Infecção pelo vírus da hepatite C em pacientes em hemodiálise: prevalência e fatores de risco

CONTEXT: Chronic renal disease patients on hemodialysis are at increased risk of infection by hepatitis C virus (HCV). High prevalence rates have been reported from dialysis units worldwide. Recent studies have shown an inverse relation between HCV infection and life expectancy of patients on hemodialysis and those undergoing renal transplant. OBJECTIVES: Assess the prevalence of and risk factors for HCV infection in patients undergoing hemodialysis. METHODS: A cross-sectional study was undertaken from January to December, 2007. During this period, 236 patients were tested for anti-HCV antibodies with third generation ELISA. Those who tested positive further underwent qualitative PCR testing for HCV-RNA. A subject was considered HCV-infected if both tests (anti-HCV and HCV-RNA) were positive. Monthly serum ALT and the mean for the 12-month period were obtained from 195 patients. Two hundred eight (88.1%) patients answered a standardized questionnaire aiming to identify risk factors for HCV infection. RESULTS: Of the 236 subjects studied, 14.8% (35/236) tested positive for anti-HCV antibodies. Of these, 71.6% (25/35) tested positive for HCV-RNA. Chronic HCV infection was thus prevalent in 10.6% (25/236). Bivariate analysis showed time on hemodialysis, number of blood transfusions, previous peritoneal dialysis and previous sexually transmitted diseases to be the main risk factors for HCV infection. Yet multivariate analysis showed that just time on hemodialysis and previous sexually transmitted diseases were significantly associated with HCV infection. Patients on hemodialysis for over 10 years were 73.9 (CI 17.5-311.8) times as likely to have acquired HCV, compared with those on hemodialysis for up to 5 years. Patients with previous sexually transmitted diseases had a 4.8 times higher risk of HCV infection compared with those without previous sexually transmitted diseases. Mean serum ALT was significantly higher in HCV-infected patients (44.0 ±13.5 U/L versus 33.5 ± 8.0 U/L, P<0,001). CONCLUSION: HCV infection was highly prevalent in the dialysis unit studied. Time on dyalitic treatment and previous sexually transmitted diseases were the main risk factors for HCV infection. HCV-infected patients on hemodialysis had higher serum ALT levels than those without chronic HCV infection.CONTEXTO: Doentes com doença renal crônica em tratamento hemodialítico apresentam risco aumentado de aquisição do vírus da hepatite C (VHC). Elevadas taxas de prevalência têm sido detectadas em unidades de diálise do mundo inteiro. Estudos recentes têm demonstrado que a infecção pelo VHC interfere de forma negativa na sobrevida dos pacientes em hemodiálise e naqueles submetidos ao transplante renal. OBJETIVOS: Determinar a prevalência e os fatores de risco da infecção pelo VHC em pacientes submetidos a hemodiálise. MÉTODOS: Realizou-se estudo transversal entre janeiro e dezembro de 2007. Neste período, 236 pacientes em hemodiálise foram testados pelo ELISA de terceira geração. Os casos positivos foram submetidos a pesquisa qualitativa do HCV-RNA pelo método de PCR. Consideraram-se como portadores de infecção pelo VHC aqueles pacientes com anti-VHC e HCV-RNA positivos. Dosagens mensais de ALT e a média do valor de 12 meses foram obtidas em 195 pacientes. Do total de pacientes, 208 (88,1%) responderam ao questionário padronizado visando a identificação de fatores de risco associados à infecção pelo VHC. RESULTADOS: A prevalência de pacientes anti-VHC positivos encontrada entre os 236 testados foi de 14,8% (35/236); destes, a pesquisa do HCV-RNA foi positiva em 71,6% (25/35). Portanto, a prevalência da infecção crônica pelo VHC foi de 10,6% (25/236) dos pacientes. Pela análise bivariada, os principais fatores de risco associados à infecção pelo VHC foram o tempo de hemodiálise, o número de transfusões de sangue, a realização prévia de diálise peritonial e história de doença sexualmente transmissível. Contudo, após análise multivariada, somente o tempo de hemodiálise e história de doença sexualmente transmissível foram significativamente associados à infecção pelo VHC. Pacientes com mais de 10 anos de hemodiálise apresentaram risco de aquisição do VHC 73,9 (IC de 17,5 a 311,8) vezes maior quando comparados a pacientes com até 5 anos de tratamento. Indivíduos com doença sexualmente transmissível prévia apresentaram risco 4,8 (IC de 1,1 a 19,9) vezes superior de contaminação pelo VHC quando comparados àqueles sem doença sexualmente transmissível. O valor médio da ALT foi significantemente maior nos pacientes infectados pelo VHC (44,0 ± 13,5 U/L versus 33,5 ± 8,0 U/L, P<0,001). CONCLUSÃO: A infecção pelo VHC apresentou elevada prevalência na unidade de diálise analisada. O tempo de tratamento dialítico e história prévia de doença sexualmente transmissível foram os principais fatores de risco associados à infecção pelo VHC. Indivíduos em hemodiálise com infecção crônica pelo VHC apresentaram maior atividade de ALT que pacientes sem hepatite C crônica

ACUPUNCTURE EFFECTIVENESS AS A COMPLEMENTARY THERAPY IN FUNCTIONAL DYSPEPSIA PATIENTS

Context Functional dyspepsia represents a frequent gastrointestinal disorder in clinical practice. According to the Roma III criteria, functional dyspepsia can be classified into two types as the predominant sympton: epigastric pain and postprandial discomfort. Even though the pathophysiology is still uncertain, the functional dyspepsia seems to be related to multiple mechanisms, among them visceral hypersensitivity, changes in the gastroduodenal motility and gastric accommodation and psychological factors. Objective Evaluate the effectiveness of acupuncture as a complementary to conventional treatment in functional dyspepsia patients. Methods Randomized clinical trial in which were enrolled patients with functional dyspepsia patients in according with Rome III criteria. One group was submitted to drug therapy and specific acupuncture (GI) and the other to drug therapy and non-specific acupuncture (GII). The gastrointestinal symptoms, presence of psychiatric disorders and quality of life were evaluated, at the end and three months after treatment. Results After 4 weeks of treatment there was improvement of gastrointestinal symptoms in Group I (55 &#177; 12 vs 29 &#177; 8.8; P = 0.001) and Group II (50.5 &#177; 10.2 vs 46 &#177; 10.5; P = 0.001). Quality of life was significantly better in Group I than group II (93.4 &#177; 7.3 vs 102.4 &#177; 5.1; P = 0.001). Anxiety (93.3% vs 0%; P = 0.001) and depression (46.7% vs 0%; P = 0.004) were significantly lower in Group I than group II. When comparing the two groups after 4 weeks of treatment, gastrointestinal symptoms (29 &#177; 8.8 vs 46 &#177; 10.5; P<0.001) and quality of life (102.4 &#177; 5.1 vs 96 &#177; 6.1; P = 0.021) were significantly better in Group I than group II. Three months after the treatment, gastrointestinal symptoms remained better only in Group I, when compared to the pre-treatment values (38 &#177; 11.3 vs 55 &#177; 12; P = 0.001). Conclusion In patients with functional dyspepsia the complementary acupuncture treatment is superior to conventional treatment. Further studies with more patients are needed to confirm these findings

Blunted blood pressure response to exercise and isolated muscle metaboreflex activation in patients with cirrhosis

We sought to test the hypothesis that the cardiovascular responses to isolated muscle metaboreflex activation would be blunted in patients with cirrhosis. Eleven patients with cirrhosis and 15 healthy controls were evaluated. Blood pressure (BP; oscillometric method), contralateral forearm blood flow (FBF; venous occlusion plethysmography), and heart rate (HR; electrocardiogram) were measured during baseline, isometric handgrip at 30% of maximal voluntary contraction followed by postexercise ischemia (PEI). Forearm vascular conductance (FVC) was calculated as follows: (FBF / mean BP) × 100. Changes in HR during handgrip were similar between groups but tended to be different during PEI (controls: Δ 0.5 ± 1.1 bpm vs. cirrhotic patients: Δ 3.6 ± 1.0 bpm, P = 0.057). Mean BP response to handgrip (controls: Δ 20.9 ± 2.7 mm Hg vs. cirrhotic patients: Δ 10.6 ± 1.5 mm Hg, P = 0.006) and PEI was attenuated in cirrhotic patients (controls: Δ 16.1 ± 1.9 mm Hg vs. cirrhotic patients: Δ 7.2 ± 1.4 mm Hg, P = 0.001). In contrast, FBF and FVC increased during handgrip and decreased during PEI similarly between groups. These results indicate that an abnormal muscle metaboreflex activation explained, at least partially, the blunted pressor response to exercise exhibited by cirrhotic patients. Novelty: •Patients with cirrhosis present abnormal muscle metaboreflex activation. •BP response was blunted but forearm vascular response was preserved. •HR response was slightly elevated.The accepted manuscript in pdf format is listed with the files at the bottom of this page. The presentation of the authors' names and (or) special characters in the title of the manuscript may differ slightly between what is listed on this page and what is listed in the pdf file of the accepted manuscript; that in the pdf file of the accepted manuscript is what was submitted by the author

Risk factors for cancer in patients with primary biliary cholangitis and autoimmune hepatitis and primary biliary cholangitis overlap syndrome

Introduction and objectives: Primary biliary cholangitis (PBC) and autoimmune hepatitis (AIH) and PBC overlap syndrome (AIH/PBC) have been associated with a higher risk of hepatocellular carcinoma (HCC) and extra-hepatic malignancy (EHM). This study aims to assess potential risk factors associated with cancer development in PBC and AIH/PBC. Materials and methods: The Brazilian Cholestasis Study Group database was reviewed to compare clinical and laboratory features of PBC patients with HCC and EHM with those without cancer. Results: Among the 752 PBC patients enrolled, 64 of them with AIH/PBC, 87 cancers were identified in 72 patients, including 20 cases of HCC and 67 of EHM. Patients with HCC had a higher prevalence of cirrhosis (95% vs. 32.5% of those subjects without cancer, p≤0.001), smoking (55% vs. 12.3%, p≤0.001), CREST syndrome (30% vs 7.6%, p=0.003) and prior azathioprine (30% vs 8%, p= 0.005) and prednisone (35% vs 14%, p= 0.018) use, whereas patients with EHM had a higher prevalence of smoking (42.3% vs 12.4% of those subjects without cancer, p= <0.001), AMA positivity (96.6% vs 80.1%, p≤0.001), azathioprine therapy (21% vs 7.9%, p= 0.01) and concurrent other autoimmune diseases. In multivariate analysis, cirrhosis, obesity and prior azathioprine therapy were independent risk factors for HCC, while Sjogren syndrome and psoriasis were associated with EHM. Fibrates reduced EHM risk. Conclusions: The prevalence of EHM is higher when compared to HCC in PBC patients. Cirrhosis, obesity, prior azathioprine use, and concurrent autoimmune diseases were significantly associated with cancer in PBC

Clinical features and treatment outcomes of primary biliary cholangitis in a highly admixed population

Introduction and objectives: Little is known about primary biliary cholangitis (PBC) in non-whites. The purpose of this study was to evaluate clinical features and outcomes of PBC in a highly admixed population. Material and methods: The Brazilian Cholestasis Study Group multicentre database was reviewed to assess demographics, clinical features and treatment outcomes of Brazilian patients with PBC. Results: 562 patients (95% females, mean age 51 ± 11 years) with PBC were included. Concurrent autoimmune diseases and overlap with autoimmune hepatitis (AIH) occurred, respectively, in 18.9% and 14%. After a mean follow-up was 6.2 ± 5.3 years, 32% had cirrhosis, 7% underwent liver transplantation and 3% died of liver-related causes. 96% were treated with ursodeoxycholic acid (UDCA) and 12% required add-on therapy with fibrates, either bezafibrate, fenofibrate or ciprofibrate. Response to UDCA and to UDCA/fibrates therapy varied from 39%-67% and 42-61%, respectively, according to different validated criteria. Advanced histological stages and non-adherence to treatment were associated with primary non-response to UDCA, while lower baseline alkaline phosphatase (ALP) and aspartate aminotransferase (AST) levels correlated with better responses to both UDCA and UDCA/fibrates. Conclusions: Clinical features of PBC in highly admixed Brazilians were similar to those reported in Caucasians and Asians, but with inferior rates of overlap syndrome with AIH. Response to UDCA was lower than expected and inversely associated with histological stage and baseline AST and ALP levels. Most of patients benefited from add-on fibrates, including ciprofibrate. A huge heterogeneity in response to UDCA therapy according to available international criteria was observed and reinforces the need of global standardization

Response to Ursodeoxycholic Acid May Be Assessed Earlier to Allow Second-Line Therapy in Patients with Unresponsive Primary Biliary Cholangitis

Background Response to ursodeoxycholic acid (UDCA) in primary biliary cholangitis (PBC) has been traditionally assessed 1 to 2 years after treatment initiation. With the development of new drugs, some patients may benefit from an earlier introduction of second-line therapies. Aims This study aims to identify whether well-validated response criteria could correctly identify individuals likely to benefit from add-on second-line therapy at 6 months. Methods Analysis of a multicenter retrospective cohort which included only patients with clear-cut PBC. Results 206 patients with PBC (96.6% women; mean age 54 +/- 12 years) were included. Kappa concordance was substantial for Toronto (0.67), Rotterdam (0.65), Paris 1 (0.63) and 2 (0.63) criteria at 6 and 12 months, whereas Barcelona (0.47) and POISE trial (0.59) criteria exhibited moderate agreement. Non-response rates to UDCA was not statistically different when assessed either at 6 or 12 months using Toronto, Rotterdam or Paris 2 criteria. Those differences were even smaller or absent in those subjects with advanced PBC. Mean baseline alkaline phosphatase was 2.73 +/- 1.95 times the upper limit of normal (x ULN) among responders versus 5.05 +/- 3.08 x ULN in non-responders (p < 0.001). Conclusions After 6 months of treatment with UDCA, the absence of response by different criteria could properly identify patients who could benefit from early addition of second-line therapies, especially in patients with advanced disease or high baseline liver enzymes levels

Diarréia nosocomial em unidade de terapia intensiva: incidência e fatores de risco Nosocomial diarrhea in the intensive care unit: incidence and risk factors

RACIONAL: Diarréia nosocomial parece ser comum em unidades de terapia intensiva, embora sua epidemiologia seja pouco documentada em nosso meio. OBJETIVO: Determinar a incidência e fatores de risco de diarréia entre pacientes adultos internados em unidade de terapia intensiva. MÉTODOS: Foram incluídos prospectivamente 457 pacientes no período entre outubro de 2005 e outubro de 2006. Dados demográficos, clínicos e bioquímicos, bem como aspecto e número de evacuações eram registrados diariamente até a saída do paciente do setor. RESULTADOS: Diarréia ocorreu em 135 (29,5%) pacientes, durando em média 5,4 dias. O tempo do seu início em relação à internação foi de 17,8 dias e casos similares de diarréia no mesmo período foram registrados em 113 (83,7%) pacientes. A mortalidade hospitalar foi maior nos pacientes com diarréia do que naqueles sem esta intercorrência. Na análise multivariada através de modelo de regressão logística, apenas o número de antibióticos (OR 1,65; IC 95% = 1,39-1,95) e o número de dias de antibioticoterapia (OR 1,16; IC 95% = 1,12-1,20) associaram-se estatisticamente com a ocorrência de diarréia. Cada dia de acréscimo a mais da antibioticoterapia aumentou em 16% o risco de diarréia (IC 12% a 20%), enquanto a adição de um antibiótico a mais ao esquema antimicrobiano aumentou as chances de ocorrência de diarréia em 65% (IC 39% a 95%). CONCLUSÃO: A incidência de diarréia nosocomial na unidade de terapia intensiva é elevada (29,5%). Os principais fatores de risco para sua ocorrência foram número de antibióticos prescritos e duração da antibioticoterapia. Além das precauções entéricas, a prescrição judiciosa e limitada de antimicrobianos, provavelmente reduzirá a ocorrência de diarréia neste setor.<br>BACKGROUND: Nosocomial diarrhea seems to be common at intensive care units, although its epidemiology be poorly documented in Brazil. AIM: To determine the incidence and risk factors of diarrhea among adult patients admitted to intensive care units. METHODS: Four hundred and fifty five patients were prospectively included during the period between October 2005 and October 2006. Demographic, clinical and biochemical data as well as aspect and number of bowel movements were recorded on a daily basis until discharge from the unit. RESULTS: Diarrhea occurred in 135 (29.5%) patients, lasting 5.4 days average. The time of its onset in according to admission was 17.8 days and similar cases of diarrhea during the same period were recorded in 113 (83.7%) patients. In a multivariate analysis through the logistics regression model, only the number of antibiotics (OR 1.65; I.C. 95% = 1.39-1.95) and the number of days of antibiotic therapy (OR 1.16; I.C. 95% = 1.12-1.20) were statistically associated with the diarrhea occurrence. Each day added of antibiotic therapy, raised in 16% the risk of diarrhea (I.C. 12% to 20%), while the addition of one more antibiotic to the scheme, increased the chances of occurring diarrhea in 65% (I.C. 39% to 95%). CONCLUSION: The incidence of nosocomial diarrhea in intensive care units is high (29.5%). The main risk factors for its occurrence were number of prescribed antibiotics and duration of the antibiotic therapy. Besides the enteric precautions, judicious and limited prescription of antimicrobians probably will reduce the occurrence of diarrhea at this unit

Infecção pelo vírus da hepatite c em pacientes em hemodiálise: prevalência e fatores de risco

CONTEXTO: Doentes com doença renal crônica em tratamento hemodialítico apresentam risco aumentado de aquisição do vírus da hepatite C (VHC). Elevadas taxas de prevalência têm sido detectadas em unidades de diálise do mundo inteiro. Estudos recentes têm demonstrado que a infecção pelo VHC interfere de forma negativa na sobrevida dos pacientes em hemodiálise e naqueles submetidos ao transplante renal. OBJETIVOS: Determinar a prevalência e os fatores de risco da infecção pelo VHC em pacientes submetidos a hemodiálise. MÉTODOS: Realizou-se estudo transversal entre janeiro e dezembro de 2007. Neste período, 236 pacientes em hemodiálise foram testados pelo ELISA de terceira geração. Os casos positivos foram submetidos a pesquisa qualitativa do HCV-RNA pelo método de PCR. Consideraram-se como portadores de infecção pelo VHC aqueles pacientes com anti-VHC e HCV-RNA positivos. Dosagens mensais de ALT e a média do valor de 12 meses foram obtidas em 195 pacientes. Do total de pacientes, 208 (88,1%) responderam ao questionário padronizado visando a identificação de fatores de risco associados à infecção pelo VHC. RESULTADOS: A prevalência de pacientes anti-VHC positivos encontrada entre os 236 testados foi de 14,8% (35/236); destes, a pesquisa do HCV-RNA foi positiva em 71,6% (25/35). Portanto, a prevalência da infecção crônica pelo VHC foi de 10,6% (25/236) dos pacientes. Pela análise bivariada, os principais fatores de risco associados à infecção pelo VHC foram o tempo de hemodiálise, o número de transfusões de sangue, a realização prévia de diálise peritonial e história de doença sexualmente transmissível. Contudo, após análise multivariada, somente o tempo de hemodiálise e história de doença sexualmente transmissível foram significativamente associados à infecção pelo VHC. Pacientes com mais de 10 anos de hemodiálise apresentaram risco de aquisição do VHC 73,9 (IC de 17,5 a 311,8) vezes maior quando comparados a pacientes com até 5 anos de tratamento. Indivíduos com doença sexualmente transmissível prévia apresentaram risco 4,8 (IC de 1,1 a 19,9) vezes superior de contaminação pelo VHC quando comparados àqueles sem doença sexualmente transmissível. O valor médio da ALT foi significantemente maior nos pacientes infectados pelo VHC (44,0 ± 13,5 U/L versus 33,5 ± 8,0 U/L, PCONTEXT: Chronic renal disease patients on hemodialysis are at increased risk of infection by hepatitis C virus (HCV). High prevalence rates have been reported from dialysis units worldwide. Recent studies have shown an inverse relation between HCV infection and life expectancy of patients on hemodialysis and those undergoing renal transplant. OBJECTIVES: Assess the prevalence of and risk factors for HCV infection in patients undergoing hemodialysis. METHODS: A cross-sectional study was undertaken from January to December, 2007. During this period, 236 patients were tested for anti-HCV antibodies with third generation ELISA. Those who tested positive further underwent qualitative PCR testing for HCV-RNA. A subject was considered HCV-infected if both tests (anti-HCV and HCV-RNA) were positive. Monthly serum ALT and the mean for the 12-month period were obtained from 195 patients. Two hundred eight (88.1%) patients answered a standardized questionnaire aiming to identify risk factors for HCV infection. RESULTS: Of the 236 subjects studied, 14.8% (35/236) tested positive for anti-HCV antibodies. Of these, 71.6% (25/35) tested positive for HCV-RNA. Chronic HCV infection was thus prevalent in 10.6% (25/236). Bivariate analysis showed time on hemodialysis, number of blood transfusions, previous peritoneal dialysis and previous sexually transmitted diseases to be the main risk factors for HCV infection. Yet multivariate analysis showed that just time on hemodialysis and previous sexually transmitted diseases were significantly associated with HCV infection. Patients on hemodialysis for over 10 years were 73.9 (CI 17.5-311.8) times as likely to have acquired HCV, compared with those on hemodialysis for up to 5 years. Patients with previous sexually transmitted diseases had a 4.8 times higher risk of HCV infection compared with those without previous sexually transmitted diseases. Mean serum ALT was significantly higher in HCV-infected patients (44.0 ±13.5 U/L versus 33.5 ± 8.0 U/L, P<0,001). CONCLUSION: HCV infection was highly prevalent in the dialysis unit studied. Time on dyalitic treatment and previous sexually transmitted diseases were the main risk factors for HCV infection. HCV-infected patients on hemodialysis had higher serum ALT levels than those without chronic HCV infection