Transjugular intrahepatic portosystemic shunt in patients with hepatocellular carcinoma: A systematic review.

BACKGROUND/AIMS Transjugular intrahepatic portosystemic shunts (TIPS) in patients with hepatocellular carcinoma (HCC) may improve access to curative therapies, treat portal hypertension (PH)-related complications without worsening liver function, and increase overall survival. Data on the efficacy and safety of TIPS to treat PH complications in HCC patients, as well as the HCC treatment response, were evaluated. METHODS Studies reporting efficacy in controlling bleeding/ascites or response to HCC therapy, safety, and survival in patients with HCC and TIPS were searched systematically on PubMed and Embase. An extraction of articles using predefined data fields and quality indicators was used. RESULTS We selected 19 studies and found 937 patients treated for ascites/bleeding and 177 evaluating HCC treatment response. Over half were under 5 cm and solitary lesions, and most studies included tumours with portal vein thrombosis. Regarding PH studies, TIPS resolved bleeding/ascites in >60% of patients, more effective for bleeding. There were no lethal complications reported and procedural bleeding occurred in 40% rate in half of the studies. CONCLUSIONS In the published studies, TIPS is effective in treating PH complications in patients with HCC. Prospective studies on TIPS placement in patients with HCC are urgently needed to evaluate the efficacy and safety of TIPS in this setting

Portal hypertension and acute liver failure as uncommon manifestations of primary amyloidosis

Hepatic involvement in primary amyloidosis is an infrequent challenge to the hepatologist. Although usually asymptomatic, amyloidosis may have unusual manifestations. Liver biopsy is an important diagnostic tool for this condition. Herein, we report three cases of portal hypertension related to primary hepatic amyloidosis, one of them in the form of acute liver failure

Subdiagnóstico de depresión en atención primaria, en pacientes del área sur-oriente de Santiago, 2006

Depression is highly prevalent in Chile. However, many patients are not detected by primary healthcare physicians (PHCP). The purpose of the present study is to analyze the consistency between the diagnosis of depression performed by PHCP, and diagnosis resulting from a structured clinical interview based on DSM-IV criteria (Diagnostic and Statistical Manual for Mental Disorders, IVth Edition) for depression, taking place at a secondary healthcare center (SHCC).A total of 174 patients were studied (mean age 57.6 15.1 years, 131 female), referred for various pathologies different from depression to one SHCC, and who had been assessed during the last month by a PHCP. All patients were assessed with the Goldberg's Anxiety and Depression Scale (GADS) and the probable cases determined to be so by the instrument used (a score 3 in depression scale subset) underwent a structured clinical interview based on the DSM-IV criteria for depression.Thirty three patients had a diagnosis of depression made by the PHCP. However, 103 (59.2%) had scores 3 in the GADS and 59, (33.9%) met the DSM-IV criteria for depression. The consistency between the diagnosis made by a PHCP and that made through the DSM-IV diagnostic criteria, assessed through Kappa index, was 0.39 (weakly consistent), with a positive consistency only in 25 cases.A low consistency was observed between the diagnosis of depression made by PHCP and the diagnosis reached through a structured clinical interview, with underdiagnosis being as relevant as nearly 60%. Additionally, the use of a screening test allowed the identification of cases not diagnosed previously.La depresión es altamente prevalente en Chile, sin embargo, muchos pacientes no son pesquisados por los médicos de atención primaria (MAP). El objetivo de esta estudio es analizar la concordancia entre el diagnóstico de depresión hecho por MAP, respecto a una entrevista clínica estructurada basada en criterios DSM-IV (Manual Diagnóstico y Estadístico de los Trastornos Mentales) para depresión, realizada en un centro de atención secundaria (CAS). Se estudiaron 174 pacientes (edad 57.6 15.1 años, 131 mujeres), derivados por diversas patologías distintas a la depresión, a un CAS, atendidos durante el último mes por MAP. Todos los pacientes fueron evaluados con la escala de ansiedad y depresión de Goldberg (E.A.D.G) y a los "probables casos" según el instrumento (puntaje 3, subescala depresión) se les realizó una entrevista clínica estructurada basada en criterios DSM-IV para depresión. Treinta y tres pacientes tenían diagnóstico de depresión hecho por MAP. Sin embargo, 103 pacientes (59.2%) tuvieron puntajes 3 en la E.A.D.G y 59 (33.9%) cumplieron criterios DSM-IV para depresión. La concordancia entre el diagnóstico de depresión hecho por MAP, respecto al diagnóstico según criterios DSM-IV, mediante el índice Kappa, fue 0.39 (acuerdo débil), existiendo coincidencia positiva sólo en 25 casos. Se observó baja concordancia entre el diagnóstico de depresión hecho por MAP y el realizado a través de una entrevista clínica estructurada, con importante subdiagnóstico, cercano al 60%. En forma adicional, la aplicación de un test de tamizaje, fue de utilidad para detectar casos previamente no diagnosticados

Conversion to Mycophenolate Mofetil Monotherapy in Liver Recipients: Calcineurin Inhibitor Levels are Key

The use of calcineurin inhibitors (CNI) after liver transplantation is associated with post-transplant nephrotoxicity. Conversion to myc-ophenolate mofetil (MMF) monotherapy improves renal function, but is related to graft rejection in some recipients. Our aim was to identify variables associated with rejection after conversion to MMF monotherapy. Conversion was attempted in 40 liver transplant recipients. Clinical variables were determined and peripheral mononuclear blood cells were immunophenotyped during a 12-month follow-up. Conversion was classified as successful (SC) if rejection did not occur during the follow-up. MMF conversion was successful with 28 patients (70%) and was associated with higher glomerular filtration rates at the end of study. It also correlated with increased time elapsed since transplantation, low baseline CNI levels (Tacrolimus ≤ 6.5 ng/mL or Cyclosporine ≤ 635 ng/mL) and lower frequency of tacrolimus use. The only clinical variable independently related to SC in multivariate analysis was low baseline CNI levels (p = 0.02, OR: 6.93, 95%, CI: 1.3-29.7). Mean baseline fluorescent intensity of FOXP3+ T cells was significantly higher among recipients with SC. In conclusion, this study suggests that baseline CNI levels can be used to identify recipients with higher probability of SC to MMF monotherapy. Clinicaltrials.gov identification: NCT01321112

Prioritization for liver transplantation using the MELD score in Chile: Inequities generated by MELD exceptions.

Introduction and aim: The MELD score has been established as an efficient and rigorous prioritization system for liver transplant (LT). Our study aimed to evaluate the effectiveness of the MELD score as a system for prioritization for LT, in terms of decreasing the dropout rate in the waiting list and maintaining an adequate survival post-LT in Chile. Materials and methods: We analyzed the Chilean Public Health Institute liver transplant registry of candidates listed from October 15th 2011 to December 31st 2014. We included adult candidates (>15 years old) listed for elective cadaveric LT with a MELD score of 15 or higher. Statistical analysis included survival curves (Kaplan–Meier), log-rank statistics and multivariate logistic regression. Results: 420 candidates were analyzed. Mean age was 53.6 ± 11.8 years, and 244 were men (58%). Causes of LT included: Liver cirrhosis without exceptions (HC) 177 (66.4%); hepatocellular carcinoma (HCC) 111 (26.4%); cirrhosis with non-HCC exceptions 102 (24.3%) and non-cirrhotic candidates 30 (7.2%). LT rate was 43.2%. The dropout rate was 37.6% at 1-year. Even though the LT rate was higher, the annual dropout rate was significantly higher in cirrhotic candidates (without exceptions) compared with cirrhotics with HCC, and non-HCC exceptions plus non-cirrhotic candidates (47.9%; 37.2% and 24.2%, respectively, with p = 0.004). Post-LT survival was 84% per year, with no significant differences between the three groups (p = 0.95). Conclusion: Prioritization for LT using the MELD score system has not decreased the dropout rate in Chile (persistent low donor's rate). Exceptions generate inequities in dropout rate, disadvantaging patients without exceptions