Impact of Everolimus-based Immunosuppression on Renal Function in Liver Transplant Recipients.

BACKGROUND: Calcineurin inhibitors have been implicated in acute and chronic kidney disease after liver transplant (LT). Everolimus (EVR) is a mammalian target of rapamycin inhibitor efficacious in preventing acute cellular rejection while preserving renal function among LT recipients. We evaluated the benefits on renal function of EVR immunosuppression in LT recipients. METHODS: We performed a retrospective and observational study in 477 LT recipients in Virgen de las Nieves Hospital from 2002 to 2019 on the use of EVR with tacrolimus minimization or withdrawal in LT recipients with renal dysfunction. The study included 100 patients starting EVR (20.96%); in 66 (66%) the indication was renal dysfunction. The change in renal function was assessed by estimated glomerular filtration rate. Statistical analyses were performed using SPSS 17.0 software (IBM, Munich, Germany). RESULTS: Fifty 8 patients received mycophenolate mofetil (87.8%), and tacrolimus therapy was stopped in 27 patients (40.9%). Induction therapy with basiliximab was administered in 41 patients (62.12%). There was significant difference between estimated glomerular filtration rate at the time of starting EVR and the first month at last follow-up (49.42 mL/min/1.73 m2 vs 75.27 mL/min/1.73 m2; P < .001) and at end of follow-up (24 months) (49.42 mL/min/1.73 m2 vs 64.32 mL/min/1.73 m2; P = .001). The rate of incidence of adverse events was 48.48% (32/66). Seven patients died during follow-up (10.6%), but there were no EVR-related deaths. Eleven patients (16.6%) developed biopsy-proven acute rejection. CONCLUSION: This study showed that EVR is associated with a beneficial effect on glomerular filtration rate in both the short and long term in LT recipients.

Therapy With Direct-Acting Antiviral Agents for Hepatitis C in Liver Transplant Recipients.

BACKGROUND: Recurrent infection with the hepatitis C virus (HCV) after liver transplantation (LT) is associated with decreased graft and patient survival. Direct-acting antiviral (DAA) therapies have changed the landscape of HCV due to their excellent safety profile and cure rates. Our aim was to evaluate the efficacy and tolerability of antiviral therapy in recurrent HCV after LT with DAA therapy. METHODS: Our retrospective analysis included 46 LT recipients with HCV recurrence. Patients received therapy with DAA therapy between November 2014 and May 2016. Stage of fibrosis was documented by transient elastography (FibroScan). RESULTS: Thirty-three of the patients were men (71.7%), with a mean age of 59.6 years. Most patients were infected with HCV genotype 1 (71.7%) (1a = 7, 1b = 26) or genotype 3 (19.6%). Cirrhosis was present in 10 (21.7%). The most frequent immunosuppression regimen was tacrolimus + mycophenolate mofetil (MMF) (41.3%). Most patients received sofosbuvir + simeprevir (SOF+SMV) (n = 13, 28.3%) and sofosbuvir + daclatasvir (SOF+DCV) (n = 15, 32.6%). A virologic response at posttreatment week 12 was detected in 93.8% of the patients. Two patients failed treatment (1 had resistance-associated variants [RAVs] Y93H in NS5A). Three patients died due to chronic rejection, acute arterial thrombosis, and spontaneous bacterial peritonitis. Adverse events were observed in 23 patients (50%). The most common events were asthenia in 17 (37%) and headache in 6 (13%) patients. One patient discontinued treatment due to serious adverse events attributable to the drug's interaction with tacrolimus. CONCLUSIONS: DAAs are safe and effective for use in treating HCV recurrence after LT, with results similar to those seen in the general population, including patients with cirrhosis.

Influence of mycophenolate mofetil on preservation of kidney function in liver transplant patients.

BACKGROUND: There are numerous studies on the effect of immunosuppressive therapy with mycophenolate mofetil (MMF) on preservation of kidney function in liver transplant (OLT) patients with chronic kidney damage. However, we have noted few studies that evaluate the role of this drug prescribed from induction on kidney function. PATIENTS AND METHODS: This prospective observational multicenter study included 296 OLT performed from 2005 to 2007. The collected variables were; gender, and age, Child-Pugh stage, Model for End-Stage Liver Disease (MELD) score, transplant indication, induction immunosuppressive therapy, and baseline and 1 year posttransplant values of creatinine and glomerular filtration rate. Patients were classified into 4 groups: group 1 received MMF from induction; group 2 was never treated with MMF; group 3 started MMF in the first month posttransplant, and group 4 started MMF therapy in the third month posttransplant. We used Wilcoxon and Mann-Whitney U statistical tests. RESULTS: There was a difference of 0.18 mg/dL in baseline creatinine values between groups 1 and 2 (P < .01). However, although patients who consistently had MMF in their treatment started with worse creatinine values, they were able to maintain them within normal ranges at 12 months. In contrast, patients in group 2 showed a significant worsening of 0.28 mg/dL in the first month that persisted throughout the study. Group 3 displayed worse baseline creatinine values than group 2 (P < .05), and also suffered an increase of 0.29 mg/dL (P < .01) versus baseline at 1 month. When MMF was added to their immunosuppressive therapy, the creatinine values reduced versus 1 month by 0.18 mg/dL (P < .05). Creatinine values remained stable at the other study assessments. Group 4 showed a normal creatinine value at baseline, but were altered at 1 and 3 months (P < .01), with increases versus baseline of 0.46 and 0.35 mg/dL, respectively. However, when MMF was introduced kidney function was restored and maintained over the study. CONCLUSION: Early introduction of MMF improved creatinine values among patients with impaired kidney function, maintaining them at stable levels. Furthermore, patients with altered creatinine values at baseline did not worsen their kidney function if they receive MMF from induction.

[Pseudotumorous hepatic tuberculosis: laparoscopic appearance]. / Tuberculosis hepática seudotumoral. Aspecto laparoscópico.

Local hepatic tuberculosis without active pulmonary or miliary tuberculosis is an uncommon diagnosis. Even less common is the finding of a nodular form of local hepatic tuberculosis. There is a growing incidence of the disease related to human immunodeficiency virus. The authors report a case of pseudotumoral hepatic tuberculosis in a patient without AIDS, manifesting as prolonged fever, diagnosed previously as metastatic liver. Imaging studies of the liver and laparoscopic findings suggested metastatic disease. The correct diagnosis was made by histology of biopsies obtained in laparoscopy, which is an easy and cheap method, with less morbidity and mortality than surgical intervention. The case report illustrates the difficulty in reaching the correct diagnosis, most often confused with carcinoma of the liver, primary or metastatic. A greater awareness of this rare clinical entity may prevent needless surgical intervention since the majority of patients respond well to antituberculous chemotherapy.

[Purtscher's retinopathy and acute alcoholic pancreatitis]. / Retinopatía de Purtscher y pancreatitis aguda alcohólica.

We report the case of a 27-year-old man with alcoholic acute pancreatitis, who developed an acute loss of visual acuity; a bilateral Purtscher's retinopathy, a rare complication of acute pancreatitis, was confirmed by ophthalmoscopy.

[Association of porphyria cutanea tarda and hepatitis C virus]. / Asociación entre porfiria cutánea tarda y virus de la hepatitis C.

UNLABELLED: Porphyria cutanea tarda (PCT) is caused by reduced activity of hepatic uroporphyrinogen decarboxylase. However extrinsic factors such as alcohol abuse and drug intake are required for the clinical manifestation of the disease. Hepatitis C virus antibodies have been detected in a high percentage of patients with PCT. Hepatitis C virus is probably the main pathogenetic factor of liver damage in patients with PCT. AIM: To study the association between hepatitis C virus and PCT in our patients with PCT. MATERIAL AND METHODS: We have investigated six patients diagnosed of PCT in order to detect the presence of hepatitis C virus and other possible causes of the disease. RESULTS: We have found that 66% of our patients had hepatitis C virus antibodies, 50% ethanol abuse, of which 2/3 presented hepatitis C virus antibodies, and one case of HIV.

[Sarcoidosis simulating carcinoma of the head of pancreas]. / Sarcoidosis simulando carcinoma de cabeza de páncreas.

Sarcoidosis is a granulomatous disease of unknown origin with a variable clinical presentation. Although involvement of every organ has been described, the pulmonary system is most frequently involved. Isolated extrapulmonary disease is rare. Hepatic manifestations include granulomatous hepatitis and hilar lymphadenopathy. We describe a case of sarcoidosis initially presenting as extrahepatic jaundice.

[Wegener's granulomatosis with gastrointestinal involvement]. / Granulomatosis de Wegener con afectación gastrointestinal.

Wegener's granulomatosis is a necrotizing granulomatous vasculitis often characterized by involvement of the upper respiratory tract, lungs and kidney, although any organic system can be affected. We present the case of a female patient with Wegener's granulomatosis diagnosed by biopsy of the kidney, and severe gastrointestinal bleeding with fatal course. Endoscopic findings of the colon and the histopathology of the biopsy are discussed.

[Caroli's syndrome: a variable entity]. / Síndrome de Caroli: una entidad variable.

We present the case of a 56 year old woman with Caroli's disease associated to congenital liver fibrosis, renal nephrocalcinosis and cutaneous vasculitis of the legs. Clinical signs of portal hypertension were treated by a shunt technique. After an asymptomatic period, the patient suffers now from crisis of angiocholitis.