21 research outputs found
Impacto del virus de la Hepatitis C en la evolución de las comorbilidades en pacientes infectados por el VIH (1993-2014)
Programa Oficial de Doutoramento en Ciencias da Saúde. 5007V01Tese por compendio de publicacións[Resumen]
La introducción del tratamiento antirretroviral (TAR) de alta eficacia ha
disminuido de manera significativa la morbimortalidad de los pacientes con infección
por el virus de la inmunodeficiencia adquirida (VIH) convirtiendo a la infección por VIH
en una patología crónica y al paciente VIH+ en un paciente cada vez más mayor, no
exento de otras comorbilidades médicas o eventos no SIDA. En este nuevo escenario,
se hace indispensable mejorar el conocimiento acerca de las diferentes comorbilidades
y los factores de riesgo que las condicionan con el propósito de establecer estrategias
en el ámbito de la prevención, del diagnóstico y del tratamiento específicas para la
población con infección por VIH. Una de las principales comorbilidades en las personas
infectadas por VIH es la coinfección por el virus de la hepatitis C (VHC), que
condiciona en gran medida el desarrollo de enfermedad hepática y también
extrahepática.
En base a lo anteriormente expuesto, es importante conocer las características
epidemiológicas y clínicas de los pacientes VIH+ de nuestra área sanitaria, sus
comorbilidades y los eventos que condicionan su vida como las hospitalizaciones y la
mortalidad. Además, es pertinente analizar el impacto que supone la coinfección en
términos de morbimortalidad de causa hepática y no hepática.
En la presente tesis se desarrollaron tres estudios:
‐ ESTUDIO 1. Analizó todas las hospitalizaciones de pacientes VIH en el CHUAC
en el periodo 1993‐2013. Se incluyeron 6917 hospitalizaciones que
correspondieron a 1937 pacientes (37% coinfectados VIH/VHC). La tasa de
hospitalización mostró una reducción progresiva desde 30,7/100 pacientes
(IC95%:27,7‐33,8) en 1993 a 19,9/100 pacientes (17,7‐22,2) en 2013, siendo
esta reducción más significativa después de 1996 (4,9% anual), pero este
descenso fue menos acusado en los pacientes coinfectados VIH/VHC (1,7%
anual). Las hospitalizaciones motivadas por enfermedades infecciosas y
trastornos psiquiátricos disminuyeron significativamente en el segundo periodo
de estudio (2003‐2013), mientras que aumentaron aquellas relacionadas con
neoplasias, enfermedad cardiovascular, gastrointestinal y enfermedades
respiratorias crónicas. En los pacientes coinfectados VIH/VHC, buena parte de
las hospitalizaciones y de las muertes fueron motivadas por enfermedad
hepática.
‐ ESTUDIO 2. Comparó la mortalidad relacionada con enfermedad
hepática y las hospitalizaciones motivadas por causa hepática en pacientes con
infección por VIH que han sido expuestos o no al VHC. Se incluyeron resultados
de 2379 pacientes VIH (1390 VIH monoinfectados, 146 aclaradores
espontáneos de VHC y 843 con coinfección crónica VIH/VHC) en el periodo
1993‐2014. La tasa de mortalidad relacionada con enfermedad hepática en los
pacientes coinfectados VIH/VHC fue de 10,01 por 1000 paciente‐años frente al
3,84 por 1000 paciente‐años en el grupo de VIH monoinfectados (p<0.001). La
fracción de mortalidad y hospitalización atribuíble a la infección crónica por
VHC fue 0.61 y 0.74, respectivamente. No se encontraron diferencias en
eventos relacionados con hígado entre pacientes VIH monoinfectados frente a
los que aclararon espontanánemente el VHC.
‐ ESTUDIO 3. Evaluó la incidencia de cáncer en pacientes con infección
por VIH en el área sanitaria de A Coruña en el periodo 1993‐2014 y permitió su
comparación con la población coinfectada VIH/VHC y con la observada en la
población general (utilizando la herramienta GLOBOCAN 2012), calculando la
razón de incidencia estandarizada (RIE). 185 pacientes (117 VIH
monoinfectados y 68 coinfectados VIH/VHC) desarrollaron cáncer en una
cohorte de 26580 paciente‐años, con una tasa de incidencia cruda de 696
neoplasias por 100000 persona‐años, mayor que en la población general
(RIE=3,8). La tasa de incidencia cruda de NNDS en pacientes coinfectados
VIH/VHC fue 415.0 (RIE=3,4), significativamente mayor que en VIH
monoinfectados (377,3; RIE=1,8). Tras el ajuste, los pacientes coinfectados
VIH/VHC tenía una mayor incidencia acumulada de NNDS que los pacientes VIH
monoinfectados (HR=1,80), incluso después de excluír del análisis el
hepatocarcinoma (HR=1,26).[Abstract]
High efficacy antiretroviral treatment (ART) introduction has significantly
decreased the morbidity and mortality of HIV+ patients, making HIV infection a chronic
disease. and HIV+ patient an older patient with other medical comorbidities or non‐
AIDS events. In this new scenario, it is essential to improve knowledge about the
different comorbidities and risk factors with the purpose of perfom new strategies in
the area of prevention, diagnosis and treatment specific to HIV population . One of the
main comorbidities in people infected with HIV is HCV coinfection, which could
modified liver and extrahepatic disease.
Therefore, it is important to know the epidemiological and clinical
characteristics of HIV + patients in our health area, their comorbidities and the events
such as hospitalizations and mortality. In addition, it is necessary to analyze the impact
of coinfection in terms of hepatic and non‐hepatic morbidity and mortality.
In this thesis, three studies has been developed:
‐ STUDY 1. All the hospitalizations of HIV patients in the CHUAC in the period
1993‐2013 were analysed. We included 6917 hospitalizations corresponding to
1937 patients (37% HIV/HCV coinfected). The hospitalization rate showed a
progressive reduction from 30.7/100 patients (IC95%: 27.7‐33.8) in 1993 to
19.9/100 patients (17.7‐22.2) in 2013; a higher reduction was seen after 1996
(4.9% per year), but this decrease was less pronounced in HIV / HCV coinfected
patients (1.7% per year). Hospitalizations motivated by infectious
diseases and psychiatric disorders decreased significantly in the second period
(2003‐2013), while those related to malignancies, cardiovascular diseases,
gastrointestinal diseases and chronic respiratory diseases increased. In HIV/HCV
coinfected patients, a large proportion of hospitalizations and deaths were due
to liver disease.
‐ STUDY 2. Liver disease related mortality and hospitalizations due to
hepatic causes were compared in patients with HIV infection who have been
exposed to HCV or not. 2,379 HIV patients (1390 HIV monoinfected, 146
with HCV spontaneous clearence and 843 HCV / HCV coinfected) were included
between 1993‐2014. Liver disease related mortality rate in coinfected
HIV/HCV patients were 10.01 per 1000 patient‐years versus 3.84 per 1000
patient‐years in the HIV monoinfected group (p <0.001). The fractions of liver
related mortality and liver‐related hospitalizations attributable to chronic
HCV coinfection were 0.61 and 0.74, respectively. There were no differences
in liver‐related events between HIVmonoinfected individuals and
those who spontaneously cleared HCV.
‐ STUDY 3. Cancer incidence in HIV infected patients between 1993 and 2014 In
La Coruña was assessed and compared with the HIV/HCV coinfected population
and with the general population ( with GLOBOCAN 2012 Tool), using the
standardized incidence ratio (SIR). 185 patients (117 HIV monoinfected and 68
HIV / HCV coinfected) developed cancer in a cohort of 26,580 patient‐years,
with a crude incidence rate of 696 malignancies per 100,000 person‐years,
higher than in the general population (SIR = 3, 8). The crude incidence rate of
NNDS in HIV / HCV coinfected patients was 415.0 (SIR = 3.4), significantly higher
than in monoinfected HIV (377.3; SIR = 1.8). After adjustment, HIV / HCV
coinfected patients had a higher cumulative incidence of NNDS than
monoinfected HIV patients (adjusted hazard ratio=1.80), even when
excluding hepatocellular carcinomas (adjusted hazard ratio=1.26).[Resumo] A introducción do tratamiento antirretroviral (TAR) de alta eficacia disminui de maneira significativa a morbimortalidade dos doentes con infección polo virus da inmunodeficiencia humana (VIH) convertindo a infección por VIH nunha patoloxía crónica e ó doente nun doente cada vez máis maior, non exento de outras comorbilidades médicas ou eventos non SIDA. Neste novo escenario, faise indispensable mellorar o coñecemento acerca das diferentes comorbilidades e os factores de risco que as condicionan co propósito de establecer estratexias no ámbito da prevención, do diagnóstico e do tratamento específicas para a poboación con infección por VIH. Unha das principais comorbilidades nas persoas infectadas é a coinfección polo virus da hepatite C (VHC), que condiciona en gran medida o desenvolvemento de enfermidade hepática e tamén extrahepática. En base ó anteriormente exposto, é importante coñecer as características epidemiolóxicas e clínicas dos doentes VIH+ da nosa área sanitaria, as súas comorbilidades e os eventos que condicionan a súa vida, como as hospitalizacións e a mortalidade. Ademáis, e pertinente analizar o impacto que supón a coinfección en termos de morbimortalidade de causa hepática e extrahepática. Na presente tese desenvolvéronse tres estudos: ‐ ESTUDO 1. Analizou todas as hospitalizacións does doentes VIH no CHUAC no periodo 1993‐2013. Incluíronse 6917 hospitalizacións que corresponderon a 1937 doentes (37% coinfectados VIH/VHC). A tasa de hospitalización mostrou unha reducción progresiva dende 30,7/100 doentes (IC 95%:27,7‐33,8) en 1993 a 19,9/100 doentes (IC 95%:17,7‐22,2) en 2013, sendo esta reducción máis significativa despóis de 1996 (4,9% anual), pero este descenso foi máis acusadonos doentes coinfectados VIH/VHC. As hospitalizacións motivadas por enfermidades infecciosas e trastornos psiquiátricos disminuíron significativamente no segundo periodo do estudo (2003‐2013), mentras que aumentaron aquelas relacionadas con neoplasias, enfermidades cardiovasculares, gastrointestinales e enfermidades respiratorias crónicas. Nos doentes coinfectados VIH/VHC, boa parte das hospitalizacións e das mortes foron motivadas por enfermidade hepática. ‐ ESTUDO 2. Comparou a mortalidade relacionada con enfermidade hepática e as hospitalizacións motivadas por causa hepática nos doentes con infección por VIH que foron expostos ou non ó VHC. Incluíronse resultados de 2379 doentes VIH (1390 VIH monoinfectados, 146 aclaradores espontáneos do VHC e 843 con coinfección crónica por VHC) no periodo 1993‐2014. A tasa de mortalidade relacionada con enfermidade hepática nos doentes coinfectados VIH/VHC foi de 10,01 por 1000 doentes‐anos fronte ó 3,84 por 1000 doentes‐anos propio dos VIH monoinfectados (p<0,001). A fracción de mortalidade e hospitalización atribuíble á infección crónica por VHC foi 0.61 e 0.74, respectivamente. Non se atoparon diferencias nos eventos relacionados con enfermidade hepática entre doentes VIH monoinfectados fronte ós que aclararon espontáneamente o VHC. ‐ ESTUDO 3. Evaluou a incidencia de cáncer en doentes con infección por VIH na área sanitaria de A Coruña no periodo 1993‐2014 e permitiu a súa comparativa coa poboación coinfectada VIH/VHC e coa observada na 8 poboación xeral (utilizando a ferramenta GLOBOCAN 2012), calculando a razón de incidencia estandarizada (RIE). 185 doentes (117 VIH monoinfectados e 68 coinfectados VIH/VHC) desenvolveron cáncer nunha cohorte de 26580 doentes‐anos, cunha tasa de incidencia cruda de 696 neoplasias por 100000 persoa‐anos, maior que na poboación xeral (RIE=3,8). A tasa de incidencia cruda de neoplasia non definitoria de SIDA (NNDS) nos pacientes coinfectados VIH/VHC foi 415.0 (RIE=3,4), significativamente maior que en VIH monoinfectados (377,3;RIE=1,8). Tras ser axustado, os doentes coinfectados VIH/VHC tiñan unha maior incidencia acumulada de NNDS que os doentes monoinfectados (HR=1,80), incluso despóis de excluír do análise o hepatocarcinoma (HR=1,26)
Delirium asociado a imipenem en paciente ingresado en una unidad quirúrgica. Diagnóstico etiológico del delirium
A 82 year-old woman with chronic renal failure who entered for acute diverticulitis in the General Surgery service. With medical treatment of rest digestive, antibiotic, parenteral nutrition, she evolves torpid until the improvement. In relation to the onset of imipenem, delirium presents a good evolution after its suspension. The identification of the risk factors and precipitating causes of delirium, investigating especially the associated drugs, are necessary for its treatment and prevention.Mujer de 82 años con insuficiencia renal crónica que ingresa por diverticulitis aguda en el servicio de Cirugía General. Con tratamiento médico de reposo digestivo, antibiótico y nutrición parenteral evoluciona tórpidamente hasta la mejoría. En relación con el inicio de imipenem presenta delirium con buena evolución tras su suspensión. La identificación de los factores de riesgo y de las causas precipitantes del delirium, investigando sobre todo los fármacos asociados, son necesarios para su tratamiento y prevención
Liver-related mortality and hospitalizations attributable to chronic hepatitis C virus coinfection in persons living with HIV
[Abstract] Objectives. The aim of this study was to compare liver-related mortality and liver-related hospitalizations for persons living with HIV (PLWH) with and without hepatitis C virus (HCV) exposure, and to estimate the fraction of liver disease attributable to chronic HCV coinfection.
Methods. An ambispective cohort study followed PLWH between 1993 and 2014. PLWH were classified into three groups: those who were HIV-monoinfected, those who cleared HCV spontaneously and those with chronic HCV coinfection. Liver-related mortality was estimated for the three groups and compared with the adjusted standardized mortality ratio.
Results. Data for 2379 PLWH were included in the study (1390 monoinfected individuals, 146 spontaneous HCV resolvers and 843 with chronic HCV coinfection). Global mortality was 33.8%, 21.4% of which was liver-related. Patients who died from liver-related causes were mostly on antiretroviral therapy and had an undetectable HIV viral load when they died. The liver-related mortality rate in those with chronic HCV coinfection was 10.01 per 1000 patient-years vs. 3.84 per 1000 patient-years in the HIV-monoinfected group (P < 0.001). The adjusted standardized mortality ratio in the chronically HCV-coinfected group was 4.52 (95% confidence interval 2.98–5.86). The fractions of liver-related mortality and liver-related hospitalizations attributable to chronic HCV coinfection were 0.61 and 0.74, respectively. There were no differences in liver-related events between HIV-monoinfected individuals and those who spontaneously cleared HCV.
Conclusions. Chronic HCV infection increases the risk of liver-related mortality and liver-related hospitalizations in PLWH, despite good control of HIV infection. Sixty per cent of liver-related mortality in chronically HCV-coinfected PLWH could be attributable to chronic HCV infection. The effect of mass HCV eradication with new therapies should be evaluated.Instituto de Salud Carlos III; CPII14/00014Instituto de Salud Carlos III; PI10/02166Instituto de Salud Carlos III; PI13/02266Instituto de Salud Carlos III; CM13/0032
Effects on insulin sensitivity and hepatic safety of Atazanavir in HCV/HIV coinfected patients versus HIV monoinfected: A prostective 48-week study
Tendencia de las hospitalizaciones, reingresos y mortalidad intrahospitalaria en los pacientes infectados por VIH entre 1993-2013: impacto de la coinfección por el virus de la hepatitis C
[Abstract] Background. New patterns in epidemiological characteristics of people living with HIV infection (PLWH) and the introduction of Highly Active Antiretroviral Therapy (HAART) have changed the profile of hospital admissions in this population. The aim of this study was to evaluate trends in hospital admissions, re-admissions, and mortality rates in HIV patients and to analyze the role of HCV co-infection.
Methods. A retrospective cohort study conducted on all hospital admissions of HIV patients between 1993 and 2013. The study time was divided in two periods (1993–2002 and 2003–2013) to be compared by conducting a comparative cross-sectional analysis.
Results. A total of 22,901 patient-years were included in the analysis, with 6917 hospital admissions, corresponding to 1937 subjects (75% male, mean age 36 ± 11 years, 37% HIV/HCV co-infected patients). The median length of hospital stay was 8 days (5–16), and the 30-day hospital re-admission rate was 20.1%. A significant decrease in hospital admissions related with infectious and psychiatric diseases was observed in the last period (2003–2013), but there was an increase in those related with malignancies, cardiovascular, gastrointestinal, and chronic respiratory diseases. In-hospital mortality remained high (6.8% in the first period vs. 6.3% in the second one), with a progressive increase of non-AIDS-defining illness deaths (37.9% vs. 68.3%, P < .001). The admission rate significantly dropped after 1996 (4.9% yearly), but it was less pronounced in HCV co-infected patients (1.7% yearly).
Conclusions. Hospital admissions due to infectious and psychiatric disorders have decreased, with a significant increase in non-AIDS-defining malignancies, cardiovascular, and chronic respiratory diseases. In-hospital mortality is currently still high, but mainly because of non-AIDS-defining illnesses. HCV co-infection increased the hospital stay and re-admissions during the study period.[Resumen] Introducción. Los cambios en las características epidemiológicas de los pacientes con infección por el VIH, y la introducción del tratamiento antirretroviral de alta eficacia, han modificado el perfil de las hospitalizaciones en esta población. El objetivo del estudio fue evaluar las tendencias en hospitalización, reingreso y mortalidad en pacientes VIH, y analizar el papel de la coinfección por el VHC.
Métodos. Estudio de cohortes retrospectivo, que incluyó todas las hospitalizaciones de pacientes VIH entre 1993-2013. El estudio fue dividido en 2 periodos (1993-2002 y 2003-2013) para ser comparados mediante un análisis transversal.
Resultados. Se analizaron 22.901 pacientes/años, que presentaron 6.917 hospitalizaciones que correspondieron a 1.937 pacientes (75% varones, edad media 36 ± 11 años, 37% coinfectados VIH/VHC). La mediana de estancia hospitalaria fue de 8 días (5-16), y la tasa de reingreso a los 30 días del 20,1%. Se observó un descenso significativo en el segundo periodo (2003-2013) de las hospitalizaciones motivadas por enfermedades infecciosas y trastornos psiquiátricos, y un incremento de aquellas relacionadas con neoplasias, enfermedad cardiovascular, gastrointestinal y enfermedades respiratorias crónicas. La mortalidad intrahospitalaria permanece elevada (6,8% en el primer periodo vs. 6,3% en el segundo), con un aumento progresivo de las muertes por enfermedades no definitorias de sida (37,9 vs. 68,3%; p < 0,001). La tasa de hospitalización disminuyó de manera significativa después de 1996 (4,9% anual), pero este descenso fue menos acusado en los pacientes coinfectados VIH/VHC (1,7% anual).
Conclusiones. Las hospitalizaciones motivadas por enfermedades infecciosas y trastornos psiquiátricos han descendido; por el contrario, se observó un aumento significativo de aquellas relacionadas con neoplasias no definitorias de sida, enfermedad cardiovascular y enfermedades respiratorias crónicas. La mortalidad intrahospitalaria permanece a día de hoy elevada, pero a expensas fundamentalmente de enfermedades no definitorias de sida. La coinfección VIH/VHC incrementó los días de hospitalización y los reingresos durante el periodo de estudio.Instituto de Salud Carlos III; CPII14/00014Instituto de Salud Carlos III; PI10/02166Instituto de Salud Carlos III; PI13/02266Instituto de Salud Carlos III; CM13/0032
Impact of HCV infection in a HIV cohort followed over18 years: past and present
Pôster abstrac
Liver-related events and mortality among elderly patients with advanced chronic hepatitis C treated with direct-acting antivirals
Research article[Abstract] BACKGROUND:
Direct-acting antivirals (DAAs) are effective in patients aged ≥65 years. However, little is known about the effects of DAAs on survival, liver decompensation and development of hepatocellular carcinoma (HCC).
OBJECTIVE:
To compare the incidence of liver-related events and mortality between patients aged ≥65 and <65 years.
METHODS:
Prospective study comparing patients aged ≥65 and <65 years treated with DAAs. The incidence of liver-related events and mortality, and HCC was compared between age groups.
RESULTS:
Five hundred patients (120 aged ≥65 and 380 aged <65 years) were included. The incidence of liver-related events was 2.62 per 100 patient-years (py) in older and 1.41/100 py in younger patients. All-cause mortality was 3.89 and 1.27/100 py in older and younger patients, respectively. The respective liver-related mortality rates were 1.12 and 0.31/100 py. In patients with cirrhosis (stage F4), all-cause mortality (P = 0.283) and liver-related mortality (P = 0.254) did not differ between groups. All five liver-related deaths were related to multifocal HCC. The incidence of HCC was 1.91 and 1.43 per 100 py in the older and younger groups, respectively (P = 0.747). The diagnosis of HCC was 8 months after the end of treatment.
CONCLUSIONS:
The incidence of liver-related events and liver-related mortality was low in older people treated with DAAs and was similar to that in younger patients. The extra mortality in people aged ≥65 years treated with DAAs seems to be secondary to non-liver-related causes. These results support the utilization of DAAs in patients aged ≥65 years.Instituto de Salud Carlos III; JR17/0002
Seroprevalence of HCV and HIV infections by year of birth in Spain: impact of US CDC and USPSTF recommendations for HCV and HIV testing
Instituto de Salud Carlos III; CP08/00214Instituto de Salud Carlos III; PI10/02166Instituto de Salud Carlos III; PI13/02266Instituto de Salud Carlos III; CM13/0032
Real life experience with direct-acting antivirals agents against hepatitis C infection in elderly patients
Short communication[Abstract] Background. New direct-acting antivirals agents (DAAs) are very safe and well tolerated.
Objectives. The purpose of this study is to analyse the efficacy and safety of DAAs in elderly patients, who have co-morbidities and are on chronic medications.
Study design. All HCV-infected patients over 65 years old in clinical follow-up at two Hospitals in Spain who initiated anti-HCV therapy were included (August 2012–October 2015).
Results. A total of 120 HCV mono-infected patients were recorded. Mean age of patients was 72.6 ± 7.4 years. There were 53.3% women and GT1b was the most frequent (83.3%); 64.2% had cirrhosis and 42.5% were treatment experienced. Ombitasvir + Paritaprevir/r ± Dasabuvir ± Ribavirin (RBV) and sofosbuvir/ledipasvir ± RBV were the most frequently used regimens. Weight-adjusted dosing of RBV was included in 61.7% and 43.6% of them required a dose reduction. Most of the patients (86.7%) had concomitant chronic medication and in 35.8% adjustment was necessary. Adverse events (AE) were seen in 65% of the patients; more frequent when a protease inhibitor (PI) was being used. The sustained virological response (SVR12) per ITT was 88.3%. Only 3 patients discontinued treatment and 2 patients died.
Conclusions. High rates of SVR12 (88.3%) were observed among elderly patients with DAAs-based regimens. The presence of AE was frequent (65%). The majority of these patients (86.7%) had concomitant medication that required adjustment in 1/3 of them. These findings highlight the high rates of response to DAAs in the elderly HCV-population. However, special caution must be taken when using RBV and a PI.Instituto de Salud Carlos III; CPII14/00014Instituto de Salud Carlos III; PI10/02166Instituto de Salud Carlos III; PI13/02266Instituto de Salud Carlos III; CM15/0023