[Post-transplant lymphoproliferative disorders in renal transplantation: two decades of experience]. / Enfermedad linfoproliferativa postrasplante renal. Dos décadas de experiencia.

INTRODUCTION: Post-transplant lymphoproliferative disease (PTLD) represents a heterogeneous group of diseases characterised by a proliferation of lymphocytes occurring after solid organ transplantation. Most cases of PTLD are B-cell and their development has been closely associated with the Epstein-Barr virus (EBV), whose proliferation is encouraged by the inhibition of the cytotoxic function of T lymphocytes due to immunosuppressive drug treatment for transplant recipients. Several risk factors have been described for the development of this disorder, such as the seronegative state of the EBV receptor, the degree of overall net immunosuppression, especially with the use of monoclonal and polyclonal antibodies, acute rejection and cytomegalovirus (CMV) disease. MATERIAL AND METHOD: We studied the incidence of PTLD and its relationship with EBV as well as its evolution and possible risk factors in 1176 adult recipients of cadaveric renal transplantation performed in our hospital between 1988 and 2009, with a follow-up of 1-255 months. The presence of EBV in the lymphoproliferative tissue was determined using in situ hybridisation. We analysed the incidence of PTLD over two time periods, 1988-1998 and 1999-2009 with 472 and 704 patients respectively. RESULTS: A total of 28 recipients (2.38%), 22 men and 6 women with a mean age of 46.5 (15.36) years (18-70 years) with a mean post-transplant evolution of 72.9 (56.3) months (1-180 months), developed PTLD. Thirteen (46.4%) did not show any of the classic risk factors described. The presence of EBV in lymphoproliferative tissue was detected in 18 out of 26 patients studied (69.2%). In terms of histology, 25 out of 28 were type B (89.2%). Ten out of 28 patients diagnosed (35.7%) received treatment with rituximab, six died during the follow-up, five as a direct result of their illness. The incidence for the two time periods was very similar for both groups, with 0.003922 cases/year-patient in the 1988-1998 period and 0.003995 cases/year-patient in the 1999-2009 period. Overall post-transplant survival for patients with PTLD was 73.6% at 5 years and 36.9% at 10 years, versus 87.8% and 75.9% for disease-free recipients (P<.0001). We calculated a graft survival of 62.6% at 5 years and 27.3% at 10 years versus 72.4% and 53.9% for grafts in disease-free recipients (P<.0001). In our study, patient survival one year after presenting the disease was 30.9% and 23.2% at year two. For the graft, survival was 15.5% and 7.7%, respectively. CONCLUSIONS: We conclude that PTLD is a disorder that is generally type B; it is significantly associated with EBV. Its incidence has not changed over time and half of all PTLD cases had no identifiable risk factors, which led to a poor prognosis despite the development of new treatments.

[Clinical course of high and low immunological risk renal transplant receptors subjected to different immunosuppressive treatments]. / Evolución de receptores de trasplante renal de alto y bajo riesgo inmunológico sometidos a diferente inmunosupresión.

We evaluate the incidence of acute rejection, opportunistic infections and non-dermatological malignancies, graft and recipient survival between a group of high immunological risk renal transplant recipients and a group of patients without immunological risk, who received grafts from the same cadaveric donors since 2001 to 2006. This is a prospective and observational study. The risk group (n= 50) included patients with high rate of antibodies (> 50%), recipients who had lost their first graft due to early rejection, cross match positive, black race or important histoincompatibility. They received thymoglobulin to maintain T-cell around 10 cells/ microl, FK 506 after five days, mycophenolate mofetyl and steroids, with ganciclovir prophylaxis for CMV. The normal risk group (n=50) ,cyclosporine, mycophenolate mofetil and steroids. Recipients who lost their graft due to technical failure were excluded..All CMV seronegative recipients who received seropositive grafts were treated with valganciclovir for 100 days.The mean follow-up was 42,7 months. Both groups were similar respect to donor and recipient gender and age, HLA incompatibility, but the percentage of patients with high rate of performed antibodies and second transplant recipients was higher in the high risk group according to the criteria of the study The incidence of acute rejection histologically diagnosed was higher in the normal risk group (30% against 6 %, p=0.03). There was no difference in opportunistic infections or malignancies, although 2 recipients of the normal risk group developed lymphoproliferative disorders. The recipients survival was 97,9% at 1 and 3 years in both groups, and the graft survival was 89,8% and 84,8% in the high risk group against 93,8 % and 90,4% at 1 and 3 years in the normal group (p=NS). We conclude that the evolution of high risk renal transplant recipients is similar to normal risk patients if a potent enough immunosuppression is used. The incidence of acute rejection was higher in the normal risk group.

Treatment of chronic he1patitis C genotype 1 with peginterferon-alpha2a (40 kDa) plus ribavirin under routine clinical practice in Spain: early prediction of sustained virological response rate.

BACKGROUND: Sustained virological response rates of up to 52% have been obtained with peginterferon alpha2a (40 kDa) plus ribavirin in patients suffering from chronic hepatitis C genotype 1 in randomized-controlled trials. AIM: To assess early virological response and its clinical utility in predicting an sustained virological response in patients suffering from chronic hepatitis C genotype 1 in routine clinical practice in Spain. METHODS: Treatment-naïve patients received pegylated interferon alpha2a (40 kDa) 180 microg/week plus ribavirin 1000/1200 mg/day for 48 weeks, and were followed for a further 24 weeks. Overall, 475 patients received at least one dose of medication and were included in the efficacy population. RESULTS: The overall sustained virological response rate was 48%. Of those with week 12 virological data, 83% had an early virological response. The negative predictive value of an early virological response was 93%. CONCLUSION: If sustained virological response is the goal, a treatment-decision based on a 12-week evaluation during routine clinical practice is feasible.

Diltiazem in the treatment of the irritable bowel syndrome.

A short-term double-blind study has been conducted to evaluate the clinical efficacy of diltiazem in 18 patients with irritable bowel syndrome, divided into two groups: group A, on the sequence placebo-diltiazem-placebo for three weeks. Group B, diltiazem-placebo-diltiazem for an identical period. The substance was administered in three daily doses of 60 mg prior to meals. Clinical manifestations and the general condition were evaluated after each period of three weeks following a pre-established score. Globally, it has been impossible to demonstrate the superiority of diltiazem over the placebo, but there seems to exist a trend to the improvement of diarrhoea and abdominal pain. It will be necessary to make an additional study to delineate the efficacy of this drug in the irritable bowel syndrome.

Effect of diltiazem on pentagastrin-induced gastric secretion in man.

The effects of diltiazem on pentagastrin-induced gastric secretion were studied in 11 normal volunteers. Diltiazem 60 mg thrice daily for 10 doses did not produce any clear-cut effect on the increase in gastric acidity induced by either standard or low doses of pentagastrin. Despite the role of calcium on gastric secretion, diltiazem does not show promise as an agent capable of reducing gastric acidity.

Treatment of gastric phytobezoars with cellulase.

BACKGROUND: The aim of our study was to analyze the efficacy of cellulase in dissolving gastric phytobezoars. METHODS: We carried out a prospective study over a period of 1 year. All patients (7 cases) diagnosed as having gastric phytobezoar on gastroscopy were treated with cellulase. RESULTS: Complete dissolution of the gastric phytobezoar was achieved in all 7 patients. No side effects or recurrences occurred during follow-up. DISCUSSION: We conclude that cellulase should be regarded as the treatment of choice for gastric phytobezoars because of its efficacy, and because of the lack of side effects or recurrences. However, further clinical trials are necessary to verify these findings.

[Symptomatic hemobilia following hepatic biopsy. Value of ultrasonography in the diagnosis and control of this complication]. / Hemobilia sintomática tras biopsia hepática. Valor de la ecografía en el diagnóstico y control de esta complicación.

Hemobilia is the term which describes the presence of blood in the biliary tract. We describe a case of symptomatic hemobilia after percutaneous liver biopsy which resolved spontaneously. We review the physiopathology of this complication and we highlight the role of abdominal ultrasonography not only in the diagnosis but also in the follow-up of hemobilia. In our case, abdominal ultrasonography was able to identify the probable point of bleeding.

[Comparative study of sucralfate and ranitidine in the treatment of bleeding duodenal ulcer]. / Estudio comparativo de sucralfato y ranitidina en el tratamiento de la úlcera duodenal sangrante.

Sixty patients with bleeding duodenal ulcers were randomized to treatment with sucralfate or ranitidine. Endoscopy was performed in all patients within 24 hours from admission. Acute phase outcome was similar in both groups. Four patients in the sucralfate group and 1 patient in the ranitidine group rebled and required surgical treatment (NS). Healing rate at 6 weeks was 88% with sucralfate and 96.6% with ranitidine. Relapsing rate without maintenance therapy at 6 and 12 months was 21.1% and 42.1% for sucralfate-treated patients and 33.3% and 56.5% for ranitidine-treated patients (NS). Sucralfate-treated patients had a significantly lesser relapsing rate at 12 months compared to ranitidine treated patients, in the smokers group.

[Mycobacterium chelonae and solitary rectal ulcer]. / Mycobacterium chelonae y úlcera rectal solitaria.

Solitary rectal ulcer is of varied etiology and the appearance of this syndrome due to Mycobacterium chelonae is exceptional. We present a case of a solitary rectal ulcer associated with Mycobacterium chelonae subspecies chelonae in an immunocompetent individual. This microorganism is involved in cutaneous, ocular, pulmonary and soft tissue infections. Treatment of infections has traditionally been surgical, although various antibiotic treatments have been used depending on the sensitivity of the microorganism, the severity of the infection and the surgical possibilities.

[Genetic variability of hepatitis C virus in the health area of Elche (Spain). Correlation between core antigen and viral load]. / Variabilidad genética del virus de la hepatitis C en el área de salud de Elche. Correlación entre el antígeno del core y la carga viral.

We investigated the prevalence of the various genotypes of hepatitis C virus (HCV) in 281 patients evaluated between March, 2000 and March, 2002 in the health area of Elche. Of these patients, 55 were coinfected with human immunodeficiency virus (HIV). The genotype was related to viral load and the co-existence of HIV infection. Likewise, the relationship between these parameters and the presence of the HCV core antigen was established. The results indicate that genotype 1b was the most prevalent (38.4%) followed by genotype 3a (23.1%). Patients coinfected with HIV presented fewer infections due to group 1 genotypes (p < 0.05).Patients with HIV presented a greater viral load in all the genotypes, with genotype 3 presenting a high viral load. Detection of the HCV core antigen showed a close correlation with viral load determinations. Although not yet sufficiently assessed, determination of the HCV core antigen constitutes a simple technique that could eventually contribute to improving the management of patients with chronic HCV hepatitis.

Relationship between bacterial load, morbidity and cagA gene in patients infected by Helicobacter pylori.

One hundred and seventy-six biopsies of the gastric corpus and antrum from 97 patients were processed using classical and molecular methods in order to study the relationship between the factor cagA of Helicobacter pylori, bacterial load and morbidity. Bacterial load in patients with cagA was greater than in patients without it, both in the antrum and corpus (p<0.01). There was a statistically significant association between cagA and consumption of proton pump inhibitors (adjusted odds ratio 3.11). Haemorrhage of the upper digestive tract was more associated with bacterial load than with the cagA gene (adjusted odds ratio 2.34 and 1.12, respectively), but none of these associations yielded statistical significance.