Efficacy and safety of mycophenolate mofetil monotherapy in liver transplant patients with renal failure induced by calcineurin inhibitors.

OBJECTIVE: To assess the efficacy and safety of mycophenolate mofetil (MMF) monotherapy in liver transplant recipients with renal failure secondary to the use of calcineurin inhibitors (CNIs). MATERIALS AND METHODS: Thirty-one patients on MMF monotherapy with creatinine levels >1.3 mg/dL, previously immunosuppressed with CNIs and MMF, were analyzed. Conversion was started in patients with no acute or chronic rejection episodes and stable liver chemistry. CNI doses were reduced by 25% every 2 to 3 months, or to 50% if the dose was lower than 1 mg/d of tacrolimus or 50 mg/d of cyclosporine. Different variables were recorded from the time that conversion to monotherapy was decided, on the discontinuation day of the calcineurin inhibitor, and during the follow-up. RESULTS: Mean times from transplant to conversion ranged from 14 to 186 months. The minimum follow-up time in monotherapy was 12 months. Renal function improved at 6 months in 70% of cases and at 12 months in 69.6%. Patients with no renal function improvement maintained stable creatinine values. There were no rejection episodes, graft losses, or deaths. No leukopenia occurred, and triglyceride and uric acid values improved. CONCLUSIONS: MMF monotherapy is a safe alternative in patients with posttransplant renal failure secondary to the use of CNIs. Renal function improvement was achieved in almost 70% of patients at 12 months, and creatinine values were maintained in all other patients. The risk of rejection due to the slow tapering of CNIs is minimum.

Scoring guide when deciding to accept an organ for a liver transplant.

UNLABELLED: Our objective was establish a scoring system that allows a donor to be evaluated quickly and easily using a set of variables that are evaluated prior to the donation and another set that are evaluated during surgery. MATERIALS AND METHODS: Prior to the donation we analyzed age, medication requirements, natremia, hepatic biochemistry, gas levels, days in ICU, history of hypertension, and weight. A value of 40% was allocated to this group of factors. During the transplant we assessed the characteristics of the organ-shine, consistency, surface, edge, color, presence of steatosis, and atheromatosis. A value of 60% was allocated to this set. We established a scale of 1 to 10, only accepting organs scoring 5 or more points. Those grafts that received a score between 5 and 7.5 points were called suboptimal and those with over 7.5 points, optimal. We prospectively analyzed 133 donors whose organs were implanted. RESULTS: The survival rate at 1 year was 85%, and the rejection rate was 12%. The incidence of primary graft dysfunction was 8.2% (n = 11) and that of primary graft nonfunction 2.2% (n = 3). The incidence of primary graft dysfunction was greater within the group with fewer points (suboptimal). There were no differences between the optimal and suboptimal groups in terms of primary malfunction, survival, or rejection rate. CONCLUSIONS: The score provided a guide to decide whether to accept viable organs for implantation, given that the point system was obtained quickly and easily. When greater than 5, it correlated with low rates of primary nonfunction (<3%) and of primary graft dysfunction (<15%), with acceptable survival at 1 year (>80%) and acute rejections rate (<15%).

Efficacy and safety of mycophenolate mofetil as part of induction therapy in liver transplantation.

AIMS: To report our experience with mycophenolate mofetil (MMF) for induction and maintenance therapy to prevent acute liver transplant rejection. METHODS: A retrospective analysis of 66 elective, noncombined liver transplant patients treated beginning de novo MMF and follow for a minimum of 2 years. Thirty-nine of the 66 cases received MMF, calcineurin inhibitors, and steroids. In 11 cases daclizumab was added; in 16 daclizumab was added without steroids. RESULTS: The global survival rate was 91% at 6 months, 89.4% at 1 year, and 87.9% after 2 years. Acute rejection episodes were observed in six patients (9.1%). All episodes responded to corticoids. Toxicity possibly, probably, or partially related to MMF was observed in 35 patients (53%) with definitive suspension required in 13 cases (20%), with dose reduction or temporary suspension in 22 (33%). Hematological toxicity associated with MMF was observed in 12 patients (18%), leading to definitive suspension in two patients (3.03%), temporary suspension in two cases (3.03%), and dose reduction in eight cases (12%). Opportunistic infection was observed in seven cases (10%). Gastrointestinal toxicity was mild and infrequent (five cases, 7.5%). CONCLUSION: Regimens containing MMF reduce rejection episodes with high survival rates and low toxicity.

New Antivirals for Hepatitis C Infection Among Infected Kidney Transplant Recipients: A Case Report.

The most common hepatopathy in end-stage renal disease is chronic hepatitis C virus (HCV) infection, which decreases allograft and patient survival in kidney transplants. Until last year we did not have treatments free of interferon, which was contraindicated after renal transplantation owing to the risk of allograft rejection. Recently, new drugs have been discovered for interferon-free regimens. These drugs present a cure rate of up to 90% and can be used in transplant recipients. Here we present our 1st 3 cases. In our experience, new antivirals have proven to be effective and safe for the treatment of HCV hepatopathy in kidney transplant recipients and liver-kidney transplantation, thus helping us to prevent complications related to HCV infection in transplant recipients.

Cytologic brushing as a simple and rapid method in the diagnosis of Helicobacter pylori infection.

OBJECTIVE: To assess broad antral cytologic brushing as an alternative approach for the diagnosis of Helicobacter pylori gastric colonization as compared to histology. STUDY DESIGN: Multiple gastric biopsies were taken from the antrum of 117 patients with an endoscopic appearance compatible with antral gastritis. Broad antral brushing was also obtained, and smears were stained with Papanicolaou stain. RESULTS: Chronic gastritis was diagnosed histopathologically in 93 patients. H pylori was identified in 115 cytologic smears. Cytologic smears from 97 patients with H pylori on biopsy specimens contained the organisms. Only two poor-quality cytologic smears with no H pylori had the organisms on biopsy specimens. In 18 patients, H pylori was identified on the cytologic smears and not on the biopsy specimens. CONCLUSION: Broad antral cytologic brushing is a useful alternative approach to histology for the diagnosis of H pylori gastric infection.

[The brown bowel syndrome. A case report]. / Síndrome de intestino marrón. Descripción de un caso.

We present a patient with celiac sprue in whom intestinal lymphoma was suspected. At laparotomy, a brown discolouration of small bowel loops was observed, and a transmural biopsy confirmed a brown bowel syndrome, an entity that is found in long-standing malabsorption conditions. We believe that the intestinal disorder caused by deposition of lipofuscin in the bowel non-striated muscle may cause radiologic changes similar to those seen in intestinal lymphoma.

[Giant gastric and duodenal trichobezoar. Presentation of a case and review of the literature]. / Tricobezoar gigante gástrico y duodenal. Presentación de un caso y revisión de la literatura.

The case of a giant trichobezoar of 2.500 g in weight observed in a 26-year old woman with paranoid disorder which led her to trichophagia is presented. A review of the literature was carried out with the different etiopathogenic theories and proposed treatments being discussed.

Monitoring the natural evolution and response to treatment of post liver transplant recurrent hepatitis C using transient elastography: preliminary results.

OBJECTIVES: To perform a prospective analysis of changes in liver stiffness (LS) using transient elastography (TE) in a consecutive series of patients with post-liver transplant (LT) recurrent hepatitis C, either left to their natural evolution or receiving antiviral treatment. METHODS: We examined the results from 17 comparisons of TE (baseline vs follow-up) from 11 patients. We evaluated: (1) upon inclusion in the study: age, sex, genotype, time transpired since LT, and baseline fibrosis (F0-4; Scheuer), and (2) during the follow-up period: time elapsed between the two TE and either specific treatment (B) or absence of treatment (A). RESULTS: Mean patient age was 56.8 ± 7.9 years, with a male/female ratio of 10:1. Ten of the eleven patients had genotype 1b. The median time transpired between the LT and inclusion in the study was 28 months (range: 6-142 months). The mean time transpired between the two TE was 11.3 ± 4.5 months. In the 11 patients from group A (9 F1/2 F2; 13 "paired" TE), a predictable increase in LS was produced in 10 cases and a paradoxical result was produced in 3 cases. In the four patients in group B (3 F2/1 F1; 4 "paired" TE), a decrease in LS was produced in 3 cases and a paradoxical result in 1 case. CONCLUSIONS: In our study of patients left to their natural evolution, a slow increase of LS was normal. However, antiviral treatment appeared to decrease LS. TE can be very useful as a complementary test to biopsy for monitoring post-LT recurrent hepatitis C. A longer follow-up period and larger sample size could confirm these preliminary results.

Prevalence and characteristics of bone disease in cirrhotic patients under evaluation for liver transplantation.

BACKGROUND: We performed a retrospective study to examine the prevalence of bone disease (BD) among cirrhotic patients being evaluated for liver transplantation (OLT) using bone densitometry dual-energy x-ray absorptiometry in the hip/femoral neck and lumbar spine. The associations of BD with demographic and clinical data, disease etiology and liver function were studied by univariate and multivariate logistic regression analyses. Osteopenia and osteoporosis were defined by World Health Organization criteria. RESULTS: We included 486 patients (79% men of mean age, 53 ± 8.8 years (range, 21-69) who included 62.6% smoker and 23.7% diabetic subjects. Body mass index (BMI) was 28.8 ± 5.7 kg/m(2) (range, 16-43). The liver disease was Child-Pugh class A (22%), B (51%), or C (27%); the Model for End-Stage Liver Disease (MELD) score was 14.6 ± 5.4 (range, 7-33). The disease etiology was alcohol (59%), hepatitis C (32%), hepatitis B (10%), primary biliary cirrhosis (PBC) (2.3%), secondary biliary cirrhosis, (2%) or other causes (10%). In all, 350 patients (72%) had BD in the hip/femoral neck and/or lumbar spine: Global hip, 26% (osteopenia, 22%; osteoporosis, 4%); femoral neck, 48% (osteopenia, 43%; osteoporosis, 5%) and lumbar spine, 63% (osteopenia, 40%; osteoporosis, 23%). Univariate analysis showed the BD risk to increase with the following variables: Female gender (odds ratio [OR], 1.88; P = .023) and lower BMI (OR, 0.95; P = .012). Upon multivariate analysis, female gender (OR, 2.43; P = .004), lower BMI (OR, 0.96; P = .016), and tobacco use (OR, 1.59; P = .043) were significant. PBC showed BD in 100% of cases. By adjusting bone mineral density (BMD) values to age (Z-score) in relation to that defined by T-score, we observed a decrease in BD prevalence in both the femoral neck (20% vs 48%) and the lumbar spine (44% vs 63%). CONCLUSION: BD, especially in the lumbar spine, is common among cirrhotic patients under evaluation for OLT. Cirrhosis is a major BD risk factor that remains even when BMD values are adjusted for age. Female gender, lower BMI, and tobacco consumption are major risk factors for BD in cirrhotic patients. Bone densitometry must be included in the OLT evaluation of all patients.

Response to vaccination against hepatitis B virus with a schedule of four 40-µg doses in cirrhotic patients evaluated for liver transplantation: factors associated with a response.

We performed a retrospective study to evaluate the rate of and factors associated with a response to recombinant hepatitis B virus (HBV) vaccination using 4 intramuscular doses (40 µg) administered at 0, 1, 2, and 6 months among 278 cirrhotic patients being evaluated for orthotopic liver transplantation (OLT). We re-vaccinated 57 non-responders with the same schedule. The 39.2% overall response rate to vaccination included 36% after three and 40.7% after four doses, namely, a median anti-HBs level of 100 IU/mL (range, 10 to 1000 IU/mL). The 51% revaccination response rate achieved a median hepatitis B surface antibody (anti-HBs) level of 99 IU/mL (range, 11 to >1000 IU/mL). Upon univariate analysis, variables associated with a higher response were: better liver function (Child-Pugh class [A, 53.8% B, 33.3%, C, 30.1%; P = .002), Model for End-stage Liver-Disease (MELD) score (11.4 versus 13.6; P = .001]), absence of diabetes (43.6% versus 20.8%; P = .002), presence of isolated hepatitis B core antibody (anti-HBc) positivity (80% versus 37.7%; P = .007), and younger age (< 45 years, 52.2%; range, 45 to 55 years, 40.4%; > 55 years, 34.1%; P = .031). Upon multivariate logistic regression analysis, lower MELD score (odds ratio [OR]: 0.922; P = .046), absence of diabetes (OR:0.359; P = .008) and isolated anti-HBc positivity (OR:5.826; P = .034) were associated with a higher response. No differences were observed to be associated with gender, weight, body mass index, etiology or tobacco consumption. Among the same patient cohort (n = 79), the responses after the third and fourth doses were 36.7% and 51.9% respectively. In conclusion, the response rate to HBV vaccination in cirrhotic patients evaluated for OLT reached more than 35% among those who received at least 3 doses. It was higher among patients who showed isolated anti-HBc positivity, better liver function, younger age, and non-diabetic status. The fourth dose only increased the response rate by 24% over that obtained after the first three doses, whereas a revaccination achieved a 50% response rate, which probably accounts for revaccination after no response to 3 doses. Vaccination should be introduced against HBV in the early stages of the disease.

Prevalence of hepatitis B and A virus markers and vaccination indication in cirrhotic patients evaluated for liver transplantation in Spain.

In the absence of immunity, vaccination against hepatitis A virus (HAV) and hepatitis B virus (HBV) is recommended for patients with chronic liver disease and those evaluated for liver transplantation (OLT) HAV and HBV infections after OLT which are frequent in this setting, are associated with a worse prognosis. The aim of this study was to estimate the need for vaccination against HBV and HAV among cirrhotic patients who were candidates for OLT and associations with gender, age, and etiologic factors. HBV and HAV serological markers HBsAg, anti-HBc, antiHBs, immunoglobulin G (IgG)-anti-HAV were investigated among 568 patients, including 75% men. The overall mean age was 53.6 ± 8.9 years range 17-69, and 20% were diabetic. This etiologies were alcohol (68%), hepatitis C virus (35%) or other causes (10.4%). Child-Pugh classes were: A (26%), B (44%), and C (30%). In contrast with 359 patients (63.2%) who had negative HBV markers, 209 (36.8%) were positive: HBsAg (+), 43 (7.6%), isolated anti-HBc (+), 57 (10%), isolated anti-HBs (+), 19 (3.3%), anti-HBc (+)/anti-HBs (+), 90 (15.8%). HBV vaccine indication was performed in 416 patients (73.2%) who either had negative HBV markers or isolated anti-HBc (+). It was more frequently performed in women (82.3% versus 70.3%, P = .005), albeit with no differences according to age or etiology. There were only 8.2% (44/538) IgG-anti-HAV-negative, an indication for vaccination against HAV, which was more frequent affecting patients who were younger [≤ 45 years (27.6%), 46-55 (7.2%), >55 (2.6%); P < .0001)]; nondiabetic (9.5% versus 2.8%, P = .023); nonalcoholic (11.4% versus 6.6%, P = .056); and displayed negative HBV markers (10.2% versus 4.6%, P = .023). Only three patients with IgG-anti- HAV (-) were over 60 years. In conclusion, there is a frequent indication for HBV vaccination among cirrhotic and especially HAV vaccine for under 45 year old patients undergoing evaluation for OLT.

Retinopathy as a systemic complication of acute pancreatitis.

We describe three cases of sudden severe retinopathy in patients with acute pancreatitis. The relative times of the organ manifestations and comparisons with other published cases strongly suggest that pancreatitis was the cause of the retinal changes. This systemic complication is unknown to most physicians, but approximately 35 cases have been published. The pathogenesis is not well known. We briefly discuss the significance of this complication and several possible pathogenetic mechanisms.