Retos y estrategias en el manejo de la trombosis de la vena porta / Challenges and strategies in the management of portal vein thrombosis

La trombosis de la vena porta (TVP) en pacientes con o sin cirrosis hepática (CH) se define como una obstrucción de la vena porta debido a la formación de un trombo que puede extenderse a las venas mesentéricas superiores y esplénica. Esta es una complicación común de la enfermedad hepática avanzada. Se creía que la TVP se producía predominantemente debido al potencial protrombótico del paciente con CH, ya que se observaba una mayor incidencia de TVP en CH con una puntuación MELD y Child-Pugh más altas, con una prevalencia informada del 10 % al 25%.

Portal vein thrombosis (PVT) in patients with or without hepatic cirrhosis (CH) is defined as an obstruction of the portal vein due to the formation of a thrombus that may extend to the superior mesenteric and splenic veins. This is a common complication of advanced liver disease. It was believed that PVT predominantly occurred due to the prothrombotic potential of the patient with CH, as a higher incidence of PVT was observed in CH with higher MELD and Child-Pugh scores, with a reported prevalence of 10% to 25%.

Hepatoprotective Effect of Cannabidiol on the Progression of Experimental Hepatic Cirrhosis in Rats.

Introduction: Liver cirrhosis is a condition characterized by the gradual replacement of normal liver tissue with scar tissue, ultimately leading to liver failure. This slow and progressive disease begins with a chronic inflammatory process induced by a noxious agent. In its advanced stages, the disease lacks effective therapies. Research has demonstrated the significant involvement of the endocannabinoid system in the pathogenesis of this disease. This study evaluated the hepatoprotective effect of cannabidiol (CBD) in the progression of experimental hepatic cirrhosis induced by thioacetamide (TAA) in rats. Methods: A randomized experimental design was employed using Holtzman rats. Hepatic cirrhosis was induced by intraperitoneal administration of TAA at a dose of 150 mg/kg for 6 weeks, with treatment initiated additionally. The groups were as follows: Group 1: TAA + vehicle; Group 2: TAA + CBD 2 mg/kg; Group 3: TAA + CBD 9 mg/kg; Group 4: TAA + CBD 18 mg/kg; Group 5: TAA + silymarin 50 mg/kg; and Group 6: Healthy control. Serum biochemical analysis (total bilirubin, direct bilirubin, ALT, AST, alkaline phosphatase, and albumin) and hepatic histopathological study were performed. The Knodell histological activity index (HAI) was determined, considering periportal necrosis, intralobular degeneration, portal inflammation, fibrosis, and focal necrosis. Results: All groups receiving TAA exhibited an elevation in AST levels; however, only those treated with CBD at doses of 2 mg/kg and 18 mg/kg did not experience significant changes compared to their baseline values (152.8 and 135.7 IU/L, respectively). Moreover, ALT levels in animals treated with CBD showed no significant variation compared to baseline. The HAI of hepatic tissue was notably lower in animals treated with CBD at doses of 9 and 18 mg/kg, scoring 3.0 and 3.25, respectively, in contrast to the TAA + vehicle group, which recorded a score of 7.00. Animals treated with CBD at 18 mg/kg showed a reduced degree of fibrosis and necrosis compared to those receiving TAA alone (p ≤ 0.05). Conclusion: Our findings demonstrate that cannabidiol exerts a hepatoprotective effect in the development of experimental hepatic cirrhosis induced in rats.

Manifestaciones dermatológicas de la cirrosis hepática: revisión de la literatura / Dermatological manifestations of liver cirrhosis: review of the literature

La piel y sus anexos tienen amplia relación con todos los órganos y sistemas. Los cambios presentes en estos pueden ser el primer hallazgo en un paciente con enfermedad hepática, encontrándose hasta en el 20 % de los casos, por lo que las manifestaciones extrahepáticas adquieren importancia, y aunque muchas de estas no son específicas, algunos marcadores dermatológicos pueden ayudar al diagnóstico de la enfermedad y se pueden correlacionar con su severidad. El desarrollo de las lesiones cutáneas en los pacientes con cirrosis hepática se genera principalmente por hipertensión portal y exceso de estrógenos circulantes, por lo tanto, su tratamiento se basa en el manejo de la patología hepática subyacente. En el presente artículo se hace una revisión de la literatura y se describe un amplio espectro de manifestaciones dermatológicas asociadas a cirrosis hepática, con sus características y etiopatogénesis, siendo las más frecuentes la ictericia, el prurito, los nevus en araña, el eritema palmar, las venas en cabeza de Medusa, y los cambios de uñas y del vello, entre otras.

The skin and its annexes have a broad relationship with all organs and systems. Changes present in these can be the initial finding in a patient with liver disease, occurring in up to 20% of cases, therefore the extrahepatic manifestations become important, and although many of these are not specific, some dermatological markers can help in the diagnosis of the disease and may correlate with its severity. The development of cutaneous lesions in patients with liver cirrhosis is mainly generated by portal hypertension and excess of circulating estrogens, therefore their treatment is based on managing the underlying liver pathology. This article reviews the literature and describes a wide range of dermatological manifestations associated with liver cirrhosis, with their characteristics and etiopathogenesis, being the most frequent jaundice, pruritus, spider nevus, palmar erythema, caput Medusae veins, nail and hair changes, among others.

Rifaximin Alfa and Liver Diseases: More Than a Treatment for Encephalopathy, a Disease Modifier.

RFX, a rifamycin-based antibacterial agent obtained by the culture of the actinomycete Streptomyces mediterranei, has a broad antibacterial spectrum covering gram- positive, gram-negative, aerobic, and anaerobic bacteria. RFX is an antibiotic that elicits its effect by inhibiting bacterial RNA synthesis. When administered orally, its intestinal absorption is extremely low (<0.4%), restricting antibacterial activity mainly in the intestinal tract, with few systemic side effects. RFX has been recommended by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver guidelines for the treatment of HE. RFX may contribute to restore hepatic function and to decrease the development of liver fibrosis. Its efficacy has been shown in patients with previous hepatic encephalopathy and several complications, such as infections, including spontaneous bacterial peritonitis, ascites and oesophageal variceal bleeding. Thus, RFX has an outstanding role in the therapeutic arsenal in hepatic cirrhosis, under the concept of disease modifier.

Assessment of mandibular cortical index in patients with hepatic cirrhosis: A case-control study.

AIMS: To assess the presence of alterations suggestive of reduced bone mineral density (BMD) by using mandibular cortical index (MCI) in panoramic radiographs of cirrhotic individuals and to evaluate their relationship with other characteristics of hepatic cirrhosis (HC). METHODS AND RESULTS: This is an observational case-control study assessing the medical records of 165 cirrhotic patients matched by sex and age with healthy individuals. MELD (model of end stage liver disease) score, etiology, complications, comorbidities, and serum levels of vitamin D were collected. MCI was used to obtain BMD. Binary logistic regression was used to test associations and the risk estimates were expressed in odds ratio. Most of the sample consisted of men (73.93%) with median age of 56 years old. In the study group, the mean value of MELD was 16.5 and hepatitis C was the main etiology of HC (33.9%). Cirrhotic individuals are 3.99 times more likely to present alterations suggestive of reduced BMD (p < .01). There was no statistical significance in the association of MCI with levels of vitamin D, comorbidities, etiology or cirrhosis complications. CONCLUSIONS: MCI suggestive of reduced BMD is more likely to be identified in panoramic radiographs of cirrhotic individuals than of healthy ones.

[Stomatological management of patients with liver disease: a review of the literature]. / Manejo estomatológico del paciente con hepatopatías: una revisión de la literatura.

Introduction: The liver is the organ responsible for the metabolism of nutrients, some drugs, and the production of coagulation factors. According to the World Health Organization, approximately 23 million people worldwide are diagnosed with liver disease each year. As a result, it is common for dentists to encounter these patients on a daily basis in their practice. The objective of this review is to establish the dental management of patients with liver disease. Material and methods: A manual literature search was conducted using the indexed articles in PUBMED and EBSCO databases using the keywords "oral surgery," AND "liver disease," AND "hepatic cirrhosis," AND "dental management". Results: Patients with liver disease present important characteristics for the dentist, which must be recognized in order to perform procedures with the lowest risk of intraoperative and postoperative complications. A patient with poorly controlled underlying liver disease is more prone to infections and bleeding, which implies a high risk of morbidity. Conclusions: Dental care for patients with liver disease should be assessed according to the reason for consultation, control of the disease, the complexity of the procedure to be performed, and both intraoperative and postoperative hemostatic measures. All necessary hemostatic measures should be considered and dose adjustments should be considered in the use of NSAIDs.

Factores asociados a la masa y la fuerza muscular en pacientes con cirrosis hepática: un estudio transversal / Factors associated with muscle mass and strength in patients with liver cirrhosis: A cross-sectional study

Resumen Introducción: la sarcopenia es una complicación frecuente de cirrosis y se ha relacionado con progresión de insuficiencia hepática y aumento de las complicaciones, incluida la mortalidad. El objetivo del presente estudió fue determinar los factores asociados a la masa y la fuerza muscular en pacientes cirróticos. Métodos: estudio de corte transversal, descriptivo y analítico. Se incluyó a todos los adultos que acudieron a valoración ambulatoria por hepatología con diagnóstico de cirrosis hepática. A todos se les realizó una valoración nutricional que incluyó mediciones antropométricas, bioimpedanciometría, fuerza de agarre y la escala de tamización Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT). Se realizó un análisis de regresión lineal o logística, según correspondiera. Resultados: se incluyó a 40 pacientes. La frecuencia de malnutrición fue de 17,5% de acuerdo con la fuerza de agarre. Los principales determinantes de la masa muscular en el análisis lineal multivariable fueron la edad, el valor de proteína corporal total y el agua corporal total. La fuerza de agarre también fue un predictor significativo en la regresión lineal univariable. Las variables relacionadas con fuerza muscular disminuida fueron el puntaje Child-Pugh, la historia de ascitis y de encefalopatía hepática, el consumo de terapias de disminución de amonio, la puntuación en la escala RFH-NPT y la masa libre de grasa. Conclusiones: la masa muscular esquelética del paciente cirrótico se asoció con la edad, cambios en la composición corporal y la fuerza de agarre. Los determinantes de la fuerza muscular fueron el estadio de la enfermedad, el consumo de terapias de disminución de amonio y la puntuación en la escala RFH-NPT.

Abstract Introduction: Sarcopenia is a frequent complication of cirrhosis and has been related to the progression of liver failure and increased complications, including mortality. This study aimed to determine the factors associated with muscle mass and strength in cirrhotic patients. Materials and methods: Cross-sectional, descriptive, analytical study. All adults who attended outpatient hepatology assessment with a diagnosis of liver cirrhosis were included. They underwent a nutritional examination that included anthropometric measurements, bioimpedanciometry, grip strength, and the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) screening scale. A linear or logistic regression analysis was performed as appropriate. Results: 40 patients were included. The frequency of malnutrition was 17.5%, according to grip strength. The main determinants of muscle mass in the multivariate linear analysis were age, total body protein value, and total body water. Grip strength was also a significant predictor in univariate linear regression. Variables related to decreased muscle strength were the Child-Pugh score, history of ascites and hepatic encephalopathy, consumption of ammonium-lowering therapies, RFH-NPT score, and fat-free mass. Conclusions: The skeletal muscle mass of the cirrhotic patient was associated with age, changes in body composition, and grip strength. The muscle strength determinants were the disease's stage, the consumption of ammonium-lowering therapies, and the score on the RFH-NPT scale.

Assessment of bone metabolism biomarkers in serum and saliva of cirrhotic patients.

OBJECTIVE: To assess the serum and salivary levels of biomarkers related to bone metabolism in cirrhotic patients as well as the evidence of osteoporotic changes on panoramic radiographs. MATERIALS AND METHODS: Thirty-eight cirrhotic patients underwent anamnesis and physical examination. Specimens of blood and saliva were collected for evaluation by using Luminex™ xMAP technology to quantify RANKL, OPG, IL-1ß, IL-6 and TNF-α. Panoramic radiographs were evaluated based on the mandibular cortical index (MCI) and the resulting data were compared to the expression of biomarkers in serum and saliva. Descriptive data analysis was performed and the Mann-Whitney's test and Spearman's correlation were used. RESULTS: Most of the sample consisted of males (68.4%) who had cirrhosis mostly resulting from alcoholism (28.9%). Median concentration values of RANKL (74.44 pg/mL), IL-1 ß (45.91 pg/mL), IL-6 (67.69 pg/mL) and TNF-α (5.97 pg/mL) in saliva were higher than those observed in serum. In 72.7% of the panoramic radiographs, MCI was found to be suggestive of osteoporotic changes. No statistically significant correlation was observed between salivary and serum expressions of biomarkers or between biomarkers and MCI. CONCLUSION: RANKL, OPG, IL-1ß, IL-6 and TNF-α are expressed differently in serum and saliva and the concentration of these biomarkers is not related to MCI. CLINICAL RELEVANCE: This study contributes to the study of the mechanisms of osteoporosis in cirrhotic individuals.

Mesohepatectomía, una alternativa para el manejo del hepatocarcinoma en paciente no cirrótico: serie de casos / Mesohepatectomy, an alternative for the management of hepatocellular carcinoma in non-cirrhotic patient: case series

Introducción. La resección quirúrgica es el tratamiento de elección de las neoplasias primarias y secundarias del hígado. Los pacientes con hepatocarcinoma de los segmentos centrales representan un reto, siendo la hepatectomía extendida la técnica más usada, sin embargo, el riesgo postquirúrgico de falla hepática es alto, dado que la resección puede comprometer entre el 65 % y el 80 % del volumen hepático. La mesohepatectomía es una alternativa que permite dejar un volumen hepático residual suficiente. El objetivo de este trabajo es presentar nuestra experiencia en el tratamiento de pacientes con hepatocarcinomas en segmentos centrales a quienes se les realizó mesohepatectomía. Serie de casos. Se presentan tres pacientes no cirróticos, con hepatocarcinoma en los segmentos 4, 5 y 8, que fueron atendidos en el Hospital San Vicente Fundación, en las sedes de Medellín y de Rionegro, entre 2018 y 2020. Resultados. La mesohepatectomía se realizó mediante ligadura selectiva de los pedículos del segmento 4 y del sector anterior derecho. Se utilizó aspirador ultrasónico y endograpadora para la transección hepática. La duración de la maniobra de Pringle varió entre 16 y 43 minutos. El sangrado promedio fue de 1000 ml. Solo un paciente presentó fuga biliar tipo B. No hubo mortalidad a 30 días. Conclusiones. La mesohepatectomía es una alternativa segura para pacientes con tumores en los segmentos centrales, que permite disminuir el riesgo de falla hepática luego de la resección.

Introduction. Surgical resection is the treatment of choice for primary and secondary neoplasms of the liver. Patients with central segment hepatocarcinoma represent a challenge, with extended hepatectomy being the most widely used technique. However, the postsurgical risk of liver failure is high since resection can compromise between 65% and 80% of liver volume. Mesohepatectomy is an alternative that allows a sufficient residual liver volume to be left. The objective of this work is to present treatment of patients with central segment hepatocarcinoma.Clinical cases. Three non-cirrhotic patients are presented, with hepatocarcinoma in segments 4, 5 and 8, who were treated at the San Vicente Fundación Hospital in Medellín and Rionegro, between 2018 and 2020.Results. Mesohepatectomy was performed by selective ligation of the pedicles of segment 4 and the right anterior sector. An ultrasonic aspirator and endostapler were used for liver transection. The duration of the Pringle ma-neuver ranged from 16 to 43 minutes. The average bleeding was 1000 cc. Only one patient had type B bile leakage. There was no 30-day mortality.Conclusions. Mesohepatectomy is a safe alternative for patients with tumors in the central segments, which reduces the risk of liver failure after resection.

Factores asociados a la mortalidad en pacientes cirróticos / Factors associated with mortality in cirrhotic patients

Introducción: La cirrosis hepática representa en Perú el 9,1 por ciento de las causas de mortalidad. Existe poca evidencia sobre la influencia de variables epidemiológicas y clínicas en la mortalidad de pacientes con cirrosis hepática en Latinoamérica, en especial en países en vías de desarrollo, como Perú. Objetivo: Identificar los factores asociados a la mortalidad en pacientes cirróticos. Métodos: Estudio trasversal en pacientes cirróticos atendidos en el Hospital Cayetano Heredia, de Piura, Perú, en el año 2017. La variable dependiente fue la mortalidad hospitalaria y las variables independientes fueron las características epidemiológicas, clínicas y de laboratorio. Se utilizó la prueba exacta de Fisher y la prueba de t para estimar los factores asociados a la mortalidad. Resultados: De 52 pacientes, la frecuencia de mortalidad debido a cirrosis fue de 35,4 por ciento. Tener ascitis moderada (p = 0,004), grado de encefalopatía (p = 0,001), leucocitosis (p = 0,004), enfermedad descompensada según índice de Child Pugh (p = 0,023), índice de Meld entre 30-39 puntos (p < 0,001) y niveles de creatinina (p = 0,009) resultaron asociados a una mayor frecuencia de mortalidad. Conclusión: La presencia de ascitis moderada, grado de encefalopatía, leucocitosis, enfermedad descompensada según índice de Child Pugh, índice de Meld entre 30-39 y los niveles de creatinina, están asociados a la mortalidad en pacientes cirróticos(AU)

Introduction: Liver cirrhosis represents 9,1 percent of causes of mortality in Peru. There is little evidence on the influence of epidemiological and clinical variables on the mortality of patients with liver cirrhosis in Latin America, especially in developing countries such as Peru. Objective: To identify the factors associated with mortality in cirrhotic patients. Methods: Cross-sectional study in cirrhotic patients treated at the Cayetano Heredia Hospital in Piura, Peru, year 2017. The dependent variable was hospital mortality and the independent variables were epidemiological, clinical and laboratory characteristics. Fisher's exact test and the T test were used to estimate the factors associated with mortality. Results: Of 52 patients, the frequency of mortality due to cirrhosis was 35,4 percent. Have moderate ascites (p = 0,004), degree of encephalopathy (p = 0,001), leukocytosis (p = 0,004), decompensated disease according to the Child Pugh index (p = 0,023), Meld index between 30-39 points (p < 0,001) and creatinine levels (p = 0,009) were associated with a higher frequency of mortality. Conclusion: The presence of moderate ascites, degree of encephalopathy, leukocytosis, decompensated disease according to the Child Pugh index, Meld index between 30-39, creatinine levels are associated with mortality in cirrhotic patients(AU)

Tuberculosis peritoneal, un diagnóstico diferencial para ascitis en cirrosis / Peritoneal tuberculosis, a differential diagnosis for ascites in cirrhosis

Resumen Se presenta el caso de un paciente con antecedente de consumo crónico de alcohol, que consultó por dolor abdominal inespecífico, fiebre intermitente no cuantificada y pérdida de peso, con posterior aumento del perímetro abdominal. Se encontró ascitis y hallazgos en imágenes que sugerían cirrosis. El estudio del líquido ascítico fue no hipertensivo con predominio de linfocitos y niveles de adenosina-desaminasa (ADA) elevados. La ecografía y tomografía de abdomen mostraron el engrosamiento del peritoneo y la biopsia peritoneal por laparoscopia fue compatible con enfermedad granulomatosa, con reacción en cadena de la polimerasa (PCR) positiva para Mycobacterium tuberculosis en un paciente sin otras causas de inmunosupresión. Este caso muestra la necesidad de mantener una alta sospecha clínica de TB en patologías abdominales con clínica inespecífica, aun en pacientes sin inmunocompromiso claro.

Abstract This is the case of a patient with a history of chronic alcohol consumption, who consulted for nonspecific abdominal pain, intermittent fever, and weight loss, with subsequent increase in the abdominal perimeter. Ascites and imaging findings suggestive of cirrhosis were found. The study of ascitic fluid was non-hypertensive with a predominance of lymphocytes and elevated adenosine deaminase (ADA) levels. Ultrasound and abdominal tomography showed peritoneal thickening. Laparoscopic peritoneal biopsy was compatible with granulomatous disease, with positive PCR for Mycobacterium tuberculosis in a patient with no other causes of immunosuppression. This report shows the importance of keeping a high index of suspicion for TB in patients with abdominal pathology, even in those without evident inmunocompromise.

La hernia umbilical en el paciente cirrótico: ¿tratamiento conservador o cirugía? / Umbilical hernia in cirrhotic patients: conservative treatment or surgery?

RESUMEN Antecedentes: la ascitis es una complicación de frecuente aparición en el paciente cirrótico que al producir un aumento de la presión intraabdominal puede originar una hernia de la pared abdominal; el defecto umbilical latente es su localización más habitual. Objetivo: presentar la incidencia y los beneficios que ofrece la resolución electiva de la patología um bilical en estos pacientes. Material y método: se presentan 15 pacientes, todos masculinos, que fueron intervenidos por hernia umbilical sintomática en forma electiva en el medio hospitalario. El período comprende desde enero del año 2015 a enero de 2019. El 100% de los enfermos cursa un cuadro de cirrosis hepática, con antecedentes de etilismo crónico. Se efectuó la reparación de la hernia con cierre del defecto y malla supraaponeurótica de polipropileno en la mayoría de los casos. Resultados: los pacientes fueron evaluados desde el punto de vista clínico con la escala (score) de Child en el preoperatorio. Se procedió a la evacuación de la ascitis en todos los casos y el control posoperatorio se efectuó cada 30 días los primeros 6 meses. Luego dos veces al año. No se evidenció recidiva. Dos pacientes no volvieron al control luego del año de la cirugía y 1 paciente falleció por la enfermedad de base a los 6 meses de la cirugía. Conclusiones: los enfermos con cirrosis hepática y hernia umbilical deben ser intervenidos quirúrgica mente en forma electiva. La observación y abstención quirúrgica conllevan el riesgo de rotura del saco herniario con alta morbimortalidad.

ABSTRACT Background: Background: Ascites is a common complication in patients with cirrhosis, and elevated intraabdominal pressure can lead to the development of abdominal wall hernias, particularly in patients with latent umbilical defects. Objectives: The aim of this study was to report the incidence and benefits of elective surgery for the management of umbilical hernias in cirrhotic patients with ascites. Material and methods: Between January 2015 and January 2019 15 patients with symptomatic umbi lical hernia underwent elective surgery in a public hospital; 100% were men with a history of alcoho lism and were hospitalized due to liver cirrhosis. The defect was closed, and a polypropylene mesh was placed in the supra-aponeurotic plane in most cases. Results: The preoperative risk was estimated using the Child-Pugh score. Ascites was evacuated in all the cases. Patients were followed-up every 30 days during the first 6 months and then twice a year. There were no hernia recurrences. Two patients were lost to follow-up 12 months after surgery and 1 patient died 9 months after the procedure due to progression of cirrhosis. Conclusions: Patients with liver cirrhosis and umbilical hernia should undergo elective surgery. Wat chful waiting is associated with higher risk of hernia rupture and high morbidity and mortality.

Clinical impact of the Model for End Liver Disease (MELD) score on the presence of microvascular invasion and on the postoperative outcome in patients undergoing liver transplantation / Impacto clínico do Model For End Liver Disease (MELD) na presença de invasão microvascular e no desfecho pós-operatório em pacientes submetidos a transplante hepático

ABSTRACT Objective: to correlate clinical and epidemiological data with the pathological analysis of liver explants from patients undergoing liver transplantation for hetapocarcinoma in the UNICAMP HC and to verify whether the MELD and MELD-Na scores are reliable factors to predict a worse post-transplant prognosis. Methods: we studied liver transplants carried out between May 2010 and November 2017. After excluding 38 patients, we included 87, analyzing clinical and laboratory data for correlation with the outcome Microvascular Invasion (MVI). Subsequently, we computed the MELD and MELD-Na scores and performed a descriptive analysis of clinical and laboratory data and, finally, calculated ROC curves to assess the association between these laboratory parameters and mortality in these patients. Results: most patients were male (78.30%), with an average age of 58.53 years. Most liver diseases were caused by HCV (53.26%). We found no predictors for MVI among the laboratory parameters. The ROC curves for death identified the MELD score as the cutoff point with the highest combined sensitivity (90.91%) and specificity (37.50%), with a value of 10 points, whereas in the MELD-Na the cutoff point was 7 points, with a sensitivity of 90.91% and a specificity of 33.33%, both scores being significant. Conclusions: there were no reliable predictors of MVI between clinical, laboratory, and epidemiological variables. The MELD-Na score is more sensitive than the MELD one for predicting mortality in patients undergoing liver transplantation.

RESUMO Objetivo: correlacionar dados clínicos e epidemiológicos com a análise patológica dos explantes hepáticos dos pacientes submetidos ao transplante hepático por hetapocarcinoma no HC da UNICAMP e verificar se os scores MELD e MELD-Na apresentam diferenças estatísticas para predizer pior prognóstico pós-transplante. Métodos: considerando os transplantes hepáticos ocorridos entre maio/2010 e novembro/2017, após excluir 38, 87 pacientes foram incluídos, analisando-se dados clínicos e laboratoriais desses pacientes para verificar se há independência entre esses e desfecho Invasão Microvascular (IMV). Posteriormente, realizou-se o cálculo do MELD e MELD-Na, a análise descritiva dos dados clínicos e laboratoriais e, por fim, curvas ROC para avaliar a associação entre esses parâmetros laboratoriais e o desfecho óbito nestes pacientes. Resultados: a maior parte dos pacientes foi do sexo masculino (78,30%), com idade, em média, de 58,53 anos. A maior parte das hepatopatias foi causada pelo VHC (53,26%). Não foi encontrado preditores para o desfecho IMV entre os parâmetros laboratoriais. As curvas ROC para o desfecho óbito identificaram o score MELD como ponto de corte de maior sensibilidade (90,91%) e especificidade (37,50%) simultâneas com o valor de 10 pontos, ao passo que no MELD-Na o ponto de corte foi 7 pontos, com sensibilidade de 90,91% e especificidade de 33,33%, sendo ambas as escalas significativas. Conclusões: não foram encontrados preditores para IMV entre critérios clínicos, laboratoriais e epidemiológicos. O score MELD-Na é mais sensível que o MELD para predizer mortalidade nos pacientes submetidos a transplante hepático.

Disfunción renal en el paciente cirrótico / Renal dysfunction in the cirrhotic patient

La disfunción renal es una complicación común en pacientes con cirrosis avanzada y está asociadaa un incremento significativo en la mortalidad. Este deterioro de la función renal puede ser reversible en algunos casos, si se identifica y se trata su etiología. La lesión renal aguda (LRA) de origen prerrenal y la necrosis tubular aguda (NTA) son las entidades más frecuentes en pacientes con enfermedad hepática crónica y cirrosis, constituyendo un desafío en los escenarios clínicos actuales. La aparición de nuevos biomarcadores como la lipocalina asociada a la gelatinasa de neutrófilos (NGAL), puede ser un factor determinante para esclarecer el origen de estas dos entidades. En la actualidad, la clasificación de la enfermedad renal establece que un aumento en la creatinina sérica basal >0,3 mg/dL dentro de las primeras 48 horas, o un incremento mayor al 50% desde la línea de base, son suficientes para definir lesión renal aguda, por lo cual, cambios leves en la creatinina sérica en un periodo corto de tiempo, contribuyen a una identificación temprana y previenen desenlaces negativos. Esta revisión de tema abordará la lesión renal aguda en cirrosis desde la fisiopatología, la clasificación actual según guías internacionales, los avances en biomarcadores y las principales etiologías, finalizando con un abordaje general y estrategias de prevención.

Kidney dysfunction is a common complication in patients with advanced cirrhosis and is associated with a significant increase in mortality. This deterioration of kidney function may be reversible in some cases, if its etiology is identified and treated. Acute kidney injury (AKI) of prerenal origin and acute tubular necrosis (ATN) are the most frequent entities in patients with chronic liver disease and cirrhosis, constituting a challenge in current clinical scenarios. The emergence of new biomarkers such as neutrophil gelatinase-associated lipocalin (NGAL), may be a determining factor in clarifying the origin of these two entities. Currently, the classification of renal disease establishes that an increase in basal serum creatinine >0,3 mg/dL within the first 48 hours, or an increase higher than 50% from the baseline, are enough to define acute kidney injury, therefore slight changes in serum creatinine in a short period of time contribute to an early identification and prevent negative outcomes. This literature review will address acute kidney injury in cirrhosis from its pathophysiology, current classification according to international guidelines, advances in biomarkers and the main etiologies associated with it, ending with a general approach and prevention strategies.

Aspectos relevantes en hemocromatosis hereditaria / Relevant features in hereditary hemochromatosis

La hemocromatosis hereditaria es una enfermedad que se caracteriza por la sobrecarga sistémica de hierro y se asocia a múltiples mutaciones genéticas que conducen a una producción inadecuadamente baja de la hormona hepcidina o a una alteración en la unión de la hepcidina a la ferroportina. Esto tiene como resultado un aumento de la absorción intestinal y el depósito de cantidades excesivas de hierro en las células, lo cual, a su vez, si no se corrige, genera daño tisular. La expresión clínica puede variar desde individuos completamente asintomáticos, hasta pacientes con cirrosis hepática a temprana edad, y eventualmente carcinoma hepatocelular. Habitualmente, el diagnóstico no es invasivo e incluye el examen clínico, la evaluación de los parámetros de hierro plasmático, imágenes y pruebas genéticas. El principal tratamiento es la flebotomía, pero terapias alternativas como la suplementación con hepcidina son un tema de investigación actual.

Hereditary hemochromatosis is a disease characterized by systemic iron overload of genetic origin, that leads to an inadequately low production of the hormone hepcidin or a reduction in hepcidinferroportin binding. This results in an increased intestinal absorption and the deposit of excessive amounts of iron in cells, which in turn results in tissue damage if not treated. The clinical expression can vary from completely asymptomatic individuals, to patients with liver cirrhosis at an early age, and eventually hepatocellular carcinoma. Diagnosis is usually noninvasive and includes clinical examination, assessment of plasma iron levels, imaging studies, and genetic testing. The main medical treatment is phlebotomy, but alternative therapies such as hepcidin supplementation are the subject of current research.

Comparison of results on the use of extended criteria liver doners for transplants in Espírito Santo / Comparação dos resultados da utilização de fígados doadores de critério expandido em transplantes hepáticos no estado do Espírito Santo

ABSTRACT Introduction: liver Transplantation is currently the treatment of choice for several terminal liver diseases. Despite the increase in performed transplants, the waiting lists continue to increase. In order to expand the supply of organs, transplantation teams have started to use previously rejected livers for transplants because of an increased risk of unfavorable outcomes. Objective: to evaluate the use of livers of expanded criterion donators. Methods: retrospective study of medical records. The livers were classified as normal or expanded criteria. The groups were divided in low and high MELD. A multivariate analysis was performed through logistic regression. Results: there was no statistical difference regarding early, late and global mortality between the groups. Decreased survival was observed in patients with high MELD (higher or equal to 20) when they received grafts from expanded criterion donators. The association between the occurrence of cardiorespiratory arrest and presence of elevated total bilirubin in donators was associated with higher mortality rates in expanded criterion livers. Conclusion: the overall results are similar, but expanded criteria liver donators was associated with higher mortality in patients with high MELD.

RESUMO Introdução: o Transplante Hepático é atualmente o tratamento de escolha para diversas doenças terminais do fígado. Apesar do aumento de transplantes realizados, as filas de espera continuam aumentando. Com a finalidade de ampliar a oferta de órgãos, as equipes transplantadoras passaram a utilizar fígados até então rejeitados para transplantes devido ao risco aumentado de desfechos desfavoráveis. Objetivo: avaliar utilização de fígados de doadores de critério expandido. Métodos: estudo retrospectivo por meio de análise de prontuários. Classificaram-se os fígados utilizados em padrão ou critério expandido. Os grupos foram subdivididos em MELD baixo e alto. Foi realizada análise multivariada por regressão logística. Resultados: não houve diferença estatística com relação à mortalidade precoce, tardia e global entre os grupos. Observou-se menor sobrevida em pacientes com MELD alto (maior ou igual a 20) quando receberam enxertos de doadores de critério expandido. Foi observada a associação entre ocorrência de parada cardiorrespiratória e presença de bilirrubina total elevada no doador com maiores taxas de mortalidade em receptores de fígados de critério expandido. Conclusão: os resultados globais são semelhantes, porém o uso de fígado de doadores de critério expandido esteve associado a maior mortalidade em pacientes com MELD alto.

Trasplante Hepático: Supervivencia global del receptor en el Hospital de Especialidades Carlos Andrade Marín / Liver Transplantation: Overall survival at the Carlos Andrade Marín Specialty Hospital

INTRODUCCIÓN. El primer trasplante hepático en el mundo se realizó en Estados Unidos en 1963 por Thomas Starzl, hasta la década de los 90 la supervivencia al año fue de 73% y a los 5 años de 64%, según diferentes series que abarcaron más de 1 000 trasplantes realizados hasta 1989. El Ecuador requiere de estas estadísticas. El Hospital de Especialidades Carlos Andrade Marín inició la actividad del programa en mayo del 2016. OBJETIVO. Conocer la supervivencia global de los pacientes sometidos a trasplante hepático. MATERIALES Y MÉTODOS. Estudio observacional, descriptivo, con una población igual a la muestra de 62 datos de Historias Clínicas del Programa de Trasplante Hepático en la Unidad Técnica de Trasplante del Hospital de Especialidades Carlos Andrade Marín en el período mayo 2016 a diciembre 2019. Criterios de inclusión: pacientes so-metidos a trasplante hepático, con seguimiento durante 43 meses. La información se obtuvo de la base de datos del sistema AS400; se analizaron en el programa estadístico International Business Machines Statistical Package for the Social Sciences, versión 23.0. RESULTADOS. La supervi-vencia global a los 12 meses fue 72% (17; 62) y a los 43 meses fue 69% (19; 62). DISCUSIÓN. Se evidenció similares resultados descritos de supervivencia en centros con actividad en periodos cortos, menor a 5 años. CONCLUSIÓN. Se pudo conocer la supervivencia global de los pacientes trasplantados del hospital, cuya expectativa motiva a potenciar el programa para mejorar la calidad de vida de los pacientes candidatos a trasplante.

INTRODUCTION. The first liver transplant in the world was performed in the United States in 1963 by Thomas Starzl, until the 90s the survival at one year was 73% and at 5 years it was 64%, accor-ding to different series that included more than 1 000 transplants carried out until 1989. Ecuador re-quires these statistics. The Carlos Andrade Marín Specialty Hospital began program activity in May 2016. OBJECTIVE. To know the overall survival of patients undergoing liver transplantation. MATE-RIALS AND METHODS. Observational, descriptive study, with a population equal to the sample of 62 data from the Medical Records of the Liver Transplant Program in the Technical Transplant Unit of the Carlos Andrade Marín Specialty Hospital in the period May 2016 to December 2019. Inclusion criteria: patients submitted to liver transplantation, with follow-up for 43 months. The information was obtained from the AS400 system database; were analyzed in the statistical program Internatio-nal Business Machines Statistical Package for the Social Sciences, version 23.0. RESULTS. Ove-rall survival at 12 months was 72% (17; 62) and at 43 months it was 69% (19; 62). DISCUSSION. Similar survival results described were evidenced in centers with activity in short periods, less than 5 years. CONCLUSION. It was possible to know the overall survival of the transplanted patients at the hospital, whose expectation motivates us to promote the program to improve the quality of life of the transplant candidates.

Physiopathological and diagnostic aspects of cirrhotic cardiomyopathy.

Cirrhotic cardiomyopathy is characterized by the presence of structural and functional cardiac alterations in patients suffering from hepatic cirrhosis, without previously known cardiac causes that may explain it. Clinically, it is characterized by the presence of variable grades of diastolic and systolic dysfunction (SD), alterations in the electric conductance (elongation of corrected QT interval) and inadequate chronotropic response. This pathology has been related to substandard response in the management of patients with portal hypertension and poor outcome after transplant. Even when the first description of this pathology dates back from 1953, it remains a poorly studied and frequently underdiagnosed entity. Echocardiography prevails as a practical diagnostic tool for this pathology since simple measurements as the E/A index can show diastolic dysfunction. SD discloses as a diminished ejection fraction of the left ventricle and the latent forms are detected by echocardiography studies with pharmacological stress. In recent years, new techniques such as the longitudinal strain have been studied and they seem promising for the detection of early alterations.

La miocardiopatía cirrótica se caracteriza por la presencia de alteraciones cardiacas estructurales y funcionales en pacientes con cirrosis hepática, sin que existan otras causas de enfermedad cardiaca. Clínicamente se caracteriza por la presencia de grados variables de disfunción diastólica y sistólica, alteraciones de la conducción eléctrica (prolongación del intervalo QT) y respuesta cronotrópica inapropiada. Esta patología se ha relacionado con desenlaces clínicos adversos, mala respuesta en el manejo de la hipertensión portal y resultados desfavorables posterior a trasplante hepático ortotópico. A pesar de que las primeras descripciones datan de 1953, es una entidad poco estudiada y frecuentemente subdiagnosticada. El ecocardiograma es una herramienta de diagnóstico importante en esta entidad. Mediciones simples como el índice E/A pueden traducir disfunción diastólica. La disfunción sistólica se manifiesta con disminución de la fracción de eyección del ventrículo izquierdo y las formas latentes se detectan mediante estudios de ecocardiografía con estrés farmacológico; en los últimos años se han estudiado otras técnicas como el strain longitudinal, que parecen prometedoras en la detección de alteraciones tempranas.

Os critérios especiais de pontuação MELD proporcionam uma enorme vantagem a pacientes listados para transplante de fígado no Brasil / Meld exception points provide an enourmous advantage for receiving a liver transplant in brazil

ABSTRACT BACKGROUND: Current policy for listing to liver transplant (LT) may place cirrhotic patients without MELD exception points (CIR) in a disadvantageous position if compared to patients enlisted with appealed MELD scores - patients with hepatocellular carcinoma (HCC) or special conditions other than hepatocellular carcinoma (SPE). Transplant rates, delisting, and waitlist mortality of CIR, HCC, and SPE candidates were compared. OBJECTIVE: The aim of this study is to counterweight the listing rate and speed of listing of HCC, SPE, and CIR patients. To the best of our knowledge, this is the first study comparing the outcomes of patients enlisted for SPE to those of HCC and CIR. In several countries worldwide, SPE patients also receive appealed MELD scores in a similar way of HCC patients. METHODS: Two cohorts of patients listed for LT in a single institution were evaluated. The first cohort (C1, n=180) included all patients enlisted on August 1st, 2008, and all additional patients listed from this date until July 31st, 2009. The second cohort (C2, n=109) included all patients present on the LT list on October 1st, 2012, and all additional patients listed from this date until May 2014. RESULTS: In both cohorts, HCC patients had a higher chance of receiving a LT than CIR patients (C1HR =2.05, 95%CI=1.54-2.72, P<0.0001; C2HR =3.17, 95%CI =1.83-5.52, P<0.0001). For C1, 1-year waiting list mortality was 21.6% (30.0% for CIR vs 9.5% for HCC vs 7.1% for SPE) (P<0.001). For C2, 1-year waiting list mortality was 13.3% (25.7% for CIR, 8.3% for HCC, and 4.0% for SPE) (P<0.001). Post-transplant survival was similar among the three groups. CONCLUSION: Compared to CIR, SPE and HCC patients had lower wait list mortality. CIR patients had the highest waitlist mortality and the lowest odd of LT. Current LT allocation system does not allow equitable organ allocation.

RESUMO CONTEXTO: É possível que política atual de inclusão no transplante de fígado (LT) esteja colocando os pacientes cirróticos sem pontos de exceção MELD (CIR) em uma posição desvantajosa se comparados aos pacientes listados com escores de critério especial MELD - pacientes com carcinoma hepatocelular (HCC) ou outras condições especiais (SPE). As taxas de transplante, exclusão e mortalidade de lista de espera de candidatos com CIR, HCC e SPE foram comparadas. OBJETIVO: O objetivo deste estudo é comparar a taxa de listagem e também a velocidade de listagem de pacientes listados pelas três possíveis categorias de listagem no Brasil (HCC, SPE e CIR). Há muito poucos estudos prévios comparando os desfechos de pacientes listados por SPE ao desfecho de pacientes com HCC e também ao desfecho de pacientes não priorizados (CIR). Em muitos países, pacientes listados para transplante de fígado com SPE são priorizados para transplante em um modo similar ao que ocorre com pacientes com HCC. MÉTODOS: Foram avaliadas duas coortes de pacientes listados para LT em uma única instituição. A primeira coorte (C1, n=180) incluiu todos os pacientes listados em 1º de agosto de 2008 e todos os pacientes adicionais listados dessa data até 31 de julho de 2009. A segunda coorte (C2, n=109) incluiu todos os pacientes presentes na LT em 1º de outubro de 2012 e todos os pacientes listados dessa data até maio de 2014. RESULTADOS: Em ambas as coortes, os pacientes com CHC tiveram uma chance maior de receber uma LT do que os pacientes com CIR (C1HR =2,05, CI95% =1,54-2,72, P<0,0001; C2HR =3,17, CI95% =1,83-5,52, P<0,0001). Para C1, a mortalidade na lista de espera em um ano foi de 21,6% (30,0% para CIR vs 9,5% para HCC vs 7,1% para SPE) (P<0,001). Para C2, a mortalidade na lista de espera em um ano foi de 13,3% (25,7% para CIR, 8,3% para HCC e 4,0% para SPE) (P<0,001). A sobrevida pós-transplante foi semelhante entre os três grupos. CONCLUSÃO: Comparados aos pacientes CIR, os pacientes SPE e HCC, apresentaram menor mortalidade na lista de espera. Os pacientes com CIR tiveram a maior mortalidade na lista de espera e a menor probabilidade de LT. O atual sistema de alocação de LT não permite alocação equitativa de órgãos.

Implicaciones de la microbiota intestinal en las enfermedades crónicas del hígado / Implications of the intestinal microbiota in the chronic liver diseases

RESUMEN La microbiota se refiere al conjunto de todos los de microorganismos que se localizan de manera normal en distintos sitios de los cuerpos de los seres vivos pluricelulares, tales como el cuerpo humano. Las modificaciones del eje intestino-hígado se ha convertido en la actualidad en un grave problema científico al haberse encontrado en diversas investigaciones, que esta microbiota está relacionada con el daño hepático con independencia de la causa de la lesión hepática. Se realizó una revisión sistemática sobre las implicaciones demamicrobiota intestinal en las enfermedades hepáticas. Se realizó una revisión de artículos científicos publicados entre 2012 y 2018 en diversas bases de datos en línea. Se presenta el conocimiento existente hasta el momento sobre la microbiota intestinal en pacientes portadores de enfermedades hepáticas, con hincapié en las hepatitis C y la cirrosis hepática. La composición de microbiota de intestino estuvo asociada con el perfil inflamatorio y marcadores de fibrosis hepática, las que mejoraron con el tratamiento de antivirales de acción directa aunque las medidas de permeabilidad intestinal e inflamación permanecían inalteradas. Se reporta mejoría de los pacientes portadores de hepatitis viral tipo C, con antivirales de acción directa la cual estuvo asociada con modificaciones de la microbiota intestinal, que se correlacionó con mejoría en la fibrosis e inflamación hepática, los avances en este campo abren nuevas perspectivas en la biomedicina (AU).

SUMMARY Microbiota refers to the whole of microorganisms located in a normal way in different places of the bodies of pluricelular living beings, like the human body. The modifications of the axis intestine-liver have become a serious scientific problem, because in different researches researchers have found that this microbiota is related to hepatic damage depending on the cause of this hepatic lesion. To carry out a systematic review on the implication of intestinal macrobiota in liver diseases. The scientific articles published in the period 2012-2018 in different databases on line were reviewed. A total of 26 bibliographic sources were used, original articles and reviews. The authors present knowledge existent up to the moment on intestinal microbiota in patients who have liver diseases, making emphasis on hepatitis C and hepatic cirrhosis. The composition of the intestine microbiota was associated to an inflammatory and markers of hepatic fibrosis that improved with the treatment of direct action antivirals although the measures of intestinal permeability and inflammation remained inalterably. It is reported an improvement of patients carriers of viral hepatitis type C with the use direct action retrovirals, what was linked to modifications in the intestinal microbiota, and correlated to an improvement of fibrosis and liver inflammation; the advances obtained in this field open new perspectives in biomedicine (AU).