The road map toward an hepatitis C virus-free transplant population.

Antiviral therapy to eradicate hepatitis C virus (HCV) infection improves outcomes in patients undergoing liver transplantation (LT) for advanced chronic HCV with or without hepatocellular carcinoma. Traditionally, antiviral therapy focused on the use of interferon (IFN)-based regimens, with antiviral treatment initiated in the posttransplant period once recurrent HCV disease with fibrosis in the allograft was identified. The use of IFN-based therapy was limited in pretransplant patients with advanced liver disease. Earlier intervention, either before transplantation or early after LT, is now feasible with the advent of second-generation direct-acting antiviral agents (DAAs) with superior tolerability and efficacy to IFN-based therapy. These agents have the potential to reduce the number of patients developing HCV-related complications requiring LT and retransplantation, as well as reducing the demand for donor organs. We discuss the pros and cons of pretransplant, peritransplant, and posttransplant therapy with current DAAs, citing available data from clinical trials and real-world experience.

Intensified blood glucose treatment in diabetic patients undergoing a liver transplant: impact on graft evolution at 3 months and at 5 years.

PURPOSE: The debate about the impact of intensified hyperglycemia treatment is still ranging. The main objective was to assess whether intensive glycemic control in hospitalized diabetic patients undergoing a liver transplant is associated with a lower rate of graft rejection at 3 months and at 5 years post-transplant. METHODS: Cross-sectional study comparing a cohort of patients undergoing liver transplant in 2010 and 2011, in whom an intensive insulin protocol was applied, with a retrospective group of patients undergoing a liver transplant in 2005 and 2006, in whom a conventional insulin protocol was applied. Both diabetics and non-diabetics were compared. As intensive insulin therapy is applied mainly in diabetic patients, it is expected that, when comparing both periods, the treatment would only benefit those patients. RESULTS: The logistic regression model showed a statistically significant interaction between the treatment group and the presence of diabetes for the rejection rate 3 months and 5 years post-transplant. At both time points, the intensive insulin treatment group had lower rejection rates in the case of diabetic patients, which did not occur in non-diabetic patients. CONCLUSIONS: Our study shows a decrease in the rate of liver graft rejection in diabetic patients undergoing intensive insulin treatment.

Longitudinal outcomes of obeticholic acid therapy in ursodiol-nonresponsive primary biliary cholangitis: Stratifying the impact of add-on fibrates in real-world practice.

BACKGROUND: Suboptimal response to ursodeoxycholic acid occurs in 40% of primary biliary cholangitis (PBC) patients, affecting survival. Achieving a deep response (normalisation of alkaline phosphatase [ALP] and bilirubin ≤0.6 upper limit of normal) improves survival. Yet, the long-term effectiveness of second-line treatments remains uncertain. AIMS: To evaluate the long-term effectiveness of obeticholic acid (OCA) ± fibrates. Focusing on biochemical response (ALP ≤1.67 times the upper limit of normal, with a decrease of at least 15% from baseline and normal bilirubin levels), normalisation of ALP, deep response and biochemical remission (deep response plus aminotransferase normalisation). METHODS: We conducted a longitudinal, observational, multicentre study involving ursodeoxyccholic acid non-responsive PBC patients (Paris-II criteria) from Spain and Portugal who received OCA ± fibrates. RESULTS: Of 255 patients, median follow-up was 35.1 months (IQR: 20.2-53). The biochemical response in the whole cohort was 47.2%, 61.4% and 68.6% at 12, 24 and 36 months. GLOBE-PBC and 5-year UK-PBC scores improved (p < 0.001). Triple therapy (ursodeoxycholic acid plus OCA plus fibrates) had significantly higher response rates than dual therapy (p = 0.001), including ALP normalisation, deep response and biochemical remission (p < 0.001). In multivariate analysis, triple therapy remained independently associated with biochemical response (p = 0.024), alkaline phosphatase normalisation, deep response and biochemical remission (p < 0.001). Adverse effects occurred in 41.2% of cases, leading to 18.8% discontinuing OCA. Out of 55 patients with cirrhosis, 12 developed decompensation. All with baseline portal hypertension. CONCLUSION: Triple therapy was superior in achieving therapeutic goals in UDCA-nonresponsive PBC. Decompensation was linked to pre-existing portal hypertension.

Nutritional status in hepatic encephalopathy and transjugular intrahepatic portosystemic shunt - TIPS, and strategies to improve the outcomes.

Hepatic encephalopathy (HE) is one of the most severe complications following transjugular intrahepatic portosystemic shunt (TIPS). The identification and treatment of risk factors associated with the development of this complication may reduce the incidence and severity of post-TIPS HE. Several studies have demonstrated that the nutritional status plays a major role in the outcome of the cirrhotic population, particularly those who are decompensated. Although scarce, there are also studies highlighting an association between poor nutritional status, sarcopenia, fragile status, and post-TIPS HE. If these data are confirmed, nutritional support could become a means for decreasing this complication, thereby enhancing the use of TIPs in the treatment of refractory ascites or variceal bleeding. In this review, we will discuss the pathogenesis of HE, the data that supports an association with sarcopenia, nutritional status and frailty and the implications that these conditions have on the use of TIPS in clinical practice.

Sequential teratoma in pediatric patients: causation or coincidence? / Teratoma de aparición secuencial en edad pediátrica: ¿casualidad o causalidad?

We describe the unusual case of a female patient with a history of two mature teratomas non-correlated in terms of location and occurrence. A 12-year-old girl presented at our consultation as a result of a growing tumor in the hypogastric region, with no further clinical signs. She had undergone surgery neonatally due to a mature cystic sacrococcygeal teratoma, which was fully removed. No clinical sequelae were noted and no additional treatment was required over a 10-year follow-up. Radiological examination showed a large 20 × 12 × 18 cm cystic mass extending from the pelvic region to the lower hemiabdomen, associated with two similar small formations adjacent to the right ovary. Tumor markers were negative, and a laparoscopic right salpingoophorectomy was carried out, with an excellent postoperative progression. Pathological examination revealed it was, again, a mature cystic teratoma. The genetic study ruled out causation in this respect.

Describimos el inusual caso de una paciente con antecedente de dos teratomas maduros no relacionados en cuanto a su localización y debut. Una niña de 12 años consultó por la aparición de una tumoración en la región hipogástrica de crecimiento progresivo sin otra clínica asociada. Había sido intervenida por un teratoma quístico maduro sacrococcígeo en el periodo neonatal con su extirpación completa y, ausencia secuelas clínicas y tratamiento adicional durante diez años de seguimiento posterior. Los exámenes radiológicos mostraron una gran masa quística de 20 × 12 × 18 cm que se extendía entre la región pélvica y el hemiabdomen inferior, acompañada por otras dos pequeñas formaciones similares adyacentes al ovario derecho. Los marcadores tumorales resultaron negativos y se llevó a cabo una salpingooforectomía derecha laparoscópica con una excelente evolución postoperatoria. El examen histopatológico, de nuevo, informó la lesión como teratoma quístico maduro. El estudio genético descartó una posible causalidad en este ámbito.

Recurrent drug-induced liver injury (DILI) with different drugs in the Spanish Registry: the dilemma of the relationship to autoimmune hepatitis.

BACKGROUND & AIMS: Multiple instances of DILI in the same patient with drugs of similar structure or function as well as completely unrelated drugs are not well understood and poorly documented. We have sought evidence of the frequency and characteristics of patients who have experienced two DILI episodes due to different drugs. METHODS: All cases of DILI systematically collected in the Spanish DILI Registry between 1994 and 2009 were retrieved. Data on demographics, clinical, laboratory and pathological findings, and outcome were analyzed. RESULTS: Nine patients (mean age 67 years, four women) out of 742, 1.21%, had evidence of two DILI episodes caused by different drugs. In four cases DILI was associated with structurally related drugs and in an additional two cases the drugs had a common target. In another case, unrelated antibiotics were implicated. In only two cases, the two drugs/herbals were not related in structure or function. All but one patient exhibited hepatocellular damage. The type of damage was consistent in both DILI episodes. Four cases presented as autoimmune hepatitis (AIH) in the second episode. CONCLUSIONS: Multiple episodes of DILI in association with different drugs occur infrequently. In each individual, the type of injury was similar during the two DILI episodes, regardless of the causative drug. Second episodes of DILI are more likely to be associated with features of AIH. It remains uncertain if this is drug-induced unmasking of true AIH or DILI with autoimmune features. These cases illustrate the dilemma faced by clinicians in distinguishing these possibilities.

Indications for and results of liver retransplantation.

Liver retransplantation (LReTx) is the therapeutic option for the irreversible failure of a hepatic graft. Our aim was to evaluate the rate of and indications for LReTx and actuarial patient survivals. Among 1260 LTx were 79 LReTx (6.3%). During the first LTx, there were no apparent differences between patients who did or did not required LReTx. The most frequent reasons were hepatic artery thrombosis (31.6%), recurrence of the VHC cirrhosis (30.4%), and primary graft failure (21.5%). The actuarial survivals at 1 and 5 years were 83% and 69% among those without LReTx versus 71% and 61% among early LReTx, and 64% and 34% among late LReTx (P < .001). Although there exists high morbidity and mortality with LReTx, it seems that this therapeutic alternative continues to be valid for patients with early hepatic loss, but not when the graft loss was late. It becomes necessary to define the minimal acceptable results that patient can benefit from LReTx.

Clinical benefits of antiviral therapy in patients with recurrent hepatitis C following liver transplantation.

Pegylated interferon (pegIFN) and ribavirin eradicates hepatitis C virus (HCV) in one third of liver recipients with recurrent disease. Side effects are frequent and potentially life threatening. Our aim was to define the long-term benefits of antiviral therapy in recurrent HCV. Eighty-nine (89) recipients (genotype 1: 86.5%) were treated with IFN (n = 31) or pegIFN (n = 58) plus ribavirin and 75 untreated contemporaneous disease-matched controls. The major end point was survival from transplantation. Survival, progression to cirrhosis and clinical decompensation since start of therapy were compared between sustained virologic responders (SVRs) and nonresponders (NRs). Results revealed 44 patients died during the follow-up (20% treated vs. 35% controls; p = 0.05). Patient survival was higher in treated compared to controls (7 years: 74% vs. 62%; p = 0.04). Among treated patients, an SVR was achieved in 37% (IFN 16% vs. peg-IFN 48%; p = 0.03). About 2/33 SVRs and 16/56 NRs died (p = 0.01) due to HCV-disease (56%), IFN-induced rejection (11%), both causes (11%) or others (22%). Five-year survival was greater in SVRs than in NRs (93% vs. 69%, p = 0.032). In patients without baseline cirrhosis, progression to cirrhosis occurred more frequently in NRs (27/42 vs. 6/16; p = 0.06). The 5-year risk of graft decompensation was higher in NRs (33% vs. 16%; p = 0.04). Antiviral therapy is associated with improved long-term outcome in recurrent HCV.

VOCs and PAHs emissions from creosote-treated wood in a field storage area.

In this study, the emissions of volatile organic compounds (VOCs, in this case aromatic hydrocarbons containing one benzene ring and furans) and polycyclic aromatic hydrocarbons (PAHs) from wood recently treated with creosote are examined. The VOCs and PAHs were identified and quantified in the gas phase. Additionally, the PAHs were quantified in the particulate phase. Glass multi-sorbent tubes (Carbotrap, Carbopack X, Carboxen-569) were used to hold the VOCs. The analysis was performed using automatic thermal desorption (ATD) coupled with capillary gas chromatography/mass spectrometry (GC/MS). PAHs vapours were collected on XAD-2 resin, and particulate matter was collected on glass fibre filters. The PAHs were analysed using GC/MS. The main components of the vapours released from the creosote-treated wood were naphthalene, toluene, m+p-xylene, ethylbenzene, o-xylene, isopropylbenzene, benzene and 2-methylnaphthalene. VOCs emission concentrations ranged from 35 mg m(-3) of air on the day of treatment to 5 mg m(-3) eight days later. PAHs emission concentrations ranged from 28 microg m(-3) of air on the day of treatment to 4 microg m(-3) eight days later. The air concentrations of PAHs in particulate matter were composed predominantly of benzo[b+j]fluoranthene, benzo[a]anthracene, chrysene, fluoranthene, benzo[e]pyrene and 1-methylnaphthalene. The emission concentrations of particulate polycyclic aromatic hydrocarbons varied between 0.2 and 43.5 ng m(-3). Finally, the emission factors of VOCs and PAHs were determined.

Development and validation of a method for air-quality and nuisance odors monitoring of volatile organic compounds using multi-sorbent adsorption and gas chromatography/mass spectrometry thermal desorption system.

An analytical method based on thermal desorption (TD) coupled to gas chromatography (GC) and mass spectrometry detection (MS) has been developed and validated for the determination of a wide range of odor nuisance and air-quality volatile organic compounds (VOC) in air. New generation isocyanates, isocyanato- and isothiocyanatocyclohexane, have been included for the first time as target compounds due to their high occurrence in air samples. A dynamic air sampling method to trap gas and vapor on multi-sorbent tubes using portable pump equipment has been also developed. Sorbent tubes were filled with Carbotrap (70mg), Carbopack X (100mg) and Carboxen-569 (90mg). Validation of the TD-GC-MS method showed good selectivity, sensibility and precision according to Compendium Method TO-17 (US Environment Protection Agency) criteria. Limits of detection (signal-to-noise=3, ng in tube) ranges were 0.004-0.03ng (alcanes), 0.001-0.1ng (aromatics), 0.03-14ng (aldehydes), 0.003-7ng (alcohols), 0.003-0.04ng (chlorides), 0.02-0.5ng (esters), 0.002-0.1ng (ketones), 0.01-0.53ng (terpenes), 14-97ng (amides), 0.2-10ng (isocyanates) and 0.001ng (carbon disulfide). The linear dynamic range was over 3-5 orders of magnitude, depending of the VOC. TD-GC-MS analysis was reproducible, with relative standard deviation (n=5) within 20%. VOCs breakthrough examination showed no significant losses when about 2000ng standard was prepared. In order to evaluate the performance of the developed method on real samples, several industrial and urban air samples were analysed. VOCs were found to be stable on the sorbent tubes for at least 1 week when stored at 4 degrees C.

[Old donors in liver transplantation for chronic hepatitis C]. / Utilización de los donantes añosos en pacientes transplantados por cirrosis por virus C.

BACKGROUND: the natural history of recurrent hepatitis C after liver transplantation (LT) is extremely variable, with progression to allograft failure in a substantial proportion of patients. The identification of factors associated with this poorer outcome may improve results. While donor age has been identified as one of the most important factors, the actual options to modify this variable are limited. OBJECTIVES: a) to describe the natural history of HCV(+) liver transplant recipients depending on donor age ( < or = 50 years), including clinical, biochemical, and histological outcomes; and b) to identify in the subgroup of organ recipients from aged donors (= 50 years) factors associated with an aggressive course. METHODS: a retrospective study of clinical and histological data including protocol liver biopsies for 162 HCV (+) liver transplant patients between 1997 and 2001 with at least one year of follow-up. Aggressive recurrent hepatitis C was defined as a progression to fibrosis > 1 during the first year post-LT, development of a cholestatic form of recurrent hepatitis C, and /or graft failure due to HCV during the first five years post-LT. Factors analyzed as potentially associated with recurrent hepatitis C included: a) recipient-related: demographics (age, sex), pre-transplantation (hepatocellular carcinoma, Child-Pugh classification, history of alcohol, HBV serological markers, antiviral treatment, nutritional status, biochemical variables); b) donor-related: demographics (age, sex), cause of death, grade of steatosis defined as minimal vs. moderate-severe > 10%); c) surgery-related: cold preservation and rewarming time, duration of procedure, blood transfusion; and d) post-LT management-related: immunosuppression, liver enzymes in the first 14 days post-LT, acute hepatitis post-LT, surgical complications (vascular and/or biliary). RESULTS: patients were divided into two groups according to donor age group 1 ( < 50 years), n = 83, 51%, and group 2 (= 50 years), n = 79, 49%). Median follow-up was 5 years (range: 3 months-8.5 years). Aggressive recurrent hepatitis C occurred significantly more frequently in the older donor group (64 vs. 20.5%, p < 0.0001). In this group, potent immunosuppression -triple and quadruple regimens- (p = 0.04) and acute hepatitis post-LT (p = 0.03) were the only variables associated with aggressive recurrence. Degree of donor steatosis was not associated with the prognosis of recurrent hepatitis C. CONCLUSION: the use of aged donors is partly responsible for the accelerated progression of hepatitis C after LT. When old donors are used we should avoid over-immunosuppression, and probably evaluate antiviral therapy in those with acute recurrent hepatitis C.

[Surfactant replacement therapy with a minimally invasive technique: Experience in a tertiary hospital]. / Terapia con surfactante con técnica mínimamente invasiva: experiencia en un hospital terciario.

INTRODUCTION: Surfactant delivered using a minimally invasive technique, known as MIST (Minimally Invasive Surfactant Therapy) is a method which allows surfactant to be administered to a patient connected to non-invasive respiratory support. This is an increasingly used therapy in Neonatal Units that reduces the intubation rate and the pathology associated with intubation and allows the surfactant to be administered to the patients who clinically need it. PATIENTS AND METHODS: In years 2013 and 2014 in the Hospital General Universitario de Elche surfactant was delivered using this method to 19 patients, five of whom were 28 or less weeks of gestation age at birth. A comparison is made with a historical cohort consisting of 28 patients with Respiratory Distress Syndrome treated initially with non-invasive respiratory support. RESULTS: No incidents were recorded that caused the interruption of the administration. A reduction in the fraction of inspired oxygen was observed in all cases after surfactant administration. Fewer intubations in the first 72 hours of life were found in the treatment group compared to the control group (42% vs. 54%). DISCUSSION: The experience recorded in the Hospital General Universitario de Elche shows that the administration of surfactant using a MIST technique is a reproducible method of treatment, which allows the surfactant distribution during spontaneous breathing with non invasive respiratory support.

[Videophone assistance and home hospitalization: the ViSaDom program]. / Téléassistance en hospitalisation b domicile: le programme ViSaDom.

OBJECTIVE: The purpose of this project was to study the clinical feasibility of videophone-based communication between patients in their homes, and the care teams who work in the Home Hospitalization department (HH). METHODS: This pilot study of videophone users compared them with a group of control patients also in HH. They came from either the adult, maternity or pediatric departments. Patients who met the inclusion criteria and consented to participate in the study were randomly assigned to one of two groups: those who had a videophone installed in their homes (telemedicine group), and those who received the standard HH care (control group). Sixteen patients in the telemedicine group were matched with 16 from the control group, according to age, Karnofsky Index score, and the reason for HH admission. RESULTS: The mean videophone call lasted six minutes, and patients averaged 23 calls each over the study period (0.7 calls per patient per working day). The videophone enabled better follow-up of wounds: for example, the nurse could transmit photos from the patient's home for real-time coordination. It was also useful for following patients suffering from pain, for technical nursing care, and for educating patients and their caregivers. Anxiety (measured with the Hospital Anxiety and Depression Scale) diminished during the study period for the telemedicine patients, compared with the control group (p=0.048). Within the telemedicine group, all patients and their families were very satisfied or satisfied with their care and with the communication (15/15), although the staff's level of satisfaction was slightly lower (14/16); there were no significant differences between groups. CONCLUSION: The ViSaDom program indicates that videophone communication is feasible and acceptable and could be a useful tool for improving the quality, efficiency and effectiveness of care.

Hepatitis C virus in the transplant setting.

Hepatitis C virus (HCV)-associated end-stage liver disease is a leading diagnosis in patients undergoing liver transplantation, accounting for approximately 20-25% of transplantations in many centres. In spite of universal viral recurrence, early post-transplantation infection generally results in indolent disease with good graft and patient survival, at least for the first 5-7 years, comparable to those observed in other patients undergoing transplantation for non-viral end-stage liver disease. The full consequences of HCV recurrence are however beginning to be delineated with development of progressive liver failure observed with longer follow-up in a still unknown proportion of patients. Factors which may influence the outcome include viral load at transplantation and the type/amount of immunosuppression. Currently, the only available drugs are interferon and ribavirin, alone and in combination, used either therapeutically when the disease has fully developed, or prophylactically early after transplantation. Unfortunately, interferon has been used with limited success and with concerns about toxicity. Ribavirin monotherapy has been ineffective in producing meaningful results. Preliminary results on combination therapy are promising, both when administered before hepatitis develops or when histologic disease is present. Current antiviral therapy is however unable to eliminate HCV in the liver transplant setting, suggesting that indefinite treatment designed to suppress the effects of virus may be necessary. Major therapeutic advances for HCV infection are awaited.

Treatment strategies for recurrent hepatitis C after liver transplantation.

Chronic hepatitis C is a common indication for liver transplantation, accounting for 25% to 50% of all transplantation candidates in most transplant centers. Despite uncertainties regarding rates of disease progression after transplantation, a consensus is emerging that recurrent HCV infection results in liver failure in a significant although currently unmeasured proportion of patients, and that the period over which this progression occurs is shorter than in the immunocompetent population. As the disease process moves into its second decade after transplantation it can be anticipated that future morbidity and liver-related mortality will increase. Whether disease progression is accelerated by definable factors is not yet fully established, but HCV RNA levels before or soon after transplantation and aggressive immunosuppressive measures appear to influence the post-transplantation outcome. Strategies to prevent or to reduce the effect of HCV infection after liver transplantation are therefore essential. The ability to intervene in this disease is currently limited. The main obstacles are the difficulty in predicting the outcome in the individual patient and the lack of effective therapy. In contrast with hepatitis B, in which hepatitis B immune globulin has improved survival, there are no therapeutic strategies to prevent recurrent HCV infection. Neither IFN nor ribavirin, when administered as a single agent, results in sustained viral clearance. However, administration of both drugs in combination, either to prevent disease or to treat recurrence, appears promising. The inability of currently available antiviral therapy to eliminate HCV in the setting of liver transplantation suggests that indefinite treatment designed to suppress viral replication will be necessary. The feasibility of such an approach will depend on the development of drugs that reduce the histologic activity of hepatitis, improve graft and patient survival, and have side effect profiles that are acceptable to patients.

Determination of DDT and related compounds in blood samples from agricultural workers.

An analytical method combining a solid-phase (C18) clean-up and GC-electron-capture detection using a capillary column, was implemented to determine p,p'-DDT and its metabolites (p,p'-DDD and p,p'-DDE), as well as other organochlorine pesticides in whole blood samples from 30 farmers and 24 non-occupationally exposed workers. The average concentrations for the quantified pesticides, p,p'-DDT, p,p'-DDD and p,p'-DDE, were 0.9, 1.5 and 8.0 micrograms/l whole blood for exposed workers and 0.3, 0.5 and 3.3 micrograms/l for unexposed workers, respectively. GC-MS was used to confirm the identity of the pesticides found. Solid-phase extraction and the protocol used give a cleaner analytical matrix, not only improving sensitivity and resolution, but also allowing analyses with smaller blood samples as compared to other methods.

Genome detection in liver and peripheral blood mononuclear cells: predictor factors of sustained response in patients with chronic hepatitis C.

BACKGROUND: In chronic hepatitis C, relapses of liver disease occur in as many as 50% of patients responding to interferon (IFN) therapy. Although the presence of serum hepatitis C virus (HCV) RNA at the end of therapy predicts a relapse, its absence is not a reliable indicator of cure. In this study we have determined whether responders to IFN (normalization of liver chemistry and clearance of serum HCV-RNA) harbour HCV-RNA in the liver and peripheral blood mononuclear cells (PBMCs), and whether finding the genome at these sites has prognostic significance. METHODS: After the conclusion of therapy, we tested for HCV-RNA in the liver of all the patients (anti-HCV-positive): 16 complete responders with normalization of liver chemistry and clearance of serum HCV-RNA and five non-responders. In 13 of the 16 complete responders we also tested for HCV-RNA in PBMCs. Patients were followed up for 9 months. RESULTS: Liver HCV-RNA was detected in each of the five non-responders and in four of the 16 complete responders (25%). The viral genome was detected in the PBMCs of six complete responders (46%). During follow-up a relapse of hepatitis C occurred in the 10 complete responders with liver or PBMC HCV-RNA but in only one (16%) of the six complete responders without HCV-RNA in liver or PBMCs. CONCLUSION: Reliable information on the prognosis of chronic hepatitis C responders can only be obtained by testing for HCV-RNA in serum, liver and PBMCs at the end of therapy. Patients with HCV-RNA at any of these sites stand a high risk of disease relapse. The risk is low but not abolished in patients without detectable HCV-RNA.

Endoscopic sclerotherapy versus oesophageal transection in the prevention of variceal rebleeding.

OBJECTIVE: To compare sclerotherapy with oesophageal transection in the prevention of rebleeding in patients with oesophageal varices. DESIGN: A prospective trial. PATIENTS: Forty-one patients with cirrhosis and variceal bleeding. METHODS: After recovering from an acute episode of oesophageal variceal bleeding patients were randomized into two groups. One patient was excluded. Twenty-two patients were treated with sclerotherapy (group 1) and 18 underwent an oesophageal transection (group 2), with a shorter elapsed time from randomization to treatment in group 1. Both groups were similar with regard to clinical and biochemical features and variceal size. Failure, defined in group 1 as rebleeding or incomplete eradication after four sclerotherapy sessions, occurred in five (22.7%) patients; in group 2, rebleeding occurred in two (11.1%) patients (no statistically significant difference). CONCLUSION: Although the survival rate was similar in both groups, sclerotherapy is preferable to oesophageal transection because it requires a shorter duration of hospitalization and has fewer complications.

Liver transplantation in hepatitis C. A Spanish multi-centre experience.

OBJECTIVE: The purpose of this retrospective survey was to determine the prevalence and outcome of hepatitis C virus (HCV) infection in cirrhotic patients undergoing liver transplantation (OLT) in Spain in 1992. METHODS: Post-OLT HCV infection was defined by anti-HCV (second-generation ELISA) and/or PCR. Patients were divided into groups A (HCV-positive pre-OLT: n = 124, 46%) and B (HCV-negative pre-OLT: n = 145, 54%). RESULTS: HCV infection was more prevalent in patients originally diagnosed as having non-A non-B cirrhosis (97%) and cryptogenic cirrhosis (79%) than in patients with cholestatic or metabolic diseases. Group A patients were older (53.3+/-7.9 versus 47.6+/-9.7; P< 0.05) and had a higher prevalence of hepatocellular carcinoma (22% versus 4%, P< 0.05). Post-OLT HCV infection was 99% in group A versus 4% in group B (P< 0.05). Histological hepatitis developed in 39% (66% in group A versus 14% in group B, P< 0.05) with similar follow-up. Chronic rejection occurred in 6% (3% in group A versus 8.5% in group B, P= 0.07). Retransplantation rate (overall 8%) and two-year patient survival did not differ between groups (79% versus 72%). Graft survival was higher in group A (74% versus 65% at 2 years, P= 0.04). CONCLUSIONS: HCV-cirrhosis represented the most frequent indication for OLT in Spain in 1992. While HCV recurrence was universal, de novo acquisition was rare. HCV accounted for most post-OLT hepatitis (87%), but was not associated with chronic rejection, nor with a higher retransplantation rate. Patient survival was not different in HCV patients compared to a control group after a follow-up of 2-3 years. Therefore, at present, HCV-cirrhosis is an acceptable indication for OLT.

Budd-Chiari syndrome caused by membranous obstruction of the inferior vena cava associated with coeliac disease.

Ten cases of Budd-Chiari syndrome associated with coeliac disease have been reported in the literature, most of them in North African subjects. Supporting this association, we report a new case in a young Spanish Caucasian man in whom the cause of the syndrome was the membranous obstruction of the inferior vena cava, an infrequent cause of Budd-Chiari syndrome in Western countries. A percutaneous balloon angioplasty was performed, with satisfactory outcome.