Differences in the incidence and clinical evolution of early neurotoxicity after liver transplantation based on tacrolimus formulation used in the immunosuppressive induction protocol.

INTRODUCTION: Posttransplant early calcineurin inhibitor (CNI)-induced neurotoxicity (ECIIN) was related to high CNI levels, among other factors. Minimizing exposure could modify its incidence or clinical evolution. OBJECTIVE: To compare the incidence, predisposing factors, and clinical evolution of ECIIN after immunosuppressive induction with low-dose tacrolimus-MR (Advagraf) or conventional dose tacrolimus (Prograf). PATIENTS AND METHODS: We matched 71 patients treated with an immunosuppression induction schedule with basiliximab and low doses of Advagraf (cases group) 1:1 by recipient age and indication for liver transplantation (OLT) with patients treated with a conventional tacrolimus regimen (control group). Baseline characteristics, liver and kidney function, operative technical characteristics, kidney function, and C0 tacrolimus levels at several time points after liver OLT were analyzed. RESULTS: There were 31 cases of ECIIN (21%), 14 in the cases group (20%) and 17 in the control group (24%; P < .001). The incidence of ECIIN was higher in alcoholic liver disease (odds ratio [OR], 8.2; 95% CI, 2.3-28.6; P < .001) and past history of encephalopathy (OR, 2.6; 95% CI, 1.16-5.9; P < .02). Among cases, the incidence of ECIIN was higher when encephalopathy signs were present at time of transplantation (36% vs 12%; P < .001). Control of ECIIN required a switch to cyclosporine therapy in all those in the cases group, whereas this was only needed for 9 cases in the control group (47%; P < .001). CONCLUSION: In this study, although the incidence rate of neurotoxicity induced by Advagraf was lower than the induced by Prograf, it did not respond to routine treatment and required a significantly higher rate of switch to cyclosporine for its control.

Maximizing the effect of biologics in inflammatory bowel disease.

The chronic course of inflammatory bowel disease (IBD) leads to recurrent episodes of active clinical symptoms, as well as long term complications, including hospitalizations, surgeries, and a decreased quality of life. Biologic agents have been shown to be effective for the induction and maintenance of remission in patients with moderate to severe IBD, and may alter the natural history of disease. Loss of response to biologic therapy is a common problem in clinical practice, the reasons for which are likely multifactorial; antibody development, alterations in drug clearance, and possibly a change to a non-TNF-driven inflammatory mechanism. Several studies have evaluated interventions that may lead to an increased rate of response and an increase in the durability. In this review, we evaluate ways to maximize anti-TNF treatment by administering scheduled therapy, using concomitant immunomodulator therapy, escalating dosage, and switching between biologic agents and classes. Finally, the role of antibody to infliximab (ATI) and infliximab serum trough levels are discussed in the context of optimizing biologic therapy for inflammatory bowel disease.

Percutaneous endoscopic suturing is an alternative treatment for persistent gastrocutaneous post-PEG fistula.

Persistent gastrocutaneous fistula after the removal of a gastrostomy tube is an unusual complication associated with percutaneous endoscopic gastrostomy (PEG). Surgical closure has been usually the treatment of choice. Several endoscopic methods have been previously attempted to close the fistula, usually with poor results. We report a successful case of percutaneous endoscopic suturing of a persistent gastrocutaneous post-PEG fistula, using a monofilament absorbable suture. A biopsy forceps was used to deepithelialize both ends of the fistulous tract to promote granulation tissue formation. The gastrocutaneous fistula closed completely after the procedure and there were no complications during the follow-up.