RESUMO
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.
Assuntos
Fosfatase Alcalina , Ácido Quenodesoxicólico , Colagogos e Coleréticos , Quimioterapia Combinada , Cirrose Hepática Biliar , Ácido Ursodesoxicólico , Humanos , Ácido Quenodesoxicólico/análogos & derivados , Ácido Quenodesoxicólico/uso terapêutico , Masculino , Feminino , Pessoa de Meia-Idade , Ácido Ursodesoxicólico/uso terapêutico , Estudos Longitudinais , Cirrose Hepática Biliar/tratamento farmacológico , Idoso , Resultado do Tratamento , Fosfatase Alcalina/sangue , Colagogos e Coleréticos/uso terapêutico , Ácidos Fíbricos/uso terapêutico , Espanha , Bilirrubina/sangue , AdultoRESUMO
Tuberculosis is a clear example of infection that requires cellular immunity for its control. The spread throughout the world of the Human Immunodeficiency Virus (HIV) resulted in its interaction with tuberculosis altering the descending curve of the latter disease in some developed countries, and brought an aggravation of the problem in other countries with few economic and health resources and where tuberculosis was endemic. HIV increases the risk of reactivation of latent tuberculosis infection and accelerates progression after infection or reinfection; on the other hand, TB aggravates the prognosis of patients infected with HIV. This article sets out the differential aspects in the clinical manifestations of TB amongst populations with and without HIV infection; we also comment on some special characteristics in the treatment of tuberculosis in HIV patients. With the exception of primary cutaneous infections produced by accidental inoculation and infantile lymphadenitis, the majority of the cases of disease due to non-tuberculosis mycobacteria (NTM) affect patients with certain predisposing factors. In the case of patients with AIDS, the deep immunological disorder provoked by HIV brings a particular susceptibility to suffering invasive disease due to certain NTM, principally M. avium complex and M. kansasii.
Assuntos
Infecções por HIV/complicações , Tuberculose/complicações , Infecções por HIV/terapia , Humanos , Tuberculose/terapiaRESUMO
We present the case of a 28 year old patient who came for consultation on a fever of up to 40.8 degrees C, pleuritic pain on the right side and the appearance of a painful mass in the lower left extremity of four days evolution. Computerised axial tomography (CAT) showed the existence of a condensation in the middle lobe of the right lung with associated pleural effusion and bilateral miliary pattern. The echographic study of the lower left extremity showed a mass of soft parts with a cystic aspect with destruction of the cortical of the fibula and osseous destruction. Magnetic resonance confirmed the presence of osteomyelitis in the left fibula and of an abscess; Mycobacterium tuberculosis was also isolated in three samples of sputum that led to a diagnosis of disseminated tuberculosis with miliary lung affectation, peroneous osteomyelitis and tuberculous abscess of the soft parts. Anti-tuberculosis treatment was started (riphampicine, isoniacide and pirazinamide) followed, two weeks later, with antiretroviral treatment (AZT, 3TC and NVP). The patient developed a clinical picture of generalised cutaneous eruption that disappeared following the replacement of the riphampicine by etambutol. Due to the persistence of the mass of soft parts following five weeks of anti-tuberculosis treatment, we proceeded to surgical draining of the abscess. The subsequent evolution was favourable, with the patient remaining asymptomatic one month after hospital discharge.
Assuntos
Abscesso/complicações , Infecções por HIV/complicações , Osteólise/complicações , Tuberculose/complicações , Adulto , Feminino , Febre/etiologia , Humanos , Derrame Pleural/etiologia , Tuberculose/diagnósticoRESUMO
Presentamos el caso de una paciente de 28 años que consultó por fiebre de hasta 40,8ºC, dolor pleurítico en costado derecho y aparición de una masa dolorosa en la extremidad inferior izquierda de cuatro días de evolución. Mediante tomografía axial computerizada (TAC) se objetivó la existencia de una condensación en el lóbulo medio del pulmón derecho con derrame pleural asociado y patrón miliar bilateral. El estudio ecográfico de la extremidad inferior izquierda mostró una masa de partes blandas de aspecto quístico con destrucción de la cortical del peroné y destrucción ósea. La resonancia magnética confirmó la presencia de osteomielitis en el peroné izquierdo y de un absceso de partes blandas asociado. En el material obtenido por punción del citado absceso así como en tres muestras de esputo se aisló Mycobacterium tuberculosis, estableciéndose el diagnóstico de tuberculosis diseminada con afectación pulmonar miliar, osteomielitis peronea y absceso tuberculoso de partes blandas. Se inició tratamiento antituberculoso (rifampicina, isoniacida y pirazinamida) seguido, dos semanas después, de tratamiento antirretroviral (AZT, 3TC y NVP). La paciente desarrolló un cuadro de erupción cutánea generalizada que desapareció tras la sustitución de la rifampicina por etambutol. Ante la persistencia de la masa de partes blandas, tras cinco semanas de tratamiento antituberculoso se procedió al drenaje quirúrgico del absceso. La evolución posterior fue favorable, permaneciendo la paciente asintomática al mes de ser dada de alta
We present the case of a 28 year old patient who came for consultation on a fever of up to 40.8º C, pleuritic pain on the right side and the appearance of a painful mass in the lower left extremity of four days evolution. Computerised axial tomography (CAT) showed the existence of a condensation in the middle lobe of the right lung with associated pleural effusion and bilateral miliary pattern. The echographic study of the lower left extremity showed a mass of soft parts with a cystic aspect with destruction of the cortical of the fibula and osseous destruction. Magnetic resonance confirmed the presence of osteomyelitis in the left fibula and of an abscess; Mycobacterium tuberculosis was also isolated in three samples of sputum that led to a diagnosis of disseminated tuberculosis with miliary lung affectation, peroneous osteomyelitis and tuberculous abscess of the soft parts. Anti-tuberculosis treatment was started (riphampicine, isoniacide and pirazinamide) followed, two weeks later, with antiretroviral treatment (AZT, 3TC and NVP). The patient developed a clinical picture of generalised cutaneous eruption that disappeared following the replacement of the riphampicine by etambutol. Due to the persistence of the mass of soft parts following five weeks of anti-tuberculosis treatment, we proceeded to surgical draining of the abscess. The subsequent evolution was favourable, with the patient remaining asymptomatic one month after hospital discharge
Assuntos
Feminino , Adulto , Humanos , Infecções por HIV/complicações , Tuberculose/diagnóstico , Febre/etiologia , Mycobacterium tuberculosis/isolamento & purificação , Derrame Pleural/etiologia , Osteomielite/etiologia , Antituberculosos/administração & dosagem , Abscesso/cirurgia , Infecções Oportunistas Relacionadas com a AIDSRESUMO
La tuberculosis es un claro ejemplo de infección que requiere la inmunidad celular para su control. La extensión en todo el mundo de la epidemia por el virus de inmunodeficiencia humana (VIH) permitió que su interacción con la tuberculosis modificase la curva de descenso de esta última enfermedad en algunos países desarrollados y que, en otros con pocos recursos económicos y sanitarios que ya sufrían una elevada endemia tuberculosa, dicho problema se agravase. El VIH incrementa el riesgo de reactivación de infección tuberculosa latente y acelera la progresión después de la infección o de la reinfección; por otra parte, la enfermedad tuberculosa agrava el pronóstico de los pacientes infectados por VIH. En este trabajo se exponen los aspectos diferenciales existentes en la clínica de la tuberculosis entre poblaciones infectadas por el VIH y no infectadas; también se comentan algunas características especiales respecto al tratamiento de la tuberculosis en pacientes VIH. Con excepción de las infecciones cutáneas primarias producidas por inoculación accidental y las linfadenitis infantiles, la mayoría de los casos de enfermedad por micobacterias no tuberculosas (MNT) afectan a pacientes con ciertos factores predisponentes. En el caso concreto de los pacientes con sida, el profundo trastorno inmunológico provocado por el VIH comporta una particular susceptibilidad a padecer enfermedad invasiva por determinadas MNT, principalmente M. avium complex y M. kansasii
Tuberculosis is a clear example of infection that requires cellular immunity for its control. The spread throughout the world of the Human Immunodeficiency Virus (HIV) resulted in its interaction with tuberculosis altering the descending curve of the latter disease in some developed countries, and brought an aggravation of the problem in other countries with few economic and health resources and where tuberculosis was endemic. HIV increases the risk of reactivation of latent tuberculosis infection and accelerates progression after infection or reinfection; on the other hand, TB aggravates the prognosis of patients infected with HIV. This article sets out the differential aspects in the clinical manifestations of TB amongst populations with and without HIV infection; we also comment on some special characteristics in the treatment of tuberculosis in HIV patients. With the exception of primary cutaneous infections produced by accidental inoculation and infantile lymphadenitis, the majority of the cases of disease due to non-tuberculosis mycobacteria (NTM) affect patients with certain predisposing factors. In the case of patients with AIDS, the deep immunological disorder provoked by HIV brings a particular susceptibility to suffering invasive disease due to certain NTM, principally M. avium complex and M. kansasii
Assuntos
Masculino , Feminino , Humanos , Tuberculose/complicações , Tuberculose/diagnóstico , Tuberculose/tratamento farmacológico , HIV/imunologia , HIV/patogenicidade , Síndrome da Imunodeficiência Adquirida/complicações , Síndrome da Imunodeficiência Adquirida/diagnóstico , Mycobacterium tuberculosis/imunologia , Mycobacterium tuberculosis/isolamento & purificação , Claritromicina/uso terapêutico , Tuberculose/prevenção & controle , Imunidade Celular/imunologia , Imunidade Celular/fisiologia , Mycobacterium avium/isolamento & purificação , Mycobacterium avium/patogenicidade , Mycobacterium kansasii , Terapia Antirretroviral de Alta Atividade/tendências , Terapia Antirretroviral de Alta Atividade , Infecções por Mycobacterium/complicaçõesRESUMO
The generally indolent, slow and protracted course of hepatitis C virus infection has limited the realisation of studies that evaluate its natural history. The aim of such studies has been the probability of death through hepatic disease, hepatic cirrhosis (compensated or decompensated), and/or hepatocarcinoma, or the development of a significant hepatic fibrosis (essential anatamopathological substrate for the development of the complications of hepatic cirrhosis). In spite of their possible limitations, the results of these studies show that chronic hepatitis C virus infection generally follows a benign evolutionary course, above all if this occurs in young patients (<50 years of age), without other aggravating factors of a possible hepatopathy (alcohol, coinfection by other viruses, immunosuppression) and if this is evaluated in the first 10-20 years of infection. At present, it is not possible to identify with precision those patients with HCV infection with a greater risk of developing a clinically relevant hepatic disease. However, it is likely that those subjects with high transaminases (> 2 times the normal value) and significant necroinflammatory activity (periportal necrosis) and fibrosis in the hepatic biopsy will show a more aggressive evolutionary course than those with normal transaminases and an almost normal hepatic biopsy.
Assuntos
Hepatite C , Estudos Transversais , Progressão da Doença , Hepatite C/complicações , Hepatite C/diagnóstico , Humanos , Cirrose Hepática/etiologia , Estudos Prospectivos , Estudos RetrospectivosRESUMO
El único tratamiento curativo bien documentado para la leucemia mieloide crónica en la infancia es el trasplante de precursores hematopoyéticos alogénico. Para los pacientes que recaen, una buena opción terapéutica es un segundo trasplante. Se debe considerar en aquellos casos que recaen tras más de 12 meses postrasplante evitando regímenes de acondicionamiento excesivos. Presentamos un caso de un paciente que recibió un segundo trasplante de precursores hematopoyéticos alogénico ante una recaída tardía de su enfermedad, consiguiéndose una remisión clínica y citogenética mantenida tras 7,5 años del mismo (AU)
Assuntos
Masculino , Criança , Humanos , Leucemia Mielogênica Crônica BCR-ABL Positiva/cirurgia , Transplante de Medula Óssea , Hepatomegalia/etiologia , Esplenomegalia/etiologia , Leucocitose/etiologia , Intervalo Livre de Doença , RecidivaAssuntos
Ascite/cirurgia , Derivação Portossistêmica Transjugular Intra-Hepática/normas , Ascite/fisiopatologia , Ascite/prevenção & controle , Ensaios Clínicos como Assunto , Humanos , Derivação Portossistêmica Transjugular Intra-Hepática/métodos , Complicações Pós-Operatórias , Prevenção SecundáriaRESUMO
El curso generalmente indolente, lento y prolongado de la infección por el virus de la hepatitis C ha limitado la realización de estudios que valoren su historia natural. Dichos estudios han tenido como objetivo la probabilidad de muerte por enfermedad hepática, cirrosis hepática (compensada o descompensada) y/o hepatocarcinoma, o el desarrollo de una fibrosis hepática importante (substrato anatomopatológico indispensable para el desarrollo de las complicaciones de la cirrosis hepática). A pesar de sus posibles limitaciones, los resultados de estos estudios demuestran que la infección crónica por VHC sigue generalmente un curso evolutivo benigno, sobre todo si ésta acontece en pacientes jóvenes (2 veces el valor normal) e importante actividad necroinflamatoria (necrosis periportal) y fibrosis en la biopsia hepática presenten un curso evolutivo más agresivo que aquellos con transaminasas normales y biopsia hepática casi normal (AU)
Assuntos
Adulto , Masculino , Pessoa de Meia-Idade , Humanos , Hepatite C/diagnóstico , Hepatite C/complicações , Hepatite C/terapia , História Natural/métodos , Carcinoma/complicações , Carcinoma/diagnóstico , Hepatopatias/complicações , Hepatopatias/diagnóstico , Hepatopatias/terapia , Fibrose/complicações , Fibrose/diagnóstico , Transaminases/análise , Transaminases , Estudos Transversais , Estudos Retrospectivos , Estudos Prospectivos , Hemocromatose/complicações , Esquistossomose/complicaçõesRESUMO
The effect of low levels of pollution on the growth, reproduction output, morphology and survival of adult sponges and settlers of the sponge Crambe crambe were examined. We transplanted sponges from a control area to a contaminated site and measured the main environmental variables (chemical and physical) of both sites during the study period. Except some punctual differences in particulate organic matter, silicates, nitrates, and water motion, most environmental variables in the water were similar at both sites during the study months. Mainly copper, lead and OM concentrations in the sediment, and water motion were significantly higher at the polluted site and may be implicated in the biological effects observed: decrease in the percentage of specimens with embryos, increase in shape irregularity and decrease in growth rate. Individuals naturally occurring at the polluted site and those transplanted there for four months accumulated ten times more copper than either untouched or transplant controls. Although lead concentration in sediment did not differ between sites, native specimens from the contaminated site accumulated this metal more than untouched controls. Vanadium concentration also tended to increase in the sponges living at or transplanted to the contaminated site but this difference was not significant. C. crambe is a reliable indicator of metal contamination since it accumulates copper, lead and vanadium in high amounts. At the contaminated site, sponge growth, fecundity and survival were inhibited, whereas sponge irregularity ending in sponge fission was promoted. All these effects may compromise the structure and dynamics of the sponge populations in sheltered, metal-contaminated habitats.
Assuntos
Sedimentos Geológicos/análise , Metais Pesados/toxicidade , Poríferos/efeitos dos fármacos , Poríferos/fisiologia , Animais , Mar Mediterrâneo , Reprodução/efeitos dos fármacos , Poluição Química da ÁguaRESUMO
BACKGROUND: The complications of varicella are one of the arguments in favor of universal vaccination programs in children. OBJECTIVE: To describe the complications of varicella requiring hospital admission in a well-defined population (Gipuzkoa, Spain) and to compare the incidence of hospitalization with that reported in other series. MATERIAL AND METHODS: Observational, retrospective, multicenter study of admissions for varicella. The medical histories codified as varicella (minimum data set, CIE-0, codes 952.0-052.9) from 1 January 1993 to 31 December 2002 were reviewed. Calculation of hospitalization rates was based on emergency department visits and population data. The pediatric population of Gipuzkoa seeking medical attention at one of the four Basque Country Health Service hospitals in the area: Hondarribia, Mendaro, San Sebastian and Zumarraga. The mean coverage in Gipuzkoa is 54,999 children aged less than 15 years/year. All the children aged 0-15 years old admitted for more than 24 h with a discharge diagnosis of varicella complications. The variables studied are: age, gender, personal history, varicella immunization, immune status, fever, chest X-ray, complementary investigations, length of hospital stay, treatment, discharge diagnosis, clinical course, complications and sequelae at discharge. RESULTS: Seventy-one children were hospitalized. None had been vaccinated against the varicella-zoster virus. Eighty percent were aged less than 5 years and three were immunocompromised. Fifty-six percent had bacterial superinfection and invasive forms were found in seven patients. The mean length of admission was 6.5 days +/- 5.1. No deaths or sequelae were reported. CONCLUSIONS: The annual incidence rate of admissions longer than 24 hours due to varicella complications was 12.9 cases per 100,000 children aged less than 15 years, representing 0.31% of all annual admissions in this age group.
Assuntos
Infecções Bacterianas/etiologia , Varicela/complicações , Varicela/reabilitação , Doenças Hematológicas/etiologia , Doenças do Sistema Nervoso/etiologia , Adolescente , Infecções Bacterianas/epidemiologia , Varicela/epidemiologia , Criança , Pré-Escolar , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Doenças Hematológicas/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Masculino , Doenças do Sistema Nervoso/epidemiologia , Estudos Retrospectivos , Espanha/epidemiologiaRESUMO
Antecedentes Las complicaciones por varicela se consideran una de las indicaciones que apoyan la cobertura vacunal universal. Objetivo Describir las complicaciones por varicela que han precisado hospitalización en una población definida (Guipuzkoa, España) y comparar la incidencia de hospitalizaciones con otras series. Material y métodos Estudio multicéntrico, retrospectivo, observacional, por revisión de historias clínicas, codificadas como varicela (CMBD, CIE-9, códigos 052.0-052.9) desde 1 de enero de 1993 a 31 de diciembre de 2002, y cálculo de las tasas de hospitalización en base a las urgencias asistidas y a los datos poblacionales. Población infantil de Guipuzkoa (España) asistida en el ámbito geográfico de los servicios de pediatría de los hospitales de agudos de Osakidetza-Servicio Vasco de Salud de Hondarribia, Mendaro, San Sebastián y Zumárraga, con una cobertura poblacional media de 54.999 niños menores de 15 años por año. Todos los niños y niñas de 0 a 15 años de edad, hospitalizados más de 24 h con el diagnóstico de varicela complicada. Se estudiaron las siguientes variables: edad, sexo, antecedentes personales, vacuna antivaricela, estado inmunológico, fiebre, radiografía de tórax, exámenes complementarios, duración del ingreso, tratamiento, diagnósticos de alta, evolución, complicaciones y secuelas al alta. Resultados Ingresaron 71 niños no vacunados frente al virus varicela-zoster, 80 por ciento menores de 5 años de edad, 68 inmunocompetentes y 3 no inmunocompetentes. Han predominado las sobreinfecciones bacterianas (56 por ciento) y destacan 7 casos con enfermedad invasiva. La estancia media ha sido de 6,50 5,15 día, sin mortalidad y sin secuelas. Conclusiones La incidencia anual de ingresos hospitalarios por varicela complicada superiores a 24 h ha sido 12,90 casos por cada 100.000 menores de 15 años, lo cual representa el 0,31 por ciento de los ingresos anuales hospitalarios en ese grupo (AU)
Assuntos
Pré-Escolar , Criança , Adolescente , Masculino , Recém-Nascido , Lactente , Feminino , Humanos , Espanha , Doenças do Sistema Nervoso , Estudos Retrospectivos , Infecções Bacterianas , Varicela , Hospitalização , Serviços Médicos de Emergência , Doenças HematológicasRESUMO
Se presenta la experiencia en el manejo de pacientes altamente sensibilizadas por incompatibilidad Rh, analizando la utilidad de la evaluación de la velocidad circulatoria fetal, por Doppler-color, a través de la medición de la velocidad máxima sistólica (VMS) de la arteria cerebral media (ACM). Se realizan 19 transfusiones intravasculares en 3 casos afectados por esta enfermedad. En 14 de ellas se encontró anemia fetal moderada o leve, la que fue diagnosticada correctamente en 13 oportunidades, (92,8 por ciento) por la medición anteriormente señalada. Se encuentra una adecuada correlación entre la velocidad máxima sistólica de la arteria cerebral media y el grado de anemia fetal moderada o severa, con un índice correlacional (r= (_) 0,78). Se destaca el beneficio de un método no invasivo en el manejo de la anemia fetal de causa inmunológica o asociada a otras condiciones mórbidas y se abre un campo para futuras investigaciones.
Assuntos
Feminino , Gravidez , Anemia Hemolítica/etiologia , Anemia Hemolítica/terapia , Doenças Fetais , Isoimunização Rh/complicações , Isoimunização Rh/terapia , Artéria Cerebral Média , Ultrassonografia Doppler em Cores , Complicações na GravidezAssuntos
Endocardite Bacteriana/microbiologia , Infecções por HIV/complicações , Infecções por Klebsiella/microbiologia , Klebsiella/isolamento & purificação , Complicações Pós-Operatórias/microbiologia , Adulto , Bioprótese , Cefotaxima/uso terapêutico , Diuréticos/uso terapêutico , Quimioterapia Combinada/uso terapêutico , Endocardite Bacteriana/tratamento farmacológico , Endocardite Bacteriana/etiologia , Endocardite Bacteriana/cirurgia , Gentamicinas/uso terapêutico , Próteses Valvulares Cardíacas , Hepatite C Crônica/complicações , Humanos , Hospedeiro Imunocomprometido , Klebsiella/classificação , Infecções por Klebsiella/tratamento farmacológico , Infecções por Klebsiella/etiologia , Masculino , Complicações Pós-Operatórias/tratamento farmacológico , Valva Pulmonar , Infecções Estafilocócicas/complicações , Infecções Estafilocócicas/cirurgiaRESUMO
To assess the incidence, clinical course, predictive factors, and prognosis of renal failure in patients with cirrhosis and gastrointestinal bleeding, 175 consecutive episodes of gastrointestinal bleeding in 161 patients were analyzed. Renal failure occurred in 20 (11%) episodes and was transient in 8 episodes and nontransient in 12. Renal failure was more common in patients with cirrhosis than in a control population of bleeding patients without cirrhosis matched by age and severity of the bleeding episode. Among 39 clinical and laboratory variables obtained at admission or during hospitalization related with the bleeding episode or with liver and renal function, the presence of hypovolemic shock, number of packed red blood cells transfused, Child-Pugh class at admission, and baseline platelet count were independent predictors of renal failure. The development of renal failure and hypovolemic shock was the only independent predictors of in-hospital mortality. Mortality rate among the 20 episodes with renal failure was 55% (11 deaths) as compared with only 3% (5 deaths) in the 155 episodes without renal failure (P <.01). The development of nontransient renal failure entailed a much greater mortality as compared with transient renal failure (10 of 12 [83%] vs. 1 of 8 [12%]; P <.01). In conclusion, renal failure is a common event in patients with cirrhosis and gastrointestinal bleeding, the occurrence of which is mainly related to the severity of bleeding and baseline liver function. Renal failure is a strong predictor of mortality in patients with cirrhosis and gastrointestinal bleeding.
Assuntos
Hemorragia Gastrointestinal/complicações , Cirrose Hepática/complicações , Insuficiência Renal/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prognóstico , Insuficiência Renal/epidemiologia , Insuficiência Renal/mortalidadeRESUMO
BACKGROUND/AIMS: Parameters evaluating renal function and systemic hemodynamics are of prognostic significance in cirrhosis with ascites but are rarely used in the evaluation of survival of these patients. The aim of the current study was to develop a prognostic model to estimate survival of patients with cirrhosis and ascites. METHODS: 216 Cirrhotic patients admitted to hospital for the treatment of ascites were evaluated. Thirty-two demographic, clinical and laboratory variables, including parameters assessing liver and renal function and systemic hemodynamics, were analyzed as predictive factors of survival by using a Cox regression model. RESULTS: Four variables had independent prognostic value: renal water excretion, as assessed by measuring diuresis after water load, mean arterial pressure, Child-Pugh class, and serum creatinine. According to these features a prognostic index was calculated that allows to estimate survival in patients with cirrhosis and ascites. The model accurately predicted survival in an independent series of 84 patients with cirrhosis and ascites. CONCLUSION: A prognostic model that uses four easily available variables and predicts prognosis in cirrhotic patients with ascites has been developed. This model may be useful in the evaluation of patients with ascites for liver transplantation.
Assuntos
Ascite/mortalidade , Cirrose Hepática/mortalidade , Feminino , Humanos , Transplante de Fígado , Masculino , Pessoa de Meia-Idade , Modelos Biológicos , Prognóstico , Estudos RetrospectivosRESUMO
De novo hepatitis B virus (HBV) infection after orthotopic liver transplantation (OLT) is commonly believed to be a relatively benign condition, in contrast to post-OLT infection recurrence, considered a very aggressive complication. We reviewed the charts of 569 non-HBV-related OLTs performed at our institution and identified 19 patients (3%) with de novo HBV infection (appearance of hepatitis B surface antigen [HBsAg] after OLT). After a median follow-up of 25 months beyond the detection of HBsAg, 12 patients (63%) had developed serious HBV-related graft damage (cirrhosis in 6 patients, bridging chronic hepatitis in 4 patients, and fulminant hepatitis in 2 patients); 7 patients (37%) had lost their grafts; and 4 patients (21%) had died. All graft losses and deaths were related to de novo HBV infection. Similar rates of severe graft damage (62%), graft loss (38%), and death (33%) related to HBV infection were found in a concomitant series of 21 patients with recurrent HBV infection after OLT. Responses to antiviral therapy (interferon or lamivudine) were also similar in the 2 groups of patients. In 12 patients with de novo HBV infection, evidence of past HBV infection (positive serum antibody to hepatitis B core antigen and/or serum or liver tissue HBV DNA) were detected in the donor (7 patients) or recipient (5 patients). No differences were observed in the clinical course after stratification according to the attributed origin of de novo HBV infection. We conclude that de novo HBV infection after OLT is associated with high rates of morbidity and mortality, similar to those described for post-OLT HBV infection recurrence.
Assuntos
Hepatite B/patologia , Transplante de Fígado , Fígado/patologia , Fígado/virologia , Adulto , Feminino , Rejeição de Enxerto/virologia , Hepatite B/complicações , Hepatite B/etiologia , Hepatite B/mortalidade , Humanos , Cirrose Hepática/patologia , Cirrose Hepática/virologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Doadores de TecidosRESUMO
BACKGROUND/AIM: Ornipressin, a vasopressin analog with potent splanchnic vasoconstrictor action, has been shown to reverse hepatorenal syndrome. However, its usefulness in clinical practice is limited by frequent ischemic complications. The aim of this study was to assess the efficacy of terlipressin, an analog of vasopressin with a low profile of side effects, plus albumin in this condition. METHODS: Nine consecutive patients with cirrhosis and hepatorenal syndrome were included in a pilot study of terlipressin (0.5-2 mg/4 h i.v.) therapy associated with iv albumin. RESULTS: Treatment (9 days, range 5-15) was associated with a marked reduction of serum creatinine (3.9+/-0.7 to 1.3+/-0.1 mg/dl, p<0.001, mean+/-SE). Reversal of hepatorenal syndrome (reduction of creatinine below 1.5 mg/dl) was observed in seven of the nine patients. There was a remarkable improvement in circulatory function, with an increase in mean arterial pressure (68+/-2 to 80+/-4 mmHg, p<0.05) and suppression of vasoconstrictor systems activity (plasma renin activity and plasma norepinephrine decreased from 23+/-12 ng/ml x h and 1549+/-373 pg/ml to 3.5+/-2 ng/ml x h and 373+/-98 pg/ml, respectively, p<0.01 for both). No patient developed signs of intestinal, myocardial or distal ischemia. CONCLUSIONS: Terlipressin associated with albumin appears to be a safe and effective treatment of hepatorenal syndrome.
Assuntos
Síndrome Hepatorrenal/tratamento farmacológico , Lipressina/análogos & derivados , Lipressina/uso terapêutico , Albumina Sérica/uso terapêutico , Vasoconstritores/uso terapêutico , Adulto , Idoso , Pressão Sanguínea/efeitos dos fármacos , Creatinina/sangue , Quimioterapia Combinada , Feminino , Seguimentos , Síndrome Hepatorrenal/sangue , Síndrome Hepatorrenal/fisiopatologia , Humanos , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Norepinefrina/sangue , Projetos Piloto , Renina/sangue , TerlipressinaAssuntos
Síndrome Hepatorrenal/terapia , Transplante de Fígado , Lipressina/análogos & derivados , Vasoconstritores/uso terapêutico , Fibrose/terapia , Síndrome Hepatorrenal/diagnóstico , Síndrome Hepatorrenal/fisiopatologia , Homeostase/fisiologia , Humanos , Lipressina/administração & dosagem , Lipressina/uso terapêutico , Valor Preditivo dos Testes , Terlipressina , Vasoconstritores/administração & dosagemRESUMO
Introducción. La Comisión de Infección Hospitalaria, Higiene Hospitalaria y Política de antibióticos (CI), es fundamental en todos los hospitales, con un papel muy definido y orientado a la vigilancia de la infección hospitalaria o nosocomial, incluyendo las comunitarias y la política de antibióticos. El objetivo del presente trabajo es elaborar un documento de consenso sobre el papel de las CI. Material y métodos. Sobre la base de un documento inicial, se recogen diversos puntos de vista de los responsables de las CI de los 5 hospitales del Servicio Navarro de Salud-Osasunbidea. Todos ellos implicados en el tema, clínicos dedicados a enfermedades infecciosas: especialistas en Medicina Preventiva, Infecciosas, Medicina Interna y Medicina Intensiva. Resultados. Se redacta un documento que intentar dar respuesta a un tema de tanta trascendencia para la sanidad de Navarra. Alcanza un consenso entre todos los especialistas que trabajan en infección nosocomial, sobre un programa común que sirva de marco general de actuación, preservando las competencias específicas de cada una de las especialidades indicadas. La función fundamental de la CI es asesorar a la dirección de los hospitales. A este respecto la composición de la misma debe garantizar la independencia con respecto a los órganos de Dirección del Hospital. Conclusión. La denominación actual debe ser CI y Política de antibióticos. Sería deseable la existencia de una estructura médica, dedicada a la asesoría científico-técnica en materia de infección hospitalaria, en el ámbito de la Comunidad de Navarra, y que establezca las directrices de los Programas de Vigilancia y Control de la infección en los hospitales del Servicio Navarro de Salud-Osasunbidea. Su puesta en práctica requiere el concurso de todos los servicios del hospital (AU)