First consensus document of waiting list prioritization for liver transplantation by the Spanish Society of Liver Transplantation (SETH).

Spain is worldwide leader in deceased donation rates per million habitants and count on a strong network of twenty-five liver transplant institutions. Although the access to liver transplantation is higher than in other countries, approximately 10% of patients qualifying for liver transplantation in Spain will die in the waiting list or would be excluded due to clinical deterioration. A robust waiting list prioritization system is paramount to grant the sickest patients with the first positions in the waiting list for an earlier access to transplant. In addition, the allocation policy may not create or perpetuate inequities, particularly in a public and universal healthcare system. Hitherto, Spain lacks a unique national allocation system for elective liver transplantation. Most institutions establish their own rules for liver allocation and only two autonomous regions, namely Andalucía and Cataluña, share part of their waiting list within their territory to provide regional priority to patients requiring more urgent transplantation. This heterogeneity is further aggravated by the recently described sex-based disparities for accessing liver transplantation in Spain, and by the expansion of liver transplant indications, mainly for oncological indications, in absence of clear guidance on the optimal prioritization policy. The present document contains the recommendations from the first consensus of waiting list prioritization for liver transplantation issued by the Spanish Society of Liver Transplantation (SETH). The document was supported by all liver transplant institutions in Spain and by the Organización Nacional de Trasplantes (ONT). Its implementation will allow to homogenize practices and to improve equity and outcomes among patients with end-stage liver disease.

Autoimmune hepatitis after COVID-19 infection.

We report the case of a 58-year-old male patient presenting with clinical and laboratory findings indicative of acute hepatitis. Abdominal ultrasound excluded biliary tract abnormalities. Two weeks prior, the patient had contracted COVID-19. Viral hepatitis was ruled out, and the presence of autoantibodies was confirmed. Liver biopsy findings were consistent with autoimmune hepatitis and grade 1 fibrosis. Initial treatment with budesonide was ineffective, leading to a switch to prednisone, with maintenance therapy comprising prednisone and azathioprine. COVID-19 infection may act as a trigger for the development of autoimmune hepatitis.

Age, period and cohort effects on gastric cancer mortality in Spain, 1980-2021.

BACKGROUND: this study aimed to evaluate the effects of age, time period and cohort (A-P-C) on gastric cancer (GC) mortality in Spain from 1980 to 2021. METHODS: an ecological trend study was performed (with aggregated data obtained from the Spanish National Statistics Institute (INE). Joinpoint regression software was used to estimate rates by sex and age group (< 35, 35-64, > 64 years) and mortality trends. The National Cancer Institute A-P-C tools were used to assess the effects of age, time of death and birth cohort. RESULTS: GC mortality rates in Spain decreased significantly in both sexes. In the under-35 age group, rates were stable after an initial significant decline. In the 35-64 age group, the decline was more pronounced in males than in females. In the 65+ age group, rates fell significantly for both sexes, but more so for females than for males. The net drift and local drift also showed significant decreases across all age groups from 24 years onwards. GC mortality rates increased with age and decreased with calendar time and successive birth cohorts, regardless of sex. The ratio of age-specific rates between males and females increased with age, and birth cohort relative risk estimates followed a steady downward trend until the mid-1970s, after which the decline stabilized. The relative risk decreased for both sexes, with a more pronounced decrease in males. CONCLUSION: GC mortality rates in Spain have been decreasing over time and across successive birth cohorts, with a stabilizing trend observed for those under 35 years of age.

Age, period and cohort effects on gastric cancer mortality in Spain, 1980-2021

Background: this study aimed to evaluate the effects of age, time period and cohort (A-P-C) on gastric cancer (GC) mortality in Spain from 1980 to 2021. Methods: an ecological trend study was performed (with aggregated data obtained from the Spanish National Statistics Institute (INE). Joinpoint regression software was used to estimate rates by sex and age group (< 35, 35-64, > 64 years) and mortality trends. The National Cancer Institute A-P-C tools were used to assess the effects of age, time of death and birth cohort. Results: GC mortality rates in Spain decreased significantly in both sexes. In the under-35 age group, rates were stable after an initial significant decline. In the 35-64 age group, the decline was more pronounced in males than in females. In the 65+ age group, rates fell significantly for both sexes, but more so for females than for males. The net drift and local drift also showed significant decreases across all age groups from 24 years onwards. GC mortality rates increased with age and decreased with calendar time and successive birth cohorts, regardless of sex. The ratio of age-specific rates between males and females increased with age, and birth cohort relative risk estimates followed a steady downward trend until the mid-1970s, after which the decline stabilized. The relative risk decreased for both sexes, with a more pronounced decrease in males. Conclusion: GC mortality rates in Spain have been decreasing over time and across successive birth cohorts, with a stabilizing trend observed for those under 35 years of age (AU)

Three double-dose reinforced hepatitis B revaccination scheme for patients with cirrhosis unresponsive to the standard regimen: an open-label randomised clinical trial.

OBJECTIVE: We aimed to compare the response rates between two different hepatitis B virus vaccination schedules for cirrhotic subjects who were non-responders to the first three 40 µg doses (month 0-1-2), and identify factors associated with the final response. DESIGN: A total of 120 cirrhotic patients (72.5% decompensated) were randomised at a 1:1 ratio to receive a single 40 µg booster vaccination at month 6 (classical arm) versus an additional round of three new 40 µg doses administered at monthly intervals (experimental arm). The main outcome was the rate of postvaccinal anti-hepatitis B surface antibodies levels ≥10 mIU/mL. RESULTS: Efficacy by ITT analysis was higher in the experimental arm (46.7%) than in the classical one (25%); OR 2.63, p=0.013. The experimental arm increased response rates compared with the classical one from 31% to 68% (OR 4.72; p=0.007), from 24.4% to 50% (OR 3.09; p=0.012) and from 24.4% to 53.8% (OR 3.62; p=0.007), in Child A, Model for End-Stage Liver Disease (MELD) <15 and MELD-Na<15 patients, respectively. Patients with more advanced liver disease did not benefit from the reinforced scheme. Both regimens showed similar safety profiles. Multivariable analysis showed that the experimental treatment was independently response associated when adjusted across three logistic regression models indicating equivalent cirrhosis severity. CONCLUSION: For cirrhotic patients, the revaccination of non-responders to the first three dose cycle, with three additional 40 µg doses, achieved significantly better response rates to those obtained with an isolated 40 µg booster dose. TRIAL REGISTRATION NUMBER: NCT01884415.

Toxicidad hepática inducida por terbinafina / Terbinafine-induced hepatotoxicity

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Hepatitis autoinmune como complicación de inmunodeficiencia común variable / Autoimmune hepatitis as a complication of common variable immunodeficiency

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Autoimmune hepatitis as a complication of common variable immunodeficiency.

In common variable immunodeficiency (CVID) there is a deregulation of the immune system, which frequently leads to an increased risk of infections, but also to autoimmunity phenomena. Autoimmune hepatitis may develop at any time of CVID's evolution, but it is difficult to diagnose due to the frequent absence of autoantibodies and low levels of IgG. Early diagnosis is important because targeted treatment may allow disease improvement. We present a case of autoimmune hepatitis in a patient with CVID.

Hepatitis aguda grave y anemia hemolítica por crioaglutininas secundarias a primoinfección por virus Epstein-Barr / Severe acute hepatitis and cold agglutinin-related hemolytic anemia secondary to prime infection with Epstein-Barr virus

El virus Ebstein-Barr, miembro de la familia Herpesviridae, es responsable del síndrome clínico conocido como mononucleosis infecciosa, que consiste principalmente en la triada faringitis, fiebre y linfadenopatía, tras un periodo de incubación de entre 30 y 50 días. La afectación hepática suele darse en el 80-90% de los pacientes de forma autolimitada y transitoria, mientras que es bastante menos frecuente que se produzca ictericia (5%). Desde el punto de vista hematológico puede cursar con anemia hemolítica, anemia aplásica, neutropenia y trombocitopenia. Presentamos un caso clínico de mononucleosis infecciosa que cursó con hepatitis aguda grave y asoció anemia hemolítica severa secundaria a crioaglutininas. Tras descartar otras etiologías y ante la sospecha clínica y posterior confirmación analítica de la asociación antes mencionada, se instauró tratamiento empírico con antivirales (aciclovir + valganciclovir) y corticoides, objetivando mejoría progresiva hasta la resolución completa del cuadro clínico. Creemos, por tanto, que este caso sirve para reforzar el cuerpo de evidencia clínica que apoya esta terapia conjunta en los casos más graves de mononucleosis infecciosa como paso previo al trasplante hepático (AU)

Epstein-Barr virus, a member of the Herpesviridae family, is responsible for the infectious mononucleosis clinical syndrome, which mainly includes the pharyngitis, fever, and lymphadenopathy triad after incubation for 30-50 days. The liver is involved in 80-90% of patients in a self-limiting transient manner, with jaundice being much more uncommon (5%). From a hematological standpoint it may manifest aplastic anemia, neutropenia, and thrombocytopenia. We report a case of infectious mononucleosis that included severe acute hepatitis and was associated with severe hemolytic anemia secondary to cold agglutinins. After exclusion of other etiologies, and given the clinical suspicion of the above association, which was later confirmed by lab tests, empiric therapy was initiated with antiviral agents (aciclovir + valganciclovir) and corticoids, which resulted in a progressive clinical improvement until complete remission. Therefore, we believe that this case report will reinforce the clinical evidence in support of the above combined therapy for serious infectious mononucleosis as a step prior to liver transplantation (AU)

Severe acute hepatitis and cold agglutinin-related hemolytic anemia secondary to prime infection with Epstein-Barr virus.

Epstein-Barr virus, a member of the Herpesviridae family, is responsible for the infectious mononucleosis clinical syndrome, which mainly includes the pharyngitis, fever, and lymphadenopathy triad after incubation for 30-50 days. The liver is involved in 80-90% of patients in a self-limiting transient manner, with jaundice being much more uncommon (5%). From a hematological standpoint it may manifest aplastic anemia, neutropenia, and thrombocytopenia. We report a case of infectious mononucleosis that included severe acute hepatitis and was associated with severe hemolytic anemia secondary to cold agglutinins. After exclusion of other etiologies, and given the clinical suspicion of the above association, which was later confirmed by lab tests, empiric therapy was initiated with antiviral agents (aciclovir + valganciclovir) and corticoids, which resulted in a progressive clinical improvement until complete remission. Therefore, we believe that this case report will reinforce the clinical evidence in support of the above combined therapy for serious infectious mononucleosis as a step prior to liver transplantation.

Bacteriemia por Streptococcus equi spp. zooepidemicus en paciente trasplantado hepático / Bacteraemia due to Streptococcus equi spp. zooepidemicus in a liver transplant recipient

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