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Ortega-Lobete O, Clemente-Sánchez A, Bañares R, Rincón D. Hepatic hemodynamic study: More than just HVPG measurement. Gastroenterol Hepatol 2024; 47:199-205. [PMID: 37028758 DOI: 10.1016/j.gastrohep.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 03/08/2023] [Accepted: 03/26/2023] [Indexed: 04/09/2023]
Abstract
Evaluation and staging of liver disease is essential in the clinical decision-making process of liver tumors. The severity of portal hypertension (PH) is the main prognostic factor in advanced liver disease. Performing an accurate hepatic venous pressure gradient (HVPG) measurement is not always possible, especially when veno-venous communications are present. In those complex cases, a refinement in HVPG measurement with a thorough evaluation of each of the components of PH is mandatory. We aimed at describing how some technical modifications and complementary procedures may contribute to an accurate and complete clinical evaluation to improve therapeutic decisions.
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Affiliation(s)
- Olga Ortega-Lobete
- Hepatology Unit, Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ana Clemente-Sánchez
- Hepatology Unit, Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Rafael Bañares
- Hepatology Unit, Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.
| | - Diego Rincón
- Hepatology Unit, Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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2
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Ocanto A, Torres L, Montijano M, Rincón D, Fernández C, Sevilla B, Gonsalves D, Teja M, Guijarro M, Glaría L, Hernánz R, Zafra-Martin J, Sanmamed N, Kishan A, Alongi F, Moghanaki D, Nagar H, Couñago F. MR-LINAC, a New Partner in Radiation Oncology: Current Landscape. Cancers (Basel) 2024; 16:270. [PMID: 38254760 PMCID: PMC10813892 DOI: 10.3390/cancers16020270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Technological advances in radiation oncology are oriented towards improving treatment precision and tumor control. Among these advances, magnetic-resonance-image-guided radiation therapy (MRgRT) stands out, with technological advances to deliver targeted treatments adapted to a tumor's anatomy on the day while minimizing incidental exposure to organs at risk, offering an unprecedented therapeutic advantage compared to X-ray-based IGRT delivery systems. This new technology changes the traditional workflow in radiation oncology and requires an evolution in team coordination to administer more precise treatments. Once implemented, it paves the way for newer indication for radiation therapy to safely deliver higher doses than ever before, with better preservation of healthy tissues to optimize patient outcomes. In this narrative review, we assess the technical aspects of the novel linear accelerators that can deliver MRgRT and summarize the available published experience to date, focusing on oncological results and future challenges.
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Affiliation(s)
- Abrahams Ocanto
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Lisselott Torres
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Miguel Montijano
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Diego Rincón
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Castalia Fernández
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Beatriz Sevilla
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Daniela Gonsalves
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Macarena Teja
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Marcos Guijarro
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Luis Glaría
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
| | - Raúl Hernánz
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
| | - Juan Zafra-Martin
- Group of Translational Research in Cancer Immunotherapy, Centro de Investigaciones Médico-Sanitarias (CIMES), Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain;
- Department of Radiation Oncology, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain
| | - Noelia Sanmamed
- Department of Radiation Oncology, Hospital Universitario Clínico San Carlos, 28040 Madrid, Spain;
| | - Amar Kishan
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, USA;
| | - Filippo Alongi
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, 37024 Negrar, Italy;
- University of Brescia, 25121 Brescia, Italy
| | - Drew Moghanaki
- UCLA Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA 90095, USA;
| | - Himanshu Nagar
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY 10065, USA;
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
- GenesisCare, 28043 Madrid, Spain
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Romero Zoghbi SE, Martín Martín M, García JC, Valero M, Rincón D, Peña Huertas M, Fusco JP, López E, Zafra J, Fernández Luengas D, López-Campos F, Couñago F. Total neoadjuvant therapy approach for the treatment of locally advanced rectal cancer. Where do we stand? Oncology 2023:000534888. [PMID: 37935161 DOI: 10.1159/000534888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/27/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND for the management of locally advanced rectal cancer (LARC), initial treatment with neoadjuvant chemoradiotherapy followed by surgery and chemotherapy in selected patients is considered one of the recommended options by the main international clinical guidelines. Nonetheless, the administration of all chemotherapy before definitive treatment (total neoadjuvant therapy or TNT) is an optimal alternative with a growing level of evidence that must be evaluated in multidisciplinary boards. This review summarizes the available data and controversies in this scenario. SUMMARY we have analyzed the characteristics of the main published studies that assess the use of TNT in patients with LARC, evaluating their inclusion criteria and distinguishing between the employed radiotherapy fractionations, systemic agents, timing, and the implications of these treatments in regard to surgery and long-term oncological results. Our aim is to describe the evidence that supports the use of a specific regime in everyday clinical practice. KEY POINTS there is solid evidence for the use of TNT in patients with LARC. There is no data indicating the superiority of one specific TNT scheme among all the existing options. International clinical guidelines leave the door open to choose the most adequate treatment based on the clinical and pathological characteristics of each patient. This review shows the different approaches to TNT and assesses the best options based on clinical evidence.
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Carrión L, Clemente-Sánchez A, Márquez-Pérez L, Orcajo-Rincón J, Rotger A, Ramón-Botella E, González-Leyte M, Echenagusía-Boyra M, Luis Colón A, Reguera-Berenguer L, Bañares R, Rincón D, Matilla-Peña A. Portal hypertension increases the risk of hepatic decompensation after 90Yttrium radioembolization in patients with hepatocellular carcinoma: a cohort study. Therap Adv Gastroenterol 2023; 16:17562848231206995. [PMID: 37920686 PMCID: PMC10619355 DOI: 10.1177/17562848231206995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/21/2023] [Indexed: 11/04/2023] Open
Abstract
Background Transarterial radioembolization (TARE) is increasingly used in patients with hepatocellular carcinoma (HCC). This treatment can induce or impair portal hypertension, leading to hepatic decompensation. TARE also promotes changes in liver and spleen volumes that may modify therapeutic decisions and outcomes after therapy. Objectives We aimed to investigate the impact of TARE on the incidence of decompensation events and its predictive factors. Design In all, 63 consecutive patients treated with TARE between February 2012 and December 2018 were retrospectively included. Methods We assessed clinical (including Barcelona Clinic Liver Cancer stage, portal hypertension assessment, and liver decompensation), laboratory parameters, and liver and spleen volumes before and 6 and 12 weeks after treatment. A multivariate analysis was performed. Results In total, 18 out of 63 (28.6%) patients had liver decompensation (ascites, variceal bleeding, jaundice, or encephalopathy) within the first 3 months after therapy, not associated with tumor progression. Clinically significant portal hypertension (CSPH) and bilobar treatment independently predicted the development of liver decompensation after TARE. A significant volume increase in the non-treated hemi-liver was observed only in patients with unilobar treatment (median volume increase of 20.2% in patients with right lobe TARE; p = 0.007), especially in those without CSPH. Spleen volume also increased after TARE (median volume increase of 16.1%; p = 0.0001) and was associated with worsening liver function scores and decreased platelet count. Conclusion Bilobar TARE and CSPH may be associated with an increased risk of liver decompensation in patients with intermediate or advanced HCC. A careful assessment considering these variables before therapy may optimize candidate selection and improve treatment planning.
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Affiliation(s)
- Laura Carrión
- Department of Gastroenterology and Hepatology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Ana Clemente-Sánchez
- Department of Gastroenterology and Hepatology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Centre for Biomedical Research in Liver and Digestive Diseases Network, Instituto de Salud Carlos III, Madrid, Spain
| | - Laura Márquez-Pérez
- Department of Gastroenterology and Hepatology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Javier Orcajo-Rincón
- Department of Nuclear Medicine, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Amanda Rotger
- Department of Nuclear Medicine, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Enrique Ramón-Botella
- Department of Diagnostic Radiology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Manuel González-Leyte
- Department of Interventional Radiology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Miguel Echenagusía-Boyra
- Department of Interventional Radiology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Arturo Luis Colón
- Department of Hepatobiliary and Pancreatic Surgery, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Laura Reguera-Berenguer
- Department of Nuclear Medicine, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Rafael Bañares
- Department of Gastroenterology and Hepatology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Centre for Biomedical Research in Liver and Digestive Diseases Network, Instituto de Salud Carlos III, Madrid, Spain
- Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Diego Rincón
- Department of Gastroenterology and Hepatology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Centre for Biomedical Research in Liver and Digestive Diseases Network, Instituto de Salud Carlos III, Madrid, Spain
- Faculty of Medicine, Complutense University of Madrid, Madrid, SpainCalle del Doctor Esquerdo 46, 28007 Madrid, Spain
| | - Ana Matilla-Peña
- Department of Gastroenterology and Hepatology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Centre for Biomedical Research in Liver and Digestive Diseases Network, Instituto de Salud Carlos III, Madrid, Spain
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Romero-Cristóbal M, Clemente-Sánchez A, Ramón E, Téllez L, Canales E, Ortega-Lobete O, Velilla-Aparicio E, Catalina MV, Ibáñez-Samaniego L, Alonso S, Colón A, Matilla AM, Salcedo M, Albillos A, Bañares R, Rincón D. CT-derived liver and spleen volume accurately diagnose clinically significant portal hypertension in patients with hepatocellular carcinoma. JHEP Rep 2022; 5:100645. [PMID: 36691569 PMCID: PMC9860348 DOI: 10.1016/j.jhepr.2022.100645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/12/2022] [Indexed: 12/05/2022] Open
Abstract
Background & Aims Clinically significant portal hypertension (CSPH) is a landmark in the natural history of cirrhosis, influencing clinical decisions in patients with hepatocellular carcinoma (HCC). Previous small series suggested that splanchnic volume measurements may predict portal hypertension. We aimed to evaluate whether volumetry obtained by standard multidetector computerised tomography (MDCT) can predict CSPH in patients with HCC. Methods We included 175 patients with HCC, referred for hepatic venous pressure gradient (HVPG) evaluation, in whom contemporary MDCT was available. Liver volume, spleen volume (SV) and liver segmental volume ratio (LSVR: volume of the segments I-III/volume of the segments IV-VIII) were calculated semi-automatically from MDCT. Other non-invasive tests (NITs) were also employed. Results Volume parameters could be measured in almost 100% of cases with an excellent inter-observer agreement (intraclass correlation coefficient >0.950). SV and LSVR were independently associated with CSPH (HVPG ≥10 mmHg) and did not interact with aetiology. The volume Index (VI), calculated as the product of SV and LSVR, predicted CSPH (AUC 0.83; 95% CI 0.77-0.89). Similar results were observed in an external cohort (n = 23) (AUC 0.87; 95% CI 0.69-1.00). Setting a sensitivity and specificity of 98%, VI could have avoided 35.9% of HVPG measurements. The accuracy of VI was similar to that of other NITs. VI also accurately predicted HVPG greater than 12, 14, 16 and 18 mmHg (AUC 0.81 [95% CI 0.74-0.88], 0.84 [95% CI 0.77-0.91], 0.85 [95% CI 0.77-0.92] and 0.87 [95% CI 0.79-0.94], respectively). Conclusions Quantification of liver and spleen volumes by MDCT is a simple, accurate and reliable method of CSPH estimation in patients with compensated cirrhosis and HCC. Impact and implications An increase in portal pressure strongly impacts outcomes after surgery in patients with early hepatocellular carcinoma (HCC). Direct measurement through hepatic vein catheterization remains the reference standard for portal pressure assessment, but its invasiveness limits its application. Therefore, we evaluated the ability of CT scan-based liver and spleen volume measurements to predict portal hypertension in patients with HCC. Our results indicate that the newly described index, based on quantification of liver and spleen volume, accurately predicts portal hypertension. These results suggest that a single imaging test may be used to diagnose and stage HCC, while providing an accurate estimation of portal hypertension, thus helping to stratify surgical risks.
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Key Words
- CSPH, clinically significant portal hypertension
- DAAs, direct-acting antivirals agents
- HCC, hepatocellular carcinoma
- HVPG, hepatic venous pressure gradient
- LSPS, liver stiffness-spleen size-to-platelet ratio score
- LSVR, liver segmental volume
- LV, liver volume
- LV/SV, liver/spleen volume ratio
- MAFLD, metabolic dysfunction-associated fatty liver disease
- MDCT, multidetector computerised tomography
- NITs, non-invasive tests
- PSR, platelet count to spleen diameter ratio
- SV, spleen volume
- TE, transient elastography
- VI, volume index
- cirrhosis
- cross-sectional imaging
- hepatocellular carcinoma
- non-invasive test
- organ size
- portal hypertension
- predictive model
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Affiliation(s)
| | - Ana Clemente-Sánchez
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Enrique Ramón
- Department of Radiology, H.G.U. Gregorio Marañón, Madrid, Spain
| | - Luis Téllez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Elena Canales
- Department of Radiology, H. U. Ramón y Cajal, Madrid, Spain
| | - Olga Ortega-Lobete
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
| | | | - María-Vega Catalina
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Luis Ibáñez-Samaniego
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Sonia Alonso
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Arturo Colón
- Liver Transplant and Hepatobiliary Surgery Unit, H.G.U. Gregorio Marañón, Madrid, Spain
| | - Ana-María Matilla
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Magdalena Salcedo
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
| | - Agustín Albillos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Rafael Bañares
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
- Corresponding author. Address: Liver Unit, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, Madrid, 28007, Spain..
| | - Diego Rincón
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
- School of Medicine, Universidad Complutense, Madrid, Spain
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Romero-Cristóbal M, Clemente-Sánchez A, Peligros MI, Ramón E, Matilla AM, Colón A, Alonso S, Catalina MV, Fernández-Yunquera A, Caballero A, García R, López-Baena JÁ, Salcedo MM, Bañares R, Rincón D. Liver and spleen volumes are associated with prognosis of compensated and decompensated cirrhosis and parallel its natural history. United European Gastroenterol J 2022; 10:805-816. [PMID: 36065767 PMCID: PMC9557954 DOI: 10.1002/ueg2.12301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/14/2022] [Indexed: 12/30/2022] Open
Abstract
Objective Cirrhosis is characterized by the complex interplay among biological, histological and haemodynamic events. Liver and spleen remodelling occur throughout its natural history, but the prognostic role of these volumetric changes is unclear. We evaluated the relationship between volumetric changes assessed by multidetector computerised tomography (MDCT) and landmark features of cirrhosis. Methods We included consecutive cirrhotic patients who underwent liver transplantation (LT) or hepatocellular carcinoma (HCC) resection in whom dynamic MDCT was available. Different volumetric indices were calculated. Fibrosis was evaluated by the collagen proportional area and Laennec sub‐stages. Correlation and logistic regression analysis were performed to explore associations of volumetric indexes and fibrosis with key prognostic features across the clinical stages of cirrhosis. Results 185 patients were included (146 LT; 39 HCC); the predominant aetiology was viral hepatitis (51.35%); 65.9% had decompensated disease and 85.08% clinically significant portal hypertension (CSPH). The standardised liver volume and liver‐spleen volume ratio negatively correlated with Model for End‐stage Liver Disease (MELD), albumin and hepatic venous pressure gradient (HVPG) and were significantly lower in decompensated patients. The liver segmental volume ratio (segments I–III/segments IV–VIII) best captured the characteristic features of the compensated phase, showing a positive correlation with HVPG and a good discrimination between patients with and without CSPH and varices. Volumetric changes and fibrosis severity were independently associated with key prognostic events, with no association between these two parameters. Conclusions Liver and spleen volumetric indices evolve differently along the natural history of cirrhosis and are associated with key prognostic factors in each phase, regardless of fibrosis severity and portal hypertension.
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Affiliation(s)
| | - Ana Clemente-Sánchez
- Liver Unit and Digestive Department H.G.U, Gregorio Marañón, Madrid, Spain.,CIBEREHD, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Enrique Ramón
- Department of Radiology, H.G.U, Gregorio Marañón, Madrid, Spain
| | - Ana-María Matilla
- Liver Unit and Digestive Department H.G.U, Gregorio Marañón, Madrid, Spain.,CIBEREHD, Instituto de Salud Carlos III, Madrid, Spain
| | - Arturo Colón
- Liver Transplant and Hepatobiliary Surgery Unit, H.G.U, Gregorio Marañón, Madrid, Spain
| | - Sonia Alonso
- Liver Unit and Digestive Department H.G.U, Gregorio Marañón, Madrid, Spain.,CIBEREHD, Instituto de Salud Carlos III, Madrid, Spain
| | | | | | - Aranzazu Caballero
- Liver Unit and Digestive Department H.G.U, Gregorio Marañón, Madrid, Spain
| | - Rita García
- CIBEREHD, Instituto de Salud Carlos III, Madrid, Spain.,Department of Internal Medicine, H.G.U, Gregorio Marañón, Madrid, Spain
| | | | - María-Magdalena Salcedo
- Liver Unit and Digestive Department H.G.U, Gregorio Marañón, Madrid, Spain.,CIBEREHD, Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Complutense University, Madrid, Spain
| | - Rafael Bañares
- Liver Unit and Digestive Department H.G.U, Gregorio Marañón, Madrid, Spain.,CIBEREHD, Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Complutense University, Madrid, Spain
| | - Diego Rincón
- Liver Unit and Digestive Department H.G.U, Gregorio Marañón, Madrid, Spain.,CIBEREHD, Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Complutense University, Madrid, Spain
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Arab JP, Díaz LA, Baeza N, Idalsoaga F, Fuentes-López E, Arnold J, Ramírez CA, Morales-Arraez D, Ventura-Cots M, Alvarado-Tapias E, Zhang W, Clark V, Simonetto D, Ahn JC, Buryska S, Mehta TI, Stefanescu H, Horhat A, Bumbu A, Dunn W, Attar B, Agrawal R, Haque ZS, Majeed M, Cabezas J, García-Carrera I, Parker R, Cuyàs B, Poca M, Soriano G, Sarin SK, Maiwall R, Jalal PK, Abdulsada S, Higuera-de la Tijera MF, Kulkarni AV, Rao PN, Guerra Salazar P, Skladaný L, Bystrianska N, Prado V, Clemente-Sanchez A, Rincón D, Haider T, Chacko KR, Cairo F, de Sousa Coelho M, Romero GA, Pollarsky FD, Restrepo JC, Castro-Sanchez S, Toro LG, Yaquich P, Mendizabal M, Garrido ML, Narvaez A, Bessone F, Marcelo JS, Piombino D, Dirchwolf M, Arancibia JP, Altamirano J, Kim W, Araujo RC, Duarte-Rojo A, Vargas V, Rautou PE, Issoufaly T, Zamarripa F, Torre A, Lucey MR, Mathurin P, Louvet A, García-Tsao G, González JA, Verna E, Brown RS, Roblero JP, Abraldes JG, Arrese M, Shah VH, Kamath PS, Singal AK, Bataller R. Identification of optimal therapeutic window for steroid use in severe alcohol-associated hepatitis: A worldwide study. J Hepatol 2021; 75:1026-1033. [PMID: 34166722 DOI: 10.1016/j.jhep.2021.06.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/18/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Corticosteroids are the only effective therapy for severe alcohol-associated hepatitis (AH), defined by a model for end-stage liver disease (MELD) score >20. However, there are patients who may be too sick to benefit from therapy. Herein, we aimed to identify the range of MELD scores within which steroids are effective for AH. METHODS We performed a retrospective, international multicenter cohort study across 4 continents, including 3,380 adults with a clinical and/or histological diagnosis of AH. The main outcome was mortality at 30 days. We used a discrete-time survival analysis model, and MELD cut-offs were established using the transform-the-endpoints method. RESULTS In our cohort, median age was 49 (40-56) years, 76.5% were male, and 79% had underlying cirrhosis. Median MELD at admission was 24 (19-29). Survival was 88% (87-89) at 30 days, 77% (76-78) at 90 days, and 72% (72-74) at 180 days. A total of 1,225 patients received corticosteroids. In an adjusted-survival-model, corticosteroid use decreased 30-day mortality by 41% (hazard ratio [HR] 0.59; 0.47-0.74; p <0.001). Steroids only improved survival in patients with MELD scores between 21 (HR 0.61; 0.39-0.95; p = 0.027) and 51 (HR 0.72; 0.52-0.99; p = 0.041). The maximum effect of corticosteroid treatment (21-30% survival benefit) was observed with MELD scores between 25 (HR 0.58; 0.42-0.77; p <0.001) and 39 (HR 0.57; 0.41-0.79; p <0.001). No corticosteroid benefit was seen in patients with MELD >51. The type of corticosteroids used (prednisone, prednisolone, or methylprednisolone) was not associated with survival benefit (p = 0.247). CONCLUSION Corticosteroids improve 30-day survival only among patients with severe AH, especially with MELD scores between 25 and 39. LAY SUMMARY Alcohol-associated hepatitis is a condition where the liver is severely inflamed as a result of excess alcohol use. It is associated with high mortality and it is not clear whether the most commonly used treatments (corticosteroids) are effective, particularly in patients with very severe liver disease. In this worldwide study, the use of corticosteroids was associated with increased 30-day, but not 90- or 180-day, survival. The maximal benefit was observed in patients with an MELD score (a marker of severity of liver disease; higher scores signify worse disease) between 25-39. However, this benefit was lost in patients with the most severe liver disease (MELD score higher than 51).
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Affiliation(s)
- Juan Pablo Arab
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Luis Antonio Díaz
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Natalia Baeza
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Idalsoaga
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo Fuentes-López
- Department of Health Sciences, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Arnold
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | | | - Dalia Morales-Arraez
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Meritxell Ventura-Cots
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Edilmar Alvarado-Tapias
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Wei Zhang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Virginia Clark
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Douglas Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Joseph C Ahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Seth Buryska
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Tej I Mehta
- Division of Gastroenterology and Hepatology, Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA; The Johns Hopkins Hospital, Department of Interventional Radiology, Baltimore, MD, USA
| | - Horia Stefanescu
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Adelina Horhat
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Andreea Bumbu
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | | | - Bashar Attar
- Division of Gastroenterology & Hepatology, Cook County Health and Hospital Systems, Chicago, Illinois, USA
| | - Rohit Agrawal
- Division of Gastroenterology and Hepatology, University of Illinois, Chicago, Illinois, USA
| | - Zohaib Syed Haque
- Division of Gastroenterology & Hepatology, Cook County Health and Hospital Systems, Chicago, Illinois, USA
| | - Muhammad Majeed
- Division of Gastroenterology & Hepatology, Cook County Health and Hospital Systems, Chicago, Illinois, USA
| | - Joaquín Cabezas
- Gastroenterology and Hepatology Department, University Hospital Marques de Valdecilla, Santander, Spain; Research Institute Valdecilla (IDIVAL), Santander, Spain
| | - Inés García-Carrera
- Gastroenterology and Hepatology Department, University Hospital Marques de Valdecilla, Santander, Spain; Research Institute Valdecilla (IDIVAL), Santander, Spain
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Berta Cuyàs
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, CIBERehd, Barcelona, Spain
| | - Maria Poca
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, CIBERehd, Barcelona, Spain
| | - German Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, CIBERehd, Barcelona, Spain
| | - Shiv K Sarin
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Prasun K Jalal
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Saba Abdulsada
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | | | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - P Nagaraja Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Lubomir Skladaný
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University, Slovak Republic; F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Natália Bystrianska
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University, Slovak Republic; F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | | | - Ana Clemente-Sanchez
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA; Liver Unit, Department of Digestive Diseases Hospital General Universitario Gregorio Marañón Madrid, Spain; CIBERehd Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas Madrid, Spain
| | - Diego Rincón
- Liver Unit, Department of Digestive Diseases Hospital General Universitario Gregorio Marañón Madrid, Spain; CIBERehd Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas Madrid, Spain
| | - Tehseen Haider
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, NY, USA
| | - Kristina R Chacko
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, NY, USA
| | - Fernando Cairo
- Liver Transplant Unit, Hospital El Cruce, Florencio Varela, Buenos Aires, Argentina
| | | | - Gustavo A Romero
- Sección Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Florencia D Pollarsky
- Sección Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Juan Carlos Restrepo
- Unidad de Hepatología del Hospital Pablo Tobon Uribe, Grupo de Gastrohepatología de la Universidad de Antioquia, Medellín, Colombia
| | - Susana Castro-Sanchez
- Unidad de Hepatología del Hospital Pablo Tobon Uribe, Grupo de Gastrohepatología de la Universidad de Antioquia, Medellín, Colombia
| | - Luis G Toro
- Hepatology and Liver Transplant Unit, Hospitales de San Vicente Fundación de Medellín y Rionegro, Colombia
| | - Pamela Yaquich
- Departamento de Gastroenterología, Hospital San Juan de Dios, Santiago, Chile
| | - Manuel Mendizabal
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Buenos Aires, Argentina
| | | | - Adrián Narvaez
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Fernando Bessone
- Hospital Provincial del Centenario, Universidad Nacional de Rosario, Rosario, Argentina
| | | | - Diego Piombino
- Servicio de Medicina Interna del Hospital de Emergencias Dr Clemente Alvarez de Rosario, Santa Fe, Argentina
| | - Melisa Dirchwolf
- Unidad de Hígado, Hospital Privado de Rosario, Rosario, Argentina
| | - Juan Pablo Arancibia
- Departamento de Gastroenterología y Hepatología, Clínica Santa María, Santiago, Chile
| | - José Altamirano
- Department of Internal Medicine, Hospital Quironsalud, Barcelona, Spain
| | - Won Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, South Korea
| | - Roberta C Araujo
- Gastroenterology Division, Ribeirão Preto Medical School, University of São Paulo, 14048-900 Ribeirão Preto, SP, Brazil
| | - Andrés Duarte-Rojo
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Victor Vargas
- Liver Unit, Hospital Vall d'Hebron, Universitat Autonoma Barcelona, CIBEREHD, Barcelona, Spain
| | - Pierre-Emmanuel Rautou
- Université de Paris, Centre de recherche sur l'inflammation, Inserm, U1149, CNRS, ERL8252, F-75018 Paris, France; Service d'Hépatologie, DHU Unity, DMU Digest, Hôpital Beaujon, AP-HP, Clichy, France; Centre de Référence des Maladies Vasculaires du Foie, French Network for Rare Liver Diseases (FILFOIE), European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Belgium
| | - Tazime Issoufaly
- Université de Paris, Centre de recherche sur l'inflammation, Inserm, U1149, CNRS, ERL8252, F-75018 Paris, France; Service d'Hépatologie, DHU Unity, DMU Digest, Hôpital Beaujon, AP-HP, Clichy, France; Centre de Référence des Maladies Vasculaires du Foie, French Network for Rare Liver Diseases (FILFOIE), European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Belgium
| | | | - Aldo Torre
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubiràn", Mexico City, Mexico
| | - Michael R Lucey
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Philippe Mathurin
- Hôpital Claude Huriez, Services des Maladies de l'Appareil Digestif, CHRU Lille, and Unité INSERM 995, Lille, France
| | - Alexandre Louvet
- Hôpital Claude Huriez, Services des Maladies de l'Appareil Digestif, CHRU Lille, and Unité INSERM 995, Lille, France
| | - Guadalupe García-Tsao
- Section of Digestive Diseases, Yale University School of Medicine/VA-CT Healthcare System, New Haven/West Haven, USA
| | - José Alberto González
- Gastroenterology Department, Hospital Universitario "Dr José E González" Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Elizabeth Verna
- Division of Digestive and Liver Diseases, Department of Medicine and Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY, USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY
| | - Juan Pablo Roblero
- Sección Gastroenterología, Hospital Clínico Universidad de Chile, Escuela de Medicina Universidad de Chile, Santiago, Chile
| | - Juan G Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Canada
| | - Marco Arrese
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA
| | - Ramon Bataller
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
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8
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Caballero-Marcos A, Romero-Cristóbal M, Puerto M, Fernández-Yunquera A, Dieguez L, Navarrete C, Clemente A, Diaz-Fontenla F, Catalán P, Rincón D, López-Baena JÁ, Bañares Cañizares R, Salcedo M. HCV eradication in recurrent hepatitis C after liver transplantation normalizes enhanced endothelial activation. Transpl Int 2021; 34:2214-2225. [PMID: 34346111 DOI: 10.1111/tri.14000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/30/2021] [Accepted: 07/26/2021] [Indexed: 02/01/2023]
Abstract
The increased risk of cardiovascular disease (CVD) conferred by hepatitis C virus (HCV) is especially relevant after liver transplantation (LT), but its mechanism is still not well defined. This study aimed to evaluate the influence of HCV eradication in inflammatory and endothelial activation markers after LT. We evaluated inflammatory (TNF-alfa, IL-6, IL-8, and MCP-1) and endothelial activation (E-selectin, ICAM-1, VCAM-1, and MMP-9) markers before and after eradication in 45 LT recipients with HCV infection (LT+/HCV+) and 44 non-transplanted HCV-infected patients (LT-/HCV+). We also considered an additional group of 40 LT recipients without HCV infection (LT+/HCV-). LT+/HCV+ patients presented a higher endothelial activation status before eradication compared with LT+/HCV- patients. However, levels of E-selectin, ICAM-1, VCAM-1, and MMP-9 were comparable between LT+/HCV+ and LT-/HCV+ patients before eradication. HCV eradication decreased ICAM-1 (5466.55 pg/ml vs. 3354.88 pg/ml, P < 0.001) and VCAM-1 (10456.52 pg/ml vs. 6658.85 pg/ml, P < 0.001) levels in LT+/HCV+ and LT-/HCV+ patients. Remarkably, HCV eradication restored levels of endothelial activation markers of LT+/HCV+ patients compared with that of LT+/HCV- patients. HCV plays a major role in endothelial dysfunction after LT. Furthermore, HCV eradication restores endothelial activation despite the exposure to immunosuppressive therapy.
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Affiliation(s)
| | - Mario Romero-Cristóbal
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marta Puerto
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Lucia Dieguez
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Cristina Navarrete
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ana Clemente
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Fernando Diaz-Fontenla
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Pilar Catalán
- Department of Microbiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Diego Rincón
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Rafael Bañares Cañizares
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Magdalena Salcedo
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Complutense University of Madrid, Madrid, Spain
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9
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Romero-Cristóbal M, Clemente-Sánchez A, Piñeiro P, Cedeño J, Rayón L, del Río J, Ramos C, Hernández DA, Cova M, Caballero A, Garutti I, García-Olivares P, Hortal J, Guerrero JE, García R, Bañares R, Rincón D. Possible unrecognised liver injury is associated with mortality in critically ill COVID-19 patients. Therap Adv Gastroenterol 2021; 14:17562848211023410. [PMID: 34178116 PMCID: PMC8207265 DOI: 10.1177/17562848211023410] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 05/20/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Coronavirus disease (COVID-19) with acute respiratory distress syndrome is a life-threatening condition. A previous diagnosis of chronic liver disease is associated with poorer outcomes. Nevertheless, the impact of silent liver injury has not been investigated. We aimed to explore the association of pre-admission liver fibrosis indices with the prognosis of critically ill COVID-19 patients. METHODS The work presented was an observational study in 214 patients with COVID-19 consecutively admitted to the intensive care unit (ICU). Pre-admission liver fibrosis indices were calculated. In-hospital mortality and predictive factors were explored with Kaplan-Meier and Cox regression analysis. RESULTS The mean age was 59.58 (13.79) years; 16 patients (7.48%) had previously recognised chronic liver disease. Up to 78.84% of patients according to Forns, and 45.76% according to FIB-4, had more than minimal fibrosis. Fibrosis indices were higher in non-survivors [Forns: 6.04 (1.42) versus 4.99 (1.58), p < 0.001; FIB-4: 1.77 (1.17) versus 1.41 (0.91), p = 0.020)], but no differences were found in liver biochemistry parameters. Patients with any degree of fibrosis either by Forns or FIB-4 had a higher mortality, which increased according to the severity of fibrosis (p < 0.05 for both indexes). Both Forns [HR 1.41 (1.11-1.81); p = 0.006] and FIB-4 [HR 1.31 (0.99-1.72); p = 0.051] were independently related to survival after adjusting for the Charlson comorbidity index, APACHE II, and ferritin. CONCLUSION Unrecognised liver fibrosis, assessed by serological tests prior to admission, is independently associated with a higher risk of death in patients with severe COVID-19 admitted to the ICU.
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Affiliation(s)
| | | | - Patricia Piñeiro
- Department of Anesthesiology, H.G.U. Gregorio Marañón, Madrid, Spain
| | - Jamil Cedeño
- Intensive Care Unit, H.G.U. Gregorio Marañón, Madrid, Spain
| | - Laura Rayón
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
| | - Julia del Río
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
| | - Clara Ramos
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
| | | | - Miguel Cova
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
| | - Aranzazu Caballero
- Liver Unit and Digestive Department, H.G.U. Gregorio Marañón, Madrid, Spain
| | - Ignacio Garutti
- Department of Anesthesiology, H.G.U. Gregorio Marañón, Madrid, Spain
| | | | - Javier Hortal
- Department of Anesthesiology, H.G.U. Gregorio Marañón, Madrid, Spain,CIBERES, Instituto de Salud Carlos III, Madrid, Spain,School of Medicine, Complutense University, Madrid, Spain
| | | | - Rita García
- CIBEREHD, Instituto de Salud Carlos III, Madrid, Spain,Department of Internal Medicine, H.G.U. Gregorio Marañón, Madrid, Spain
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10
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Alonso López S, Manzano ML, Gea F, Gutiérrez ML, Ahumada AM, Devesa MJ, Olveira A, Polo BA, Márquez L, Fernández I, Cobo JCR, Rayón L, Riado D, Izquierdo S, Usón C, Real Y, Rincón D, Fernández-Rodríguez CM, Bañares R. A Model Based on Noninvasive Markers Predicts Very Low Hepatocellular Carcinoma Risk After Viral Response in Hepatitis C Virus-Advanced Fibrosis. Hepatology 2020; 72:1924-1934. [PMID: 33022803 DOI: 10.1002/hep.31588] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/15/2020] [Accepted: 09/22/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Patients with hepatitis C virus (HCV) and advanced fibrosis remain at risk of hepatocellular carcinoma (HCC) after sustained viral response (SVR) and need lifelong surveillance. Because HCC risk is not homogenous and may decrease with fibrosis regression, we aimed to identify patients with low HCC risk based on the prediction of noninvasive markers and its changes after SVR. APPROACH AND RESULTS This is a multicenter cohort study, including patients with HCV and compensated advanced fibrosis that achieved SVR after direct antivirals. Clinical and transient elastography (TE) data were registered at baseline, 1 year, and 3 years after the end of treatment (EOT). All patients underwent liver ultrasound scan every 6 months. Patients with clinical evaluation 1 year after EOT were eligible. Univariate and multivariate Cox regression analysis were performed, and predictive models were constructed. HCC occurrence rates were evaluated by Kaplan-Meier. Nine hundred and ninety-three patients were eligible (56% male; 44% female; median age 62 years), 35 developed HCC (3.9%), and the median follow-up was 45 months (range 13-53). Baseline liver stiffness measurement (LSM) (HR 1.040; 95% CI 1.017-1.064), serum albumin (HR 0.400; 95% CI 0.174-0.923), 1-year DeltaLSM (HR 0.993; 95% CI 0.987-0.998), and 1-year FIB-4 score (HR 1.095; 95% CI 1.046-1.146) were independent factors associated with HCC. The TE-based HCC risk model predicted 0% of HCC occurrence at 3 years in patients with score 0 (baseline LSM ≤ 17.3 kPa, albumin >4.2 g/dL, and 1-year DeltaLSM > 25.5%) versus 5.2% in patients with score 1-3 (Harrell's C 0.779; log-rank 0.002). An alternative model with FIB-4 similarly predicted HCC risk. CONCLUSIONS A combination of baseline and dynamic changes in noninvasive markers may help to identify patients with a very low risk of HCC development after SVR.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antiviral Agents/therapeutic use
- Biomarkers, Tumor/blood
- Carcinoma, Hepatocellular/blood
- Carcinoma, Hepatocellular/epidemiology
- Carcinoma, Hepatocellular/pathology
- Carcinoma, Hepatocellular/virology
- Disease Progression
- Elasticity Imaging Techniques
- Female
- Follow-Up Studies
- Hepacivirus/isolation & purification
- Hepatitis C, Chronic/blood
- Hepatitis C, Chronic/drug therapy
- Hepatitis C, Chronic/pathology
- Hepatitis C, Chronic/virology
- Humans
- Liver/diagnostic imaging
- Liver/pathology
- Liver Cirrhosis/blood
- Liver Cirrhosis/drug therapy
- Liver Cirrhosis/pathology
- Liver Cirrhosis/virology
- Liver Neoplasms/blood
- Liver Neoplasms/epidemiology
- Liver Neoplasms/pathology
- Liver Neoplasms/virology
- Male
- Middle Aged
- Retrospective Studies
- Risk Assessment/methods
- Risk Factors
- Sustained Virologic Response
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Affiliation(s)
- Sonia Alonso López
- Liver Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto De Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | | | - Francisco Gea
- Liver Unit, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | | | - María José Devesa
- Gastroenterology Unit, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Antonio Olveira
- Hepatology Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Benjamin Arturo Polo
- Gastroenterology Unit, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Laura Márquez
- Liver Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Laura Rayón
- Liver Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Daniel Riado
- Gastroenterology Unit, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Sonia Izquierdo
- Gastroenterology Unit, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Clara Usón
- Liver Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Yolanda Real
- Gastroenterology Unit, Hospital Universitario La Princesa Madrid, Madrid, Spain
| | - Diego Rincón
- Liver Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto De Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Universidad Complutense de Madrid, Madrid, Spain
- Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Conrado M Fernández-Rodríguez
- Gastroenterology Unit, Hospital Universitario Fundación Alcorcón, Madrid, Spain
- Universidad Rey Juan Carlos Madrid, Madrid, Spain
| | - Rafael Bañares
- Liver Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto De Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Universidad Complutense de Madrid, Madrid, Spain
- Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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11
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Gómez-Centurión I, Bailén R, Oarbeascoa G, Muñoz C, Luque AÁ, Boyra ME, Calleja E, Rincón D, Dorado N, Barzallo P, Anguita J, Díez-Martín JL, Kwon M. Transjugular Intrahepatic Portosystemic Shunt for Very Severe Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome (VOD/SOS) after Unmanipulated Haploidentical Hematopoietic Stem Cell Transplantation with Post-transplantation Cyclophosphamide. Biol Blood Marrow Transplant 2020; 26:2089-2097. [PMID: 32791193 DOI: 10.1016/j.bbmt.2020.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/13/2020] [Accepted: 08/03/2020] [Indexed: 12/12/2022]
Abstract
Hepatic veno-occlusive disease or sinusoidal obstruction syndrome (VOD/SOS) is a threatening complication after both autologous and allogeneic hematopoietic stem cell transplantation (HSCT), with high mortality rates despite early medical treatment, including the use of defibrotide (DF). We retrospectively analyzed 185 unmanipulated haploidentical (haplo-) HSCT with post-transplantation cyclophosphamide as graft-versus-host disease prophylaxis performed consecutively between 2011 and June 2019 in a single center. Seventeen patients (9.2%) were diagnosed with VOD/SOS. Based on revised European Society for Blood and Marrow Transplantation severity criteria, the VOD/SOS cases were classified as mild in 2 patients (11.7%), moderate in 2 (11.7%), severe in 2 (11.7%), and very severe in 11 (64.9%). Thirteen patients (76%) were treated with DF, including all patients with severe or very severe VOD/SOS, except 1 patient with CNS hemorrhage. Sixteen patients (94%) were alive at day +100 after HSCT. Seven patients (41%) with very severe VOD/SOS were treated with transjugular intrahepatic portosystemic shunt (TIPS) owing to rapid clinical or analytical deterioration or refractory hepatorenal syndrome despite medical treatment, including DF. TIPS insertion was performed at a median time since VOD/SOS diagnosis of 4 days (range, 1 to 28 days) without technical complications in any case. The median hepatic venous pressure gradient before and after TIPS treatment was 24 mmHg (range, 14 to 29 mmHg) and 7 mmHg (range, 2 to 11 mmHg), respectively, with a median drop of 16 mmHg (range, 9 to 19 mmHg). Following TIPS insertion, all patients showed clinical improvement with hepatomegaly, ascites, and renal failure resolution, and all showed analytical improvement with reduced alanine aminotransferase (ALT), creatinine, and international normalized ratio values, except for patient 2, whose indication for TIPS was refractory hepatorenal syndrome with a normal ALT level. The 6 patients who had initiated DF before TIPS insertion completed 21 days of treatment. All patients met the criteria for complete remission (CR) at a median of 8 days after TIPS insertion (range, 2 to 82 days). The 100-day overall survival was 100%. For patients with rapid progressive VOD/SOS, early TIPS insertion allowed completion of DF therapy. The use of TIPS together with DF resulted in CR and no associated complications with no VOD/SOS-associated mortality despite high severity. In our experience, timely and individualized use of TIPS significantly improves outcomes of very severe VOD/SOS after haplo-HSCT. Therefore, TIPS should be promptly considered in rapidly progressive cases.
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Affiliation(s)
| | - Rebeca Bailén
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Gillen Oarbeascoa
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Cristina Muñoz
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Arturo Álvarez Luque
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Miguel Echenagusia Boyra
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Department of Interventional Radiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Enrique Calleja
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Department of Interventional Radiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Diego Rincón
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Department of Hepatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Nieves Dorado
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Paola Barzallo
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Anguita
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - José Luis Díez-Martín
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain; Department of Hematology, Universidad Complutense de Madrid, Madrid, Spain
| | - Mi Kwon
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain
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12
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Manuel Sousa J, Vergara M, Pulido F, Sánchez Antolín G, Hijona L, Carnicer F, Rincón D, Salmerón J, Mateos-Muñoz B, Jou A, Polo-Lorduy B, Rubín Á, Escarda A, Aguilar P, Aldámiz-Echevarría T, García-Buey L, Carrión JA, Hernández-Guerra M, Chimeno-Hernández S, Espinosa N, Morillas RM, Andrade RJ, Delgado M, Gallego A, Magaz M, Moreno-Planas JM, Estébanez Á, Rico M, Menéndez F, Sampedro B, Morano L, Izquierdo S, Zozaya JM, Rodríguez M, Morán-Sánchez S, Lorente S, Martín-Granizo I, Von-Wichmann MÁ, Delgado M, Manzanares A. Real-world evidence of the effectiveness of ombitasvir-paritaprevir/r ± dasabuvir ± ribavirin in patients monoinfected with chronic hepatitis C or coinfected with human immunodeficiency virus-1 in Spain. PLoS One 2019; 14:e0225061. [PMID: 31714950 PMCID: PMC6850697 DOI: 10.1371/journal.pone.0225061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 10/27/2019] [Indexed: 12/27/2022] Open
Abstract
Aim We describe the effectiveness and safety of the interferon-free regimen ombitasvir/paritaprevir/ritonavir plus dasabuvir with or without ribavirin (OBV/PTV/r ± DSV ± RBV) in a nationwide representative sample of the hepatitis C virus (HCV) monoinfected and human immunodeficiency virus-1/hepatitis C virus (HIV/HCV) coinfected population in Spain. Material and methods Data were collected from patients infected with HCV genotypes 1 or 4, with or without HIV-1 coinfection, treated with OBV/PTV/r ± DSV ± RBV at 61 Spanish sites within the initial implementation year of the first government-driven “National HCV plan.” Effectiveness was assessed by sustained virologic response at post-treatment week 12 (SVR12) and compared between monoinfected and coinfected patients using a non-inferiority margin of 5% and a 90% confidence interval (CI). Sociodemographic and clinical characteristics or patients and adverse events (AEs) were also recorded. Results Overall, 2,408 patients were included in the intention-to-treat analysis: 386 (16%) were patients with HIV/HCV. Patient selection reflected the real distribution of patients treated in each participating region in Spain. From the total population, 96.6% (95% CI, 95.8–97.3%) achieved SVR12. Noninferiority of SVR12 in coinfected patients was met, with a difference between monoinfected and coinfected patients of −2.2% (90% CI, −4.5% - 0.2%). Only genotype 4 was associated with non-response to OBV/PTV/r ± DSV ± RBV treatment (p<0.001) in the multivariate analysis. Overall, 286 patients (11.9%) presented AEs potentially related to OBV/PTV/r ± DSV, whereas 347 (29.0%) presented AEs potentially related to ribavirin and 61 (5.1%) interrupted ribavirin. Conclusions Our results confirm that OBV/PTV/r ± DSV ± RBV is effective and generally well tolerated in a representative sample of the HCV monoinfected and HCV/HIV coinfected population in Spain within the experience of a national strategic plan to tackle HCV.
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Affiliation(s)
- José Manuel Sousa
- Hepatology Department, Hospital Universitario Virgen del Rocío, Sevilla, Sevilla, Spain
| | - Mercedes Vergara
- Hepatology Unit, Digestive Disease Department, Parc Taulí Sabadell Hospital Universitari, Sabadell, Barcelona, Spain, CIBERehd, Instituto Carlos III, Madrid, Spain
| | - Federico Pulido
- HIV Unit, Hospital Universitario 12 de Octubre, imas12, Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Gloria Sánchez Antolín
- Hepatology Department, Hospital Universitario Río Hortega, Valladolid, Valladolid, Spain
| | - Lander Hijona
- Hepatology Department, Hospital Universitario Araba, Vitoria-Gasteiz, Álava, Spain
| | - Fernando Carnicer
- Hepatology Department, Hospital General Universitario de Alicante, Alicante, Alicante, Spain
| | - Diego Rincón
- Hepatology Department, Hospital General Universitario Gregorio Marañón, CIBERehd and (UCM), Madrid, Spain
| | - Javier Salmerón
- Hepatology Department, Complejo Hospitalario Universitario de Granada, Granada, Granada, Spain
| | | | - Antoni Jou
- HIV Clinical Unit, Internal Medicine Department and Fundació de la Lluita contra la SIDA, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Benjamín Polo-Lorduy
- Hepatology Department, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Ángel Rubín
- Hepatology Department, Hospital Universitario y Politécnico de La Fe, Valencia, Valencia, Spain
| | - Ana Escarda
- Hepatology Department, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Patricia Aguilar
- Digestive System Clinical Unit, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía/Córdoba University, Córdoba, Spain
| | - Teresa Aldámiz-Echevarría
- Infectious Diseases-HIV, Hospital General Universitario Gregorio Marañón (IiSGM), Madrid, Madrid, Spain
| | - Luisa García-Buey
- Hepatology Department, Hospital Universitario de La Princesa, Madrid, Spain
| | - José A. Carrión
- Liver Section, Gastroenterology Department, Hospital del Mar, IMIM (Hospital del Mar Medical Research Institute), UAB (Universitat Autonoma de Barcelona) Barcelona, Spain
| | - Manuel Hernández-Guerra
- Hepatology Department, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain
| | | | - Nuria Espinosa
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC,Sevilla, Spain
| | - Rosa Mª Morillas
- Liver Section, Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, IGTP, Badalona, Barcelona, Spain, and CIBEREHD
| | - Raúl J. Andrade
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Málaga, Spain
| | - Manuel Delgado
- Hepatology Department, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Adolfo Gallego
- Hepatology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Barcelona, Spain
| | - Marta Magaz
- Hepatology Department, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | | | - Ángel Estébanez
- Hepatology Department, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Mikel Rico
- Infectious Diseases Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Fernando Menéndez
- Hepatology Department, Hospital Universitario Basurto, Bilbao, Vizcaya, Spain
| | - Blanca Sampedro
- Hepatology Department, Hospital Galdakao, Galdakao, Vizcaya, Spain
| | - Luís Morano
- Infectious Diseases Unit, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - Sonia Izquierdo
- Hepatology Department, Hospital Clínico San Carlos, Madrid, Spain
| | - José Manuel Zozaya
- Hepatology Department, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
| | - Manuel Rodríguez
- Liver Unit, Division of Gastroenterology & Hepatology. Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Senador Morán-Sánchez
- Hepatology Department, Hospital General Universitario Santa Lucía, Cartagena, Murcia, Spain
| | - Sara Lorente
- Hepatology Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Zaragoza, Spain
| | - Ignacio Martín-Granizo
- Department of Gastroenterology, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | | | - Marcial Delgado
- Infectious Diseases Unit, Hospital Regional Universitario de Málaga, Málaga, Spain
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13
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Romero-Cristóbal M, Mombiela T, Caballero A, Clemente A, Fernández-Yunquera A, Diaz-Fontenla F, Rincón D, Ripoll C, Bermejo J, Catalina MV, Matilla AM, Ibáñez-Samaniego L, Pérez-Peña J, López-Baena JÁ, Díaz-Zorita B, Fernández-Avilés F, Salcedo MM, Bañares R. Clinical Utility of a Risk-Adapted Protocol for the Evaluation of Coronary Artery Disease in Liver Transplant Recipients. Liver Transpl 2019; 25:1177-1186. [PMID: 31106506 DOI: 10.1002/lt.25493] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 04/22/2019] [Indexed: 01/13/2023]
Abstract
The prevalence and management of coronary artery disease (CAD) in liver transplantation (LT) candidates are not well characterized. The aims of this study were to evaluate the impact on clinical outcomes of a specifically designed protocol for the management of asymptomatic CAD in LT candidates and to investigate noninvasive risk profiles for obstructive and nonobstructive CAD for 202 LT candidates. Those with high baseline cardiovascular risk (CVR; defined by the presence of classic CVR factors and/or decreased ejection fraction) received coronary angiography and significant arterial stenosis and were treated with percutaneous stents. Patients were followed up after LT until death or coronary event (CE). There were 78 patients who received coronary evaluation (62 direct angiography, 14 computed tomography coronary angiography, and 2 both). Of them, 39 (50%) patients had CAD of any severity, and 6 (7.7%) had significant lesions (5 were amenable to be treated with stents, whereas 1 patient had diffuse lesions which contraindicated the LT). Insulin-dependent diabetes was the only factor related to CAD of any severity (odds ratio, 3.44; 95% confidence interval [CI], 1.00-11.97). A total of 69 patients (46 with coronary evaluation) received LT. The incidence of CEs and overall survival after LT were similar between patients with and without coronary evaluation. Furthermore, no differences occurred between these groups in a multivariate competing risk model (subhazard ratio, 0.84; 95% CI, 0.27-2.61; P = 0.76). In conclusion, the application of an angiographic screening protocol of CAD in a selected high-risk Mediterranean population is safe and effective. The short- and medium-term incidence rates of CEs and death after LT in this population are similar to that observed in low-risk patients.
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Affiliation(s)
- Mario Romero-Cristóbal
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Teresa Mombiela
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Aranzazu Caballero
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ana Clemente
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Fernando Diaz-Fontenla
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Diego Rincón
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Cristina Ripoll
- Innere Medizin I, Martin-Luther-Universität Halle-Wittenberg, Halle, Germany
| | - Javier Bermejo
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - María-Vega Catalina
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ana-María Matilla
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Luis Ibáñez-Samaniego
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José Pérez-Peña
- Department of Anesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Benjamín Díaz-Zorita
- Department of Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Francisco Fernández-Avilés
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - M Magdalena Salcedo
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Rafael Bañares
- Liver Unit and Digestive Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.,School of Medicine, Complutense University of Madrid, Madrid, Spain
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14
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H. Tovar JH, Pinzón MA, Rincón D, Jiménez-Canizalez CE, Arrieta-Mendoza ME, Mondragón-Cardona Á. Consideraciones anestésicas en el paciente con enfermedad por virus dengue. Rev Chil Anest 2018. [DOI: 10.25237/revchilanestv47n01.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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15
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Sallabanda M, García-Berrocal M, Expósito M, García-Jarabo V, Rincón D, Sánchez S, Martínez I, Magallón R, Zapata I, De la Torre A. EP-1185: Outcome for brain metastasis of NSCLC treated with SRS or hypofractionation. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)31495-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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16
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Muñoz-Gómez R, Rincón D, Ahumada A, Hernández E, Devesa MJ, Izquierdo S, Ortiz M, Hernández-Albujar A, Fernández-Rodríguez C, Calvo M, González R, Lozano M, Castellano G, Fernández-Vázquez I. Therapy with ombitasvir/paritaprevir/ritonavir plus dasabuvir is effective and safe for the treatment of genotypes 1 and 4 hepatitis C virus (HCV) infection in patients with severe renal impairment: A multicentre experience. J Viral Hepat 2017; 24:464-471. [PMID: 27976490 DOI: 10.1111/jvh.12664] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 11/28/2016] [Indexed: 12/16/2022]
Abstract
Limited data are available on direct-acting antivirals for treating hepatitis C virus (HCV) infection in patients with severe renal impairment. The aim of this study was to evaluate the effectiveness and safety of ombitasvir/paritaprevir/ritonavir (OBV/PTV/r) ± dasabuvir (DSV) ± ribavirin (RBV) in patients with stage 4 or 5 chronic kidney disease (CKD) and HCV genotype 1 or 4 infection in real clinical practice, and to investigate pharmacological interactions. This retrospective study included patients treated with OBV/PTV/r+DSV±RBV or OBV/PTV/r+RBV with CKD stage 4 (eGFR: 15-29 mL/min/1.73m2 ) or 5 (eGFR<15 mL/min/1.73m2 or requiring dialysis) and HCV infection by genotypes 1 and 4 between April 2015 and October 2015 in nine Spanish centres. Sustained virological response at 12 weeks (SVR12) was assessed, and clinical and laboratory data, fibrosis stage, adverse events and pharmacological interactions were reported. Forty-six patients were included: 10 (21.7%) had CKD stage 4 and 36 (78.2%) CKD stage 5. Seventeen (36.9%) had cirrhosis. SVR12 rate in the intention-to-treat population was 95.7%. Twenty-one (45.6%) received RBV, which was discontinued in two (9.5%) patients. Anaemia (haemoglobin <10 g/dl) occurred in 12 patients (57.1%) with RBV vs 10 (40.0%) without RBV (P=.246). Renal function remained stable during antiviral therapy. Nine patients (19.5%) experienced serious adverse events unrelated to antiviral therapy. Concomitant medication was discontinued or modified in 41.3% of patients. In conclusion, the effectiveness of OBV/PTV/r±DSV±RBV in patients with CKD 4-5 was similar to that observed in those with normal renal function and was not associated with severe adverse events.
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Affiliation(s)
- R Muñoz-Gómez
- Department of Gastroenterology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - D Rincón
- Unit of Hepatology, Hospital Universitario Gregorio Marañón, CIBERehd , Madrid, Spain
| | - A Ahumada
- Unit of Hepatology, Hospital Universitario Gregorio Marañón, CIBERehd , Madrid, Spain
| | - E Hernández
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - M J Devesa
- Department of Gastroenterology, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - S Izquierdo
- Department of Gastroenterology, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - M Ortiz
- Department of Gastroenterology, Hospital Universitario Infanta Cristina, Madrid, Spain
| | - A Hernández-Albujar
- Department of Gastroenterology, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - C Fernández-Rodríguez
- Department of Gastroenterology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - M Calvo
- Department of Gastroenterology, Complejo Asistencial de Segovia, Segovia, Spain
| | - R González
- Department of Gastroenterology, Hospital Universitario del Sureste, Madrid, Spain
| | - M Lozano
- Department of Gastroenterology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - G Castellano
- Department of Gastroenterology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - I Fernández-Vázquez
- Department of Gastroenterology, Hospital Universitario 12 de Octubre, Madrid, Spain
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17
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Crespo J, Calleja JL, Fernández I, Sacristan B, Ruiz-Antorán B, Ampuero J, Hernández-Conde M, García-Samaniego J, Gea F, Buti M, Cabezas J, Lens S, Morillas RM, Salcines JR, Pascasio JM, Turnes J, Sáez-Royuela F, Arenas J, Rincón D, Prieto M, Jorquera F, Sanchez Ruano JJ, Navascués CA, Molina E, Moya AG, Moreno-Planas JM. Real-World Effectiveness and Safety of Oral Combination Antiviral Therapy for Hepatitis C Virus Genotype 4 Infection. Clin Gastroenterol Hepatol 2017; 15:945-949.e1. [PMID: 28238958 DOI: 10.1016/j.cgh.2017.02.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 02/17/2017] [Accepted: 02/18/2017] [Indexed: 02/07/2023]
Abstract
Patients with hepatitis C virus (HCV) genotype 4 infection are poorly represented in clinical trials of second-generation direct-acting antiviral agents (DAAs). More data are needed to help guide treatment decisions. We investigated the effectiveness and safety of DAAs in patients with genotype 4 infection in routine practice. In this cohort study, HCV genotype 4-infected patients treated with ombitasvir/paritaprevir/ritonavir (OMV/PTVr) + ribavirin (RBV) (n=122) or ledipasvir/sofosbuvir (LDV/SOF) ± RBV (n=130) included in a national database were identified and prospectively followed up. Demographic, clinical and virologic data and serious adverse events (SAEs) were analyzed. Differences between treatment groups mean that data cannot be compared directly. Overall sustained virologic response at Week 12 post treatment (SVR12) was 96.2% with OMV/PTVr+RBV and 95.4% with LDV/SOF±RBV. In cirrhotic patients, SVR12 was 91.2% with OMV/PTVr+RBV and 93.2% with LDV/SOF±RBV. There was no significant difference in SVR12 according to degree of fibrosis in either treatment group (P = .243 and P = .244, respectively). On multivariate analysis, baseline albumin <3.5 g/dL (OMV/PTVr) and bilirubin >2 mg/dL (both cohorts) were significantly associated with failure to achieve SVR (P < .05). Rates of SAEs and SAE-associated discontinuation were 5.7% and 2.5%, respectively, in the OMV/PTVr subcohort and 4.6% and 0.8%, respectively, in the LDV/SOF subcohort. DAA-based regimens returned high rates of SVR12, comparable to limited data from clinical trials, in cirrhotic and non-cirrhotic HCV genotype 4 patients managed in a realworld setting. Safety profiles of both regimens were good and comparable to those reported for other HCV genotypes.
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Affiliation(s)
- Javier Crespo
- Gastroenterology and Hepatology Unit, Hospital Universitario Marqués de Valdecilla, Santander, IDIVAL, Universidad de Cantabria, Santander, Spain.
| | - Jose Luis Calleja
- Department of Gastroenterology, Hospital Universitario Puerta de Hierro, Universidad Autonoma de Madrid and CIBERehd, Madrid, Spain
| | - Inmaculada Fernández
- Department of Gastroenterology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Begoña Sacristan
- Department of Gastroenterology, Hospital San Pedro, Logroño, Spain
| | - Belén Ruiz-Antorán
- Department of Clinical Pharmacology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Javier Ampuero
- Department of Gastroenterology, Hospital Universitario Virgen del Rocío, IBIS and CIBERehd, Sevilla, Spain
| | - Marta Hernández-Conde
- Department of Gastroenterology, Hospital Universitario Puerta de Hierro, Universidad Autonoma de Madrid and CIBERehd, Madrid, Spain
| | | | - Francisco Gea
- Department of Gastroenterology, Hospital Universitario Ramon y Cajal and CIBERehd, Madrid, Spain
| | - Maria Buti
- Liver Unit, Hospital Universitario Vall D'Hebrón and CIBERehd, Barcelona, Spain
| | - Joaquin Cabezas
- Gastroenterology and Hepatology Unit, Hospital Universitario Marqués de Valdecilla, Santander, IDIVAL, Universidad de Cantabria, Santander, Spain
| | - Sabela Lens
- Liver Unit, Hospital Cliníc de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | | | | | - Juan Manuel Pascasio
- Department of Gastroenterology, Hospital Universitario Virgen del Rocio, Sevilla, Spain
| | - Juan Turnes
- Department of Gastroenterology, Complejo Hospitalario Universitario de Pontevedra and IISGS, Pontevedra, Spain
| | | | - Juan Arenas
- Department of Gastroenterology, Hospital Universitario Donostia, San Sebastian, Spain
| | - Diego Rincón
- Department of Gastroenterology, Hospital General Universitario Gregorio Marañón and CIBERehd, Madrid, Spain
| | - Martin Prieto
- Servicio de Medicina Digestiva, Unidad de Hepatología, Hospital Universitari i Politècnic La Fe and CIBERehd, Valencia, Spain
| | - Francisco Jorquera
- Department of Gastroenterology, Complejo Asistencial Universitario León, León, Spain
| | | | - Carmen A Navascués
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Esther Molina
- Department of Gastroenterology, Hospital Clínico Universitario Santiago, Santiago de Compostela, Spain
| | - Adolfo Gallego Moya
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - José Maria Moreno-Planas
- Department of Gastroenterology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
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Calleja JL, Crespo J, Rincón D, Ruiz-Antorán B, Fernandez I, Perelló C, Gea F, Lens S, García-Samaniego J, Sacristán B, García-Eliz M, Llerena S, Pascasio JM, Turnes J, Torras X, Morillas RM, Llaneras J, Serra MA, Diago M, Rodriguez CF, Ampuero J, Jorquera F, Simon MA, Arenas J, Navascues CA, Bañares R, Muñoz R, Albillos A, Mariño Z. Effectiveness, safety and clinical outcomes of direct-acting antiviral therapy in HCV genotype 1 infection: Results from a Spanish real-world cohort. J Hepatol 2017; 66:1138-1148. [PMID: 28189751 DOI: 10.1016/j.jhep.2017.01.028] [Citation(s) in RCA: 142] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 01/25/2017] [Accepted: 01/29/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Clinical trials evaluating second-generation direct-acting antiviral agents (DAAs) have shown excellent rates of sustained virologic response (SVR) and good safety profiles in patients with chronic hepatitis C virus (HCV) genotype 1 infection. We aimed to investigate the effectiveness and safety of two oral DAA combination regimens, ombitasvir/paritaprevir/ritonavir plus dasabuvir (OMV/PTV/r+DSV) and ledipasvir/sofosbuvir (LDV/SOF), in a real-world clinical practice. METHODS Data from HCV genotype 1 patients treated with either OMV/PTV/r+DSV±ribavirin (RBV) (n=1567) or LDV/SOF±RBV (n=1758) in 35 centers across Spain between April 1, 2015 and February 28, 2016 were recorded in a large national database. Demographic, clinical and virological data were analyzed. Details of serious adverse events (SAEs) were recorded. RESULTS The two cohorts were not matched with respect to baseline characteristics and could not be compared directly. The SVR12 rate was 96.8% with OMV/PTVr/DSV±RBV and 95.8% with LDV/SOF±RBV. No significant differences were observed in SVR according to HCV subgenotype (p=0.321 [OMV/PTV/r+DSV±RBV] and p=0.174 [LDV/SOF]) or degree of fibrosis (c0.548 [OMV/PTV/r/DSV±RBV] and p=0.085 [LDV/SOF]). Only baseline albumin level was significantly associated with failure to achieve SVR (p<0.05) on multivariate analysis. Rates of SAEs and SAE-associated treatment discontinuation were 5.4% and 1.7%, in the OMV/PTV/r+DSV subcohort and 5.5% and 1.5% in the LDV/SOF subcohort, respectively. Hepatocellular carcinoma (HCC) recurred in 30% of patients with a complete response to therapy for previous HCC. Incident HCC was reported in 0.93%. CONCLUSIONS In this large cohort of patients managed in the real-world setting in Spain, OMV/PTV/r+DSV and LDV/SOF achieved high rates of SVR12, comparable to those observed in randomized controlled trials, with similarly good safety profiles. LAY SUMMARY In clinical trials, second-generation direct-acting antiviral agents (DAAs) have been shown to cure over 90% of patients chronically infected with the genotype 1 hepatitis C virus and have been better tolerated than previous treatment regimens. However, patients enrolled in clinical trials do not reflect the real patient population encountered in routine practice. The current study, which includes almost 4,000 patients, demonstrates comparable rates of cure with two increasingly used DAA combinations as those observed in the clinical trial environment, confirming that clinical trial findings with DAAs translate into the real-world setting, where patient populations are more diverse and complex.
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Affiliation(s)
- Jose Luis Calleja
- Hospital Universitario Puerta de Hierro, Universidad Autonoma de Madrid and CIBERehd, Madrid, Spain.
| | - Javier Crespo
- Hospital Universitario Marques de Valdecilla, IDIVAL, Santander and Facultad de Medicina, Universidad de Cantabria, Spain
| | - Diego Rincón
- Hospital General Universitario Gregorio Marañón, Facultad de Medicina de la Universidad Complutense and CIBERehd, Madrid, Spain
| | | | | | | | | | - Sabela Lens
- Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | | | | | | | - Susana Llerena
- Hospital Universitario Marques de Valdecilla, IDIVAL, Santander, Cantabria, Spain
| | | | - Juan Turnes
- Complejo Hospitalario Universitario de Pontevedra and IISGS, Spain
| | - Xavier Torras
- Hospital Santa Creu i Sant Pau and CIBERehd, Barcelona, Spain
| | | | | | | | - Moises Diago
- Hospital Universitario General de Valencia, Valencia, Spain
| | | | - Javier Ampuero
- Hospital Universitario Virgen del Rocío, IBIS and CIBERehd, Spain
| | - Francisco Jorquera
- Complejo Asistencial Universitario León, León, IBIOMED and CIBERehd, Spain
| | - Miguel A Simon
- Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Juan Arenas
- Hospital Universitario Donostia, San Sebastian, Spain
| | | | - Rafael Bañares
- Hospital General Universitario Gregorio Marañón, Facultad de Medicina de la Universidad Complutense and CIBERehd, Madrid, Spain
| | - Raquel Muñoz
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Zoe Mariño
- Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
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Yotti R, Ripoll C, Benito Y, Catalina MV, Elízaga J, Rincón D, Fernández-Avilés F, Bermejo J, Bañares R. Left ventricular systolic function is associated with sympathetic nervous activity and markers of inflammation in cirrhosis. Hepatology 2017; 65:2019-2030. [PMID: 28195341 DOI: 10.1002/hep.29104] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/13/2017] [Accepted: 02/04/2017] [Indexed: 12/17/2022]
Abstract
UNLABELLED An accurate evaluation of cardiac function in patients with cirrhosis remains a challenge. We used robust echocardiographic indices to characterize left ventricular (LV) systolic function and its relationship to activation of the sympathetic nervous system and inflammation in 59 patients with cirrhosis and 59 age-matched controls. Additionally, in 11 patients we withdrew beta-blockers and diuretics and used phenylephrine and albumin infusion to evaluate the response to acute afterload and preload changes (interventional substudy). Measures of systolic LV function such as the ejection intraventricular pressure difference (EIVPD) and the systolic strain rate were higher in patients with cirrhosis than in controls (median [1st-3rd quartile], 4.0 [3.1-5.1] versus 2.9 [2.4-3.6] mm Hg and -1.3 [-1.6 to -1.1] versus -1.2 [-1.6 to -1.1)] s-1 , respectively; P < 0.05 for both). EIVPD was related to the severity of liver disease (Model for End-Stage Liver Disease, rho = 0.45, P < 0.001), the degree of sympathetic nervous system activation (noradrenaline, rho = 0.26, P = 0.05; heart rate variability, rho = -0.43, P = 0.003), and treatment with beta-blockers (P = 0.001). In the interventional substudy, EIVPD was higher in patients with ascites (6.5 [5.4-8.5] versus 4.0 [3.9-5.1] mm Hg, P = 0.045). The decrease in EIVPD induced by phenylephrine was inversely related to baseline systolic function (P < 0.05) and associated with markers of systemic vasodilatation (nitric oxide, rho = -0.66, P = 0.06; diastolic blood pressure, rho = 0.68, P = 0.04) and inflammation (interleukin-1beta, rho = -0.80, P = 0.009). CONCLUSION LV systolic function is enhanced in cirrhosis due to augmented adrenergic tone and modulated by treatment with beta-blockers; acute afterload stress induces a deeper impairment of systolic function in patients with more advanced degrees of vasodilatation and inflammation; these changes in LV function related to cirrhosis can be assessed using robust echocardiographic methods. (Hepatology 2017;65:2019-2030).
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Affiliation(s)
- Raquel Yotti
- Department of Cardiology and CIBERCV, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, and Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Cristina Ripoll
- Department of Digestive Diseases and CIBEREHD, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, and Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Yolanda Benito
- Department of Cardiology and CIBERCV, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, and Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Maria Vega Catalina
- Department of Digestive Diseases and CIBEREHD, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, and Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Jaime Elízaga
- Department of Cardiology and CIBERCV, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, and Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Diego Rincón
- Department of Digestive Diseases and CIBEREHD, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, and Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Francisco Fernández-Avilés
- Department of Cardiology and CIBERCV, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, and Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Javier Bermejo
- Department of Cardiology and CIBERCV, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, and Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Rafael Bañares
- Department of Digestive Diseases and CIBEREHD, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, and Facultad de Medicina, Universidad Complutense, Madrid, Spain
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20
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Aguiar D, Martínez-Urbistondo D, Baroja-Mazo A, de la Mata M, Rodríguez-Perálvarez M, Rubín A, Puchades L, Serrano T, Montero J, Cuadrado A, Casafont F, Salcedo M, Rincón D, Pons JA, Herrero JI. Real-World Multicenter Experience of Immunosuppression Minimization Among 661 Liver Transplant Recipients. Ann Transplant 2017; 22:265-275. [PMID: 28461684 PMCID: PMC6248177 DOI: 10.12659/aot.902523] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 12/30/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Long-term morbidity and mortality in liver transplant recipients is frequently secondary to immunosuppression toxicity. However, data are scarce regarding immunosuppression minimization in clinical practice. MATERIAL AND METHODS In this cross-sectional, multicenter study, we reviewed the indications of immunosuppression minimization (defined as tacrolimus levels below 5 ng/mL or cyclosporine levels below 50 ng/mL) among 661 liver transplant recipients, as well as associated factors and the effect on renal function. RESULTS Fifty-three percent of the patients received minimized immunosuppression. The median time from transplantation to minimization was 32 months. The most frequent indications were renal insufficiency (49%), cardiovascular risk (19%), de novo malignancy (8%), and cardiovascular disease (7%). The factors associated with minimization were older age at transplantation, longer post-transplant follow-up, pre-transplant diabetes mellitus and renal dysfunction, and the hospital where the patients were being followed. The patients who were minimized because of renal insufficiency had a significant improvement in renal function (decrease of the median serum creatinine level, from 1.50 to 1.34 mg/dL; P=0.004). Renal function significantly improved in patients minimized for other indications, too. In the long term, glomerular filtration rate significantly decreased in non-minimized patients and remained stable in minimized patients. CONCLUSIONS Immunosuppression minimization is frequently undertaken in long-term liver transplant recipients, mainly for renal insufficiency. Substantial variability exists regarding the use of IS minimization among centers.
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Affiliation(s)
- Diego Aguiar
- Liver Unit, University Clinic of Navarra, Pamplona, Spain
| | | | - Alberto Baroja-Mazo
- Network for Biomedical Research for Hepatic and Digestive Diseases (CIBERehd), Pamplona, Spain
- Murcia Institute for Biomedical Research (IMIB-Arrixaca), Pamplona, Spain
| | - Manuel de la Mata
- Network for Biomedical Research for Hepatic and Digestive Diseases (CIBERehd), Pamplona, Spain
- Liver Unit, Reina Sofia University Hospital, Córdoba, Spain
- Maimónides Institute of Biomedical Research (IMBIC), Córdoba, Spain
| | - Manuel Rodríguez-Perálvarez
- Network for Biomedical Research for Hepatic and Digestive Diseases (CIBERehd), Pamplona, Spain
- Liver Unit, Reina Sofia University Hospital, Córdoba, Spain
- Maimónides Institute of Biomedical Research (IMBIC), Córdoba, Spain
| | - Angel Rubín
- Network for Biomedical Research for Hepatic and Digestive Diseases (CIBERehd), Pamplona, Spain
- Liver Unit, La Fe University Hospital, Valencia, Spain
| | | | - Trinidad Serrano
- Gastroenterology Service, Lozano Blesa University Hospital, Zaragoza, Spain
| | - Jessica Montero
- Gastroenterology Service, Lozano Blesa University Hospital, Zaragoza, Spain
| | - Antonio Cuadrado
- Gastroenterology Service, Marques de Vadecilla University Hospital, Santander, Spain
| | - Fernando Casafont
- Gastroenterology Service, Marques de Vadecilla University Hospital, Santander, Spain
| | - Magdalena Salcedo
- Network for Biomedical Research for Hepatic and Digestive Diseases (CIBERehd), Pamplona, Spain
- Gastroenterology Service, Gregorio Marañon University Hospital, Madrid, Spain
| | - Diego Rincón
- Gastroenterology Service, Gregorio Marañon University Hospital, Madrid, Spain
| | - Jose A. Pons
- Network for Biomedical Research for Hepatic and Digestive Diseases (CIBERehd), Pamplona, Spain
- Murcia Institute for Biomedical Research (IMIB-Arrixaca), Pamplona, Spain
- Gastroenterology and Hepatology Division and Liver Transplantation Unit, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - Jose I. Herrero
- Liver Unit, University Clinic of Navarra, Pamplona, Spain
- Network for Biomedical Research for Hepatic and Digestive Diseases (CIBERehd), Pamplona, Spain
- Institute for Health Investigation of Navarra (IdiSNA), Pamplona, Spain
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21
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Díaz R, Carbonell C, Pérez L, Romero M, Vicario JL, Rincón D, Bañares R, Salcedo MM. Presence of Donor-Specific HLA Alloantibodies (DSAs) After Liver Transplantation is a Frequent Fact. Prospective Study in a Pilot Cohort. Transplantation 2017. [DOI: 10.1097/01.tp.0000520353.85938.90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Alonso S, Riveiro-Barciela M, Fernandez I, Rincón D, Real Y, Llerena S, Gea F, Olveira A, Fernandez-Carrillo C, Polo B, Carrión JA, Gómez A, Devesa MJ, Baliellas C, Castro Á, Ampuero J, Granados R, Pascasio JM, Rubín A, Salmeron J, Badia E, Planas JMM, Lens S, Turnes J, Montero JL, Buti M, Esteban R, Fernández-Rodríguez CM. Effectiveness and safety of sofosbuvir-based regimens plus an NS5A inhibitor for patients with HCV genotype 3 infection and cirrhosis. Results of a multicenter real-life cohort. J Viral Hepat 2017; 24:304-311. [PMID: 27935168 DOI: 10.1111/jvh.12648] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 11/01/2016] [Indexed: 12/12/2022]
Abstract
Patients with HCV genotype 3 (GT3) infection and cirrhosis are currently the most difficult to cure. We report our experience with sofosbuvir+daclatasvir (SOF+DCV) or sofosbuvir/ledipasvir (SOF/LDV), with or without ribavirin (RBV) in clinical practice in this population. This was a multicenter observational study including cirrhotic patients infected by HCV GT3, treated with sofosbuvir plus an NS5A inhibitor (May 2014-October 2015). In total, 208 patients were included: 98 (47%) treatment-experienced, 42 (20%) decompensated and 55 (27%) MELD score >10. In 131 (63%), treatment was SOF+DCV and in 77 (37%), SOF/LDV. Overall, 86% received RBV. RBV addition and extension to 24 weeks was higher in the SOF/LDV group (95% vs 80%, P=.002 and 83% vs 72%, P=.044, respectively). A higher percentage of decompensated patients were treated with DCV than LDV (25% vs 12%, P=.013). Overall, SVR12 was 93.8% (195/208): 94% with SOF+DCV and 93.5% with SOF/LDV. SVR12 was achieved in 90.5% of decompensated patients. Eleven treatment failures: 10 relapses and one breakthrough. RBV addition did not improve SVR (RR: 1.08; P=.919). The single factor associated with failure to achieve SVR was platelet count <75×10E9/mL (RR: 3.50, P=.019). In patients with MELD <10, type of NS5A inhibitor did not impact on SVR12 (94% vs 97%; adjusted RR: 0.49). Thirteen patients (6.3%) had serious adverse events, including three deaths (1.4%) and one therapy discontinuation (0.5%), higher in decompensated patients (16.7% vs 3.6%, P<.006). In patients with GT3 infection and cirrhosis, SVR12 rates were high with both SOF+DCV and SOF/LDV, with few serious adverse events.
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Affiliation(s)
- S Alonso
- Gastroenterology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - M Riveiro-Barciela
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - I Fernandez
- Digestive Diseases Service, Hospital 12 Octubre, Madrid
| | - D Rincón
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.,Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Y Real
- Hospital Universitario La Princesa, Madrid, Spain
| | - S Llerena
- Gastroenterology and Hepatology Unit, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - F Gea
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - A Olveira
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.,Hospital Universitario La Paz, Madrid, Spain
| | - C Fernandez-Carrillo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.,Liver Unit, Hospital Universitario Puerta de Hierro-Majadahonda, IDIPHIM, CIBERehd, Majadahonda, Madrid, Spain
| | - B Polo
- Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - J A Carrión
- Liver Section, Gastroenterology Department, Hospital del Mar, Universitat Autònoma de Barcelona, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - A Gómez
- Hospital Universitario Donostia, Donostia, Spain
| | - M J Devesa
- Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - C Baliellas
- Hospital Universitari de Bellvitge, IDIBELL, Barcelona, Spain
| | - Á Castro
- Hospital Universitario de A Coruña, A Coruña, Spain
| | - J Ampuero
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.,Hospital Virgen de Valme, and Institute of Biomedicine of Seville, Spain
| | - R Granados
- H. U. de Gran Canaria Dr. Negrín, Gran Canaria, Spain
| | - J M Pascasio
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.,H. U. Virgen del Rocío, Seville, Spain
| | - A Rubín
- Hepatology Unit, Digestive Medicine Service, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - E Badia
- Hospital Universitario de Burgos, Burgos, Spain
| | | | - S Lens
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.,Liver Unit, Hospital Clínic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - J Turnes
- Department of Gastroenterology, Complejo Hospitalario Universitario de Pontevedra and IISGS, Pontevedra, Spain
| | | | - M Buti
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - R Esteban
- Liver Unit, Internal Medicine Department, Vall d'Hebron Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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23
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Perelló C, Carrión JA, Ruiz-Antorán B, Crespo J, Turnes J, Llaneras J, Lens S, Delgado M, García-Samaniego J, García-Paredes F, Fernández I, Morillas RM, Rincón D, Porres JC, Prieto M, Lázaro Ríos M, Fernández-Rodríguez C, Hermo JA, Rodríguez M, Herrero JI, Ruiz P, Fernández JR, Macías M, Pascasio JM, Moreno JM, Serra MÁ, Arenas J, Real Y, Jorquera F, Calleja JL. Effectiveness and safety of ombitasvir, paritaprevir, ritonavir ± dasabuvir ± ribavirin: An early access programme for Spanish patients with genotype 1/4 chronic hepatitis C virus infection. J Viral Hepat 2017; 24:226-237. [PMID: 27976491 DOI: 10.1111/jvh.12637] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 10/11/2016] [Indexed: 12/16/2022]
Abstract
Over the last 5 years, therapies for hepatitis C virus (HCV) infection have improved significantly, achieving sustained virologic response (SVR) rates of up to 100% in clinical trials in patients with HCV genotype 1. We investigated the effectiveness and safety of ombitasvir/paritaprevir/ritonavir±dasabuvir in an early access programme. This was a retrospective, multicentre, national study that included 291 treatment-naïve and treatment-experienced patients with genotype 1 or 4 HCV infection. Most patients (65.3%) were male, and the mean age was 57.5 years. The mean baseline viral load was 6.1 log, 69.8% had HCV 1b genotype, 72.9% had cirrhosis and 34.7% were treatment-naïve. SVR at 12 weeks posttreatment was 96.2%. Four patients had virological failure (1.4%), one leading to discontinuation. There were no statistical differences in virological response according to genotype or liver fibrosis. Thirty patients experienced serious adverse events (SAEs) (10.3%), leading to discontinuation in six cases. Hepatic decompensation was observed in five patients. Four patients died during treatment or follow-up, three of them directly related to liver failure. Multivariate analyses showed a decreased probability of achieving SVR associated with baseline albumin, bilirubin and Child-Pugh score B, and a greater probability of developing SAEs related to age and albumin. This combined therapy was highly effective in clinical practice with an acceptable safety profile and low rates of treatment discontinuation.
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Affiliation(s)
- C Perelló
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHIM, Madrid, Spain.,CIBERehd, Madrid, Spain
| | - J A Carrión
- Hospital del Mar, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Universitat Autonoma de Barcelona, Barcelona, Spain
| | - B Ruiz-Antorán
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHIM, Madrid, Spain
| | - J Crespo
- Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain.,Facultad de Medicina, Universidad de Cantabria, Santander, Spain
| | - J Turnes
- Complejo Hospitalario Universitario de Pontevedra and IISGS, Pontevedra, Spain
| | - J Llaneras
- Hospital Universitario Vall D'Hebrón, Barcelona, Spain
| | - S Lens
- CIBERehd, Madrid, Spain.,Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - M Delgado
- Hospital Universitario A Coruña, A Coruña, Spain
| | | | | | - I Fernández
- Hospital Universitario Doce de Octubre, Madrid, Spain
| | - R M Morillas
- CIBERehd, Madrid, Spain.,Hospital Universitario Germans Trias i Pujol, Badalona, Spain
| | - D Rincón
- CIBERehd, Madrid, Spain.,Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - J C Porres
- Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - M Prieto
- CIBERehd, Madrid, Spain.,Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Lázaro Ríos
- Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - J A Hermo
- Hospital Álvaro Cunqueiro, Vigo, Spain
| | - M Rodríguez
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | - J I Herrero
- CIBERehd, Madrid, Spain.,Clínica Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - P Ruiz
- Hospital Universitario Basurto, Bilbao, Spain
| | | | - M Macías
- Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - J M Pascasio
- CIBERehd, Madrid, Spain.,Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - J M Moreno
- Complejo Hospitalario Albacete, Albacete, Spain
| | - M Á Serra
- Hospital Universitario Clínico Valencia, INCLIVA, Valencia, Spain.,University of Valencia, Valencia, Spain
| | - J Arenas
- Hospital Universitario Donostia, Donostia, Spain
| | - Y Real
- Hospital Universitario La Princesa, Madrid, Spain
| | - F Jorquera
- CIBERehd, Madrid, Spain.,Complejo Asistencial de León, IBIOMED, León, Spain
| | - J L Calleja
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHIM, Madrid, Spain.,CIBERehd, Madrid, Spain.,Universidad Autónoma de Madrid, Madrid, Spain
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24
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Abad S, Vega A, Rincón D, Hernández E, Mérida E, Macías N, Muñoz R, Milla M, Luño J, López-Gómez JM. Effectiveness of direct-acting antivirals in Hepatitis C virus infection in haemodialysis patients. Nefrologia 2016; 37:158-163. [PMID: 27914803 DOI: 10.1016/j.nefro.2016.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 09/29/2016] [Accepted: 10/02/2016] [Indexed: 02/07/2023] Open
Abstract
Hepatitis C virus (HCV) infection is highly prevalent among patients on haemodialysis and leads to a poorer prognosis compared to patients who do not have said infection. Treatment with interferon and ribavirin is poorly tolerated and there are limited data on the experience with new direct-acting antivirals (DAAs). The aim of this study is to retrospectively analyse the current prevalence of HCV infection and efficacy and safety results with different DAA regimens in the haemodialysis population of 2hospital areas. This is a multicentre, retrospective and observational study in which HCV antibodies were analysed in 465 patients, with positive antibody findings in 54 of them (11.6%). Among these, 29 cases (53.7%) with genotypes 1 and 4 were treated with different DAA regimens, including combinations of paritaprevir/ritonavir, ombitasvir, dasabuvir, sofosbuvir, simeprevir, daclatasvir and ledipasvir, with/without ribavirin. Mean age was 53.3±7.9 years, 72.4% of patients were male and the most important aetiology of chronic kidney disease involved glomerular abnormalities. In 100% of cases, a sustained viral response was achieved after 24 weeks, regardless of DAA regimen received. Adverse effects were not relevant and no case required stopping treatment. In 15 cases, ribavirin was combined with the DAA. In these cases, the most significant adverse effect was anaemic tendency, which was reflected in the increase of the dose of erythropoietin stimulating agents, although none required transfusions. In summary, we conclude that new DAAs for the treatment of HCV in haemodialysis patients are highly effective with minimal adverse effects; it is a very important advance in HCV management. These patients are therefore expected to have a much better prognosis than they have had until very recently.
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Affiliation(s)
- Soraya Abad
- Servicio de Nefrología, Hospital Universitario Gregorio Marañón, Madrid, España
| | - Almudena Vega
- Servicio de Nefrología, Hospital Universitario Gregorio Marañón, Madrid, España
| | - Diego Rincón
- Servicio de Aparato Digestivo, Hospital Universitario Gregorio Marañón, Madrid, España
| | | | | | - Nicolás Macías
- Servicio de Nefrología, Hospital Universitario Gregorio Marañón, Madrid, España
| | - Raquel Muñoz
- Servicio de Medicina del Aparato Digestivo, Hospital 12 de Octubre, Madrid, España
| | - Mónica Milla
- Servicio de Nefrología. Hospital 12 de Octubre, Madrid, España
| | - Jose Luño
- Servicio de Nefrología, Hospital Universitario Gregorio Marañón, Madrid, España
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25
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Ibáñez-Samaniego L, Catalina MV, Rincón D, Lo Iacono O, Fernández A, Clemente G, Bañares R, Vaquero J, Salcedo M. Liver Support With Albumin Dialysis Reduces Hepatitis C Virus Viremia and Facilitates Antiviral Treatment of Severe Hepatitis C Virus Recurrence After Liver Transplantation. Ther Apher Dial 2016; 20:189-96. [PMID: 26929255 DOI: 10.1111/1744-9987.12381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 09/11/2015] [Accepted: 10/09/2015] [Indexed: 11/29/2022]
Abstract
Patients with severe hepatitis C virus (HCV) recurrence after liver transplantation (LT) present an ominous prognosis, rarely achieving sustained virological response (SVR). Dialysis procedures may transiently decrease the HCV viral load, but the effect of albumin dialysis is currently unknown. Here, we evaluated the impact of albumin dialysis using the Molecular Adsorbent Recirculating System (MARS) used as a co-adjuvant antiviral treatment for severe HCV recurrence after LT. Thirteen patients (11 males, median age 48 years) with fibrosing cholestatic hepatitis or METAVIR fibrosis score ≥ F3 with severe portal hypertension underwent three consecutive MARS sessions. Antiviral therapy was initiated in 11 patients within 24 h after the MARS sessions. A contemporary cohort of seven patients who did not follow the MARS protocol is shown for comparison. MARS treatment resulted in consistent decreases of viral load from 7.59 log10 IU/mL [6.15-8.90] to 6.79 log10 IU/mL [5.18-7.84] (P = 0.003) as well as in decreases of serum bilirubin, gamma-glutamyl transpeptidase, alanine aminotransferase and aspartate aminotransferase (all P < 0.05). The overall rate of SVR was 0% in the Control group and 54.6% in patients initiating antiviral therapy within 24 h after MARS. Survival at 1 and 3 years was, respectively, 93% and 70% in patients undergoing MARS, compared with 29% and 14% in the Control group (P = 0.001). No major adverse events related to MARS treatment were observed. In conclusion, the use of MARS may facilitate the achievement of SVR and improve the prognosis of patients with severe HCV-recurrence after LT by reducing viral load and improving liver function prior to antiviral therapy.
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Affiliation(s)
- Luis Ibáñez-Samaniego
- Unidad de Hepatología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - María-Vega Catalina
- Unidad de Hepatología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.,CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Diego Rincón
- Unidad de Hepatología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.,CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Oreste Lo Iacono
- Servicio de Gastroenterología, Hospital del Tajo, Aranjuez, Madrid, Spain
| | - Ainhoa Fernández
- Unidad de Hepatología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Gerardo Clemente
- Unidad de Hepatología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.,CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Rafael Bañares
- Unidad de Hepatología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.,CIBERehd, Instituto de Salud Carlos III, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Javier Vaquero
- Unidad de Hepatología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.,CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Magdalena Salcedo
- Unidad de Hepatología, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.,CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
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26
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Latorre R, Vaquero J, Rincón D, Puerto M, Ponce MD, Sarnago F, Matamoros JA, Ramón E, Elizaga J, Bañares R, Ripoll C. Determinants of platelet count are different in patients with compensated and decompensated cirrhosis. Liver Int 2016; 36:232-9. [PMID: 26134264 DOI: 10.1111/liv.12908] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 06/23/2015] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Different mechanisms including portal hypertension and hypersplenism have been involved in the development of thrombocytopenia in cirrhosis. However, the relative contribution of each one is unknown. The aim was to evaluate simultaneously different mechanisms that determine platelet count in cirrhosis. METHODS Cross-sectional study including cirrhotics (n = 120) with hepatic venous pressure gradient (HVPG) measurement. Samples were obtained from peripheral (P) veins to evaluate thrombopoietin (TPO), stem cell factor, hepatocyte growth factor (HGF), tumour necrosis factor, interleukin-(IL6) and (IL11) and from hepatic (H) veins to evaluate TPO. A subgroup (n = 72) had spleen volume estimation. H and P-TPO were also measured in non-cirrhotic patients (n = 15). RESULTS Patients (Child A: 55, B: 43, C: 22) had a median platelet count of 81 000/mm(3) (IQR 60 500, 110 750), which correlated with spleen volume (r = -0.38, P < 0.001). Platelets were associated also to HVPG (r = -0.47, P = 0.004) and P-TPO (r = 0.31, P = 0.050) only in compensated patients. H-TPO decreased, and the proportion of patients with P-TPO > H-TPO increased, with the presence and the severity of liver disease. H-TPO was correlated with liver function (bilirubin r = -0.350, P < 0.001 and international normalized ratio r = -0.227, P = 0.011). Patients with H-TPO < P-TPO had higher levels of IL-11 and HGF. CONCLUSION Platelet count in cirrhosis is associated mainly to spleen volume, although portal hypertension as estimated by HVPG and liver function plays a significant role in compensated patients. H-TPO and the proportion of patients with P-TPO > H-TPO were associated to the presence and severity of liver disease.
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Affiliation(s)
- Raquel Latorre
- Department of Digestive Diseases, Liver Unit, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERehd, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Javier Vaquero
- Department of Digestive Diseases, Liver Unit, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERehd, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Diego Rincón
- Department of Digestive Diseases, Liver Unit, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERehd, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marta Puerto
- Department of Digestive Diseases, Liver Unit, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERehd, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - María D Ponce
- Department of Radiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Fernando Sarnago
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jose A Matamoros
- Department of Digestive Diseases, Liver Unit, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Enrique Ramón
- Department of Radiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jaime Elizaga
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rafael Bañares
- Department of Digestive Diseases, Liver Unit, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERehd, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense Madrid Spain, Madrid, Spain
| | - Cristina Ripoll
- Department of Digestive Diseases, Liver Unit, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,CIBERehd, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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27
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Pérez-Romero P, Bulnes-Ramos A, Torre-Cisneros J, Gavaldá J, Aydillo T, Moreno A, Montejo M, Fariñas M, Carratalá J, Muñoz P, Blanes M, Fortún J, Suárez-Benjumea A, López-Medrano F, Barranco J, Peghin M, Roca C, Lara R, Cordero E, Alamo J, Gasch A, Gentil-Govantes M, Molina-Ortega F, Lage E, Martínez-Atienza J, Sánchez M, Rosso C, Arizón J, Aguera M, Cantisán S, Montero J, Páez A, Rodríguez A, Santos S, Vidal E, Berasategui C, Campins M, López-Meseguer M, Saez B, Marcos M, Sanclemente G, Diez N, Goikoetxea J, Casafont F, Cobo-Beláustegy M, Durán R, Fábrega-García E, Fernández-Rozas S, González-Rico C, Zurbano-Goñi F, Bodro M, Niubó J, Oriol S, Sabé N, Anaya F, Bouza E, Catalán P, Diez P, Eworo A, Kestler M, Lopez-Roa P, Rincón D, Rodríguez M, Salcedo M, Sousa Y, Valerio M, Morales-Barroso I, Aguado J, Origuen J. Influenza vaccination during the first 6 months after solid organ transplantation is efficacious and safe. Clin Microbiol Infect 2015; 21:1040.e11-8. [DOI: 10.1016/j.cmi.2015.07.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 07/01/2015] [Accepted: 07/17/2015] [Indexed: 10/23/2022]
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28
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Lens S, Rincón D, García-Retortillo M, Albillos A, Calleja JL, Bañares R, Abraldes JG, Bosch J, Sanchez-Tapias JM, Forns X, García-Pagán JC. Association Between Severe Portal Hypertension and Risk of Liver Decompensation in Patients With Hepatitis C, Regardless of Response to Antiviral Therapy. Clin Gastroenterol Hepatol 2015; 13:1846-1853.e1. [PMID: 25912838 DOI: 10.1016/j.cgh.2015.04.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 03/17/2015] [Accepted: 04/09/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Hepatic venous pressure gradient (HVPG) is associated with a risk of liver events in patients with chronic hepatitis C. Antiviral therapies that lead to a sustained virologic response (SVR) reduce portal pressure and prevent liver disease progression. However, it is not clear to what extent the progression of hepatitis C is modified once patients develop cirrhosis with severe portal hypertension (CSPH) (HVPG ≥ 10 mm Hg). We assessed the effects of HVPG and SVR on the risk of liver decompensation, hepatocellular carcinoma, and/or death in patients with hepatitis C-related cirrhosis. METHODS We collected data from 100 patients with hepatitis C and compensated cirrhosis who underwent HVPG measurement 3 months or less before (baseline) and 24 weeks after therapy with pegylated interferon alfa-2a and ribavirin at 4 hospitals in Spain, from 2001 through 2009. SVR was defined as undetectable serum HCV RNA level 24 weeks after treatment ended. Clinical data were collected until death, liver transplantation, or December 2012 (median, 5 y; interquartile range, 1.4-7 y). RESULTS Seventy-four patients had CSPH at baseline and 35% of patients achieved an SVR. During the follow-up period, 19 patients developed liver decompensation (ascites, variceal bleeding, or encephalopathy). The actuarial probability values for liver decompensation at 1, 5, and 7 years were 3%, 19% and 22%, respectively. The baseline level of HVPG, but not SVR, was associated independently with the risk of liver decompensation. CONCLUSIONS Patients with CSPH, regardless of an SVR to therapy for hepatitis C, remain at risk for liver decompensation within the first 5 years after treatment; they should be monitored closely.
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Affiliation(s)
- Sabela Lens
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain
| | - Diego Rincón
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain; Liver Unit, Hospital Gregorio Marañón, Madrid, Spain
| | | | - Agustín Albillos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain; Liver Unit, Hospital Ramón y Cajal, Madrid, Spain
| | | | - Rafael Bañares
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain; Liver Unit, Hospital Gregorio Marañón, Madrid, Spain
| | - Juan González Abraldes
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Barcelona, Spain
| | - Jaume Bosch
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Barcelona, Spain
| | - Jose Maria Sanchez-Tapias
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain
| | - Xavier Forns
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain
| | - Juan Carlos García-Pagán
- Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivass, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Barcelona, Spain.
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29
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Guzmdn R, Rincón D, Camacho J. [Case report and literature review: elbow fracture dislocation in children]. Acta Ortop Mex 2015; 29:118-122. [PMID: 27012086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Elbow dislocation in children is a very infrequent traumatic event which was first described by Stimson in 1900 and then by Tachdjian in 1990. Its estimated incidence ranges from 3% to 6% of all elbow injuries, peaking at 13-14 years. Elbow trauma is classified considering the direction in which the proximal radioulnar joint shifts with respect to the humerus, into posterior and anterior dislocation. The former is the most frequent and accounts for 95% of cases. Elbow fracture dislocation is an even rarer event. The incidence rate of avulsion fracture of the medial epicondyle is 25-36%, of the lateral condyle 4%, of the olecranon 1.7%, of the radial head 8%, of the coronoid process 3.5%, and others, 3.5%. At present there is no consensus in the literature on how to treat this type of lesions, particularly because some authors advocate nonsurgical management, while others propose surgical management as the definitive treatment. What is clear, however, is that a late diagnosis or untimely treatment may affect the child's growth and lead to serious complications. The purpose of this study is to share our experience and good results with the surgical management of these infrequent cases.
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30
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Chiva T, Ripoll C, Sarnago F, Rincón D, Gómez-Camarero J, Galindo E, Catalina MV, Elizaga J, Bañares R. Characteristic haemodynamic changes of cirrhosis may influence the diagnosis of portopulmonary hypertension. Liver Int 2015; 35:353-61. [PMID: 24797536 DOI: 10.1111/liv.12562] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 04/01/2014] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Diagnosis of portopulmonary hypertension (POPH) is based on the presence of portal hypertension and the same haemodynamic criteria as pulmonary arterial hypertension (PAH). However, the typical hyperdynamic circulation of cirrhosis may have some impact on the diagnosis of POPH. The aim was to compare the haemodynamic pattern of the pulmonary circulation between cirrhotics and non-cirrhotics, including patients with PAH. PATIENTS AND METHODS 600 patients with cirrhosis [male 77.5%, age 54 (47-60) years, Child A: 14.7%, B: 54.3%, C: 31%] received right heart catheterization. For comparison, 118 non-cirrhotic patients [male 60%, age 64 (53-65) years] with right heart catheterization and PCWP <20 mmHg were included. Both were divided into 3 groups, A: absence of pulmonary arterial hypertension; B or intermediate group: MPAP >25 mmHg, PVR 120-240 dyn s cm(-5) and PCWP <15 mmHg (or PCWP >15 mmHg with TPG ≥12 mmHg); C: pulmonary arterial hypertension (same criteria as B except PVR ≥240 dyn s cm(-5) ). RESULTS Distribution of patients with cirrhosis was A 583, B 7 and C 10. Prevalence of POPH was 1.7%. Cirrhotics had lower SVR and greater CO than non-cirrhotics (P < 0.05). Interestingly, patients with cirrhosis without PAH (groups A and B) had lower PVR (P < 0.05) when comparing with non-cirrhotics, while no differences in PVR were observed in group C. However, mean TPG was greater in group C of cirrhotics [36.6 mmHg (12.2) vs. 27.1 mmHg (10.1); P = 0.034]. CONCLUSIONS Patients with cirrhosis have lower PVR. TPG is greater in POPH than PAH. Characteristic haemodynamic changes of cirrhosis may influence the diagnosis of POPH.
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Affiliation(s)
- Teresa Chiva
- Liver Unit Digestive Disease Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain
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31
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Rincón D, Vaquero J, Hernando A, Galindo E, Ripoll C, Puerto M, Salcedo M, Francés R, Matilla A, Catalina MV, Clemente G, Such J, Bañares R. Oral probiotic VSL#3 attenuates the circulatory disturbances of patients with cirrhosis and ascites. Liver Int 2014; 34:1504-12. [PMID: 24661740 DOI: 10.1111/liv.12539] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 03/16/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS The modulation of gut flora constitutes a therapeutic tool in patients with liver disease, but some of its modalities require further investigation. Here, we evaluated the effects of probiotics on the hepatic and systemic haemodynamic alterations of advanced liver disease. METHODS Seventeen patients with cirrhosis and ascites were prospectively included, five of whom abandoned this study prematurely. Hepatic and systemic haemodynamic evaluations were performed at baseline and after 6 weeks of receiving an oral VSL#3 probiotic preparation. Peripheral blood analyses included the evaluation of cytokines (TNF-alpha, IL-1beta, IL-6), bacterial translocation [bacterial DNA and lipopolysaccharide-binding protein (LBP)] and nitric oxide end-products (NOx). RESULTS In 12 patients completing this study, the oral administration of VSL#3 resulted in reductions of the hepatic venous pressure gradient (HVPG, P < 0.001), cardiac index and heart rate (both P < 0.01) and in increases of the systemic vascular resistance (P < 0.05) and mean arterial pressure (P = 0.06). HVPG decreased at least 10% from baseline in eight patients (67%). Serum sodium increased in most patients (P < 0.01). All these changes were unrelated to the detection of bacterial DNA or to the levels of LBP, pro-inflammatory cytokines or NOx. No significant adverse effects were observed. CONCLUSION Administration of the probiotic mixture VSL#3 improved the hepatic and systemic haemodynamics and serum sodium levels in patients with cirrhosis. Our results identify major effects of probiotics in liver disease and provide the rationale for assessing their therapeutic potential against the progression of portal hypertension and its complications in future clinical trials.
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Affiliation(s)
- Diego Rincón
- Medicina-Ap. Digestivo, Hospital General Universitario Gregorio Marañón - CIBERehd - IiSGM., Madrid, Spain
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32
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Rincón D, Guzmén R, Camacho J, Abril C. [Elbow dislocation and lateral epicondyle fracture in a five year-old girl. Case report]. Acta Ortop Mex 2014; 28:369-373. [PMID: 26016289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Traumatic elbow dislocation in the pediatric population is a particularly unusual injury. It was first described by Stimson in 1900 and almost 100 years later revisited by Tachdjian in 1990. Three percent of cases are associated with lateral epicondyle fracture, so this is an infrequent injury that has been described in only a few papers as case reports. The mechanism of injury is not clearly known, nor is the best type of treatment or its complications. We report herein the case of a five year-old girl with fracture dislocation of the lateral epicondyle who was managed with closed reduction and percutaneous fixation with Kirschner nails, with good functional results.
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Rincón D, Foguet A, Rojas M, Segarra E, Sacristán E, Teixidor R, Ortega A. Time of cord clamping and neonatal complications, a prospective study. An Pediatr (Barc) 2014. [DOI: 10.1016/j.anpede.2013.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Rincón D, Foguet A, Rojas M, Segarra E, Sacristán E, Teixidor R, Ortega A. Tiempo de pinzamiento del cordón umbilical y complicaciones neonatales, un estudio prospectivo. An Pediatr (Barc) 2014; 81:142-8. [DOI: 10.1016/j.anpedi.2013.10.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 10/04/2013] [Accepted: 10/28/2013] [Indexed: 11/29/2022] Open
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Altamirano J, Miquel R, Katoonizadeh A, Abraldes JG, Duarte-Rojo A, Louvet A, Augustin S, Mookerjee RP, Michelena J, Smyrk TC, Buob D, Leteurtre E, Rincón D, Ruiz P, García-Pagán JC, Guerrero-Marquez C, Jones PD, Barritt AS, Arroyo V, Bruguera M, Bañares R, Ginès P, Caballería J, Roskams T, Nevens F, Jalan R, Mathurin P, Shah VH, Bataller R. A histologic scoring system for prognosis of patients with alcoholic hepatitis. Gastroenterology 2014; 146:1231-9.e1-6. [PMID: 24440674 PMCID: PMC3992184 DOI: 10.1053/j.gastro.2014.01.018] [Citation(s) in RCA: 297] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 01/06/2014] [Accepted: 01/06/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS There is no histologic classification system to determine prognoses of patients with alcoholic hepatitis (AH). We identified histologic features associated with disease severity and created a histologic scoring system to predict short-term (90-day) mortality. METHODS We analyzed data from 121 patients admitted to the Liver Unit (Hospital Clinic, Barcelona, Spain) from January 2000 to January 2008 with features of AH and developed a histologic scoring system to determine the risk of death using logistic regression. The system was tested and updated in a test set of 96 patients from 5 academic centers in the United States and Europe, and a semiquantitative scoring system called the Alcoholic Hepatitis Histologic Score (AHHS) was developed. The system was validated in an independent set of 109 patients. Interobserver agreement was evaluated by weighted κ statistical analysis. RESULTS The degree of fibrosis, degree of neutrophil infiltration, type of bilirubinostasis, and presence of megamitochondria were independently associated with 90-day mortality. We used these 4 parameters to develop the AHHS to identify patients with a low (0-3 points), moderate (4-5 points), or high (6-9 points) risk of death within 90 days (3%, 19%, and 51%, respectively; P < .0001). The AHHS estimated 90-day mortality in the training and test sets with an area under the receiver operating characteristic value of 0.77 (95% confidence interval, 0.71-0.83). Interrater agreement values were 0.65 for fibrosis, 0.86 for bilirubinostasis, 0.60 for neutrophil infiltration, and 0.46 for megamitochondria. Interestingly, the type of bilirubinostasis predicted the development of bacterial infections. CONCLUSIONS We identified histologic features associated with the severity of AH and developed a patient classification system that might be used in clinical decision making.
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Affiliation(s)
- José Altamirano
- Liver Unit, Hospital Clinic, Institut d’Investigacions
Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. CIBER de
Enfermedades Hepáticas y Digestivas (CIBERehd)
| | - Rosa Miquel
- Pathology Unit, Hospital Clinic, Institut d’Investigacions
Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. CIBER de
Enfermedades Hepáticas y Digestivas (CIBERehd)
| | - Aezam Katoonizadeh
- Department of Morphology and Molecular Pathology, University
Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Juan G Abraldes
- Division of Gastroenterology, Department of Medicine. University of
Alberta, Edmonton, Canada,Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut
d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS),
Barcelona, Spain. CIBER de Enfermedades Hepáticas y Digestivas
(CIBERehd)
| | - Andrés Duarte-Rojo
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester,
MN,Division of Gastroenterology and Hepatology, University of Arkansas
for Medical Sciences, Little Rock, AK
| | - Alexandre Louvet
- Services d’Hepáto-Gastroentérologie, CHRU,
Université de Lille. EA2686, Faculté de Médecine
Pôle Recherche and Inserm U837 Lille, France. Hôpital Huriez Lille,
France
| | - Salvador Augustin
- Liver Unit, Department of Internal Medicine, Hospital Universitari
Vall d’Hebron, Institut de Recerca (VHIR), Universitat Autònoma de
Barcelona, Barcelona, Spain
| | | | - Javier Michelena
- Liver Unit, Hospital Clinic, Institut d’Investigacions
Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. CIBER de
Enfermedades Hepáticas y Digestivas (CIBERehd)
| | | | - David Buob
- Institut de Pathologie, CHRU, Université de Lille. EA2686,
Faculté de Médecine Pôle Recherche and Inserm U837 Lille,
France. Hôpital Huriez Lille, France
| | - Emmanuelle Leteurtre
- Institut de Pathologie, CHRU, Université de Lille. EA2686,
Faculté de Médecine Pôle Recherche and Inserm U837 Lille,
France. Hôpital Huriez Lille, France
| | - Diego Rincón
- Liver Unit, Gastroenterology and Hepatology Division, Hospital
General Universitario Gregorio Marañon, IISGM, School of Medicine,
Universidad Complutense, Madrid, Spain. CIBER de Enfermedades Hepáticas y
Digestivas (CIBERehd)
| | - Pablo Ruiz
- Liver Unit, Hospital Clinic, Institut d’Investigacions
Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. CIBER de
Enfermedades Hepáticas y Digestivas (CIBERehd)
| | - Juan Carlos García-Pagán
- Liver Unit, Hospital Clinic, Institut d’Investigacions
Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. CIBER de
Enfermedades Hepáticas y Digestivas (CIBERehd),Hepatic Hemodynamic Laboratory, Hospital Clinic, Institut
d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS),
Barcelona, Spain. CIBER de Enfermedades Hepáticas y Digestivas
(CIBERehd)
| | - Carmen Guerrero-Marquez
- Pathology Department, Hospital General Universitario Gregorio
Marañon, IISGM, School of Medicine, Universidad Complutense, Madrid, Spain.
CIBER de Enfermedades Hepáticas y Digestivas (CIBERehd)
| | - Patricia D. Jones
- Division of Gastroenterology and Hepatology. Departments of
Medicine and Nutrition. University of North Carolina at Chapel Hill, Chapel Hill,
NC
| | - A. Sidney Barritt
- Division of Gastroenterology and Hepatology. Departments of
Medicine and Nutrition. University of North Carolina at Chapel Hill, Chapel Hill,
NC
| | - Vicente Arroyo
- Liver Unit, Hospital Clinic, Institut d’Investigacions
Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. CIBER de
Enfermedades Hepáticas y Digestivas (CIBERehd)
| | - Miquel Bruguera
- Liver Unit, Hospital Clinic, Institut d’Investigacions
Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. CIBER de
Enfermedades Hepáticas y Digestivas (CIBERehd)
| | - Rafael Bañares
- Liver Unit, Gastroenterology and Hepatology Division, Hospital
General Universitario Gregorio Marañon, IISGM, School of Medicine,
Universidad Complutense, Madrid, Spain. CIBER de Enfermedades Hepáticas y
Digestivas (CIBERehd)
| | - Pere Ginès
- Liver Unit, Hospital Clinic, Institut d’Investigacions
Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. CIBER de
Enfermedades Hepáticas y Digestivas (CIBERehd)
| | - Juan Caballería
- Liver Unit, Hospital Clinic, Institut d’Investigacions
Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. CIBER de
Enfermedades Hepáticas y Digestivas (CIBERehd)
| | - Tania Roskams
- Department of Morphology and Molecular Pathology, University
Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | | | - Rajiv Jalan
- UCL Institute of Hepatology, Royal Free Hospital, London, UK
| | - Philippe Mathurin
- Services d’Hepáto-Gastroentérologie, CHRU,
Université de Lille. EA2686, Faculté de Médecine
Pôle Recherche and Inserm U837 Lille, France. Hôpital Huriez Lille,
France
| | - Vijay H. Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester,
MN
| | - Ramón Bataller
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, CIBER de Enfermedades Hepáticas y Digestivas, Barcelona, Spain; Division of Gastroenterology and Hepatology, Departments of Medicine and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
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Fernández-Yunquera A, Rincón D, Salcedo M, Bañares R. Update on the use of direct-acting antiviral agents for the treatment of chronic hepatitis C virus infection. Rev Esp Quimioter 2013; 26:189-192. [PMID: 24080883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Ainhoa Fernández-Yunquera
- Rafael Bañares, Unidad de Trasplante Hepático. Servicio de Medicina de Aparato Digestivo. Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón. C/ Doctor Esquerdo, 46. 28007 Madrid, Spain.
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Rincón D, Lo Iacono O, Tejedor M, Hernando A, Ripoll C, Catalina MV, Salcedo M, Matilla A, Senosiain M, Clemente G, Molinero LM, Albillos A, Bañares R. Prognostic value of hepatic venous pressure gradient in patients with compensated chronic hepatitis C-related cirrhosis. Scand J Gastroenterol 2013; 48:487-95. [PMID: 22871085 DOI: 10.3109/00365521.2012.711848] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Hepatic venous pressure gradient (HVPG) is the main predictor of clinical decompensation in cirrhotic patients with compensated disease of any etiology without varices. However, the predictive factors of decompensation are not so well known in patients with hepatitis C-related compensated cirrhosis, in whom etiology-based therapy is difficult. The aim of this study was to identify predictors of decompensation in patients with compensated chronic hepatitis C (CHC)-related cirrhosis with and without esophageal varices (Baveno stages 1 and 2). METHODS The study population was a cohort of 145 of such consecutive patients who received hepatic hemodynamic study. All patients were similarly followed every 6 months. Through multivariate Cox regression and bootstrap analyses, a prognostic index (PI) was developed and tested in an external cohort (n = 38). RESULTS Forty-two patients (29%) suffered a first decompensation episode after a median follow-up of 27 months (2-110). Cox regression analysis identified HVPG (hazard ratio (HR) 1.11; 95% confidence interval (CI): 1.05-1.17) and albumin (HR 0.42; 95% CI: 0.22-0.82) as independent predictors of decompensation. Bootstrapping confirmed that HVPG (95% CI: 1.05-1.18) and albumin (95% CI: 0.12-0.74) were the most robust predictive variables. Using a cut-off level of 2.5, the PI [4 + (0.11 × HVPG - 0.8 × albumin)] was able to distinguish two populations of patients with very different risks of decompensation in both the exploratory and validation cohorts. A time-dependent ROC curve identified HVPG as the best predictive variable. CONCLUSION HVPG and albumin are independent predictors of clinical decompensation in patients with compensated CHC-related cirrhosis irrespective of the existence of varices.
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Affiliation(s)
- Diego Rincón
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Diaz-Sanchez A, Matilla A, Nuñez O, Lorente R, Fernandez A, Rincón D, Campos R, Bañares R, Clemente G. Serum angiopoietin-2 level as a predictor of tumor invasiveness in patients with hepatocellular carcinoma. Scand J Gastroenterol 2013; 48:334-43. [PMID: 23249262 DOI: 10.3109/00365521.2012.746391] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Because hepatocellular carcinoma (HCC) has important angiogenic activity, the expression of angiopoietin-2 (Ang-2) may have a pathogenic role. The information about the influence of serum Ang-2 (sAng-2) in patients with HCC is scarce. AIMS The aim was to assess the association between sAng-2 levels and characteristics of tumor and liver disease in patients with HCC. METHODS sAng-2 concentrations in peripheral (sAng-2-P) and hepatic (sAng-2-H) veins were analyzed by ELISA in 33 patients with chronic liver disease who underwent a splanchnic hemodynamic study. Thirty-two patients received treatment for HCC. RESULTS The median age was 61 years and 79% were male. Hepatitis C infection (70%) was the main etiology. Most patients were Child-Pugh grade A (72.7%). sAng-2-P and sAng-2-H were well correlated (r = 0.95; p < 0.0001). A significant association was found between sAng-2-H and lobar tumor extension, vascular thrombosis, BCLC staging, infiltrating pattern, abnormal alpha-fetoprotein level, fulfillment of the Milan criteria, and performance of nonsystemic treatment. sAng-2-H also showed a significant correlation with the MELD score (r = 0.49; p = 0.007), albumin (r = -0.63; p < 0.001), and HVPG (r = 0.44; p = 0.02). Eleven patients received treatment with radiofrequency ablation and eight with transarterial chemoembolization. HCC treatment did not influence the sAng-2 concentration while the necrosis response to treatment was not influenced by previous sAng-2 levels. CONCLUSIONS Ang-2 seems to play an important role in the angiogenic processes of HCC and its serum levels are associated with tumor characteristics and invasive behavior. Our results suggest that Ang-2 is not related with treatment response and its level is not modified by treatment.
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Affiliation(s)
- Antonio Diaz-Sanchez
- Gastroenterology Unit, Hospital Universitario del Sureste, Arganda del Rey, Madrid, Spain.
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Bañares R, Catalina MV, Ripoll C, Rincón D. Prognostic markers in patients who have recovered from an acute variceal bleeding: role of HVPG measurement. Dis Markers 2012; 31:165-9. [PMID: 22045402 PMCID: PMC3826886 DOI: 10.3233/dma-2011-0839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Rafael Bañares
- Liver and Transplant Unit, Instituto de Investigación Sanitaria Gregorio Marañón, Ciberehd, Madrid, Spain.
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Ripoll C, Lastra P, Rincón D, Catalina V, Bañares R. Comparison of MELD, HVPG, and their changes to predict clinically relevant endpoints in cirrhosis. Scand J Gastroenterol 2012; 47:204-11. [PMID: 22242615 DOI: 10.3109/00365521.2011.645500] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIM Identification of predictors in the natural history of cirrhosis is based on determinations at a fixed time point. However, changes of these predictors may offer more information. To evaluate the predictive value of Model for End Stage Liver Disease (MELD) and hepatic venous pressure gradient (HVPG) and their changes in cirrhosis. METHODS Patients with repeat HVPG measurements between January 2000 and December 2008 were considered for inclusion. Patients were followed until decompensation/death or July 2009. Multivariate Cox regression was used to analyze the predictive value of a single measurement of MELD and HVPG, and changes between measurements. Compensated and decompensated patients were analyzed separately. RESULTS One hundred and seventeen patients were included (51 compensated, 66 decompensated). Median time between measurements and follow-up was 13 (2-24) and 11 (6-38) months in compensated and 8 (1-16) and 10 (3-21) months in decompensated patients, respectively. Fifteen compensated patients developed decompensation while twelve decompensated patients died. On multivariate analysis, MELD (HR 1.12 (95% CI 1-1.24)) and HVPG (HR 1.16 (95% CI 1.04-1.29)) were independent predictors of decompensation in compensated, while MELD (HR 1.18 (95% CI 1.09-1.27)) was the only predictor of death in the decompensated. CONCLUSION Single and repeat measurements of MELD and HVPG are associated to outcomes in cirrhosis. Use of repeat measurements does not seem to add further information.
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Affiliation(s)
- Cristina Ripoll
- Digestive Diseases Department, Hospital General Universitario Gregorio Marañón, Liver and Transplant Unit, CiberEHD, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
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Sánchez-Conde M, Miralles P, Bellón JM, Rincón D, Ramírez M, Gutiérrez I, Ripoll C, López JC, Cosín J, Clemente G, Lo Iacono O, Bañares R, Berenguer J. Use of transient elastography (FibroScan®) for the noninvasive assessment of portal hypertension in HIV/HCV-coinfected patients. J Viral Hepat 2011; 18:685-91. [PMID: 21914085 DOI: 10.1111/j.1365-2893.2010.01371.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The hepatic venous pressure gradient (HVPG) is the gold standard for assessing portal pressure and correlates with the occurrence of portal hypertension (PH)-related complications. Transient elastography (TE) is a new, highly accurate noninvasive technique, which enables us to evaluate hepatic fibrosis to detect advanced fibrosis and cirrhosis. We performed a hepatic haemodynamic study and TE in 38 HIV/HCV-coinfected patients. The association between HVPG and liver stiffness was assessed by linear regression. The diagnostic value of TE was assessed by receiver operating characteristic (ROC) curves. We considered clinically significant PH as an HVPG ≥ 10 mmHg and severe PH as an HVPG ≥ 12 mmHg. A total of 38 HIV/HCV-coinfected patients were included. Twenty-eight patients (73.7%) had clinically significant PH (HVPG ≥ 10 mmHg), and 23 (60.5%) of these had severe PH (HVPG ≥ 12 mmHg). We found a statistically significant association between liver stiffness (kPa) and HVPG (r(2) = 0.46, P < 0.001, straight line equation HVPG=7.4 + 0.204*TE). The areas under the ROC curves were 0.80 [95% confidence interval (CI), 0.64-0.97] and 0.80 (95% CI, 0.66-0.94) for the prediction of HVPG ≥ 10 and ≥ 12 mmHg, respectively. Our data suggest that TE can predict the presence of clinically significant and severe PH in HIV/HCV-coinfected patients.
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Affiliation(s)
- M Sánchez-Conde
- Infectious Diseases and HIV Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
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Díaz-Sánchez A, Matilla A, Núñez O, Merino B, Peligros I, Rincón D, Salcedo M, Lo Iacono O, Vega Catalina M, Clemente G, Bañares R. [Influence of treatment of hepatocellular carcinoma before liver transplantation on post transplant tumor recurrence and survival]. Gastroenterol Hepatol 2009; 33:155-64. [PMID: 19945770 DOI: 10.1016/j.gastrohep.2009.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Revised: 10/04/2009] [Accepted: 10/08/2009] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To evaluate the effectiveness of treatment of hepatocellular carcinoma (HCC) before liver transplantation (LT) and its influence on survival and tumor recurrence in patients transplanted for HCC. PATIENTS AND METHODS We included 67 liver transplant patients with a preoperative diagnosis of HCC and pathological confirmation in the native liver between January 2000 and October 2007. Treatment before LT was performed in 46 (68.7%) patients [radiofrequency ablation in 18, transarterial chemoembolization in 31 and percutaneous ethanol injection in two]. RESULTS The median time between inclusion on the waiting list and LT was 4 months and was similar in treated and untreated patients. The median time between pre-transplantation locoregional therapy and LT was less than 6 months in 65.2% of the patients. Treated patients had better liver function (Child A 52.2 vs 19%; Child B 39.1 vs 33.3%; Child C 8.7 vs. 47.6%; p=0.001) and a higher proportion of total tumor size > 3 cm (59.1% vs 30%; p=0.031). Total tumor necrosis was observed in 26.1% of the patients, with no differences according to treatment modality or tumor size. Tumor recurrence occurred in six patients (9%). The median time between LT and tumor recurrence was 26.5 months with a subsequent median survival of 6.6 months. Overall survival was 83.5%, 69.9% and 59.5%, and tumor recurrence-free survival was 83.5%, 68.3% and 58% at 1, 3 and 5 years, respectively. Previous HCC treatment showed no influence on survival or tumor recurrence. Likewise, the grade of tumor necrosis was unrelated to overall survival or the probability of recurrence. CONCLUSION Treatment of HCC before LT in patients with a waiting list time of less than 6 months does not appear to influence survival or tumor recurrence.
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Affiliation(s)
- Antonio Díaz-Sánchez
- Sección de Hepatología, CIBEREHD, Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón, Madrid, España.
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Micheloud D, Salcedo M, Bañares R, Rincón D, Jensen J, Rodríguez J, Fernández-Cruz E, Carbone Campoverde J, Resino S. High rate of infection and immune disorders in patients with hepatitis C virus after liver transplantation. Transpl Infect Dis 2009; 11:367-72. [DOI: 10.1111/j.1399-3062.2009.00408.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Salcedo M, Rodríguez-Mahou M, Rodríguez-Sainz C, Rincón D, Alvarez E, Vicario JL, Catalina MV, Matilla A, Ripoll C, Clemente G, Bañares R. Risk factors for developing de novo autoimmune hepatitis associated with anti-glutathione S-transferase T1 antibodies after liver transplantation. Liver Transpl 2009; 15:530-9. [PMID: 19399747 DOI: 10.1002/lt.21721] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
De novo autoimmune hepatitis (de novo AIH) is a rare form of graft dysfunction that develops after liver transplantation (LT) in patients transplanted for conditions other than autoimmune disorders. Although characterized by biochemical, serological, and histological features of AIH, de novo AIH is sometimes associated with atypical serum autoantibodies, many of which are directed against glutathione S-transferase T1 (anti-GSTT1). GSTT1 donor/recipient genotype mismatch has been suggested as a necessary condition for the appearance of autoantibodies and de novo AIH. However, clinically evident disease is not observed in all patients with anti-GSTT1 antibodies. We examined the incidence of de novo AIH and its conditioning (risk) factors in patients with anti-GSTT1 antibodies. Anti-GSTT1 autoantibodies were detected in 29 of 419 [6.9%; 95% confidence interval (CI), 4.9-9.8] consecutive adult LT recipients with donor/recipient GSTT1 mismatch. Twenty of 27 assessable patients (74%) developed de novo AIH after a median follow-up of 26 months (95% CI, 19.2-32.8). The probability of de novo AIH was 11%, 44%, and 60% 12, 24, and 36 months after LT, respectively. No relationship emerged between de novo AIH and recipient gender, donor and recipient age, rejection episodes, immunosuppressive regime, allelic GSTT1 expression, human leukocyte antigen distribution, or cytomegalovirus infection. Multivariate analysis identified male donor [hazard ratio (HR), 3.3; 95% CI, 1.18-9.26; P = 0.018], nonalcoholic etiology (HR, 4.67; 95% CI, 1.64-13.3; P = 0.002), and high anti-GSTT1 titer (HR, 2.98; 95% CI, 1.04-8.57; P = 0.035) as independent predictors of de novo AIH. Most patients with anti-GSTT1 antibodies and donor/recipient GSTT1 mismatch developed clinically evident de novo AIH after LT. The risk of developing the disease was increased by male donor gender, nonalcoholic etiology of original liver disease, and a high anti-GSTT1 titer.
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Affiliation(s)
- Magdalena Salcedo
- Liver Transplantation Unit, Gastroenterology and Hepatology Division (CIBERHED), Madrid, Spain.
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Micheloud D, Salcedo M, Bañares R, Rincón D, Lorente R, Muñoz-Fernández MA, Resino S. Serum levels of fibrosis biomarkers measured early after liver transplantation are associated with severe hepatitis C virus recurrence. Transpl Infect Dis 2009; 11:183-8. [PMID: 19254326 DOI: 10.1111/j.1399-3062.2009.00370.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
This prospective study analyzed the relationship between several biological markers related to liver fibrosis at 3 months and 1 year post liver transplantation in 37 patients (19 with hepatitis C virus [HCV], 18 with alcoholic liver disease). Severe HCV recurrence (HCV-SR) was defined as fibrosis stage > or =F1 (METAVIR score) at 1 year and/or a value of hepatic venous pressure gradient > or=6 mmHg. We found HCV-SR patients had higher values of monocyte chemotactic protein-1 (MCP-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), and hyaluronic acid (HA) than non-severe HCV recurrence patients (P<0.05). Moreover, receiver operating characteristic curve analysis showed that interferon-inducible protein 10 (IP-10) (area under the curve [AUC]: 0.74; confidence interval [CI] 95%: 0.49-0.91; P=0.043), MCP-1 (AUC: 0.78; CI 95%: 0.54-0.94; P=0.007), sVCAM-1 (AUC: 0.89; CI 95%: 0.67-0.98; P=0.005), and HA (AUC: 0.80; CI 95%: 0.55-0.94; P=0.035) have good predictive capacity for identifying severe HCV infection. The evaluation of these biomarkers may be useful in the early identification of patients in whom a more aggressive therapeutic approach could be necessary.
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Affiliation(s)
- D Micheloud
- Unidad de Investigación, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
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46
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Dominguez M, Rincón D, Abraldes JG, Miquel R, Colmenero J, Bellot P, García-Pagán JC, Fernández R, Moreno M, Bañares R, Arroyo V, Caballería J, Ginès P, Bataller R. A new scoring system for prognostic stratification of patients with alcoholic hepatitis. Am J Gastroenterol 2008; 103:2747-56. [PMID: 18721242 DOI: 10.1111/j.1572-0241.2008.02104.x] [Citation(s) in RCA: 207] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Prognostic stratification of patients with alcoholic hepatitis (AH) may improve the clinical management and facilitate clinical trials. We aimed at developing a scoring system capable of providing prognostic stratification of patients with AH. METHODS Patients with biopsy-proven AH were prospectively included between 2000 and 2006. The biochemical, clinical, portal hemodynamic and histological parameters were evaluated. A Cox regression model was used for univariate and multivariate analyses. A predictive score was built using variables obtained at admission identified in the multivariate analysis. The resulting score was validated in an independent prospective cohort. RESULTS In total, 103 patients with biopsy-proven AH were included in the study cohort. Age, serum bilirubin, serum creatinine, and international normalized ratio (INR) independently predicted 90-day mortality. We generated the Age, serum Bilirubin, INR, and serum Creatinine (ABIC) score: (age x 0.1) + (serum bilirubin x 0.08) + (serum creatinine x 0.3) + (INR x 0.8). The area under the curve (AUC) was 0.82. Using the Kaplan-Meier analysis with the cutoff values of 6.71 and 9.0, we identified patients with low, intermediate, and high risk of death at 90 days (100%, 70%, and 25% of survival rate, respectively). Using the same cutoff values, the ABIC score also stratified patients according to their risk of death at 1 yr. These results were validated by a confirmatory cohort (N = 80). CONCLUSIONS The ABIC score is a new tool that allows the stratification of risk of death in patients with AH at 90 days and 1 yr. This score can help improve the management of these patients and also help to perform clinical trials.
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Affiliation(s)
- Marlene Dominguez
- Liver Unit, Institut Clínic Malalties Digestives i Metabòliques, Hospital Clinic, and Centro de Investigación Biomédica Esther Koplowitz, Barcelona, Catalonia, Spain
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47
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Lo Iacono O, Rincón D, Hernando A, Ripoll C, Catalina MV, Salcedo M, Clemente G, Gomez J, Nuñez O, Matilla A, Bañares R. Serum levels of soluble vascular cell adhesion molecule are related to hyperdynamic circulation in patients with liver cirrhosis. Liver Int 2008; 28:1129-35. [PMID: 18482273 DOI: 10.1111/j.1478-3231.2008.01763.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In patients with liver cirrhosis, serum levels of soluble vascular cell adhesion molecule-1 (sVCAM-1) have been associated with increasing fibrosis and are related to angiogenesis. AIM To assess the possible correlation between sVCAM-1 and splanchnic and systemic haemodynamic and clinical staging of cirrhotic patients. METHODS We assessed, using immunoassays, the serum levels of sVCAM-1, in the peripheral and hepatic vein, in all consecutive patients with liver cirrhosis, who underwent a haemodynamic study as part of its routine clinical work-up. RESULTS We studied 86 patients [61 M/25 F; age 51.1 (8.3) years] with alcoholic (31) or viral (HBV:6, HCV:49) cirrhosis, 10 of them with hepatocellular carcinoma (Milan criteria). The mean follow-up was 391(187) days; 29 patients died or underwent transplantion during follow-up. A strong correlation in serum levels of sVCAM-1 was observed between the peripheral and the hepatic vein (r=0.8; P=0.0001). There was no correlation between levels of sVCAM-1 and hepatic venous pressure gradient. At univariate analysis, sVCAM-1 was inversely related with mean arterial pressure (r=-0.292; P=0.007), systemic vascular resistance (SVR) (r=-0.37; P=0.005) and serum sodium levels (r=-0.326; P=0.002). In multivariate linear regression only SVR remained as an independent variable associated to sVCAM-1. A correlation of sVCAM-1 with Child-Pugh scores, model for end-stage liver disease (MELD) and the clinical stage proposed in the Baveno IV consensus conference was also observed. Finally, patients who died or underwent transplantion during follow-up had significantly greater values of sVCAM-1 at baseline than those who did not [3505(1329) vs. 2488(1208) P=0.001]. CONCLUSION This study supports a potential role of sVCAM-1 as a marker of hyperdynamic circulation, closely related to the different stage of liver cirrhosis.
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Affiliation(s)
- Oreste Lo Iacono
- CIBEREHD and Servicio de Aparato Digestivo, Sección de Hepatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
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48
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Clemente M, Núñez O, Lorente R, Rincón D, Matilla A, Salcedo M, Catalina MV, Ripoll C, Iacono OL, Bañares R, Clemente G, García-Monzón C. Increased intrahepatic and circulating levels of endoglin, a TGF-beta1 co-receptor, in patients with chronic hepatitis C virus infection: relationship to histological and serum markers of hepatic fibrosis. J Viral Hepat 2006; 13:625-32. [PMID: 16907850 DOI: 10.1111/j.1365-2893.2006.00733.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Endoglin, a transforming growth factor (TGF)-beta1 co-receptor, has been associated with renal and cutaneous fibrosis, as overexpression of this protein has been observed in biopsies from patients with glomerulosclerosis and scleroderma, respectively. Our aim was to evaluate whether endoglin may be associated with hepatic fibrosis featuring chronic hepatitis C virus (HCV) infection. Fifty-two anti-HCV+ patients, five anti-HCV- patients and 27 healthy subjects were studied. Western blot and immunohistochemistry were used to quantify the expression levels of endoglin and TGF-beta1 in liver biopsy samples, and serum concentrations of endoglin and hyaluronic acid were determined by enzyme-linked immunosorbent assays (ELISAs). In patients with advanced fibrosis, intrahepatic expression levels of endoglin and TGF-beta1 were significantly higher than those in patients with early fibrosis (mean: 3- and 5.8-fold, respectively) and normal liver (mean: 3.9- and 12-fold, respectively). Interestingly, activated hepatic stellate cells as well as portal and septal myofibroblasts expressed endoglin. Serum levels of endoglin were also significantly higher in patients with advanced fibrosis than in those with early fibrosis (55.5 +/- 1.6 vs 47.5 +/- 0.9 ng/mL, P < 0.001), showing a positive correlation with serum hyaluronic acid concentrations (r = 0.57, P = 0.01). In conclusion, increased intrahepatic endoglin and TGF-beta1 expression is significantly associated with progressive hepatic fibrosis in chronic HCV infection. Circulating endoglin levels are elevated in HCV patients showing a significant correlation with histological and serum markers of hepatic fibrosis. These data suggest an active role for endoglin in the fibrotic process featuring chronic HCV infection.
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Affiliation(s)
- M Clemente
- Liver Research Unit, University Hospital Santa Cristina, Madrid, Spain
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49
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Abstract
Chronic hepatitis C is the leading cause of advanced liver disease in the Western world. Most patients with liver cirrhosis develop portal hypertension (PHT) (i.e. an abnormal gradient between portal and inferior vena cava pressures), responsible for the most frequent and severe complications of liver disease and, as a consequence, the main cause of death and liver transplantation in those patients. The existence of a potential beneficial effect of antiviral therapy (AVT) on liver inflammation and fibrosis, partially independent of the degree of virological response, has been recently reported. However, the possible influence of these histological changes on PHT has not been evaluated. In this article, we summarize the available findings regarding the effect of AVT on PHT in patients with advanced chronic hepatitis C, as well as its possible implications for clinical practice and future avenues of investigation.
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Affiliation(s)
- Diego Rincón
- Hospital General Universitario Gregorio Marañón Dr Esquerdo 46, 28007, Madrid, Spain
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50
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Ripoll C, Bañares R, Rincón D, Catalina MV, Lo Iacono O, Salcedo M, Clemente G, Núñez O, Matilla A, Molinero LM. Influence of hepatic venous pressure gradient on the prediction of survival of patients with cirrhosis in the MELD Era. Hepatology 2005; 42:793-801. [PMID: 16175621 DOI: 10.1002/hep.20871] [Citation(s) in RCA: 180] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Measurements of portal pressure, usually obtained via the hepatic venous pressure gradient (HVPG) may be a prognostic marker in cirrhosis. The aim of this study was to evaluate the impact of HVPG on survival in patients with cirrhosis in addition to the Model for End-Stage Liver Disease (MELD) score. We also examined whether inclusion of HVPG in a model with MELD variables improves its prognostic ability. Retrospective analyses of all patients who had HVPG measurements between January 1998 and December 2002 were considered. Proportional hazards Cox models were developed. Prognostic calibrative and discriminative ability of the model was evaluated. In this period, 693 patients had a hepatic hemodynamic study, and 393 patients were included. Survival was significantly worse in those patients with greater HVPG value (univariate HR, 1.05; 95% CI, 1.02-1.08; P = .001). HVPG remained as an independent variable in a model adjusted by MELD, ascites, encephalopathy, and age (multivariate HR, 1.03; 95% CI, 1.00-1.06; P = .05) so that each 1-mmHg increase in HVPG had a 3% increase in death risk. In addition, HVPG as well as MELD score variables and age, significantly contributes to the calibrative predictive capacity of the prognostic model; however, discriminative ability improved only slightly (overall C statistic [95% CI]; MELD score variables: 0.71 [0.62-0.80], MELD score variables, age, and HVPG 0.76: [0.69-0.83]). In conclusion, HVPG has an independent effect on survival in addition to the MELD score. Although inclusion of HVPG and age in a survival predicting model would improve the calibrative ability of MELD, its discriminative ability is not significantly improved.
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Affiliation(s)
- Cristina Ripoll
- Sección de Hepatología, Servicio de Aparato Digestivo, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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