Efficacy of a hepatitis B vaccination schedule with two cycles of four double doses of conventional vaccine and four doses of adjuvanted vaccine in chronic kidney disease patients evaluated for renal transplantation.

INTRODUCTION: The response to hepatitis B (HB) vaccine remains suboptimal among chronic kidney disease patients. The aim of this study was to analyze the efficacy of a hepatitis B vaccination schedule with two 4-double doses of conventional vaccine and four doses of adjuvant vaccine in chronic kidney disease patients evaluated for renal transplantation. METHODS: In this prospective study, we recruited chronic kidney disease patients evaluated for renal transplantation to receive four 40-µg doses of hepatitis B virus vaccine (0, 1, 2 and 6 months) and another four 40 µg doses of hepatitis B virus vaccine and four 20 µg doses of adjuvant vaccine if they were nonresponders. AntiHBs titers were analyzed before every vaccine dose and 1 month after the fourth dose. RESULTS: One hundred fifty-five patients were enrolled in the study. The response to the vaccination increased until the seventh dose: first dose, 5.4%; second, 29.5%; third, 66.7%; fourth, 75.9%; fifth, 83.3%; sixth, 87.3%; seventh, 92.5%; and eighth, 93.8%. AntiHBs titers after the first and second vaccination with Engerix were 10 to 99 mIU/mL in the 12% and 7.7%, 100 to 999 mIU/mL in the 30.1%, and 46.2%, and 1000 mIU/mL in the 34.9% and 15.4%, respectively. Fendrix was administrated in 6.2% of the patients and 75% of them obtained a response. AntiHBc-positive patients obtained a response with one vaccination cycle in the 71.4%. The response was influenced by age and was greater in women. Adverse events were found in 11.5% of the patients (inflammation and/or local pain), which were less frequent in men (8.9% versus 16.1%) and similar for both vaccines. CONCLUSION: The response to the hepatitis B vaccination with four double doses of conventional vaccine and revaccination with the same schedule and adjuvanted vaccine shows a high response rate in chronic kidney disease evaluated for renal transplantation.

Usefulness of biodegradable polydioxanone stents in the treatment of postsurgical colorectal strictures and fistulas.

Benign colonic strictures and fistulas are a growing problem presenting most commonly after bowel resection. Standard treatment is with endoscopic bougies or, more usually, balloon dilation. When these approaches are not successful, other solutions are available and different endoscopic and surgical approaches have been used to treat fistulas. We present an additional option--biodegradable stents--for the treatment of colonic strictures and fistulas that have proven refractory to other endoscopic interventions. We analyzed the results from 10 patients with either a postsurgical colorectal stricture (n =7) or rectocutaneous fistula (n =3) treated with the biodegradable SX-ELLA esophageal stent (covered or uncovered). Stents were successfully placed in nine patients, although early migration subsequently occurred in one. Placement was impossible in one patient due to deformity of the area and the fact that the stricture was approximately 30cm from the anus. The fistulas were successfully closed in all patients, although symptoms reappeared in one patient. In the six patients who received stents for strictures, symptoms resolved in five; in the remaining patient, the stent migrated shortly after the endoscopy. Treatment of colonic strictures and rectocutaneous fistulas with biodegradable stents is an effective alternative in the short-to-medium term. The stent does not have to be removed and is subject to very few complications. The drawbacks of this approach are the need to repeat the procedure in some patients and the lack of published series on efficacy.

Respuesta al comentario sobre el Manejo de la infección por el virus de la hepatitis C en la enfermedad renal crónica / Response to the comment made on Treatment of HCV infection in chronic kidney disease

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El gradiente de presión venoso hepático y la biopsia hepática transyugular en la evaluación de los pacientes con insuficiencia renal y hepatopatía crónica / Hepatic venous pressure gradient and transjugular liver biopsy to assess patients with kidney failure and chronic liver disease

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Manejo de la infección por el VHC en la enfermedad renal crónica / Management of HCV infection in chronic kidney disease

La prevalencia de la infección crónica por el virus de la hepatitis C (VHC) en pacientes con enfermedad renal crónica es mayor que en la población general. En hemodiálisis, se estima una prevalencia del 13%, con una amplia variabilidad geográfica y entre las unidades de un mismo país. La biopsia hepática es una herramienta útil para decidir el inicio de la terapia antiviral y excluir causas concomitantes de disfunción hepática, como la hepatopatía grasa no alcohólica, cuya incidencia está en auge, y la hemosiderosis, que pueden afectar a la progresión de la enfermedad y condicionar la respuesta al tratamiento antiviral; además, la vía transyugular se puede utilizar para medir el gradiente de presión venoso hepático y confirmar la existencia de hipertensión portal. La hepatitis crónica por el VHC ha demostrado reducir la supervivencia en hemodiálisis y en el trasplante renal, así como la supervivencia del injerto. Constituye la cuarta causa de mortalidad y la principal causa de disfunción hepática postrasplante renal. El VHC se comporta como un factor de riesgo independiente para la aparición de proteinuria, aumenta el riesgo de desarrollar diabetes, una glomerulonefritis de novo o una nefropatía crónica del injerto, de empeorar la enfermedad hepática y de provocar un mayor número de infecciones. También se ha descrito un incremento de la frecuencia de hepatitis colestásica fibrosante que, junto a la evolución acelerada a cirrosis, puede elevar significativamente la morbimortalidad y conllevar la necesidad de un trasplante (..) (AU)

The prevalence of chronic infection with the hepatitis C virus (HCV) in patients with chronic kidney disease is higher than in the general population. The estimated prevalence is 13% in haemodialysis, with wide variations geographically and between units in the same country. A liver biopsy is a useful tool for deciding whether to start antiviral therapy and to exclude concomitant causes of liver dysfunction. Examples of this include nonalcoholic fatty liver disease, whose incidence is on the rise, and haemosiderosis, which may affect the progression of the disease and determine the response to antiviral therapy. In addition, the transjugular approach can be used to measure the hepatic venous pressure gradient and confirm the existence of portal hypertension. Chronic hepatitis due to HCV has been shown to reduce survival in haemodialysis, renal transplantation and graft survival. It is the fourth leading cause of death and the leading cause of post-renal transplantation liver dysfunction. HCV behaves as an independent risk factor for the occurrence of proteinuria; it increases the risk of developing diabetes mellitus, de novo glomerulonephritis and chronic allograft nephropathy; it leads to a deterioration in liver disease and causes a greater number of infections. An increased frequency of fibrosing cholestatic hepatitis has also been described which, together with the rapid evolution to cirrhosis, can significantly increase morbidity (..) (AU)

Management of HCV infection in chronic kidney disease.

The prevalence of chronic infection with the hepatitis C virus (HCV) in patients with chronic kidney disease is higher than in the general population. The estimated prevalence is 13% in haemodialysis, with wide variations geographically and between units in the same country. A liver biopsy is a useful tool for deciding whether to start antiviral therapy and to exclude concomitant causes of liver dysfunction. Examples of this include non-alcoholic fatty liver disease, whose incidence is on the rise, and haemosiderosis, which may affect the progression of the disease and determine the response to antiviral therapy. In addition, the transjugular approach can be used to measure the hepatic venous pressure gradient and confirm the existence of portal hypertension. Chronic hepatitis due to HCV has been shown to reduce survival in haemodialysis, renal transplantation and graft survival. It is the fourth leading cause of death and the leading cause of post-renal transplantation liver dysfunction. HCV behaves as an independent risk factor for the occurrence of proteinuria; it increases the risk of developing diabetes mellitus, de novo glomerulonephritis and chronic allograft nephropathy; it leads to a deterioration in liver disease and causes a greater number of infections. An increased frequency of fibrosing cholestatic hepatitis has also been described which, together with the rapid evolution to cirrhosis, can significantly increase morbidity and mortality and lead to the need for liver transplantation. In addition, immunosuppression in renal transplantation predisposes a reactivation of HCV. However, as the pharmacokinetics of interferon and ribavirin is impaired in kidney failure and their use has adverse effects on function and graft survival, a combination therapy must be limited to non-transplanted individuals with an estimated glomerular filtration rate greater than 50ml/min, and with the interferon being used as monotherapy in dialysis. The fact that a quarter of HCV-positive patients evaluated for a renal transplant have bridging fibrosis or cirrhosis in the liver biopsy may renew renal pre-transplant treatment planning.