Effectiveness of Direct-acting Agents After Liver Transplantation A Real-life Study in Rio de Janeiro.

BACKGROUND: Data concerning hepatitis C virus (HCV) treatment using direct-acting agents (DAAs) post liver transplantation (LT) remains scarce in low- and average-income countries. AIM OF THE STUDY: To evaluate the safety and efficacy of post-LT HCV treatment using DAAs in Rio de Janeiro (Brazil), and to assess the course of hepatic biomarkers after sustained virological response (SVR). METHODS: Data from LT recipients with recurrent HCV treated using DAAs was retrospectively analyzed. HCV was defined by detectable HCV-RNA with elevated aminotransferases and/or histological signs of infection on liver biopsy post LT. SVR was defined as undetectable HCV-RNA 12 weeks after the end of treatment. Aspartate-to-Platelet Ratio Index (APRI) and Fibrosis-4 score (FIB-4) were calculated before treatment and after SVR. RESULTS: 116 patients (63% male, median age 62 years, 75% genotype 1 and 62% with hepatocellular carcinoma [HCC] prior to LT) were included. Cirrhosis was identified in the allograft of 21 subjects (18%). The overall SVR was 96.6% without differences in SVR proportion according to clinical/demographic characteristics, genotype or presence of cirrhosis. SVR rates were similar in individuals with and without HCC pre-LT (95.8% [95% CI: 87.6-98.7] vs. 97.7% [95% CI: 85.0-99.7%], p = 0.588). No serious adverse events were observed and the use of ribavirin was associated with at least one adverse event (OR = 8.71 [95% CI: 3.17-23.99]). SVR was associated with regression of APRI (OR = 26.00 [95% CI 4.27-1065.94]) and FIB-4 (OR = 15.00 [95% CI: 2.30-631.47]). CONCLUSION: Post-LT HCV treatment with DAAs was safe and effective and associated with a significant decrease in hepatic biomarker levels after SVR.

Survival and tolerance to sorafenib in Child-Pugh B patients with hepatocellular carcinoma: a prospective study.

Sorafenib has been widely used to treat unresectable hepatocellular carcinoma (HCC) but most studies have been done in Child-Pugh A (CP-A) patients with well-preserved liver function. We evaluated the overall survival (OS) and tolerance to sorafenib in a large cohort of Child-Pugh B (CP-B) HCC patients as compared to CP-A HCC patients. We prospectively studied 130 patients with advanced HCC who started sorafenib between January 2011 and December 2015. Patients were classified as CP-A (n = 65) or CP-B (n = 65). The average OS for all 130 patients was 10 months. CP-A patients had a median survival rate significantly longer than CP-B patients: 12 months vs. 6 months. The OS found in our group of CP-B patients was 6.5 months, which is higher than that found in most studies done so far. When stratified, our CP-B patients had better OS than ever reported. The dose of the drug was interrupted due to adverse events (AEs) in 38 (29%) of the patients, of whom 20 (30%) were CP-A patients and 18 (28%) were CP-B patients. This real-life cohort of CP-B HCC patients treated with sorafenib had a higher survival than that described in the literature, with a satisfactory safety profile. Despite the high prevalence of severe AEs in CP-B patients, there were fewer treatment interruptions in this group, indicating that Child-Pugh B patients can tolerate treatment and may benefit from sorafenib.

A influência do tempo de referencia no tratamento das lesões iatrogênicas da via biliar / The influence of time referral in the treatment of iatrogenic lesions of biliary tract

OBJETIVO: Avaliar o prognóstico dos pacientes com lesão iatrogênica da via biliar (LIVB) em relação ao tempo de referencia (TR) para a unidade de transplante hepático (TH). MÉTODOS: Foram revisados 51 prontuários de pacientes que sofreram algum tipo de LIVB durante a colecistectomia e que foram encaminhados para a unidade de TH no Hospital Geral de Bonsucesso (HGB). As lesões foram agrupadas de acordo com a classificação de Bismuth. Além da colecistectomia (momento da lesão), também avaliamos o TR e o desfecho. RESULTADOS: Dentre os 51 pacientes estudados encontramos 17 homens e 34 mulheres com uma média de idade de 42,7 anos. Vinte e dois pacientes (43,1%) tinham uma lesão do tipo II; 13 (25,5 %) do tipo III; 10 (19,6 %) do tipo I, 5 (9,8 %) do tipo IV; e apenas um (2 %) do tipo V. Quarenta pacientes foram operados, sendo que três não retornaram para revisão médica e portanto, 37 foram avaliados em relação ao desfecho. Dentre esses, 25 pacientes (67,6 %) tiveram resultados excelentes ou bons com TR médio de 11,5 meses (intervalo: 2-48 meses) e 47,2 meses (intervalo: 3-180 meses) respectivamente. Os 12 pacientes (32,4 %) com resultados ruins tiveram um TR médio de 65,9 meses (intervalo: 3-264 meses), que foi significativamente maior do que o grupo com resultados excelentes ou bons (p=0,004). Sete pacientes foram listadas para fila de TH, porém apenas dois foram realizados. O TR desses sete pacientes foi significativamente mais elevado (p=0,04) do que o daqueles pacientes não listados. Sete pacientes morreram, dos quais seis foram causados por complicações hepáticas. CONCLUSÃO: O TR influenciou significativamente no prognóstico dos pacientes da nossa amostra.

OBJECTIVE: To evaluate the prognosis of patients with iatrogenic bile duct injury (IBDI) regarding time of referral (RT) to the unit of liver transplantation (LT). METHODS: We reviewed 51 charts of patients who had suffered some kind of IBDI during cholecystectomy and who were referred to the Bonsucesso General Hospital (HGB) LT unit. Lesions were grouped according to the Bismuth classification. Besides cholecystectomy (time of injury), we also evaluated the RT and outcome. RESULTS: Among the 51 patients studied, there were 17 men and 34 women, with a mean age of 42.7 years. Twenty-two patients (43.1%) had a type II lesion, 13 (25.5%) type III, 10 (19.6%) type I, 5 (9.8%) type IV and only 1 (2%) type V. Forty patients were operated, and three did not return for medical review, therefore, 37 were evaluated in relation to outcome. Among these, 25 patients (67.6%) had excellent or good results with average RT of 11.5 months (range: 2-48 months) and 47.2 months (range: 3-180 months) respectively. The 12 patients (32.4%) with poor results had a mean RT of 65.9 months (range: 3 264 months), which was significantly higher than the group with excellent or good results (p=0.004). Seven patients were listed for LT, but only two were transplanted. The RT of these seven patients was significantly higher (p=0.04) than those patients not listed. Seven patients died, six of which were due to liver complications. CONCLUSION: RT significantly influenced the prognosis of patients in our sample.

The influence of time referral in the treatment of iatrogenic lesions of biliary tract.

OBJECTIVE: To evaluate the prognosis of patients with iatrogenic bile duct injury (IBDI) regarding time of referral (RT) to the unit of liver transplantation (LT). METHODS: We reviewed 51 charts of patients who had suffered some kind of IBDI during cholecystectomy and who were referred to the Bonsucesso General Hospital (HGB) LT unit. Lesions were grouped according to the Bismuth classification. Besides cholecystectomy (time of injury), we also evaluated the RT and outcome. RESULTS: Among the 51 patients studied, there were 17 men and 34 women, with a mean age of 42.7 years. Twenty-two patients (43.1%) had a type II lesion, 13 (25.5%) type III, 10 (19.6%) type I, 5 (9.8%) type IV and only 1 (2%) type V. Forty patients were operated, and three did not return for medical review, therefore, 37 were evaluated in relation to outcome. Among these, 25 patients (67.6%) had excellent or good results with average RT of 11.5 months (range: 2-48 months) and 47.2 months (range: 3-180 months) respectively. The 12 patients (32.4%) with poor results had a mean RT of 65.9 months (range: 3 264 months), which was significantly higher than the group with excellent or good results (p=0.004). Seven patients were listed for LT, but only two were transplanted. The RT of these seven patients was significantly higher (p=0.04) than those patients not listed. Seven patients died, six of which were due to liver complications. CONCLUSION: RT significantly influenced the prognosis of patients in our sample.

Evaluation of atherosclerosis in renal transplanted patients by non-invasive methods.

BACKGROUND: Endothelial dysfunction can be considered an early atherogenic event. OBJECTIVE: To assess atherosclerosis in renal transplanted patients through the coronary calcium score, carotid duplex scan and brachial reactivity through ultrasonography. METHODS: We assessed 30 renal transplanted male patients with stable renal function, with a mean age of 41.3 years. RESULTS: The detection of the atherosclerotic load in this population was very significant when the brachial reactivity technique was used (86.7%); it was less frequent when based on the presence of carotid plaque (33.3%) or the coronary calcium score (20%). The carotid plaque was considered when the thickness was > 12 mm. The coronary calcium score was abnormal when > 80 according to the Agatston scale, being observed in a low percentage of patients (21.7%), possibly due to the fact that the tomography is not the ideal method to detect atherosclerosis in renal patients, as it does not differentiates intimal calcifications of the medial layer. The adequate clinical control, the low age range and the factors related to the time of pre-transplant dialysis or the anti-inflammatory effect of the post-transplant drugs can delay the onset of the calcifications. CONCLUSION: The evaluation of the atherosclerotic load through the carotid duplex scan (33,3%) and the coronary calcium score (20%) was not frequent; there was no correlation with the high rate of endothelial dysfunction detection observed with the brachial reactivity assessment (86.7%).

Avaliação de aterosclerose em transplantados renais através de métodos não invasivos / Evaluation of atherosclerosis in renal transplanted patients by non-invasive methods / Evaluación de aterosclerosis en trasplantados renales mediante métodos no invasivos

Fundamento: A disfunção endotelial pode ser considerada um evento precoce da aterogênese. Objetivo: Avaliar a aterosclerose em transplantados renais através do escore de cálcio coronariano, do duplex scan das carótidas e da reatividade braquial através do ultra-som. Métodos: Avaliamos trinta transplantados renais do sexo masculino com função renal estável, idade média de 41,3 anos.Resultados: A detecção da carga aterosclerótica nesta população foi significativa quando utilizada a técnica da reatividade braquial (86,7%), menos freqüente baseando-se na presença de placa carotídea (33,3%) ou no escore de cálcio coronariano (20%). Placa carotídea foi considerada quando a espessura era superior a 12 mm. O escore de cálcio coronariano foi anormal quando acima de oitenta pela escala de Agatston, sendo observado em um percentual baixo (21,7%) dos pacientes, possivelmente porque a tomografia pode não ser o método ideal para detectar aterosclerose em doentes renais, por não distinguir calcificações intimais da camada média. O controle clínico adequado, a baixa faixa etária e fatores relacionados ao tempo de diálise pré-transplante ou ao efeito antiinflamatório das drogas pós- transplante podem retardar o aparecimento das calcificações. Conclusão: A avaliação da carga aterosclerótica através do duplex scan das carótidas (33,3%) e do escore de cálcio coronariano (20%) não foi freqüente, não havendo correlação com o elevado índice de detecção de disfunção endotelial observado com o exame da reatividade braquial (86,7%).

Background: Endothelial dysfunction can be considered an early atherogenic event. Objective: To assess atherosclerosis in renal transplanted patients through the coronary calcium score, carotid duplex scan and brachial reactivity through ultrasonography.Methods: We assessed 30 renal transplanted male patients with stable renal function, with a mean age of 41.3 years. Results: The detection of the atherosclerotic load in this population was very significant when the brachial reactivity technique was used (86.7%); it was less frequent when based on the presence of carotid plaque (33.3%) or the coronary calcium score (20%). The carotid plaque was considered when the thickness was > 12 mm. The coronary calcium score was abnormal when > 80 according to the Agatston scale, being observed in a low percentage of patients (21.7%), possibly due to the fact that the tomography is not the ideal method to detect atherosclerosis in renal patients, as it does not differentiates intimal calcifications of the medial layer. The adequate clinical control, the low age range and the factors related to the time of pre-transplant dialysis or the anti-inflammatory effect of the post-transplant drugs can delay the onset of the calcifications. Conclusion: The evaluation of the atherosclerotic load through the carotid duplex scan (33,3%) and the coronary calcium score (20%) was not frequent; there was no correlation with the high rate of endothelial dysfunction detection observed with the brachial reactivity assessment (86.7%).

Fundamento: Se puede considerar la disfunción endotelial como un evento precoz de la aterogénesis. Objetivo: Evaluar la aterosclerosis en trasplantados renales con el empleo del score de calcio coronario y del duplex scan de las carótidas y la reactividad braquial mediante el ultrasonido. Métodos: Evaluamos a 30 trasplantados renales del sexo masculino con función renal estable, edad promedio de 41,3 años. Resultados: La detección de la carga aterosclerótica en esta población fue significativa cuando utilizada la técnica de la reactividad braquial (86,7%), menos frecuente, basándose en la presencia de placa carotídea (33,3%) o en el score de calcio coronario (20%). Se tomó en cuenta la placa carotídea cuando el espesor era superior a 12 mm. El score de calcio coronario fue anormal cuando >80 por la escala de Agatston, y se lo observó en un porcentaje bajo (21,7%) de los pacientes, posiblemente porque la tomografía puede no ser el método ideal para detectar aterosclerosis en enfermos renales, por no distinguir calcificaciones intimales de la capa media. El control clínico adecuado, la baja franja de edad y factores relacionados al tiempo de diálisis pre-transplante o al efecto antiinflamatorio de los fármacos post-trasplante pueden retardar el aparecimiento de las calcificaciones. Conclusión: La evaluación de la carga aterosclerótica con el empleo del duplex scan de las carótidas (33,3%) y del score de calcio coronario (20%) no fue frecuente, no habiendo correlación con el elevado índice de detección de disfunción endotelial observado con el examen de la reactividad braquial (86,7%).