Treatment of chronic hepatitis C in patients with chronic kidney disease with Sofosbuvir-basead regimes

Background

To analyze the effectiveness and the safety of Sofosbuvir-based regimens to treat patients with chronic hepatitis C virus (HCV) infection and chronic kidney disease (CKD).

Methods

A retrospective, observational study in patients with chronic HCV infection and CKD treated with Sofosbuvir-based regimens was performed. Liver fibrosis, comorbidities, HCV genotype and sustained virological resposnse (SVR) at 12th week post-treatment were evaluated. Kidney function was accessed by serum creatinine and glomerular filtration rate (GFR). The assumed level of significance was 5 %.

Results

Thirty-five patients were treated. The mean age was 52.1 ± 10.9 years, 19 (54.3 %) were women, 32 (91.4 %) were already kidney transplanted and 3 (8.6 %) were on hemodialysis. The SVR by intention to treat was 88.6 %. The mean GFR was 65.8 ± 28.6 and 63.7 ± 28.3 ml/min pre- and post-treatment respectively (p > 0.05). Treatment was interrupted in 1 (2.85 %) patient due to anemia and in 2 (5.7 %) due to loss of kidney function.

Conclusion

Sofosbuvir-based regimens are effective to treat HCV in patients with CKD. In patients with mild CKD this type of therapy seems to be safe.

PROFILE OF PATIENTS WITH CHRONIC HEPATITIS C IN A PUBLIC HEALTH PROGRAM IN SOUTHERN BRAZIL

BACKGROUND

Chronic hepatitis C (CHC) can progress to cirrhosis and its complications as hepatocellular carcinoma, leading to morbidity and mortality. To know the profile of patients with CHC virus is fundamental to optimize management.

OBJECTIVE

To describe the profile of patients with CHC in a public health program in Southern Brazil.

METHODS

A retrospective study was carried out in patients with CHC who underwent treatment against hepatitis C virus in a dispensation and pharmaceutical assistance center of the Public Health Department of the State of Rio Grande do Sul, South Brazil. All medical records of patients attended between December/2015 and December/2016 were evaluated.

RESULTS

A total of 1,431 records of patients with CHC were evaluated. Males were the most prevalent (802; 56%) patients. The mean age was 58.6±9.9 years, ranging from 18 to 89 years. Genotype 1 was the most frequent (866;60.5%) of the patients. Ninety (6.3%) patients were transplanted from a solid organ, and of these, 73 (5.1%) were transplanted from the liver. The fibrosis evaluation was performed in 1,300 (90.8%) patients. Of these, 566 (39.6%) were evaluated through liver biopsy. Regarding the degree of fibrosis, 779 (54.4%) presented fibrosis grade 4 (cirrhosis). The genotype 3 was the most associated with fibrosis grade 4, and genotype 1 was associated with high viral load.

CONCLUSION

The present study made possible the evaluation of the characteristics of patients with CHC in a public health program in South Brazil. There was a predominance of CHC in males, and the mean age was 59 years. They presented a predominance of genotype 1, higher viral load in patients with genotype 1 and greater degree of fibrosis in patients with genotype 3.

IMPACT OF MICROBIOLOGICAL CHANGES ON SPONTANEOUS BACTERIAL PERITONITIS IN THREE DIFFERENT PERIODS OVER 17 YEARS

BACKGROUND

Spontaneous bacterial peritonitis is a serious complication in cirrhotic patients, and changes in the microbiological characteristics reported in the last years are impacting the choice of antibiotic used for treatment.

OBJECTIVE

The aim of the present study is to evaluate the changes in the epidemiology and bacterial resistance of the germs causing spontaneous bacterial peritonitis over three different periods over 17 years.

METHODS

All cirrhotic patients with spontaneous bacterial peritonitis and positive culture of ascites fluid were retrospectively studied in a reference Hospital in Southern Brazil. Three periods were ramdomly evaluated: 1997-1998, 2002-2003 and 2014-2015. The most frequent infecting organisms and the sensitivity in vitro to antibiotics were registered.

RESULTS

In the first period (1997-1998) there were 33 cases, the most common were: E. coli in 13 (36.11%), Staphylococcus coagulase-negative in 6 (16.66%), K. pneumoniae in 5 (13.88%), S. aureus in 4 (11.11%) and S. faecalis in 3 (8.33%). In the second period (2002-2003), there were 43 cases, the most frequent were: Staphylococus coagulase-negative in 16 (35.55%), S. aureus in 8 (17.77%), E. coli in 7 (15.55%) and K. pneumoniae in 3 (6.66%). In the third period (2014-2015) there were 58 cases (seven with two bacteria), the most frequent were: E. coli in 15 (23.1%), S. viridans in 12 (18.5%), K. pneumoniae in 10 (15.4%) and E. faecium 5 (7.7%). No one was using antibiotic prophylaxis. Considering all staphylococci, the prevalence increased to rates of the order of 50% in the second period, with a reduction in the third period evaluated. Likewise, the prevalence of resistant E. coli increased, reaching 14%.

CONCLUSION

There was a modification of the bacterial population causing spontaneous bacterial peritonitis, with high frequency of gram-positive organisms, as well as an increase in the resistance to the traditionally recommended antibiotics. This study suggests a probable imminent inclusion of a drug against gram-positive organisms in the empiric treatment of spontaneous bacterial peritonitis.

IMPACT OF THE PEGYLATED-INTERFERON AND RIBAVIRIN THERAPY ON THE TREATMENT-RELATED MORTALITY OF PATIENTS WITH CIRRHOSIS DUE TO HEPATITIS C VIRUS

Although the protease inhibitors have revolutionized the therapy of chronic hepatitis C (CHC), the concomitant use of pegylated-interferon (PEG-IFN) and ribavirin (RBV) is associated to a high rate of adverse effects. In this study, we evaluated the consequences of PEG-IFN and RBV and their relationship with mortality in patients with cirrhosis.

METHODS

Medical records of CHC who underwent treatment with PEG-IFN and RBV in a public hospital in Brazil were evaluated. All the patients with cirrhosis were selected, and their clinical and laboratory characteristics, response to treatment, side effects and mortality were evaluated.

RESULTS

From the 1,059 patients with CHC, 257 cirrhotic patients were evaluated. Of these, 45 (17.5%) achieved sustained viral response (SVR). Early discontinuation of therapy occurred in 105 (40.8%) patients, of which 39 (15.2%) were due to serious adverse effects. The mortality rate among the 257 cirrhotic patients was 4.3%, occurring in 06/242 (2.4%) of the Child-A, and in 05/15 (33.3%) of the Child-B patients. In conclusion, the treatment of patients with cirrhosis due to HCV with PEG-IFN and RBV shows a low SVR rate and a high mortality, especially in patients with liver dysfunction.

Percutaneous liver biopsy--2 decades of experience in a public hospital in the South of Brazil

INTRODUCTION

Liver biopsy is a complementary method for diagnosis, staging and therapeutic guidance in liver diseases, where chronic viral hepatitis are the most acknowledged causes for the indication of histopathological study. The objective is to assess the patients' profile as well as the indication and results of percutaneous liver biopsies in a tertiary hospital.

MATERIAL AND METHODS

A descriptive, cross-section study was carried out through the review of medical charts (retrospective cohort) of patients submitted to blind percutaneous liver biopsies (PLB) at a hospital in Porto Alegre, South Brazil, from October 1993 to December 2011.

RESULTS

1,955 PLB were carried out, the mean patients' age was 44.8 years old, and 1,127 (57.65%) were men. Chronic hepatitis C was the main indication (60.5%), followed by HCV-HIV coinfection (12.2%) and chronic hepatitis B (3.5%). Seven cases (0.3%) had complications, without deaths.

CONCLUSION

PLB is a safe method and continues to be an important option to assist patients with chronic liver disease.

Chronic hepatitis C genotype 1 virus: Who should wait for treatment?

Elucidation of the natural history of chronic hepatitis C (CHC) and the identification of risk factors for its progression to advanced liver disease have allowed many physicians to recommend deferral treatment (triple therapy) in favour of waiting for new drug availability for patients who are at low risk of progression to significant liver disease. Newer generation drugs are currently under development, and are expected to feature improved efficacy and safety profiles, as well as less complex and shorter duration delivery regimens, compared to the current standards of care. In addition, patients with cirrhosis and prior null responders have a low rate (around 15%) of achieving sustained virological response (SVR) with triple therapy, and physicians must also consider the decision to wait for new treatments in the future for these patients as well. Naïve patients are the most likely to achieve a close to 100% SVR rate; therefore, it may be advisable to recommend that patients with mild to moderate CHC should wait for the newer therapy options. In contrast, patients with advanced fibrosis and cirrhosis will be those with the greatest need for expedited therapeutic intervention. There remains a need, however, for establishing definitive clinical management guidelines to maximize the benefit of waiting for new drugs and minimize risk of side effects and non-response to the current triple therapy.

Progression of liver fibrosis in monoinfected patients by hepatitis C virus and coinfected by HCV and human immunodeficiency virus

CONTEXT

The progression of liver fibrosis in patients coinfected by hepatitis C virus and human immunodeficiency virus (HCV/HIV) has been increasingly studied in the past decade. Studies made before the highly active antiretroviral therapy suggest that HIV can change the natural history of the HCV infection, leading to a faster progression of the liver fibrosis.

OBJECTIVE

To evaluate and compare the fibrosis progression in two groups of patients (HCV/HIV coinfected and HCV monoinfected)

METHODS

Seventy patients HCV monoinfected and 26 patients HCV/HIV coinfected who had not undertaken HCV treatment and were submitted to serial percutaneous liver biopsies were retrospectively evaluated. There was no difference in the fibrosis progression between the two groups.

CONCLUSION

The fibrosis grade evolution was not worse in the coinfected patients. The immunosuppression absence and the shortest time period between the biopsies in the coinfected group are possible explanations.

Acute hepatitis C in Brazil: results of a national survey

The incidence of acute hepatitis C has decreased in the world. However, new cases are still reported. The objective of this study was to obtain data of acute hepatitis C in Brazil and to identify risk factors of transmission, diagnostic criteria, clinical presentation, evolution, and treatment. A questionnaire was sent to all members of the Brazilian Society of Hepatology. Sixteen centers participated with a total of 170 cases between 2000 and 2008. Among them, 37 had chronic renal failure on hemodialysis and were evaluated separately. The main diagnostic criterion in non-uremic patients was ALT (alanine aminotransferase) elevation associated with risk factors. In patients with chronic renal failure, anti-hepatitis C virus (HCV) seroconversion was the most frequent criterion. Among the 133 non-uremic patients the main risk factors were hospital procedures, whereas in hemodialysis patients, dialysis was the single risk factor in 95% of the cases. Jaundice was more frequent in non-uremic patients (82% vs. 13%; P < 0.001) and ALT levels were higher in these individuals (P < 0.001). Spontaneous clearance was more frequent in non-uremic patients (51% vs. 3%; P < 0.001). Sixty-five patients were treated: 39 non-uremic patients and 26 on dialysis. Sustained virological response rates were 60% for non-uremic and 58% for uremic patients (P = 0.98). There was no association of these rates with the study variables. These findings show that cases of acute hepatitis C are still occurring and have been related predominantly to hospital procedures. Measures to prevent nosocomial transmission should be adopted rigorously and followed to minimize this important source of infection observed in this survey.

Acute hepatitis C treatment

There are no well established treatment guidelines about acute hepatitis C (AHC), leaving physicians to make several challenging decisions, such whether to treat, when to treat and what treatment regimens to use. This article examines the diagnosis of acute infection and critically appraises the various treatment regimens.

Interferon convencional versus interferon peguilado associados à ribavirina no tratamento de pacientes coinfectados pelo vírus da hepatite C (genótipo 1) e da imunodeficiência humana

CONTEXTO: Tem sido sugerido que os pacientes coinfectados por vírus da hepatite C e da imunodeficiência humana (VHC/HIV) devam ser tratados com interferon peguilado associado à ribavirina (PEG+RBV) porque as taxas de resposta virológica sustentada seriam maiores do que aquelas obtidas com interferon convencional associado à ribavirina (IFN+RBV). No entanto, há escassez de trabalhos na literatura comparando as duas opções de tratamento nesta população de pacientes, em especial fora do cenário de ensaios clínicos. OBJETIVO: Avaliar a resposta virológica sustentada ao tratamento com IFN+RBV versus PEG+RBV em pacientes coinfectados pelo vírus da hepatite C genótipo 1 e vírus da imunodeficiência humana (VHC-1/HIV), no âmbito do programa do Ministério da Saúde. MÉTODOS: Trata-se de estudo de coorte misto, onde foram revisados prontuários de pacientes coinfectados por VHC-1/HIV tratados com IFN+RBV (antes de 2002) ou PEG+RBV (a partir de 2002) pelo período de 48 semanas, no âmbito da Secretaria da Saúde do Estado do Rio Grande do Sul. Foram avaliadas as características demográficas (idade, gênero e peso), contagem de células CD4 e histopatologia - atividade inflamatória (A) e fibrose - segundo classificação METAVIR. O nível de significância adotado na análise estatística foi de 5%. RESULTADOS: Foram avaliados 81 pacientes coinfectados por VHC-1/HIV, 22 que utilizaram IFN+RBV e 59 que utilizaram PEG+RBV por 48 semanas. Os grupos eram semelhantes no que tange à média de idade, gênero, peso, contagem de células CD4 e grau de fibrose. Os pacientes que utilizaram IFN+RBV apresentaram maior atividade histológica com proporção de A2+A3 que superava aqueles que utilizaram PEG+RBV (P<0,01). A resposta virológica sustentada foi 14% no grupo que utilizou IFN+RBV e 23% naqueles que utilizaram PEG+RBV (P = 0,54), com Odds Ratio de 1,9 (0,5 a 7,3). CONCLUSÃO: Os pacientes coinfectados por HCV-1/HIV tratados com PEG+RBV apresentaram chance 1,9 vezes maior de obter resposta virológica sustentada do que aqueles tratados com IFN+RBV, no entanto, este resultado não apresentou significância estatística.

[Spontaneous bacterial peritonitis: impact of microbiological changes]

BACKGROUND

Spontaneous bacterial peritonitis is a serious complication in cirrhotic patients, and the changes in the microbiological characteristics reported in the last years are impacting the choice of antibiotic used in the treatment.

AIM

To evaluate the change in the epidemiology and antibiotic resistance of the bacteria causing spontaneous bacterial peritonitis in a 7 years period.

METHODS

All the cases of cirrhotic patients with spontaneous bacterial peritonitis with positive cultural examination were retrospectively studied. Two periods were evaluated: 1997-1998 and 2002-2003. The most frequent infecting organisms and the sensitivity in vitro to antibiotics were registered.

RESULTS

In the first period (1997-1998) there were 33 cases, 3 (9%) with polymicrobial infection. The most common were: E.coli in 13 (36,11%), Staphylococcus coagulase-negative in 6 (16,66%), K. pneumoniae in 5 (13,88%), S. aureus in 4 (11,11%) and S. faecalis in 3 (8,33%). In 2003-2004, there were 43 cases, 2 (5%) with polymicrobial infection. The most frequent were: Staphylococus coagulase-negative in 16 (35,55%), S. aureus in 8 (17,77%), E. coli in 7 (15,55%) and K. pneumoniae in 3 (6,66%). No one was using antibiotic prophilaxys. The prevalence of S. aureus methicillin-resitant to quinolone and trimethoprim-sulfamethoxazole changed from 25% to 50%, and vancomicin was the only one with absolute activity during all the period. In the same way, the prevalence of E. coli resistant to third generation cephalosporin and to quinolone changed from 0% to 16%.

CONCLUSION

There was a modification of the bacterial population causing spontaneous bacterial peritonitis, with high frequency of gram-positive organisms, as well as an increase in the resistance to the traditionally recommended antibiotics. This study suggests a probable imminent inclusion of a drug against gram-positive organisms in the empiric treatment of spontaneous bacterial peritonitis.

[Ambulatorial prevalence of hepatitis B and C markers in patients with human immunodeficiency virus infection in a general hospital]

BACKGROUND

Hepatitis B and C viruses and human immunodeficiency virus share the same route of transmission, and the prevalence of HBV and HCV infection in patients infected with HIV is greater than it is in the general population.

AIM

To determine the prevalence of hepatitis B and C markers in a population of patients with HIV as well as the risk factors involved.

PATIENTS AND METHODS

From 5,870 registration forms of patients with HIV of an Infectology Unit, 587 were randomly selected. From these, the 343 which had investigated the presence of any hepatitis B (HBsAg, anti-HBc or anti-HBs) or C (anti-HCV) marker were retrospectively analyzed.

RESULTS

HBsAg was positive in 14/306 (4.6%), anti-HBs was positive in 40/154(26.0%), and anti-HBc in 79/205 (38.5%). The anti-HCV test was reactive in 126/330 (38.2%). HBV and HCV co-infection was observed in 7 of the 296 patients who had both HBsAg and anti-HCV tests (2.4%). For those who were HBsAg positive, the main exposure factor was homosexual intercourse (50.0%). For those who were anti-HCV reactive, the main risk factor was intravenous drug use (75.3%). In the HIV mono-infected (185 patients), the most prevalent exposure risk factor was promiscuous heterosexual practices or sexual intercourse with a spouse infected with HIV (83 patients - 44.9%).

CONCLUSION

In our environment HBV-HIV and HCV-HIV co-infections are frequent, a greater relevance being observed in the association between HCV and HIV.

Impact of human immunodeficiency virus infection in patients infected with the hepatitis C virus

BACKGROUND/AIMS

The objective of the present study is to evaluate the impact of human immunodeficiency virus (HIV) in patients with hepatitis C virus (HCV) infection.

METHODS

Three different groups of patients were considered: group 1, 385 HCV/HIV coinfected; group 2, 198 HIV monoinfected; and group 3, 311 HCV monoinfected. Demographic and epidemiological data were collected. Blood tests included anti-HCV, HCV-RNA test, genotyping, CD4 cell count, anti-HIV, and HIV viral load. Treatment with interferon and ribavirin was proposed. The fibrosis progression rate was assessed.

RESULTS

The most prevalent risk factor in the group of coinfected was the use of intravenous drugs; in the HIV monoinfection group, heterosexual relations at risk; in the HCV monoinfection group, the transfusion of blood. There was no difference concerning the distribution of genotypes or HCV viral load between groups 1 and 3. Although the mean time of duration of HCV infection was greater in group 3 than in group 1, there was no difference when the fibrosis progression rate was evaluated. The response to treatment was similar.

CONCLUSION

In the present series there was no relevant impact of HCV infection in patients with HIV.