Predisposing factors of diminished survival in simultaneous liver/kidney transplantation.

Since the adoption of the Model for End-Stage Liver Disease, simultaneous liver/kidney transplants (SLKT) have substantially increased. Recently, unfavorable outcomes have been reported yet contributing factors remain unclear. We retrospectively reviewed 74 consecutive adult SLKT performed at our center from 2000 to 2010 and compared with kidney transplant alone (KTA, N = 544). In SLKT, patient and death-censored kidney graft survival rates were 64 ± 6% and 81 ± 5% at 5 years, respectively (median follow-up, 47 months). Multivariable analyses revealed three independent risk factors affecting patient survival: hepatitis C virus positive (HCV+, hazard ratio [HR] 2.9, 95% confidence interval [CI] 1.1-7.9), panel reactive antibody (PRA) > 20% (HR 2.8, 95% CI 1.1-7.2) and female donor gender (HR 2.9, 95% CI 1.1-7.9). For death-censored kidney graft survival, delayed graft function was the strongest negative predictor (HR 8.3, 95% CI 2.5-27.9), followed by HCV+ and PRA > 20%. The adjusted risk of death-censored kidney graft loss in HCV+ SLKT patients was 5.8 (95% CI 1.6-21.6) compared with HCV+ KTA (p = 0.008). Recurrent HCV within 1 year after SLKT correlated with early kidney graft failure (p = 0.004). Careful donor/recipient selection and innovative approaches for HCV+ SLKT patients are critical to further improve long-term outcomes.

Liver enzymes elevation after HAART in HIV-HCV co-infection.

Hepatitis C virus (HCV) co-infection is common among human immunodeficiency virus (HIV) patients. The incidence and risk factors associated with hepatotoxicity in this population after high active antiretroviral therapy (HAART) is initiated are still not well-understood. We argued to evaluate the incidence and risk factors associated with liver enzyme elevation (LEE) and their clinical significance. A retrospective chart review of patients who started HAART and had follow up at our centre for at least 1 year was undertaken. The frequency and severity of alanine aminotransferase (ALT)/aspartate aminotransferase (AST) elevation after treatment initiation were investigated and searched for clinical manifestations. Between January 1996 and March 2002, 85 HIV-HCV co-infected patients began HAART and continued follow up for at least 1 year. The incidence of severe toxicity [grades 3 + 4 LEE: >5 and >10 times the upper limit of normal (ULN) of ALT or AST] was calculated at 4% per person-years. There were no clinical manifestations of liver toxicity, and patients continued their treatment with a trend towards a decrease of their enzymes. No statistical differences in opportunistic infections or mortality were evident. The variables associated with severe hepatotoxicity were a higher baseline AST, higher international normalized ratio (INR) and lower albumin. A baseline AST < 2.1 ULN had a negative predictive value of 92% of leading to severe hepatotoxicity. In HIV-HCV co-infected patients therefore, the group at a higher risk of developing higher transaminase elevations is the one with a higher baseline AST, higher INR and lower albumin.

Current and future treatment of chronic hepatitis B.

Hepatitis B virus (HBV) infection is an ongoing worldwide pandemic. In general, the mode of transmission is different according to its prevalence in different areas: mostly perinatal in highly prevalent zones and predominantly sexual and/or parenteral in low prevalence areas. The variation in presentations of chronic hepatitis B (CHB) make its management complex. Aminotransferase levels, viral load, histologic changes, age of the patient, viral mutations (e.g. hepatitis B e antigen negative) and pregnancy are all factors that impact on treatment decisions. The ideal drug that will eradicate the HBV has yet to be developed. This review focuses on the currently available medications for CHB: alpha-interferon, lamivudine, adefovir, as well as new drugs that have proven to be active against HBV in clinical trials and are closer to licensure; pegylated interferon tenofovir, entecavir, emtricitabine, telbivudine and clevudine. The antiviral properties and the advantages and disadvantages in HBeAg-positive and negative patients are discussed. Combinations of different medications currently under study were not included in this review. A suggested algorithm, developed from recent literature, may serve as a practical guide on tailoring drug selection based on viral load, aminotransferases, hepatitis B e antigen status and histological findings. Finally, practical management questions are raised.

Cancer gastrico en Chiriqui. Frecuencia y algunos datos epidemiologicos. / Gastric cancer in Chiriqui. Occurrence and some epidemiologic data

El cancer gastrico se presenta con una rata de 3.49/100,000 habitantes en la provincia de Chiriqui. Los datos epidemiologicos investigados coinciden con los de otros paises excepto en el tipo sanguineo que en nuestra investigacion, al igual que en la realizada por Santamaria en el lapso de 10 anos (10) fue del tipo "O", siendo informado en otros paises el tipo "A" como el mas frecuente en esta enfermedad. Pensamos que aunque existen algunos factores ambientales que se sospeche pueden predisponer a esta enfermedad como son el alto contenido mineral de algunas zonas de provincia, el area volcanica que en ella se encuentra y la costumbre de ingerir carnes ahumadas, por otro lado existen factores tambien sospechados - que la protegen. Entre estos factores podemos mencionar la baja altitud de la mayor parte de la provincia, una ingesta adecuada de leche, frutas, y legumbres frescas, una mejor conservacion de alimentos refrigerados y es posible que el predominio del grupo sanguineo "O" - propio de razas indigenas - ejerza algun papel protector