Interacciones clínicas y farmacocinéticas entre metadona y nelfinavir (estudio Nemesia)

BACKGROUND AND OBJECTIVE

Patients on methadone maintenance therapy who are administered nelfinavir show a decrease in methadone plasma levels. However, the clinical relevance of this fact is seldom significant because it does not correlate with the appearance of opioid withdrawal symptoms (OWS). The objective of this study was to assess the clinical and pharmacokinetic interactions between methadone and nelfinavir.

PATIENTS AND METHOD

A prospective multicenter study of human immunodeficiency virus (HIV) positive patients on stable methadone therapy who initiated nelfinavir was performed. To determine the presence of OWS, 2 questionnaires, objective and subjective, were administered at weeks 1, 2, 3 and 4. A pharmacokinetic study measuring the minimal plasmatic concentration of methadone was done at baseline and at week 4.

RESULTS

29 patient were included. In 7 patients who underwent pharmacokinetic studies, the minimal plasmatic concentration of methadone decreased after 4 weeks of nelfinavir treatment from 6.889 ng/ml to 4.354 ng/ml (37%; p = 0.046). However the results of the questionnaires did not show the significant OWS, which precluded an increase in the dose of methadone.

CONCLUSIONS

In patients under stable methadone treatment, antiretroviral therapy including nelfinavir does not require any significant modification of methadone dose. The decrease in methadone plasmatic levels does not correlate with OWS.

Polymorphism of RANTES chemokine gene promoter is not associated with long-term nonprogressive HIV-1 infection of more than 16 years

To examine whether polymorphisms of the RANTES chemokine gene promoter are associated with long-term nonprogressive HIV-1 infection in white Spanish subjects, we performed a cross-sectional genetic association case-control study. Two-hundred sixty-seven white Spaniards were studied: 58 were HIV-1-infected long-term nonprogressors (LTNPs) of more than 16 years, 109 were HIV-1-infected usual progressors (UPs), and 100 were control subjects. Three RANTES single nucleotide polymorphisms (SNPs) at positions -28C>G, -109T>C, and -403G>A were assessed. The prevalence of the CCR5Delta 32 allele was also examined. Genotyping was performed using polymerase chain reaction and automatic sequencing analysis methods. Genotype and allele frequencies between the 3 groups were compared by the chi2 test and the Fisher exact test. The distribution of allelic variants of RANTES in controls, UPs, and LTNPs, respectively, was 3%, 2%, and 5% for -28G; 4%, 2%, and 2% for -109C; and 18%, 18%, and 18% for -403A (P = not significant). The differences were still nonsignificant when we exclusively analyzed individuals not carrying the CCR5Delta32 allele. We conclude that LTNP of more than 16 years is not associated with SNPs in the RANTES gene promoter in white Spanish HIV-1-infected subjects.

Vitamin B-12 metabolism in HIV-infected patients in the age of highly active antiretroviral therapy: role of homocysteine in assessing vitamin B-12 status

BACKGROUND

Before the advent of highly active antiretroviral therapy (HAART), 20% and 10% of HIV-infected patients had low vitamin B-12 and red blood cell folate (RBCF) concentrations, respectively. However, few patients had real vitamin B-12 deficiency.

OBJECTIVE

We evaluated the prevalence of low vitamin B-12 and RBCF concentrations in HIV-infected patients receiving HAART and the usefulness of serum homocysteine (sHcy) for differentiating patients with deficiency from those with harmlessly low vitamin B-12.

DESIGN

The prevalence of low vitamin B-12 and RBCF was evaluated in 126 HIV-infected patients receiving HAART. Moreover, sHcy concentrations were evaluated in 40 HIV-infected patients with low vitamin B-12 and in 37 HIV-infected patients with low RBCF and were compared with those in 128 HIV-infected patients with normal vitamin B-12 and RBCF. sHcy was used to monitor treatment with vitamin B-12 and folic acid in 28 patients (24 with low vitamin B-12 and RBCF and 4 with hyperhomocysteinemia but normal vitamin B-12 and RBCF).

RESULTS

The prevalence of low vitamin B-12 was significantly lower in patients receiving HAART than in previously studied patients who did not receive HAART (8.7% compared with 27%). Nine of the 40 patients (22.5%) with low vitamin B-12 (< or = 200 pmol/L) had hyperhomocysteinemia (> 17.5 micromol homocysteine/L). Nineteen (51.4%) of the 37 patients with low RBCF (< or = 580 nmol/L, percentile 10) had hyperhomocysteinemia. Among the 9 patients with an RBCF concentration < or = 450 nmol/L (percentile 2.5), all had hyperhomocysteinemia. The treatment with vitamin B-12 and folic acid normalized sHcy concentrations.

CONCLUSIONS

The prevalence of low vitamin B-12 decreased after the introduction of HAART. The study of sHcy is useful for detecting HIV-infected patients with low vitamin B-12 and real deficiency.

Beta 2-microglobulin and immunoglobulins are more useful markers of disease progression in HIV than neopterin and adenosine deaminase

Reference change values of six biochemical quantities (beta 2-microglobulin, neopterin, adenosine deaminase and immunoglobulins IgA, IgG and IgM) have been established in asymptomatic human immunodeficiency virus (HIV)-infected patients following the method described by Harris and Yasaka in 1983. Patients included in the evaluation were classified as A1, A2 or A3 according to the classification of the Centers for Disease Control (CDC) (January 1993). All patients were followed-up quarterly, with a minimum of four samples each available for statistical analysis. The main objective of this paper was to study whether differences found to be greater than calculated reference change values could predict clinical or immunological worsening in patients' status. Retrospective analysis was made in asymptomatic patients (n = 256) included in an HIV infection protocol carried out in our hospital. Of these patients, 179 showed clinical or immunological worsening during the study period and 77 maintained their clinical and immunological status. Changes in beta 2-microglobulin showed the greatest sensitivity to detect clinical or immunological worsening (43.0%), whereas changes in adenosine deaminase showed the lowest (21.8%). Clinical or immunological worsening in 169 of the 179 patients was detected by one of the six biochemical quantities evaluated. Ten patients showed clinical or immunological worsening, although differences between measurements were lower than the reference change values calculated. Of 77 patients whose clinical state did not deteriorate, there was a change in biochemical analytes greater than the reference value calculated in 29 patients (a period of 12 months had elapsed since detection). In 48 patients, no increases greater than calculated reference change values were detected. The sensitivity obtained using the six analytes was 94.4% and the specificity was 62.3%.

Absence of thallium-201 brain uptake in progressive multifocal leukoencephalopathy in AIDS patients

OBJECTIVE

To evaluate the presence of thallium-201 brain uptake determined by thallium-201 brain SPECT (Tl-201 SPECT) in patients with progressive multifocal leukoencephalopathy (PML) and AIDS.

MATERIAL AND METHODS

Six AIDS patients with stereotactic biopsy diagnosis of PML were prospectively evaluated with Tl-201 SPECT, Magnetic Resonance Imaging (MRI), and proton magnetic resonance spectroscopy (1H-MRS). Tl-201 SPECT results were compared with 2 patients with AIDS and biopsy proven primary CNS lymphoma.

RESULTS

In all patients with PML, Tl-201 SPECT studies showed lack of uptake while MRI demonstrated subcortical white matter focal brain lesions and 1H-MRS disclosed metabolic abnormalities. Intense thallium uptake (uptake ratios of 3.2 and 5.6) was demonstrated in the 2 patients with primary CNS lymphoma.

CONCLUSIONS

The present study shows that PML lesions are not detectable on Tl-201 SPECT while MRI and 1H-MRS demonstrate abnormalities, and intense thallium-201 uptake may be detected in primary CNS lymphoma. These results suggest that Tl-201 SPECT is a method which, combined with other non-invasive techniques such as MRI and 1H-MRS, may help in the diagnostic approach of PML and to differentiate PML from other high proliferative brain lesions characterized by positive thallium uptake.

Proton magnetic resonance spectroscopy pattern of progressive multifocal leukoencephalopathy in AIDS

The objective was to determine whether the use of intermediate echo times (135 ms) in proton magnetic resonance spectroscopy (1H-MRS) detects a homogenous pattern in progressive multifocal leukoencephalopathy (PML) in HIV-1 infected people, and to confirm the results of previous studies. Six patients infected with HIV-1, with PML established by biopsy, and six healthy age and sex matched volunteers were evaluated to define their spectroscopic pattern. 1H-MRS spectra performed at 1.5 T were obtained with the STEAM sequence: TE/TM/TR, 20 ms/13.7 ms/2000 ms; 2500 Hz, size 2048 points, 256 acquisitions (STEAM-20) and with the PRESS sequence; TE/TR, 135 ms/2000 ms; 2500 Hz, size 2048 points, 256 acquisitions (PRESS-135). A single voxel was placed on the lesions and on the parieto-occipital white matter of controls. The peaks of N-acetylaspartate (NAA), choline (Cho), myoinositol (mI), lactate, and lipids were considered, and the results were expressed using creatine as reference. Spectra of PML lesions were characterised by significantly reduced NAA, lactate presence, and by significantly increased Cho and lipids compared with control group values. These results indicate that 1H-MRS detects a homogenous pattern in PML lesions. Recent studies, together with this, suggest that 1H-MRS may help in the diagnostic approach to patients with suspected PML lesions associated with AIDS.

Cobalamin deficiency in patients infected with the human immunodeficiency virus

Serum vitamin B12 levels are often low in human immunodeficiency virus (HIV)-infected patients. However, only a few patients appear to have actual vitamin B12 deficiency. A low red cell folate level accompanying the low vitamin B12 level makes the presence of vitamin B12 deficiency more likely. Our experience suggests that a low red cell folate level always indicates deficiency, but does not differentiate between vitamin B12 and folate deficiency. The deoxyuridine suppression test and the assay of serum or plasma total homocysteine and/or of methylmalonic acid levels can also be useful in the identification of patients with true vitamin B12 deficiency. HIV-positive patients frequently have absorption disorders, including vitamin B12 malabsorption. However, the correlation between vitamin B12 malabsorption and serum vitamin B12 and plasma homocysteine levels is poor. Abnormalities in vitamin B12-binding proteins, which are often found in HIV-positive patients, may explain many cases of low vitamin B12 levels. Current evidence suggests that low vitamin B12 levels are more common as the HIV disease progresses. The results of vitamin B12 treatment have been disappointing thus far, including the prevention of toxicity induced by azidothymidine. The possible role of vitamin B12 treatment in the long-term survival of HIV-infected patients is at present unknown. However, it is important to identify those patients who have real vitamin B12 deficiency to treat or prevent their hematologic and/or neurological symptoms.

The deoxyuridine suppression test in HIV-1 positive patients: the role of azydothymidine (AZT)

The deoxyuridine suppression test (dUST) was used to evaluate human immunodeficiency virus type 1 positive (HIV-1) patients with low serum levels of vitamin B12 and/or low red cell folate and to assess any possible interferences of azydothymidine (AZT) in this test. The dUST was studied in 29 HIV-1 positive patients, 18 without low serum vitamin B12 or low red cell folate and 11 with low serum vitamin B12 (6 patients), low red cell folate (4 patients) and 1 case with both. The role of AZT was studied using different concentrations (0.2, 2.5 and 10 microM/ml) in 2 groups: 1 group of 5 patients with vitamin B12 and/or folate deficiency and another group consisting of 13 healthy subjects. Methotrexate (MTX)(50 micrograms/ml) was added to induce a folate megaloblastic pattern in the latter group. Results of the dUST in the HIV-1 group without low levels of serum vitamin B12 fell within the health-related reference interval values. A vitamin B12 deficiency was only detected in 1 case in the HIV-1 group with low serum vitamin B12, although a folate deficiency pattern was observed in the 4 patients with low red cell folate. In the healthy subjects AZT induced a dose-dependent decrease of the MTX-induced folate megaloblastic pattern. The pattern was also observed in the group of patients with vitamin B12 or folate deficiency, although AZT did not entirely interfere with the dUST. The effect of AZT on the dUST was attributed to a decrease in the incorporation of the isotope in the absence of deoxyuridine. The dUST is useful in differentiating vitamin B12 deficient patients from HIV-1 infected patients with low levels of serum vitamin B12.

[Movement disorders and AIDS]

We describe the clinical characteristics, causes and response to treatment in 6 patients with AIDS who presented with abnormal movement disorders between January 1987 and July 1993 in our hospital, 3 with hemiballismus-hemichorea, 1 with athetosis, 1 myoclonia and 1 with "rubric" tremor. Brain imaging showed lesions in the corpus striatum in all the patients. Suspected diagnoses were cerebral toxoplasmosis in 4, cerebral lymphoma in 1 and progressive multifocal leukoencephalopathy in 1. The toxoplasmosis patients showed improvement (2 cases) or disappearance (2 cases) of movements with antiparasitic therapy. Treatment provided no benefit to the patients with leukoencephalopathy and lymphoma. Hemiballismus-hemichorea was the most common movement disorder in AIDS patients. The underlying cause is usually lesions in the basal ganglia arising from toxoplasmosis. If the lesions are so caused, movements may improve with antiparasitic therapy.

[Cerebral toxoplasmosis in patients with human immunodeficiency virus (HIV) infection. Clinico-radiological and therapeutic aspects in 63 patients]

We have retrospectively reviewed 63 cases of encephalic toxoplasmosis (ET) in HIV-infected patients in order to determine clinical and radiological characteristics, the diagnostic value of serologic determinations, and the response to antioxoplasmic therapy. ET was the AIDS-defining condition in 44% of the patients. Eighty of the patients had a CD4 cell count < 100/microliters when ET was diagnosed. Only 4.8% of the patients had been taking anti-Pneumocytis carinii prophylaxis with cotrimoxazol. The most frequent clinical presentation was focal neurologic signs in 80.9% of the patients, with headache and fever in 53.3% and 42.4%, respectively. The most frequent cerebral CT finding was hipodense lesions (92%) with ring enhancement (68.9%). They were most frequently had a hemisferic location. Seroconversion was detected in two patients (6%), whereas 55 patients had serologic evidence of latent infection by Toxoplasma gondii (87.3%). Ninety eight percent of the patients were treated with sulphadiazine plus pyrimethamine. However, such therapy should be discontinued in 22% of them and switched to clindamycin plus pyrimethamine. The overall mortality rate during the acute phase of the disease was 7.9%, but 41.4% of the survivors exhibited neurologic sequelae. Relapsing ET was detected in 33.3% of the patients, and it was usually due to discontinuation of treatment. The mean survival time after the diagnosis of ET was 11.5 months. ET is the most common opportunistic infection of the central nervous system among our AIDS patients. Primary prophylaxis for toxoplasmic infection seems advisable in our epidemiologic environment, when CD4 cell count is less than 200/microliters and there is serologic evidence of latent infection. Acute ET usually has a good response to therapy, and the acute mortality rate is low. However, most of the survivors will remain with neurologic sequelae. The high frequency of adverse effects to sulphamide therapy with clindamycin make the need of alternative treatment strategies urgent.

Prevalence of high serum and red cell ferritin levels in HIV-infected patients

We report a high prevalence of elevated serum and red cell ferritin (SF and RCF) levels in 168 patients with HIV infection. SF levels increase with clinical worsening of infection and with decreasing CD4+ lymphocyte counts (ANOVA, p < 0.001) while RCF is significantly higher in asymptomatic AIDS patients (ANOVA, p < 0.001) and in those treated with zidovudine (AZT) (ANOVA, p < 0.001). It is suggested that, although inflammatory processes may explain high SF levels, if we also take in account RCF levels a possible association between iron overload and HIV infection might exist, and this may be worsened by AZT treatment. The significance of these high ferritin levels and their effects on immune system suppression and susceptibility to infectious and neoplastic complications in these patients merits further investigation.

Vitamin B12 transport proteins in patients with HIV-1 infection and AIDS

BACKGROUND

Low vitamin B12 levels (B12) are often observed in patients infected with human immunodeficiency virus type 1 (HIV-1). The causes underlying this finding are thought to be intestinal malabsorption and/or abnormalities in the vitamin plasma binding proteins (BP).

MATERIAL AND METHODS

Serum levels of B12 and BP were studied in eighty HIV-1-positive patients, 55 of whom met the diagnostic criteria for AIDS. Subjects were divided into various subgroups: non-AIDS HIV-1 positive versus AIDS; low serum B12 levels (DB12, < 150 pmol/L) versus normal serum B12 levels (NB12); and the results obtained were compared both between groups and with respect to a reference population (RF) of normal volunteers.

RESULTS

Low levels of serum B12 were found in 14 patients (17.5%), without differences between the AIDS and non-AIDS subgroups. The levels of holohaptocorrin (holoHP) were lower in the DB12 group than in the NB12 and RF groups (p < 0.01), and no differences were found between the AIDS and non-AIDS groups. The levels of apotranscobalamin (apoTC) were higher in the AIDS group than in the non-AIDs and RF subjects (p < 0.01), but no differences were found between the DB12 and NB12 groups. Likewise, no differences were noted in the levels of holoTC between the DB12 and NB12 groups. A positive correlation between neutrophil counts and free serum haptocorrin levels (apoHP) (rs = 0.36; p = 0.002), and a negative one between the former and the levels of apoTC (rs = -0.3; p = 0.009) were observed. Furthermore, a positive correlation was detected between the erythrocyte sedimentation rate and the levels of apoHP and TC.

CONCLUSIONS

Low serum levels of HP in HIV-1 positive patients could lead to the low levels of serum vitamin B12 frequently observed in this patient population, while the high levels of TC could merely represent a non-specific marker of inflammation (acute phase, reactant).

Findings on Doppler echocardiography in asymptomatic intravenous heroin users

To detect potential cardiac abnormalities induced by intravenous heroin use, 68 persons without a previous episode of infective endocarditis were studied by Doppler echocardiography. A control group of 41 normal subjects was studied for comparison. The following measurements were considered: (1) diameter of heart chambers, (2) systolic left ventricular function, (3) morphologic valvular abnormalities, (4) presence of valve regurgitations, (5) Doppler indexes of diastolic function, and (6) estimation of pulmonary arterial resistances. Results showed no significant differences regarding the size of the heart chambers or systolic left ventricular function. A significantly higher incidence of valvular abnormalities (focal thickening or valve prolapse) was found in drug addicts (p = 0.0009) at the mitral and tricuspid valves, as was valvular regurgitation detected by Doppler (p = 0.04). Also, a significantly prolonged deceleration time of mitral and tricuspid early diastolic Doppler flow was found in the study group (p = 0.0001 and 0.027, respectively) although a different hemodynamic condition in the study group (pharmacologically reduced preload) precluded these findings to be attributable to an actual diastolic dysfunction. No differences were observed in pulmonary arterial resistances. It is concluded that mitral and tricuspid valve abnormalities can be detected by echocardiography in asymptomatic intravenous heroin users, whereas no apparent effects are observed in morphologic or functional parameters of cardiac structures other than the valves.

Vitamin B-12 abnormalities in HIV-infected patients

A prospective study of 60 consecutively admitted patients with HIV infection was performed to document the prevalence, etiology and manifestations of low serum vitamin B-12 in such patients. Low serum B-12 levels were found in 10 patients (16.7%). In 6, vitamin B-12 absorption was impaired and hog intrinsic factor addition did not improve it. Patients with low vitamin B-12 levels showed lower hemoglobin, leukocytes, lymphocytes, CD4 lymphocytes and CD4/CD8 lymphocyte ratio than HIV patients with physiological serum vitamin B-12 levels. However, bone marrow megaloblastosis was found in only 3 low vitamin B-12 patients and the deoxyuridine suppression test was pathological in only 1 case. In 7 patients, parenteral treatment was begun with variable response despite serum vitamin B-12 correction. In conclusion, low serum vitamin B-12 is often found in HIV-infected patients and it could be related to malabsorption, but clear megaloblastic abnormalities and treatment response could not be demonstrated. A decreased concentration of the serum binders due to disturbances in the leukocytes and related immunocompetent cell may play an additional role.

[Liver actinomycosis: diagnosis using fine-needle punction-aspiration]

Hepatic actinomycosis is very rare. Usually, the specific diagnosis is only made after exploratory laparotomy and surgical drainage. We present a case diagnosed by cytologic study after fine needle aspiration biopsy. The treatment consisted of longterm antibiotic therapy, at high doses, without surgical drainage.

Acute appendicitis complicating infectious mononucleosis: case report and review

Acute appendicitis is an uncommon complication of infectious mononucleosis (IM) and can readily be misdiagnosed because of the acute abdominal pain with which patients with IM occasionally present. A case report is presented of a patient with IM who developed acute appendicitis during the acute phase of the illness. The appendicitis progressed to the formation of an abscess, which was evacuated at surgery. Histologic examination of the appendix showed absence of lymphoid follicles in the mucosal layer and intense lymphoid infiltration of the mucosa and submucosa by a mixed diffuse proliferation of lymphoid cells with groups of immunoblasts scattered among them. The lymphoid infiltrate was mainly composed of T lymphocytes; the anticomplementary immunofluorescent staining of the appendix for EBNA (Epstein-Barr nuclear antigen) was negative. Three cases of appendicitis complicating IM published in the literature are reviewed. All had clinical and histopathologic features similar to those of our patient and were cured after surgery. Our case report together with the literature review confirms that appendicitis in the acute phase of IM has distinct clinical and histopathologic features and thus has to be considered a true complication of IM rather than merely a simultaneous disease.

Rotational behaviour induced by theophylline in 6-OHDA nigrostriatal denervated rats is dependent on the supersensitivity of striatal dopaminergic receptors

We studied apomorphine- and theophylline-induced rotational behaviour in rats with a unilateral 6-hydroxydopamine lesion of the dopaminergic nigrostriatal pathway. It was seen that there was a direct correlation between the number of apomorphine- and theophylline-induced contralateral turns. These data suggest the existence of a relationship between theophylline-induced rotational behaviour and the degree of supersensitivity of the striatal dopaminergic receptors. Because the rotational behaviour induced by theophylline is in the same direction as dopaminergic agonists, contralateral to the nigrostriatal pathway lesion, these results suggest the possibility of a direct dopaminergic agonism of methylxanthines.

Conditioning of rotational behavior after the administration of a single dose of apomorphine in rats with unilateral denervation of the dopaminergic nigrostriatal pathway: relevance to drug addiction

Our aim is to study the relationship of drug activation of the dopamine neurotransmission system and the conditioning of environmental stimuli present at the time of drug administration. We injected a single dose of apomorphine (0.05 mg/kg SC) in rats with the nigrostriatal dopamine pathways unilaterally denervated with 6-hydroxydopamine, which generates rotational behavior contralateral to the lesioned hemisphere. We observed rotational behavior without apomorphine administration when animals were reexposed at different time intervals to the same environment in which they performed turning behavior. The present findings show that this rotational behavior can be conditioned to environmental stimuli in a strong and long-lasting way. In light of the relationship between opioids and the dopaminergic system, similar conditioning could take place in the learning processes implicated in drug addiction.

Comparison between apomorphine and amphetamine-induced rotational behaviour in rats with a unilateral nigrostriatal pathway lesion

Apomorphine and amphetamine-induced rotational behaviour in 310 rats with a unilateral 6-OHDA nigrostriatal pathway lesion has been studied. Animals presenting an apomorphine-induced contralateral rotation with a "two-peak" pattern, showed a greater number of contralateral turns induced by apomorphine and fewer ipsilateral turns induced by amphetamine than rats without this pattern. In addition, we have not found any correlation between apomorphine and amphetamine-induced turning behaviour.

Hepatobiliary fibropolycystic diseases. A clinical and histological review of 51 patients

The clinical, radiological and hepatic histological features of 51 patients with hepatobiliary fibropolycystic disease were reviewed. Many of the patients had more than one of the diseases; the combination of both congenital hepatic fibrosis (CHF) and Caroli's disease was most striking. Twelve patients with CHF (50% male) presented at 6 +/- 2 years of age (mean +/- SEM) with hepatosplenomegaly or variceal bleeding. Their main problems were recurrent variceal bleeds and renal disease. Polycystic kidneys and renal stones were present in 79% and chronic renal failure in 30%. Six of the 8 patients with Caroli's disease were male (75%) and presented later (aged 37 +/- 8 years) with hepatomegaly or cholangitis. Recurrent cholangitis developed in most (7/8) and 2 had polycystic kidneys. Twelve patients had a combination of CHF and Caroli's disease presenting with hepatosplenomegaly, bleeding or cholangitis. As in Caroli's disease, most (83%) were male, but the age of presentation (15 +/- 4 years), and the incidence of polycystic kidneys (42%) and renal failure (8%) was intermediate between CHF and Caroli's disease. In these patients, bleeds always predated cholangitis. Histologically, acute cholangitis was superimposed on the changes of CHF. Adult polycystic liver disease (10 patients) presented later (43 +/- 3 years) in females (90%) with pain, a mass or incidentally; polycystic kidneys were present in 33%. Microhamartomas (10 patients), which were usually incidental findings, were diagnosed latest (50 +/- 6 years). Three choledochal cysts were seen. The hazard of cancer in these diseases was reflected by 2 bile duct cancers and 1 pancreatic cancer (incidence 6%). This study has confirmed that hepatobiliary fibropolycystic diseases form part of a family and are often associated together. However, the diseases are of greatly differing severity and the prognosis in an individual patient is determined by the fibropolycystic diseases present.