RESUMO
BACKGROUND & AIM: Retrospective studies show an association between proton pump inhibitor (PPI) therapy and spontaneous bacterial peritonitis (SBP). We investigate the relationship between PPI and SBP in decompensated cirrhotic patients in a large nationwide prospective study. METHODS: Seven hundred seventy patients with a diagnosis of decompensated cirrhosis were admitted consecutively in 23 hospitals in Argentina from March 2011 to April 2012; the patients were carefully investigated for PPI consumption in the previous 3 months. In total, 251 patients were excluded because of active gastrointestinal hemorrhage, antibiotic use during the preceding weeks, HIV-positive status and immunosuppressive therapy. RESULTS: Two hundred twenty-six out of 519 patients (43.5%) had received PPI therapy within the last 3 months. In 135 patients, PPIs were administered for longer than 2 weeks. A bacterial infection was shown in 255 patients (49.1%). SBP was diagnosed in 95 patients out of 394 patients with ascites (24.7%). There was no significant difference in the rate of PPI consumption between the infected and the non-infected patients (44.3% vs. 42.8%) or between the SBP patients and the patients with ascites without SBP (46% vs. 42%). In the SBP patients, the duration of PPI administration did not influence the rate of SBP occurrence. The type of bacteria and the origin of SBP infection were similar in the patients with and without PPI. CONCLUSION: In the current large, multicenter, prospective study, PPI therapy, specifically evaluated at admission of consecutive cirrhotic patients, was not associated with a higher risk of SBP.
Assuntos
Infecções Bacterianas , Cirrose Hepática , Peritonite , Inibidores da Bomba de Prótons , Adulto , Idoso , Argentina/epidemiologia , Infecções Bacterianas/diagnóstico , Infecções Bacterianas/epidemiologia , Infecções Bacterianas/etiologia , Infecções Bacterianas/terapia , Progressão da Doença , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico , Cirrose Hepática/fisiopatologia , Testes de Função Hepática/métodos , Masculino , Pessoa de Meia-Idade , Peritonite/diagnóstico , Peritonite/epidemiologia , Peritonite/etiologia , Peritonite/terapia , Estudos Prospectivos , Inibidores da Bomba de Prótons/administração & dosagem , Inibidores da Bomba de Prótons/efeitos adversos , Medição de Risco , Fatores de Risco , Estatística como AssuntoRESUMO
BACKGROUND & AIMS: Several studies have reported that low doses of interferon can delay the development of hepatocellular carcinoma (HCC) and progression of chronic hepatitis C. We investigated the incidence of clinical events among participants of the Evaluation of PegIntron in Control of Hepatitis C Cirrhosis (EPIC)3 program. METHODS: Data were analyzed from an open-label randomized study of patients with chronic hepatitis C who had failed to respond to interferon alfa plus ribavirin. All patients had compensated cirrhosis with no evidence of HCC. Patients received peginterferon alfa-2b (0.5 µg/kg/week; n=311) or no treatment (controls, n=315) for a maximum period of 5 years or until 98 patients had a clinical event (hepatic decompensation, HCC, death, or liver transplantation). The primary measure of efficacy was time until the first clinical event. RESULTS: There was no significant difference in time to first clinical event among patients who received peginterferon alfa-2b compared with controls (hazard ratio [HR], 1.452; 95% confidence interval [CI]: 0.880-2.396). There was no decrease in the development of HCC with therapy. The time to disease progression (clinical events or new or enlarged varices) was significantly longer for patients who received peginterferon alfa-2b compared with controls (HR, 1.564; 95% CI: 1.130-2.166). In a prospectively defined subanalysis of patients with baseline portal hypertension, peginterferon alfa-2b significantly increased the time to first clinical event compared with controls (P=.016). There were no new safety observations. CONCLUSIONS: Maintenance therapy with peginterferon alfa-2b is not warranted in all patients and does not prevent HCC. However, there is a potential clinical benefit of long-term suppressive therapy in patients with preexisting portal hypertension.
Assuntos
Antivirais/administração & dosagem , Carcinoma Hepatocelular/prevenção & controle , Hepatite C Crônica/tratamento farmacológico , Interferon-alfa/administração & dosagem , Cirrose Hepática/tratamento farmacológico , Neoplasias Hepáticas/prevenção & controle , Polietilenoglicóis/administração & dosagem , Antivirais/efeitos adversos , Biomarcadores/sangue , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/virologia , Progressão da Doença , Esquema de Medicação , Europa (Continente) , Feminino , Hepacivirus/genética , Hepatite C Crônica/complicações , Hepatite C Crônica/diagnóstico , Hepatite C Crônica/mortalidade , Humanos , Hipertensão Portal/tratamento farmacológico , Hipertensão Portal/virologia , Interferon alfa-2 , Interferon-alfa/efeitos adversos , Estimativa de Kaplan-Meier , Cirrose Hepática/diagnóstico , Cirrose Hepática/mortalidade , Cirrose Hepática/virologia , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/virologia , Masculino , Pessoa de Meia-Idade , América do Norte , Seleção de Pacientes , Polietilenoglicóis/efeitos adversos , Modelos de Riscos Proporcionais , Estudos Prospectivos , RNA Viral/sangue , Proteínas Recombinantes , Medição de Risco , Fatores de Risco , América do Sul , Fatores de Tempo , Resultado do Tratamento , Carga ViralRESUMO
BACKGROUND: Patients with spontaneous bacterial peritonitis (SBP) are at a high risk for renal failure and death despite successful treatment of infection. Intravenous (IV) albumin administration combined with antibiotic treatment has been shown to significantly decrease these risks. Clinical evidence is lacking on which patients are appropriate candidates for albumin treatment. AIM: To retrospectively analyse the usefulness of serum creatinine and bilirubin levels in predicting renal failure and mortality of patients hospitalized for SBP. METHODS: Between March 1995 and September 1998, 127 cirrhotic patients with SBP who had not received plasma expansion were evaluated. Eighty-one patients (64%) were classified as having a high risk for renal failure and mortality (serum bilirubin >4 mg/dl or serum creatinine >1 mg/dl) and 46 (36%) as having a low risk. RESULTS: At admission, 36.3% of all patients presented renal failure. Mortality during their hospitalization was 23% among those with a high risk and 6.5% among those with a low risk (P=0.01). Renal failure occurred in 23% of the high-risk patients, compared with 2.6% of the low-risk patients (P=0.006). The presence of hyponatraemia was significantly associated with higher mortality and renal failure in the high-risk group. CONCLUSIONS: Our retrospective review of patients with SBP suggests that serum bilirubin levels >4 mg and serum creatinine levels >1 mg/dl at the time of diagnosis represent significant risk factors for the clinical outcomes of patients with SBP. Patients without these risk factors may have a very low likelihood of death or renal failure.
Assuntos
Bilirrubina/sangue , Creatinina/sangue , Cirrose Hepática/complicações , Peritonite/complicações , Insuficiência Renal/metabolismo , Insuficiência Renal/mortalidade , Adulto , Idoso , Argentina , Humanos , Hiponatremia/etiologia , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Prognóstico , Insuficiência Renal/etiologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND/AIM: primary sclerosing cholangitis (PSC) is associated with ulcerative colitis (UC) and seems to be a risk factor for colon cancer. However, taking into account that no data are available in South American population, we analyzed the prevalence of PSC in 1,333 patients with UC and the risk for developing colon cancer. MATERIAL: patients with persistent increases of alkaline phosphatase were studied by cholangiography and liver biopsy. To assess the risk of colon cancer, each patient with PSC and UC was matched with two control patients with UC without PSC of the same age, gender, extent and duration of UC. RESULTS: the whole prevalence of PSC was 2.9% (39 patients) reaching 6.2% in extensive colitis. Seven (18%) out of 39 patients with PSC developed colorectal carcinoma compared with 2 out of 78 (2.6%) in the control group (p=0.006). The cumulative risk of colorectal carcinoma was 11% and 18% after 10 and 20 years in the PSC group compared with 2% and 7% in the control group, respectively (p=0.002). CONCLUSION: this is the first prospective study performed in Latin America showing that the prevalence of PSC in patients with UC is similar to that reported in the Anglo-Saxon population. Patients with UC and PSC have a high risk of colorectal cancer.
Assuntos
Fosfatase Alcalina/sangue , Colangite Esclerosante/complicações , Colite Ulcerativa/complicações , Neoplasias Colorretais/etiologia , Lesões Pré-Cancerosas/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Argentina/epidemiologia , Biomarcadores Tumorais/sangue , Biópsia , Colangiopancreatografia Retrógrada Endoscópica , Colangiopancreatografia por Ressonância Magnética , Colangite Esclerosante/epidemiologia , Colangite Esclerosante/patologia , Colite Ulcerativa/patologia , Neoplasias Colorretais/epidemiologia , Métodos Epidemiológicos , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND/AIMS: Low protein concentration in ascitic fluid has been identified as a risk factor for spontaneous bacterial peritonitis (SBP). Until now, primary prophylaxis has not been recommended in these patients. The aim was to investigate the efficacy of long-term administration of ciprofloxacin to prevent SBP. METHODS: One hundred cirrhotic patients with <1.5 g/dl of total protein in ascitic fluid were randomized prospectively, in a double blind fashion to receive ciprofloxacin 500 mg/day (n=50) or placebo (n=50) for 12 months. RESULTS: Baseline data were similar in both groups. In the ciprofloxacin group, SBP occurred almost four times less frequently than in the placebo group but it was not statistically significant. The probability of survival at 12 months was significantly higher in patients receiving ciprofloxacin (86% versus 66%) (p<0.04). SBP and sepsis were the most frequent causes of death in the placebo group whereas gastrointestinal bleeding was responsible for the most deaths in the ciprofloxacin group. The probability of remaining free of bacterial infections was higher in patients receiving ciprofloxacin (80% versus 55%) (p=0.05). CONCLUSIONS: Patients with cirrhosis and low protein concentration in ascitic fluid are candidates to receive long-term prophylaxis to reduce the risk of infections and improve survival.
Assuntos
Anti-Infecciosos/uso terapêutico , Infecções Bacterianas/tratamento farmacológico , Ciprofloxacina/uso terapêutico , Peritonite/tratamento farmacológico , Adulto , Idoso , Infecções Bacterianas/mortalidade , Humanos , Pessoa de Meia-Idade , Peritonite/mortalidadeRESUMO
Background/aim: primary sclerosing cholangitis (PSC) is associated with ulcerative colitis (UC) and seems to be a risk factor for colon cancer. However, taking into account that no data are available in South American population, we analyzed the prevalence of PSC in 1.333 patients with UC and the risk for developing colon cancer. Material: patients with persistent increases of alkaline phosphatase were studied by cholangiography and liver biopsy. To assess the risk of colon cancer, each patient with PSC and UC was matched with two control patients with UC without PSC of the same age, gender, extent and duration of UC. Results: the whole prevalence of PSC was 2.9% (39 patients) reaching 6.2% in extensive colitis. Seven (18 %) out of 39 patients with PSC developed colorectal carcinoma compared with 2 out of 78 (2.6%) in the control group (p=0.006). The cumulative risk of colorectal carcinoma was 11% and 18% after 10 and 20 years in the PSC group compared with 2% and 7% in the control group, respectively (p=0.002). Conclusion: this is the first prospective study performed in Latin America showing that the prevalence of PSC in patients with UC is similar to that reported in the Anglo-Saxon population. Patients with UC and PSC have a high risk of colorectal cancer.
Introducción/objetivos: la colangitis esclerosante primaria (CEP) se asocia a colitis ulcerosa (CU) y parece ser un factor de riesgo para cáncer de colon. Sin embargo, teniendo en cuenta que no existen datos disponibles en población de Sudamérica, nosotros analizamos la prevalencia de CEP en 1.333 pacientes con CU y el riesgo de desarrollar cáncer de colon. Material: los pacientes con fosfatasa alcalina persistentemente elevada fueron estudiados con colangiografía y biopsia hepática. Para determinar el riesgo de cáncer de colon cada paciente con CEP y CU fueron apareados con dos pacientes controles con CU sin CEP de la misma edad, sexo, extensión y duración de la CU. Resultados: la prevalencia total de CEP fue de 2.9% (39 pacientes), alcanzando una prevalencia del 6.2% en colitis extensa. Siete (18%) de 39 pacientes con CEP desarrollaron cáncer colorectal comparado con 2 de 78 en el grupo control (p=0.006). El riesgo acumulado de cáncer colorectal fue 11 y 18% después de 10 y 20 años en el grupo con CEP comparado con 2 y 7% en el grupo control, respectivamente (p=0.002). Conclusión: este es el primer estudio prospectivo realizado en Latinoamérica mostrando que la prevalencia de CEP en pacientes con CU es similar a la reportada en población anglosajona. Los pacientes con CU y CEP tienen un alto riesgo de cáncer colorectal.
Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Fosfatase Alcalina/sangue , Colangite Esclerosante/complicações , Colite Ulcerativa/complicações , Neoplasias Colorretais/etiologia , Lesões Pré-Cancerosas/patologia , Argentina/epidemiologia , Biópsia , Estudos de Casos e Controles , Colangiopancreatografia Retrógrada Endoscópica , Colangiopancreatografia por Ressonância Magnética , Colangite Esclerosante/epidemiologia , Colangite Esclerosante/patologia , Colite Ulcerativa/patologia , Neoplasias Colorretais/epidemiologia , Prevalência , Estudos Prospectivos , Fatores de Risco , Biomarcadores Tumorais/sangueAssuntos
Antivirais/administração & dosagem , Hepatite C/tratamento farmacológico , RNA Viral/sangue , Quimioterapia Combinada , Humanos , Interferon alfa-2 , Interferon-alfa/administração & dosagem , Polietilenoglicóis/administração & dosagem , Proteínas Recombinantes , Ribavirina/administração & dosagemRESUMO
Treatment with beta-blockers fails to decrease portal pressure in nearly 40% of cirrhotic patients. Recent studies have suggested that treatment with spironolactone reduces pressure and flow in the portal and variceal systems. This trial was designed to assess if nadolol plus spironolactone is more effective than nadolol alone to prevent the first variceal bleeding. One hundred patients with medium and large varices who had never bled and were without ascites were included in a prospective, randomized, multicenter, double-blind, placebo-controlled trial. The patients were randomized into 2 groups: 51 received nadolol plus placebo (N + P) and 49 received nadolol plus spironolactone 100 mg/d (N + S). Hepatic venous pressure gradient (HVPG) and activity of the renin-aldosterone system (plasma renin activity/plasma aldosterone levels) were measured in 24 patients. There were no significant differences in the appearance of variceal bleeding and ascites between groups at a mean follow-up of 22 +/- 16 months. However, analyzing both complications together, the incidence was significantly higher in the N + P group than in the N + S group (39% vs. 20%; P <.04). Clinical ascites was also higher in patients in the N + P group than in the N + S group (21% vs. 6%; P <.04). Significant increases in plasma renin activity and plasma aldosterone levels were only observed in patients in the N + S group (P <.01). The cumulative probabilities of remaining free of bleeding and ascites were similar in both groups after 70 months of follow-up. In conclusion, these results suggest that nadolol plus spironolactone does not increase the efficacy of nadolol alone in the prophylaxis of the first variceal bleeding. However, when bleeding and ascites were considered together, the combined therapy effectively reduced the incidence of both portal-hypertensive complications.
Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Varizes Esofágicas e Gástricas/etiologia , Hemorragia/etiologia , Hemorragia/prevenção & controle , Cirrose Hepática/complicações , Cirrose Hepática/tratamento farmacológico , Antagonistas de Receptores de Mineralocorticoides/uso terapêutico , Nadolol/uso terapêutico , Espironolactona/uso terapêutico , Idoso , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Hemodinâmica/efeitos dos fármacos , Humanos , Cirrose Hepática/fisiopatologia , Masculino , Pessoa de Meia-Idade , Circulação Esplâncnica/efeitos dos fármacos , Resultado do TratamentoRESUMO
BACKGROUND/AIMS: To assess the efficacy and safety of naltrexone for the short and long term treatment of pruritus of cholestasis. METHODS: Twenty patients with pruritus and cholestasis were included. A baseline pruritus score was obtained over 1 week. Patients were then randomized to receive 50 mg/day of naltrexone or placebo for 2 weeks. Subsequently, a 1-week washout period ensued and patients were crossed over to the other therapy for 2 additional weeks. Pruritus was assessed daily with a visual analogue scale (VAS) from 0 to 10. Patients whose pruritus decreased >50% of basal with naltrexone received naltrexone 50 mg/day for 2 additional months. RESULTS: Mean basal VAS was similar in both groups. VAS showed greater and more significant changes with naltrexone than with placebo (P<0.0003). In nine out of 20 patients (45%) receiving naltrexone, pruritus decreased >50% compared to basal value, including five whose pruritus disappeared completely. No significant changes were observed in serum biochemistry. Most of the adverse events that occurred during the first 48 h of naltrexone therapy were consistent with opioid withdrawal-like phenomena and spontaneously disappeared 2 days after starting treatment. CONCLUSIONS: Naltrexone can be considered as an alternative option to treat pruritus of cholestasis. In the current study, side effects were transient and did not require specific medication.
Assuntos
Colestase/complicações , Naltrexona/administração & dosagem , Naltrexona/efeitos adversos , Antagonistas de Entorpecentes/administração & dosagem , Antagonistas de Entorpecentes/efeitos adversos , Prurido/tratamento farmacológico , Prurido/etiologia , Administração Oral , Adulto , Idoso , Estudos Cross-Over , Método Duplo-Cego , Esquema de Medicação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Prurido/fisiopatologia , SegurançaRESUMO
The findings by epidemiological studies on the link between PBC and HCC are in general agreement with the notion that cirrhosis is a risk factor for HCC development. From the clinical perspective, this implies that in PBC patients with cirrhosis, the screening for HCC should be considered for evaluating prognosis as well as therapeutic options. At this time, it is not possible to determine whether any PBC-specific risk factors other than cirrhosis per se exist for the development of HCC. Identification of such risk factors may point to new mechanisms involved in the carcinogenesis of HCC. In order to answer the question whether the underlying mechanisms for PBC are risk factors for HCC, more aggressive clinical studies with larger patient populations are needed. Such studies should include patients with PBC as well as patients with cirrhosis of other etiologies, both have to be carefully matched for patient characteristics including race, gender, age, disease stage and period of follow-up. On the other hand, the resolution of this issue also relies on a better understanding of the molecular pathogenesis of PBC itself.
Assuntos
Carcinoma Hepatocelular/etiologia , Cirrose Hepática Biliar/complicações , Neoplasias Hepáticas/etiologia , Carcinoma Hepatocelular/complicações , Feminino , Humanos , Neoplasias Hepáticas/complicações , Masculino , Fatores de RiscoRESUMO
Se presenta una experiencia en el tratamiento de la hepatopatia alcohólica con sulfo-adenosil-L-metionina (SAMe). La misma, se efectuó en un grupo de 20 pacientes durante 60 días y en una dosis de 200 mg/día de SAMe (i.m.) durante 30 días y 100 mg/día los 30 restantes. La respuesta clínica, valorada en forma subjetiva, evidenció una mejoría en el apetito, la astenia y la respuesta intelectual. Desde el punto de vista analítico se observaron mejorías significativas (p < .05 en adelante) en la gamaGT, TGP, TGO, bilirrubinemia, tiempo de Quick y colesterolemia. Los autores concluyen que la SAMe constituye un elemento terapéutico en la hepatopatía alcohólica, permitiendo una mejoría de la función hepática expresada mediante la clínica y las pruebas de síntesis proteica, de necrosis y de colestasis
Assuntos
Adulto , Pessoa de Meia-Idade , Humanos , Hepatopatias Alcoólicas/tratamento farmacológico , S-Adenosilmetionina/uso terapêuticoRESUMO
Se presenta una experiencia en el tratamiento de la hepatopatia alcohólica con sulfo-adenosil-L-metionina (SAMe). La misma, se efectuó en un grupo de 20 pacientes durante 60 días y en una dosis de 200 mg/día de SAMe (i.m.) durante 30 días y 100 mg/día los 30 restantes. La respuesta clínica, valorada en forma subjetiva, evidenció una mejoría en el apetito, la astenia y la respuesta intelectual. Desde el punto de vista analítico se observaron mejorías significativas (p < .05 en adelante) en la gamaGT, TGP, TGO, bilirrubinemia, tiempo de Quick y colesterolemia. Los autores concluyen que la SAMe constituye un elemento terapéutico en la hepatopatía alcohólica, permitiendo una mejoría de la función hepática expresada mediante la clínica y las pruebas de síntesis proteica, de necrosis y de colestasis (AU)