RESUMO
Acute-on chronic liver failure (ACLF) has been an intensively debated topic mainly due to the lack of a unified definition and diagnostic criteria. The growing number of publications describing the mechanisms of ACLF development, the progression of the disease, outcomes and treatment has contributed to a better understanding of the disease, however, it has also sparked the debate about this condition. As an attempt to provide medical professionals with a more uniform definition that could be applied to our population, the first Mexican consensus was performed by a panel of experts in the area of hepatology in Mexico. We used the most relevant and impactful publications along with the clinical and research experience of the consensus participants. The consensus was led by 4 coordinators who provided the most relevant bibliography by doing an exhaustive search on the topic. The entire bibliography was made available to the members of the consensus for consultation at any time during the process and six working groups were formed to develop the following sections: 1.- Generalities, definitions, and criteria, 2.- Pathophysiology of cirrhosis, 3.- Genetics in ACLF, 4.- Clinical manifestations, 5.- Liver transplantation in ACLF, 6.- Other treatments.
RESUMO
AIM: The aim of this study was to assess the effects of the molecular absorbent recirculating system (MARS) on patients with acute liver failure (ALF) and liver failure with cirrhosis (AoCLF) as well as in cholestatic patients with intractable pruritus in a Mexican population. MATERIAL AND METHODS: From August 2003 to December 2011, MARS was used in 38 patients with ALF, 15 patients with AoCLF, and 17 cholestatic patients with intractable pruritus. The patients were examined using a standard liver function test and for vital signs, presence of ascites and encephalopathy before and after each treatment. The therapeutic response, patient status, follow-up status, and need for liver transplantation were determined. RESULTS: Seventy-nine MARS procedures were performed. MARS was used for ALF in 54.3% of patients, AoCLF in 24.2%, and cholestatic disease in 21.5%. There were significant improvements in serum bilirubin (p = 0.000), aspartate aminotransferase (p = 0.000), alanine aminotransferase (p = 0.030), gamma-glytamyl transpeptidase (p = 0.044), alkaline phosphatase (p = 0.006), and encephalopathy grade (p = 0.000). Thirty-eight ALF patients were listed for emergency liver transplantation and treated with MARS; 20 of these patients died on a waiting list, 18 survived. only four underwent liver transplantation and 14 (37%) recovered without transplantation after the MARS procedure. CONCLUSION: MARS is a safe and effective procedure, especially for ALF patients. Our results suggest that MARS therapy can contribute to native liver recovery in ALF patients.
Assuntos
Colestase/terapia , Circulação Extracorpórea/métodos , Sistemas de Manutenção da Vida/instrumentação , Cirrose Hepática/terapia , Falência Hepática Aguda/terapia , Adulto , Colestase/epidemiologia , Colestase/fisiopatologia , Feminino , Seguimentos , Encefalopatia Hepática/epidemiologia , Humanos , Incidência , Fígado/enzimologia , Fígado/fisiopatologia , Cirrose Hepática/epidemiologia , Cirrose Hepática/fisiopatologia , Falência Hepática Aguda/epidemiologia , Falência Hepática Aguda/fisiopatologia , Transplante de Fígado , Masculino , México/epidemiologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Listas de EsperaRESUMO
Content available: Author Interview and Audio Recording.
RESUMO
Infection by hepatitis C virus constitutes an important health problem in Mexico. Diagnosis of high-risk population is essential given the probability of developing chronic disease, cirrhosis and cirrhosis decompensation, likely leading to the need of a liver transplant and/or the development of hepatocellular carcinoma. Currently, the standard of care (SOC) treatment includes pegylated interferon and ribavirin, which have shown an approximately 57% rate response in genotype 1, the most prevalent in Mexico. It is known that between 30 and 60% of the infected population does not show a sustained virological response or cure. Therefore, in this article, we review existing therapeutic strategies in order to optimize the treatment. Future treatment strategies are also described. Eventually, it will be possible to add one or two molecules of the new directly acting antiviral drugs, to the SOC treatment. Each of them has a different action mechanism, and we are envisioning the possibility of an interferon-free therapy after 2015.
Assuntos
Antivirais/uso terapêutico , Hepatite C/tratamento farmacológico , Antivirais/classificação , Antivirais/farmacologia , Desenho de Fármacos , Quimioterapia Combinada , Previsões , Predisposição Genética para Doença , Genótipo , Hepacivirus/efeitos dos fármacos , Hepacivirus/genética , Hepatite C/cirurgia , Interações Hospedeiro-Patógeno , Humanos , Interferons/efeitos adversos , Interferons/classificação , Interferons/uso terapêutico , Adesão à Medicação , Terapia de Alvo Molecular , Polimorfismo de Nucleotídeo Único , Medicina de Precisão , Padrão de Cuidado , Proteínas Virais/antagonistas & inibidoresRESUMO
BACKGROUND: Liver transplantation is the best treatment for end stage liver diseases. In April 2003, our institution started a Liver Transplantation Program for both pediatric and adults population. OBJECTIVE: Shown the results of the Liver Transplantation Program in the UMAE 25 Monterrey N.L. MATERIALS AND METHODS: This is a retrospective cohort study of patients with liver transplantation. RESULTS: A total of 51 liver transplantations have been done in 49 patients with two retrasplantation, 15 in children and 36 in adults. The principal indication for liver transplantation in children was biliary atresia and hepatitis C cirrhosis in adults. The acute renal failure was the main early complication, the acute cellular rejection in the mediate period, and the cardiovascular diseases as late complication related to obesity, metabolic syndrome, diabetes mellitus and hypertension. Overall survival at 1 and 5 years was 57.1 and 54.2%, respectively. During the first three years post-transplantation, the quality of life was good or very good. CONCLUSIONS: Although still a young and perfectible program, the effort of a multidisciplinary team has made possible to perform liver transplantation in two patient populations, pediatric and adults.
Assuntos
Transplante de Fígado/estatística & dados numéricos , Adulto , Criança , Estudos de Coortes , Feminino , Humanos , Transplante de Fígado/efeitos adversos , Masculino , México , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos RetrospectivosRESUMO
BACKGROUND AND AIM: To identify the geographic distribution of hepatitis C virus (HCV) genotypes and HCV RNA viral load in a large number of HCV-infected carriers in Mexico. METHODS: Patients with chronic hepatitis C (n = 8,802) were studied to identify HCV genotype using an immune line probe assay in samples shown previously to be positive for viral RNA by an RT-PCR test. Baseline HCV RNA was also evaluated. RESULTS: Genotype 1 accounted for 70.3%, genotype 2 for 21.8%, genotype 3 for 7.2%, genotype 4 for 0.3%, and genotype 5 for 0.1% of all cases; coinfection was present in 0.3%. Overall, Genotype 1 was the most prevalent Genotype. Regionally, genotype 1 occurred more frequently in the North-East, North, and Center- East regions of Mexico; genotype 2 was more prevalent in the South, East, and Peninsula regions; and genotype 3 was more prevalent in the North and North-West regions. Only 22.4% of patients with genotype 1 were classified in the low HCV RNA viral load category, and the distribution of this genotype did not differ significantly between regions. CONCLUSION: The prevalence of HCV genotypes and viral load in Mexico was 70.3% for genotype 1, but only 22.4% of these patients had a low HCV viral load. Distribution was not uniform in Mexico, with greater frequency of genotype 2 in South, East and Peninsula Regions and Genotype 3 in North and North-West Regions.
Assuntos
Hepacivirus/genética , Hepatite C Crônica/epidemiologia , RNA Viral/sangue , Carga Viral/genética , Feminino , Genótipo , Hepatite C Crônica/sangue , Heterozigoto , Humanos , Masculino , México/epidemiologia , Prevalência , Estudos RetrospectivosAssuntos
Antivirais/uso terapêutico , Hepacivirus/efeitos dos fármacos , Hepatite C Crônica/diagnóstico , Hepatite C Crônica/tratamento farmacológico , Fatores Etários , Antivirais/efeitos adversos , Coinfecção , Consenso , Farmacorresistência Viral , Genótipo , Infecções por HIV/diagnóstico , Infecções por HIV/epidemiologia , Infecções por HIV/terapia , Hepacivirus/genética , Hepatite C Crônica/epidemiologia , Humanos , Transplante de Fígado/efeitos adversos , México/epidemiologia , Valor Preditivo dos Testes , Fatores de Risco , Resultado do TratamentoRESUMO
La hepatitis por virus C constituye un problema de salud importante en México. El diagnóstico de poblaciones de alto riesgo es esencial dada la probabilidad de desarrollar enfermedad crónica, cirrosis, descompensación de la cirrosis y la consecuente necesidad de un trasplante hepático o de desarrollar carcinoma hepatocelular. Actualmente, el tratamiento de elección establecido (TEE) incluye interferón pegilado y ribavirina, los cuales han mostrado una tasa de respuesta de alrededor de 57 por ciento en el caso del genotipo 1, el más prevalente en México. Sabemos que entre 30 y 60 por ciento de la población no muestra una respuesta viral sostenida (RVS) o curación. Por lo tanto, en este artículo se revisan las estrategias terapéuticas existentes para optimizar el tratamiento, y se describen también las estrategias de tratamiento para el futuro. Eventualmente, será posible adicionar una o dos moléculas de los nuevos antivirales que actúan directamente (AAD) sobre áreas específicas del virus al TEE. Cada una de ellas cuenta con mecanismo de acción diferente y se está contemplando la posibilidad de una terapéutica libre de interferón después del año 2015.
Infection by hepatitis C virus constitutes an important health problem in Mexico. Diagnosis of high-risk population is essential given the probability of developing chronic disease, cirrhosis and cirrhosis decompensation, likely leading to the need of a liver transplant and/or the development of hepatocellular carcinoma. Currently, the standard of care (SOC) treatment includes pegylated interferon and ribavirin, which have shown an approximately 57 percent rate response in genotype 1, the most prevalent in Mexico. It is known that between 30 and 60 percent of the infected population does not show a sustained virological response or cure. Therefore, in this article, we review existing therapeutic strategies in order to optimize the treatment. Future treatment strategies are also described. Eventually, it will be possible to add one or two molecules of the new directly acting antiviral drugs, to the SOC treatment. Each of them has a different action mechanism, and we are envisioning the possibility of an interferon-free therapy after 2015.
Assuntos
Humanos , Antivirais/uso terapêutico , Hepatite C/tratamento farmacológico , Antivirais/classificação , Antivirais/farmacologia , Desenho de Fármacos , Quimioterapia Combinada , Previsões , Predisposição Genética para Doença , Genótipo , Hepacivirus/efeitos dos fármacos , Hepacivirus/genética , Hepatite C/cirurgia , Interações Hospedeiro-Patógeno , Medicina de Precisão , Interferons/efeitos adversos , Interferons/classificação , Interferons/uso terapêutico , Adesão à Medicação , Terapia de Alvo Molecular , Polimorfismo de Nucleotídeo Único , Padrão de Cuidado , Proteínas Virais/antagonistas & inibidoresRESUMO
"Área de Estudio: Ciencias de la Salud Propósito y Método de Estudio: Los pacientes que son sometidos a trasplante Hepático por cirrosis por virus de Hepatitis C, presentan de manera universal recidiva de la infección por el VHC, con una característica fundamental, fibrosis acelerada con rápida progresión a hepatopatía grave e irreversible. Sin embargo los factores involucrados en las fibrosis aceleradas del injerto en éstos pacientes nunca habían sido investigados. El TGFo3 es la citoquina más importante en el desarrollo del proceso fibrogénico, al favorecer la fibrogénesis a través de su efecto estimulador sobre las células estrelladas, aumentando los niveles del RNAm del procolágeno tipo 1, además de inhibir los procesos colagenolíticos. Distintos estudios fn vitro han sugerido que los dos inmunosupresores fundamentales en el trasplante hepático. La Ciclosporina y el Tacrolimus , tienen efectos contrapuestos, Ciclosporina estimulando la producción de TGFp y Tacrolimus inhibiéndolo. Este posible efecto regulador de los inmunosupresores sobre el TGFp no había sido investigado en el trasplante hepático. Por lo que el objetivo general del presente estudio fue: Investigar la correlación de los niveles del RNAmTGFp y el grado de fibrosis en la recidiva del VHC postrasplante, y como objetivos específicos fueron. Determinar los niveles del RNamTGFp en tejido hepático en pacientes con trasplante hepático con recidiva de la hepatitis C y determinar el grado de fibrosis en los mismos pacientes estableciendo su correlación, así como investigar sí eí tipo de fármaco inmunosupresor fundamental: Ciclosporina o Tacrolimus, y sus dosis acumulativas determinan los niveles del RNAmTGFp en éstos pacientes, por lo que se realizó un estudio observacional analítico, trasversal comparativo incluyéndose tres poblaciones de pacientes, pacientes trasplantados y con recidiva de la hepatitis C, pacientes no trasplantados tanto portadores de cirrosis hepática por virus C, como de hepatitis crónica secundaria a virus C y pacientes controles determinándoseles en muestras de tejido el RNAmTGFp ,por RT-PCR y realizando una PCR sem¡cuantitativa para la obtención de los resultados. Contribuciones y Conclusiones: Se encontró relación estadísticamente significativa entre el nivel del RNAmTGFp y el grado de fibrosis en la biopsia hepática. El RNAmTGFp se expresa más a mayor grado de fibrosis. El grado de expresión no depende del tipo de inmunosupresor empleado, ya que no existió diferencia significativa en la expresión del RNAmTGFp en relación al tipo de inmunosupresor usado. Así mismo se encontró mayor intensidad de expresión del RNAmTGFp en pacientes trasplantadas con recidiva C y fibrosis rápida que en los que tenían fibrosis lenta, lo cual nos dice que la expresión del RNAmTGFp es más intensa a mayor rapidez de progresión de la fibrosis. El índice de progresión de la fibrosis en los pacientes trasplantadas con recidiva de hepatitis C fue de 12 años en comparación de los 30 años que se han reportado en la literatura por Poynard el cual se encuentra en pacientes con hepatitis crónica C no inmunosuprimidos. EL TGFp juega un papel en la fibrosis del injerto en pacientes con trasplante hepático y recidiva C, no obstante ya que la intensidad de la expresión del TGFp en los pacientes trasplantados no difiere significativamente de la observada en los pacientes no trasplantados con hepatitis C, por lo que la gran rapidez de progresión de la fibrosis en los pacientes trasplantados con recidiva C , ha de ser debida a mecanismos no reflejados por el grado de expresión del TGFp , cabe sugerir que otros mecanismos profibrogénrcos están también activados y/o que los mecanismos colágeno Uticos están disminuidos para poder justificar la progresión acelerada del depósito de colágena en el injerto hepático en los pacientes con recidiva C postrasplante."(AU)