Noninvasive Prediction of Outcomes in Autoimmune Hepatitis-Related Cirrhosis

The value of noninvasive tools in the diagnosis of autoimmune hepatitis (AIH)-related cirrhosis and the prediction of clinical outcomes is largely unknown. We sought to evaluate (1) the utility of liver stiffness measurement (LSM) in the diagnosis of cirrhosis and (2) the performance of the Sixth Baveno Consensus on Portal Hypertension (Baveno VI), expanded Baveno VI, and the ANTICIPATE models in predicting the absence of varices needing treatment (VNT). A multicenter cohort of 132 patients with AIH-related cirrhosis was retrospectively analyzed. LSM and endoscopies performed at the time of cirrhosis diagnosis were recorded. Most of the patients were female (66%), with a median age of 54 years. Only 33%-49% of patients had a LSM above the cutoff points described for the diagnosis of AIH-related cirrhosis (12.5, 14, and 16 kPa). Patients with portal hypertension (PHT) had significantly higher LSM than those without PHT (15.7 vs. 11.7 kPa; P = 0.001), but 39%-52% of patients with PHT still had LSM below these limits. The time since AIH diagnosis negatively correlated with LSM, with longer time being significantly associated with a lower proportion of patients with LSM above these cutoffs. VNT was present in 12 endoscopies. The use of the Baveno VI, expanded Baveno VI criteria, and the ANTICIPATE model would have saved 46%-63% of endoscopies, but the latter underpredicted the risk of VNT. Conclusions: LSM cutoff points do not have a good discriminative capacity for the diagnosis of AIH-related cirrhosis, especially long-term after treatment initiation. Noninvasive tools are helpful to triage patients for endoscopy.

Long-term clinical outcomes in patients with chronic hepatitis delta: the role of persistent viraemia

BACKGROUND

Chronic hepatitis delta is a severe liver disease with rapid progression to cirrhosis. The impact of hepatitis delta virus (HDV)-RNA on disease progression and interferon treatment in a real-world cohort has been barely explored.

AIM

To assess the development of clinical events in a cohort of chronic hepatitis delta patients according to the presence or absence of HDV-RNA METHODS: Multicentre study at four academic hospitals in Spain included anti-HDV-positive patients with compensated liver disease with a follow-up ≥12 months.

RESULTS

Among 2888 HBsAg-positive subjects, 151 (5.2%) tested positive for anti-HDV, and 118 were included (58% men; median age, 49 years; 73% detectable HDV-RNA and 30% cirrhosis, most often in subjects with HDV-RNA). After a median follow-up of 8 years, subjects with initially detectable HDV-RNA were more prone to developing cirrhosis (31% vs 0%, P = .002) and/or liver decompensation (28% vs 3%, P = .019). Mortality rate was 0.44 per 1000 person-months. The probability of a clinical event was 6%, 25%, and 80% according to initial baseline-event-anticipation score. HDV-RNA became undetectable in 21 (24%) subjects either due to interferon or spontaneously (48% vs 52%, P = .29). Liver decompensation was reduced in interferon-treated patients (13% vs 38%, P = .026).

CONCLUSIONS

Subjects with persistently positive HDV-RNA had a worse prognosis in terms of clinical events. Baseline-event-anticipation score is useful in predicting the risk of developing liver decompensation and hepatocellular carcinoma. Interferon was beneficial in reducing liver decompensation, even in the absence of virological response.

Effectiveness, safety/tolerability of OBV/PTV/r ± DSV in patients with HCV genotype 1 or 4 with/without HIV-1 co-infection, chronic kidney disease (CKD) stage IIIb-V and dialysis in Spanish clinical practice - Vie-KinD study

BACKGROUND AND AIMS

Limited data are available on the effectiveness and tolerability of direct-acting antivirals (DAAs) therapies in the real world for HCV-infected patients with comorbidities. This study aimed to describe the effectiveness of OBV/PTV/r ± DSV (3D/2D regimen) with or without ribavirin (RBV) in HCV or HCV/HIV co-infected patients with GT1/GT4 and CKD (IIIb-V stages), including those under hemodialysis and peritoneal dialysis in routine clinical practice in Spain in 2015.

MATERIAL AND METHODS

Non-interventional, retrospective, multicenter data collection study in 31 Spanish sites. Socio-demographic, clinical variables, study treatment characteristics, effectiveness and tolerability data were collected from medical records.

RESULTS

Data from 135 patients with a mean age (SD) of 58.3 (11.4) years were analyzed: 92.6% GT1 (81.6% GT1b and 17.6% GT1a) and 7.4% GT4, 14 (10.4%) HIV/HCV co-infected, 19.0% with fibrosis F3 and 28.1% F4 by FibroScan®, 52.6% were previously treated with pegIFN and RBV. 11.1%, 14.8% and 74.1% of patients had CKD stage IIIb, IV and V respectively. 68.9% of patients were on hemodialysis; 8.9% on peritoneal dialysis and 38.5% had history of renal transplant. A total of 125 (96.2%) of 135 patients were treated with 3D, 10 (7.4%) with 2D and 30.4% received RBV. The overall intention-to-treat (ITT) sustained virologic response at week 12 (SVR12) was 92.6% (125/135) and the overall modified-ITT (mITT) SVR12 was 99.2% (125/126). The SVR12 rates (ITT) per sub-groups were: HCV mono-infected (91.7%), HCV/HIV co-infected (100%), GT1 (92.0%), GT4 (100%), CKD stage IIIb (86.7%), stage IV (95%) and stage V (93%). Among the 10 non-SVR there was only 1 virologic failure (0.7%); 4 patients had missing data due lost to follow up (3.0%) and 5 patients discontinued 3D/2D regimen (3.7%): 4 due to severe adverse events (including 3 deaths) and 1 patient´s decision.

CONCLUSIONS

These results have shown that 3D/2D regimens are effective and tolerable in patients with advanced CKD including those in dialysis with GT 1 or 4 chronic HCV mono-infection and HIV/HCV coinfection in a real-life cohort. The overall SVR12 rates were 92.6% (ITT) and 99.2% (mITT) without clinically relevant changes in eGFR until 12 weeks post-treatment. These results are consistent with those reported in clinical trials.

Incidence and risk factors associated with hepatocellular carcinoma surveillance failure

BACKGROUND AND AIM

Surveillance for hepatocellular carcinoma (HCC) intends to detect tumors at an early stage to improve survival. The study aims were to assess the frequency and risk factors associated with HCC surveillance failure.

METHODS

The study analyzed data from 188 consecutive patients diagnosed with HCC within a surveillance program conducted among 1,242 cirrhotic patients and based on ultrasonography and alpha-fetoprotein (AFP) testing every 3 or 6 months. Program failure was defined as the detection of HCC exceeding the Milan criteria. Variables recorded at entry into the program, during follow-up and at HCC diagnosis, were analyzed.

RESULTS

At diagnosis, 50 (26.6%) HCC tumors were beyond the Milan criteria. In univariate analysis, Child-Pugh B at entry (P = 0.03), development of complications of portal hypertension before tumor diagnosis (P = 0.03), and failure to complete the prior screening round (P = 0.02), Child-Pugh B/C (P = 0.001) and AFP ≥ 100 ng/mL (P = 0.03) at diagnosis, were associated with failure. In multivariate analysis, only Child-Pugh B/C (hazard ratio, 3.18; 95% confidence interval, 1.66-6.10, P < 0.001) and AFP ≥ 100 ng/mL, both at diagnosis (hazard ratio, 2.80; 95% confidence interval, 1.37-5.71, P = 0.005), were independently associated with failure. Survival was higher among patients with tumors within the Milan criteria than those with program failure (33.9 vs 7.6 months, P < 0.001).

CONCLUSIONS

Approximately 25% of HCC cases diagnosed among patients included in a surveillance program were beyond the Milan criteria. Child-Pugh B/C and AFP ≥ 100 ng/mL at diagnosis were associated with program failure. However, Child-Pugh B at entry and development of liver-related complications during follow-up can be early predictors of failure.

Real-World Effectiveness and Safety of Oral Combination Antiviral Therapy for Hepatitis C Virus Genotype 4 Infection

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.

Annual incidence of hepatocellular carcinoma among patients with alcoholic cirrhosis and identification of risk groups

BACKGROUND & AIMS

The incidence of hepatocellular carcinoma (HCC) and associated risk factors in patients with alcoholic cirrhosis are not well defined. Surveillance for HCC among patients with cirrhosis who do not have hepatitis B is cost effective only if the expected risk of HCC exceeds 1.5% per year. We performed a prospective study to determine the incidence of HCC among patients with alcoholic cirrhosis and to identify risk factors.

METHODS

We analyzed data from a surveillance program of 450 patients, aged 40 to 75 years, with alcoholic cirrhosis of Child-Pugh class A or B; patients were enrolled at the liver unit of a tertiary center from September 1992 through March 2010. Data were collected on 20 demographic, clinical, and laboratory variables at the start of the study. Patients were examined every 3 to 6 months for 5 years to identify risk factors for HCC; incidence was determined from a median follow-up time of 42 months.

RESULTS

Over the follow-up period, 62 patients developed HCC (43 in the first 5 y of follow-up evaluation), with an annual incidence of 2.6%. By using multivariate analysis, age 55 years and older (hazard ratio, 2.39; 95% confidence interval, 1.27-4.51) and platelet counts less than 125 × 10(3)/mm(3) (hazard ratio, 3.29; 95% confidence interval, 1.39-7.85) were associated independently with the development of HCC. These variables were used to define 3 risk groups. The annual incidence of HCC in the group without either of these factors was 0.3% (n = 93), the annual incidence with 1 factor was 2.6% (n = 228), and the annual incidence with both factors was 4.8% (n = 129) (P < .0001).

CONCLUSIONS

The annual incidence of HCC among patients with alcoholic cirrhosis of Child-Pugh class A or B is around 2.5%. Age and platelet count can be used to classify the patients in 3 different risk groups for HCC development within the next 5 years.

Granulocytic sarcoma of the small bowel, greater omentum and peritoneum associated with a CBFβ/MYH11 fusion and inv(16) (p13q22): a case report

Introduction

Granulocytic sarcoma (GS) is an extramedullary disease which is composed of immature myeloid cells or myeloblasts and usually occurs in association with acute myeloid leukemia (AML), as an initial presentation or a relapse. GS has been associated with various cytogenetic abnormalities, particularly with the t(8;21) translocation and less frequently the inv(16) type.

Case presentation

We present a rare case of GS of the small bowel, greater omentum and peritoneum, which caused obstruction, in a patient with AML associated with a CBFβ/MYH11 fusion gene and an inv(16) (p13q22). In this patient there was only mild myeloid hyperplasia in bone marrow aspiration but molecular analysis identified a CBFβ-MYH11 fusion and inv(16) (p13;q22).

Conclusion

Because of its nonspecific clinical and radiologic findings, this entity can be misdiagnosed and can mimic other solid neoplasms, making it a diagnostic challenge. In a GS with no or minimal morphological changes in bone marrow aspiration it is very important to perform a cytogenetic analysis to benefit from the diagnosis and therapeutic strategy.

Prospective analysis of risk factors for hepatocellular carcinoma in patients with liver cirrhosis

Better knowledge of the risk factors associated with the appearance of hepatocellular carcinoma (HCC) could improve the efficacy of surveillance programs. A total of 463 patients aged 40 to 65 years with liver cirrhosis in Child-Pugh class A or B were included in a program of early diagnosis. The predictive value of different risk factors was evaluated using the Kaplan-Meier method and Cox regression model. Thirty-eight patients developed HCC. In the multivariate analysis, 4 variables showed an independent predictive value for the development of HCC: age 55 years or older, antibody to hepatitis C virus (anti-HCV) positivity, prothrombin activity 75% or less, and platelet count less than 75 x 10(3)/mm(3). According to the contribution of each of these factors to the final model, a score ranging between 0 and 4.71 points was constructed to allow the division of patients into 2 different risk groups. The low-risk group included those with a score of 2.33 points or less (n = 270; 4 with HCC; cumulative incidence of HCC at 4 years, 2.3%), and the high-risk group included those with a score greater than 2.33 (n = 193; 34 with HCC; cumulative incidence of HCC at 4 years, 30.1%) (P =.0001). In conclusion, a simple score made up of 4 clinical and biological variables allowed us to distinguish 2 groups of cirrhotic patients at high and low risk for the development of HCC. We believe this score can be useful in establishing a subset of cirrhotic patients in whom a surveillance program for early detection of HCC could be unjustified.

Prospective analysis of risk factors for hepatocellular carcinoma in patients with liver cirrhosis

Better knowledge of the risk factors associated with the appearance of hepatocellular carcinoma (HCC) could improve the efficacy of surveillance programs. A total of 463 patients aged 40 to 65 years with liver cirrhosis in Child-Pugh class A or B were included in a program of early diagnosis. The predictive value of different risk factors was evaluated using the Kaplan-Meier method and Cox regression model. Thirty-eight patients developed HCC. In the multivariate analysis, 4 variables showed an independent predictive value for the development of HCC: age 55 years or older, antibody to hepatitis C virus (anti-HCV) positivity, prothrombin activity 75% or less, and platelet count less than 75 x 10(3)/mm(3). According to the contribution of each of these factors to the final model, a score ranging between 0 and 4.71 points was constructed to allow the division of patients into 2 different risk groups. The low-risk group included those with a score of 2.33 points or less (n = 270; 4 with HCC; cumulative incidence of HCC at 4 years, 2.3%), and the high-risk group included those with a score greater than 2.33 (n = 193; 34 with HCC; cumulative incidence of HCC at 4 years, 30.1%) (P =.0001). In conclusion, a simple score made up of 4 clinical and biological variables allowed us to distinguish 2 groups of cirrhotic patients at high and low risk for the development of HCC. We believe this score can be useful in establishing a subset of cirrhotic patients in whom a surveillance program for early detection of HCC could be unjustified.

Mortality and causes of death in patients with chronic inflammatory bowel disease in Gijón, Asturias (Spain)

OBJECTIVE

to review mortality, survival, influence of age at diagnosis and at death, cause of death, and relation with the extent of chronic inflammatory bowel disease, in a city in northern Spain.

METHOD

descriptive retrospective epidemiological study of 516 patients diagnosed in Gijón (Asturias) between 1954 and 1997.

RESULTS

of the 26 patients who died (5.03%), 18 had ulcerative colitis, 8 had Crohn's disease, and none had indeterminate colitis. Mortality was higher than in the general population, with a standard mortality ratio (SMR) of 5 (95% confidence interval 1.6-11.6). We found no differences in sex ratio (p = 0.63). Mean duration of the disease was 10 +/- 8 years in surviving patients, and 6 +/- 6 years in patients who died (p = 0.02). Duration was longer in Crohn's disease than in ulcerative colitis (p = 0.014). Mean age at diagnosis for chronic inflammatory bowel disease was 37.5 +/- 17 years in patients who survived, and 58 +/- 18 years in patients who died (p = 0.0005). Mean age at death was 64 +/- 20 years. In Crohn's disease, the most frequent cause of death was the primary disease (50%), followed by tumors of different origin (37.5%). In ulcerative colitis the primary disease was also the most frequent cause of death (38.%), followed by thromboembolic disease (22.2%) and tumors (22.2%).

CONCLUSIONS

mortality among patients with chronic inflammatory bowel disease is higher than in the general population in our setting, decreases as duration of the disease increases, and is higher in patients diagnosed at older ages. Fewer than half the deaths were due to the primary disease; many patients with Crohn's disease died from tumors or thromboembolic disease.

Serological markers of hepatitis A, B and C in first year student nurses

OBJECTIVE

To know the prevalence of serological markers of hepatitis A, B and C virus in first year student nurses.

SETTING

A transversal study of prevalence.

SUBJECTS AND METHODS

81 first year student nurses, mean age 20.6 years (18-37, S.D. 3.8), with demographic, epidemiologic and clinical variables, performing liver enzymes, anti-HAV IgG, anti-HBcore and anti-HCV.

RESULTS

The anti-HAV IgG was positive in 9 students (11.1%), with a prevalence of 6.7% between 17 and 19 years (C.I.95% 1.7 to 19.3%), 8.7% between 20 and 22 years (C.I.95% 1.5 to 29.5%), 20% between 23 and 25 years (C.I.95% 10.5 to 70.1%), and 37.5% (C.I.95% 10.2 to 74.1) in those over 25 years (p < 0.001). No other significative variables existed according to age-group. Regarding hepatitis B virus, of the 65 not previously vaccinated, only 1 (1.5%, C.I.95% 0.08 to 9.4%) was immunized, and there were no cases of HBsAg positive. The anti-VHC was positive in one case (1.2%, C.I.95% 0.06 to 7.6%), RIBA indeterminate and with normal ALT. Only one student (1.2%) showed increased transaminase values, attributed to liver steatosis. None of the students had suffered any episode of acute clinic hepatitis.

CONCLUSIONS

The anti-HAV IgG prevalence in first year student nurses in our area is very low, and it is not necessary to carry out prevacunal screening. The low prevalence of anti-Hbcore also rejects a similar screening with respect to HBV. There were no HBsAg or anti-HCV positive cases, but it should not be the cause of forgetting to take the universal precautions or giving a false sensation of security.

[The prevalence of hepatitis A, B and C viral markers in the population of Gijón between 26 and 65 years old]

The aim of this study was to know the prevalence of hepatitis A, B and C markers in an adult population in Gijón, Spain. A randomized, transversal sample according to the census was made in a population between 26 and 65 years of age in Gijón, analyzing demographic, epidemiologic and clinical variables, liver function tests, anti-HAV IgG, anti-HBcore and anti-HCV. Of the 476 individuals included a census error was detected in 26 (5.5%) and 340 (71.4%) were studied. Of these anti-HAV IgG was positive in 210 (61.8%) with prevalences of 17.9% from 26 to 30 years (CI: 95%, 11.1%-27.4%), 54.7% from 31 to 35 years (CI: 95%, 41.8%-67%), 73.6% from 36 to 40 years (CI: 95%, 59.4%-84.3%) and 93% (CI: 95%, 86.7%-96.5%) above 40 years of age (p < 0.001). No other significant variables were found adjusted by age groups. With regard to HBV, of the 331 unvaccinated cases, 35 (10.6, CI 95%, 7.6%-14.5%) presented immune markers and 4 (1.2% CI: 95%, 0.4%-3.3%) HBsAg positivity, with all having normal ALT and no viral replication. Anti-HCV was positive in 1.7% (CI: 95%, 0.7-3.9%), being significantly related to IVDA or tattoos. Hypertransaminasemias were detected in 18 (5.3%) being attributed to virus C (27.8%), alcoholism (27.8%) or obesity (44.4%). History of clinical manifestations of acute hepatitis was collected in 9.7% of the cases with no memory of the episode in 84.3% of the anti-HAV IgG positive cases, 79.5% of the anti-HBcore positive cases and 83.3% of the anti-HCV positive cases. The current curve of prevalence of anti-HAV IgG in the Gijón population varies in the decade from 30 to 40 years in age ranging from values discarding prevaccination screening under the age of 30 to levels of minimum susceptibility to infection above the age of 40. The low prevalence of anti-HBcore underestimates its use as prevaccination screening versus HBV in the population of Gijón. The prevalences of HBsAg or anti-HCV thereby make this area a zone of intermediate endemicity, with around 3% of the population being chronically infected by one of these viruses.

[The prevalence of markers for the hepatitis A and B viruses in the population of Gijón between 6 and 25 years old]

BACKGROUND

The aim of this study was to know the prevalence of previous infection markers for hepatitis A and B viruses in a pediatric-juvenile population from Gijón, Spain.

PATIENTS AND METHODS

A representative (according to the census) transversal randomized sample of a population from 6 to 25 years in age from Gijón, Spain, was included in the study analyzing demographic, epidemiologic and clinical variables, liver tests, anti-HAV IgG and anti-HBc.

RESULTS

Of the 630 individuals selected a demographic error was detected in 28 (4.4%) and 453 subjects were studied (71.9%) in whom the anti-HAV IgG was positive in 37 cases (8.75% of prevalence adjusted for age), with 4.4% (12/271) (CI 95% 2.3%-7.6%) for the younger cases and 13.7% (25/182) (CI 95% 9.1%-19.6%) in the group ranging from 18 to 25 years in age (p < 0.001). No anti-HAV IgG positive case was detected in the population under the age of 10 years. Among the young adults the prevalence of anti-HAV IgG positive cases was higher in those born in the south of Spain (2/6, 33.3%) (CI 95% 4.3%-77.7%) with respect to those from the northern regions of Spain (9/259, 3.5%) (CI 95% 1.6%-6.4%). (p = 0.02). With respect to HBV markers, of the 433 unvaccinated cases, 6 (1.4%) presented markers of past infection and 2 (0.46%) HBsAg positivity. Both had normal serum ALT without viral replication. Six cases of hypertransaminasemia levels (1.3%) were detected all being related with obesity or alcoholism. All the cases with previous acute clinical hepatitis were found to be anti-HAV IgG positive and anti-HBc negative.

CONCLUSIONS

The current prevalence of anti-HAV IgG in the population from 6 to 25 years from Gijón, Spain is very low and given the high degree of susceptibility (86%) for HAV infection in the young adult population (18-25 years) the implementation of vaccination programs is recommended even without previous serologic screening. The low prevalence of anti-Hbc would also undervalue its use as prevaccination screening against HB in this geographical area.

Epidemiology of hepatitis D virus infection: changes in the last 14 years

To calculate the prevalence of hepatitis D virus (HDV) superinfection, antibody to HDV (anti-HD) was tested on admission in 696 hepatitis B virus (HBV) chronic carriers diagnosed between 1979 and 1992. Anti-HD was positive in 67 patients (9.6%), and it was more frequently detected in i.v. drug abusers (IVDA) (59/74, 79.7%) than in non-IVDA (8/622, 1.3%) (p = 0.0001). The prevalence of anti-HD was higher in HBV chronic carriers diagnosed between 1979 and 1985 (33/219, 15.1%) than in those diagnosed from 1986 to 1992 (34/477, 7.1%) (p < 0.001). However, these figures were not different when IVDA were analyzed alone; 29/34 (85%) and 30/40 (75%) (p = 0.4) IVDA diagnosed in both time frames were anti-HD-positive. Four hundred and thirty anti-HD-negative HBV carriers were prospectively followed, and serial determinations of anti-HD were made. Seroconversion to anti-HD was observed in only six patients (1.4%), and again the rate of seroconversion was higher in IVDA (5/10, 50%) than in non-IVDA (1/420, 0.2%) (p < 0.0001). These findings show that IVDA HBV chronic carriers are still an extremely high risk group for HDV superinfection in Spain and that this virus has little penetrance in other epidemiological categories of HBV carriers.

[The prevalence of anti-HCV positivity among blood donors in Asturias. A clinical-epidemiologic study]

BACKGROUND

The aim of this study was to know the prevalence, epidemiology, clinical manifestations and analytical changes present in anti-HCV positive blood donors detected in Asturias.

METHODS

A prospective analysis of the incidence and prevalence of anti-HCV positivity in the blood donations carried out in Asturias from October 1989 to October 1991 was performed, as was a clinical and analytical study of the anti-HCV positive cases who attended a clinic specifically created for the same.

RESULTS

The prevalence of the anti-HCV was 0.87% of the donors (372/42,789) and 0.50% of the donations (372/73,831) being higher among new donors (1.77%, 165/9,322). Of the 288 cases studied (77.4%), only 51 (17.7%) had been transfused and 105 (36.5%) lacked the previous parenteral risk factor. Only 31 (10.8%) presented symptoms or signs of liver disease and the positivity of the anti-HBc was not associated to any relevant analytical change. The existence of previous major surgery or transfusion was variable with the independent predictive value versus a negative anti-HCV control group. The mean follow up was 12.4 +/- 7.3 months (6-30 months) with an increase in aminotransferases (ALT) being detected in 108 cases (52.7%). A good correlation was found between this data, an ELISA-2 score greater than 5 and RIBA-2 positivity: of the 177 cases in whom RIBA-2 was determined this was found to be positive in 109 (61.6%); 84 cases (77.1%) had an increase in ALT and 100 (91.8%) an ELISA-2 score greater than 5.

CONCLUSIONS

In Asturias the prevalence of anti-HCV positivity among blood donors is almost 1% and is greater if new donors are considered, being confirmed by RIBA-2 in 61% of the cases. The subjects are usually asymptomatic and up to one third of the same lack any known risk factor, while almost half have hypertransaminasemia during follow up.

[Ascitic peritonitis due to Candida albicans]

We report a case of spontaneous peritonitis due to Candida albicans, in a diabetic patient with alcoholic liver cirrhosis, ascites, gastrointestinal bleeding from esophageal varices, sepsis, renal failure and encephalopathy. These factors, added to prolonged antibiotic therapy and instrumental manipulations, could have resulted in the colonization by Candida, usually described in secondary peritonitis, but perhaps underdiagnosed in cirrhotic patients with spontaneous peritonitis and severe multiorgan failure.

Epidemiological, clinical and biological characteristics of acute non-A, non-B hepatitis with and without hepatitis C virus infection

Serially collected serum samples from 81 patients with acute non-A, non-B hepatitis were tested for the presence of antibodies to hepatitis C virus (anti-HCV) by a second-generation enzyme immunoassay (EIA) test. Anti-HCV was detected in 56 cases (69%) during the first month, in 61 cases (75%) at 3 months and in 63 cases (78%) at 6 months. In those 18 patients showing anti-HCV negative results in the three determinations, hepatitis C virus (HCV) RNA was tested using a nested polymerase chain reaction (PCR) in the first serum sample and was detected in only one case. Anti-HCV or HCV-RNA positive episodes were considered as acute hepatitis C, while those negative for both markers were classified as acute non-A, non-B, non-C hepatitis. On comparing acute hepatitis C with the non-A, non-B, non-C episodes, no significant differences were found in the presence of jaundice, mean maximum alanine-aminotransferase (ALT) levels and positivity of markers of past hepatitis B virus (HBV) infection. However, patients with hepatitis C were significantly younger than those with non-A, non-B, non-C hepatitis (p = 0.002). Male sex (78.1% vs. 35.3%; p = 0.001), history of parenteral exposure (90.6% vs. 11.8%; p = 0.0001), and progression to chronicity (73.4% vs. 5.9%; p = 0.0001) were significantly more frequent in the HCV-related group. Although other possibilities cannot be excluded, these results suggest that there might be a different infectious agent implicated in the etiology of acute non-A, non-B, non-C hepatitis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ulcerative colitis with Coombs+ autoimmune hemolytic anemia. A report of a case with favorable response to medical treatment]

We report the case of a patient with ulcerative colitis and autoimmune hemolytic anemia, that improved with steroid therapy, and during the follow-up showed analytical changes of iron deficiency anemia and anemia of chronic disorders. We discuss the possible etiologies of the anemia in patients with ulcerative colitis, and the treatments suggested for the associated Coombs-positive hemolytic anemia in these cases, stressing the good response to steroids in our patient.

[Blood donors with positive HBsAg in Asturias: its current prevalence and significance]

BACKGROUND

The aim of the present study was to know the current prevalence of HBsAg positivity in Asturias blood donors and to carry out a clinical study of the carriers of the hepatitis B virus (HBV) accidentally detected in a blood donation program.

METHODS

A prospective study of incidence and prevalence of HBsAg positivity in blood donations performed in Asturias over two years from October 1989 and 1991 was carried out and the epidemiologic, clinical, and analytical characteristics, as well as histologic liver lesions in the HBsAg positive cases were determined.

RESULTS

Among the 42,789 blood donors during this above mentioned period in Asturias 119 cases of HBsAg positivity were found, representing a prevalence of 0.16% of the donations and 0.28% of the donors, generally new donors (95.8%) with a prevalence of 1.2% in this subgroup. No risk factors or known source of contagion were found in 43.6% of the cases and in most occasions the donors were asymptomatic HBsAg carriers (96.5%) with normal transaminases (87.3%) with 4.6% of the cases being HBeAg positive and 3.5% being mutant "e minus" carriers.

CONCLUSIONS

The prevalence of HBsAg was almost limited to new donors with a higher prevalence being observed with respect to other regions. Most of the cases may be considered as "apparently healthy" and in the group with positive replicative markers a similar number of positive HBeAg carriers and "e minus mutants" were present.

[The accidental detection of anti-HCV positivity and monoclonal gammapathy]

The study presents four cases of monoclonal gammopathy accidentally detected in anti-HCV-positive blood donors without previously known hepatopathy. A hematological and hepatic studies were performed, including liver biopsy in all the cases, discussing the implications of the association between the two phenomena and the possible false positives of anti-HCV in hypergammaglobulinemias.

[A ventriculoperitoneal shunt as a rare cause of ascites]

We report the case of a 22-year-old man with a craniopharyngioma, who developed ascites following a ventriculoperitoneal shunt procedure for hydrocephalus. The ascites was resolved with diversion of the distal catheter into the right atrium. A ventriculoperitoneal shunt can cause ascites, even without neurological symptoms suggestive of shunt malfunction.

[Mixed type-II cryoglobulinemia associated with a chronic hepatitis C virus infection]

We describe the case of a patient with non A-non B post-transfusional cirrhosis and type-II mixed cryoglobulinemia, who showed in relation with said processes several acute symptoms of vasculitis, polyarthritis, pericarditis and autoimmune hemolytic anemia, finally dying due to an advanced hepatocellular insufficiency. In this patient the determination of antibodies against hepatitis C virus (anti-HCV) was positive, that is why we assume a possible relationship between both processes and the first literature references, after the clonation of the hepatitis C virus (HCV) genome, are reviewed.

Response related factors in recombinant interferon alfa-2b treatment of chronic hepatitis C

In an analysis of the clinical and laboratory variables that can influence the response to interferon alfa-2b treatment, 48 patients with chronic hepatitis C virus infection received interferon 5 million units (MU) subcutaneously three times weekly for eight weeks followed by 3 MU three times weekly for seven months. Response related factors on univariate analysis were found to be age > 40 years, non-parenteral source of infection, pretreatment positive antinuclear antibodies (ANA), cirrhosis, and high serum iron, ferritin, gamma glutamyl transferase, and IgM. An independent predictive value (multivariate analysis) was also found for cirrhosis, ANA, serum iron, and ferritin. A baseline aspartate aminotransferase/alanine aminotransferase ratio of 0.5 and a striking increase during interferon treatment were associated with a complete response.

Hepatitis C virus infection in patients with acute hepatitis B

The prevalence of antibodies to hepatitis C virus (anti-HCV) was studied using a second-generation ELISA test in 121 patients with self-limiting acute hepatitis B, including 63 intravenous drug addicts (IVDA). Within the first month after the onset of illness, 47.1% of the patients were anti-HCV positive, this figure reaching 52.1% six months later. The prevalence in the sixth month was significantly higher in the IVDA (93.6%) than in the non-IVDA (6.9%) (p < 0.00001). Among the IVDA, anti-HCV was more frequent in those with (100%) than in those without hepatitis delta virus (HDV) coinfection (84.6%) (p = 0.004). Of the 63 anti-HCV positive patients, 36 (57.1%) continued to exhibit abnormal transaminase levels for more than six months, while this was not observed in anti-HCV negative patients. These results show a high prevalence of infection by hepatitis C virus (HCV) in IVDA with acute B hepatitis. As a rule, infection by HCV occurred prior to the hepatitis B infection, although occasionally simultaneous infections were observed. HCV appears to be the agent responsible for chronic liver disease in patients with acute B hepatitis who become HBsAg negative.

[The prevalence of HCV antibodies in 3 groups with distinct patterns of sexual activity]

We studied the prevalence of antibodies to hepatitis C virus (anti-HCV) among 164 heterosexual partners of anti-HCV-positive subjects, 131 prostitutes and 52 homosexual men. 6.7% of heterosexual monogamous partners had anti-HCV; the seropositivity rate was associated with a long-term sexual practice and with age. Of the 131 prostitutes, 6 (4.6%) had anti-HCV; there were significant associations in patients positive for anti-HCV, with a history of parenteral drug addiction. 11.5% of homosexual men were anti-HCV positive; there were significant associations with positivity for antibodies to HIV, intravenous drug abuse and with the number of sexual partners. We concluded that the HCV may be transmitted by sexual route, but the high seroprevalence among prostitutes and homosexuals may be explained by other parenteral mechanisms.

Involved factors in the intrafamilial spread of hepatitis C virus

To investigate the risk of non-parenteral HCV infection, sera from 302 relatives of 120 anti-HCV positive subjects were tested for the presence of anti-HCV antibodies. For the sake of comparison, sera from 17,000 blood donors were also assayed. The prevalence of HCV positivity was 4.3% in household contacts, compared to 0.78% in the donor population, indicating a significantly higher risk of infection for family members. Close personal contact may not be as critical a factor for infection as is duration of the disease.

Prevalence of antibodies against hepatitis C virus in primary biliary cirrhosis and autoimmune chronic hepatitis

We have determined the prevalence of antibodies against hepatitis C virus (anti-HCV) in 45 patients with primary biliary cirrhosis (PBC) and 6 with autoimmune chronic active hepatitis (AI-CAH). Anti-HCV was positive in two cases of PBC, both with a history of previous blood transfusion, and in one patient with AI-CAH, only during an active phase of the disease.

[Crohn's disease and amyloidosis. An association to be considered]

Two instances of Crohn's disease and amyloidosis are presented. The time elapsed between the diagnosis of Crohn's disease and that of amyloidosis was 2 and 8 years respectively. The first case had hepatosplenomegaly and moderate proteinuria; the other one, severe proteinuria in the nephrotic syndrome range. One patient had ileocolic disease and the other disease limited to the terminal ileum. In both cases renal functional was normal. The diagnosis was made by liver biopsy in one patient and by repeated renal biopsy in the one with nephrotic syndrome. Ileocolic resection was undertaken in one patient without complications. Screening for amyloidosis is important in patients with Crohn's disease.

[Changes in the number of and indications for laparoscopy at a general hospital from 1979 to 1989]

Laparoscopic examinations done during 1979-1989 have been reviewed. From 214 examinations done during the first year of the review, the number of laparoscopies has been steadily declining to 7 examinations in 1989. Indications have also changed during this decade. Laparoscopy does not any more belong to the first choice examinations for diagnosis. Its usefulness is restricted to highly selected individual cases.