo riesgo, con baja frecuencia de complicaciones y relacionadas con el estado nutricional del paciente y grado de pericia adquirido

Efectividad terapéutica de la S-Adenosil-L-Metionina en hepatitis viral aguda A,B, NANB

La hepatitis viral aguda es una causa frecuente de enfermedad en el mundo, ocasionado serias complicaciones, y altos costos como consecuencia de la incapacidad resultante. A pesar de esto, no disponemos de ninguna modalidad terapéutica de probada eficacia. El papel exacto de la SAMe en el tratamiento de las hepatopatías ha sido parcialmente clarificado por estudios recientes que muestran, que esta molécula es de efecto benéfico en la colestasis intrahepática (DRUGS 0:111, 1990) y otras hepatopatías. Para evaluar la efectividad de la SAMe se realizó un estudio doble ciego, placebo, control en 28 pacientes entre enero 25 de 1989 y junio 15 de 1991 con los siguientes criterios de inclusión: Edad entre 10 y 65 años, evidencia clínica de hepatitis aguda A, B o NANB, menos de 15 días de evolución, AST y-o ALT mayor de 500 U-L y bilirrubina total mayor de 3 mg-dl. Todos los pacientes fueron aleatorizados para recibir SAMe 500 mgr IV diariamente por 10 días o Placebo (l-Lisina 150 mg; Hidróxido de sodio 4.5 mgs; agua destilada estéril 5.0 ml) IV diariamente por 10 días. Ambos grupos eran comparables en relación con la edad, etiología y pruebas hepáticas. Las diferencias entre los grupos se evaluaron utilizando las pruebas ANOVA, t de Student, con programa estadístico SPSS-PC. Un valor de menos de 0.005 se consideró significativo

Chronic cholestasis, paucity of bile ducts, red cell aplasia, and the Stevens-Johnson syndrome. An ampicillin-associated case.

The unique case of severe chronic cholestasis with paucity of bile ducts accompanied by pure red cell aplasia and the Stevens-Johnson syndrome in a 35-year-old woman after ampicillin ingestion is presented. The patient improved gradually and is asymptomatic 4 years later. Sequential histological and clinical follow-up substantiate the course of her disease.

Laparoscopia diagnostica en medicina interna. / Diagnostic laparoscopies in internal medicine

El presente estudio representa un analisis retrospectivo de 200 laparoscopias diagnosticas realizadas por el autor en tres Instituciones Hospitalarias de la ciudad de Medellin. La indicacion mas frecuente para realizarla fue la patologia hepatobiliar (42.5%), que tambien represento el diagnostico mas frecuentemente encontrado (57.5%). Las complicaciones mayores del 3% y la mortalidad del 0.5% hacen del procedimiento un metodo seguro y eficaz con posibilidades diagnosticas de hasta 95%