SUMMARY OBJECTIVE: The aim of the present study was to evaluate the outcomes of cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt. METHODS: A retrospective longitudinal observational study was carried out evaluating 38 cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt. The outcomes were evaluated in an outpatient follow-up period of 3 months. The assumed significance level was 5%. RESULTS: The indications for transjugular intrahepatic portosystemic shunt were refractory ascites in 21 (55.3%), variceal hemorrhage in 13 (34.2%), and hydrothorax in 4 (10.5%) patients. There was development of hepatic encephalopathy in 10 (35.7%) patients after transjugular intrahepatic portosystemic shunt. From the 21 patients with refractory ascites, resolution was observed in 1 (3.1%) patient, and in 16 (50.0%) patients, there was ascites control. Regarding transjugular intrahepatic portosystemic shunt after variceal bleeding, 10 (76.9%) patients remained without new bleeding or hospitalizations in the follow-up period. The global survival in the follow-up period in patients with and without hepatic encephalopathy was 60 vs. 82%, respectively (p=0.032). CONCLUSION: Transjugular intrahepatic portosystemic shunt can be considered in decompensated cirrhotic patients; however, the development of hepatic encephalopathy which can shorten survival should be focused.

RESUMO CONTEXTO A vitamina D é conhecida por possuir propriedades imunomoduladoras, anti-inflamatórias e antifibróticas, relevantes na patogênese e tratamento de muitas causas de doença hepática crônica. OBJETIVO Este estudo tem como objetivo avaliar a associação entre os níveis séricos de vitamina D e os achados histopatológicos em pacientes com infecção crônica do vírus da hepatite C. MÉTODOS Estudo transversal, composto por pacientes com hepatite C crônica. Todos os pacientes foram submetidos à dosagem de vitamina D 25 e análise de dados antropométricos. A biópsia hepática foi realizada em um período máximo de 36 meses antes da inclusão no estudo. RESULTADOS Dos 74 pacientes incluídos no estudo, 45 (60,8%) eram mulheres, média de idade de 57,03±9,24 anos e 63 (85,1%) eram brancos. Não foi observada associação entre os níveis séricos de vitamina D e atividade inflamatória (P=0,699), nem com o grau de fibrose hepática (P=0,269). CONCLUSÃO No presente estudo, não foi observada associação entre a vitamina D e a atividade inflamatória, bem como com o grau de fibrose hepática, em pacientes com hepatite C crônica.

ABSTRACT BACKGROUND Vitamin D is known for its immunomodulatory, anti-inflammatory and antifibrotic properties, which are quite relevant in the pathogenesis and treatment of many causes of chronic liver disease. OBJECTIVE This study aimed to evaluate the association between serum vitamin D levels and the histopathological findings in patients with chronic hepatitis C virus infection. METHODS Cross-sectional study composed of patients with chronic hepatitis C. All patients underwent vitamin D 25 dosage and anthropometric data analysis. Liver biopsy was performed in a maximum 36-month period before inclusion in the study. RESULTS Of the 74 patients included in the study, 45 (60.8%) were women, mean age was 57.03±9.24 years, and 63 (85.1%) were white. No association was observed between the serum levels of vitamin D and inflammatory activity (P=0.699) nor with the degree of liver fibrosis (P=0.269). CONCLUSION In this study, no association was observed between vitamin D and inflammatory activity, as well as the degree of liver fibrosis, in patients with chronic hepatitis C.

RESUMO Contexto - O aumento da sobrevida após a introdução da terapia antirretroviral nos pacientes vivendo com HIV tem como consequência o aparecimento de doenças emergentes nestes pacientes, como a hepatite pelo vírus C, doenças renais e cardiovasculares. Objetivo - O presente estudo tem como objetivo investigar as diferenças entre monoinfectados por HIV e coinfectados por HIV/virus da hepatite C, considerando aspectos demográficos e clínicos de pacientes atendidos em uma clínica de HIV/AIDS em Porto Alegre, Brasil. Métodos - Revisão de prontuários médicos de 1.030 indivíduos vivendo com HIV em uma clínica especializada em Porto Alegre, Brasil. Dados clínicos e demográficos foram coletados a partir dos registros dos pacientes atendidos entre março de 2008 e dezembro de 2012 na referida clínica. Resultados - O presente estudo é um estudo transversal com indivíduos vivendo com HIV, atendidos em um serviço municipal de HIV/AIDS em Porto Alegre, Brasil. A prevalência de hepatite pelo vírus C na presente coorte de estudo foi 11,8% (IC 95%: 9,9%-13,8%). Hipertensão e proteinúria patológica eram ocorrências mais comuns em coinfectados do que monoinfectados. Por outro lado, dislipidemia foi mais comuns entre monoinfectados. Não houve diferença entre os grupos quanto contagem de linfócitos CD4 totais ou HIV-RNA. Variáveis significativas na análise univariada com P<0,05 foram ainda analisadas usando um modelo de regressão de Poisson com variância robusta. Coinfectados eram mais velhos, com os níveis de lipídios mais baixos e maior prevalência de proteinúria patológica em comparação com indivíduos monoinfectados. Apesar de os coinfectados apresentarem maior prevalência de estarem em uso de regime contendo tenofovir, houve uma forte associação dos indivíduos infectados pelo vírus da hepatite C com proteinúria patológica e ausência de dislipidemia. Conclusão - Clínicos devem reconhecer que coinfectados e monoinfectados pertencem a grupos diferentes quanto aos fatores de risco tradicionais e aqueles associados ao HIV, devendo estes serem manejados e rastreados de forma individual, para prevenir complicações cardiovasculares e renais.

ABSTRACT Background - The increase in the survival following the introduction of highly active antiretroviral therapy (HAART) has seen the emergence of hepatitis C virus (HCV) infection, renal and cardiovascular diseases as important morbidity and mortality causes together with HIV. Objective - The present study aimed to investigate the differences between HIV/hepatitis C virus coinfected and HIV-monoinfected regarding demographic and clinical aspects from a HIV/AIDS clinic in Porto Alegre, Brazil. Methods - Review of medical records of 1,030 HIV infected individuals aged 18 years or more in an urban HIV/AIDS clinic based in Porto Alegre, Southern Brazil. Clinical and demographical Data were collected from the records of the patients attended between March 2008 and December 2012. Results - The present study is a cross-sectional study among HIV-infected patients attended at a public HIV/AIDS clinic in Porto Alegre, Brazil. The prevalence of hepatitis C virus in the present study cohort was 11.8% (CI 95%: 9.9%-13.8%). Hypertension and pathological proteinuria were more common in the coinfected compared to monoinfected group. By the other hand, dyslipidemia were more common among monoinfected patients. There was no difference between the groups regarding CD4+ count or HIV-RNA. Variables significant in the univariate analysis with P<0.05 were further analyzed using a Poisson regression model with robust variance. Coinfected were likely to be older, with lower lipid levels and higher prevalence of pathological proteinuria compared to HIV-monoinfected patients. Although coinfected patients had higher prevalence of tenofovir-based regimen, there was a strong association between hepatitis C virus individuals to pathological proteinuria and dyslipidemia. Conclusion - Clinicians should recognize that coinfected and monoinfected individuals are different groups regarding the traditional and HIV-related risk factors and should be managed and screened individually in order to prevent cardiovascular and renal complications.

Contexto O consumo de cafeína tem sido relacionado à diminuição dos níveis de enzimas hepáticas e menor risco de fibrose em pacientes portadores do vírus da hepatite C. Objetivo O presente estudo tem por objetivo avaliar a associação do consumo da cafeína com a atividade inflamatória e o grau de fibrose hepática em pacientes com infecção pelo vírus da hepatite C. Métodos Estudo transversal, constituído por pacientes com infecção pelo vírus da hepatite C atendidos no ambulatório de Gastroenterologia do Complexo Hospitalar Santa Casa (Porto Alegre - Brasil). Os pacientes foram entrevistados e avaliados individualmente quanto ao consumo de cafeína e antropometria. A biópsia hepática foi realizada em um período de no máximo 36 meses antes da inclusão no estudo. Resultados Foram avaliados 113 pacientes, sendo 67 (59,3%) do sexo feminino, 48 (42,5%) apresentavam idade entre 52 e 62 anos, e 101 (89,4%) eram de cor branca. O consumo médio de cafeína foi de 251,41 ± 232,32 mg/dia, sendo que 70 (62%) pacientes consumiam até 250 mg/dia de cafeína. Não houve associação entre o consumo de cafeína e a atividade inflamatória na biópsia hepática. Por outro lado, quando avaliada a associação entre o consumo de cafeína e fibrose hepática observou-se relação inversa. Conclusões O maior consumo de cafeína apresentou associação com menor grau de fibrose hepática. Não houve associação entre o consumo de cafeína e a atividade inflamatória.

Background Caffeine consumption has been associated to decreased levels of liver enzymes and lower risk of fibrosis in patients with hepatitis C virus. Objectives This study aimed to evaluate the association between caffeine consumption and inflammatory activity or degree of liver fibrosis in patients with hepatitis C virus infection. Methods A cross-sectional study of patients with chronic hepatitis C virus infection treated in an outpatient Gastroenterology Unit of Santa Casa Hospital (Porto Alegre - Brasil). Patients were interviewed regarding the consumption of caffeine and anthropometric assessment was performed. Liver biopsy was performed in a maximum period of 36 months before inclusion in the study Results There were 113 patients, 67 (59.3%) females, 48 (42.5%) were aged between 52 and 62 years, and 101 (89.4%) were white. The average caffeine consumption was 251.41 ± 232.32 mg/day, and 70 (62%) patients consumed up to 250 mg/day of caffeine. There was no association between caffeine consumption and inflammatory activity on liver biopsy. On the other hand, when evaluating the caffeine consumption liver fibrosis an inverse association was observed. Conclusions The greater consumption of caffeine was associated with lower liver fibrosis. There was no association between caffeine consumption and inflammatory activity.

Given the loss of therapeutic efficacy associated with the development of resistance to lamivudine (LMV) and the availability of new alternative treatments for chronic hepatitis B patients, early detection of viral genotypic resistance could allow the clinician to consider therapy modification before viral breakthrough and biochemical relapse occur. To this end, 28 LMV-treated patients (44 ± 12 years; 24 men), on their first therapy schedule, were monitored monthly at four Brazilian centers for the emergence of drug resistance using the reverse hybridization-based INNO-LiPA HBV DR assay and occasionally sequencing (two cases). Positive viral responses (HBV DNA clearance) after 6, 12, and 18 months of therapy were achieved by 57, 68, and 53% of patients, while biochemical responses (serum alanine aminotransferase normalization) were observed in 82, 82, and 53% of cases. All viral breakthrough cases (N = 8) were related to the emergence of YMDD variants observed in 7, 21, and 35% of patients at 6, 12, and 18 months, respectively. The emergence of these variants was not associated with viral genotype, HBeAg expression status, or pretreatment serum alanine aminotransferase levels. The detection of resistance-associated mutations was observed before the corresponding biochemical flare (41 ± 14 and 60 ± 15 weeks) in the same individuals. Then, if highly sensitive LMV drug resistance testing is carried out at frequent and regular intervals, the relatively long period (19 ± 2 weeks) between the emergence of viral resistance and the onset of biochemical relapse can provide clinicians with ample time to re-evaluate drug therapy.

RACIONAL: O estado de ativação imune provocado pelo vírus da hepatite C pode agir deleteriamente em indivíduos portadores do vírus da imunodeficiência humana, favorecendo a destruição mais rápida dos linfócitos CD4. Por outro lado, a recuperação imune observada após o início da terapia antiretroviral pode ser parcialmente embotada em indivíduos co-infectados pelo vírus da hepatite C. OBJETIVO: Avaliar o impacto da co-infecção pelo vírus da hepatite C na imunidade celular dos pacientes infectados pelo vírus da imunodeficiência humana. MÉTODOS: Foram avaliados pacientes co-infectados por ambos os vírus, atendidos prospectivamente no Ambulatório de Gastroenterologia do Hospital Nossa Senhora da Conceição, Porto Alegre, RS (grupo 1 - 385 pacientes), e monoinfectados pelo vírus da imunodeficiência humana cujos dados foram obtidos através da revisão dos prontuários do Serviço de Infectologia do mesmo Hospital (grupo 2 - 198 pacientes). Foram avaliados dados demográficos (gênero, raça, idade), contagem de células CD4 e CD8, relação CD4/CD8 e carga viral do vírus da imunodeficiência humana. O nível de significância adotado foi de 5%. RESULTADOS: Não houve diferença estatisticamente significativa quando avaliados os valores médios da contagem de células CD4 (374,7 ± 215,7 x 357,5 ± 266,0), CD8 (1.512,4 ± 7.274,6 x 986,7 ± 436,4) e da carga viral do vírus da imunodeficiência humana (83.744,2 ± 190.292,0 x 104.464,0 ± 486.880,5), respectivamente nos grupos 1 e 2, bem como na proporção de pacientes com relação CD4/CD8 menor que 1. CONCLUSÃO: A co-infecção por estes vírus não trouxe impacto negativo relevante em relação aos monoinfectados pelo vírus da imunodeficiência humana e as características de imunidade foram semelhantes.

BACKGROUND: The immune activation provoked by the hepatitis C virus can be deleterious in patients with human immunodeficiency virus, favouring the destruction of CD4 cells. By the other side, the immune restoration observed after the onset of antiretroviral therapy can be partially obscured in patients with the hepatitis C virus. AIM: The objective of the present study was to evaluate the impact of coinfection by hepatitis C virus and the human immunodeficiency virus in the cellular immunity. METHODS: Two groups of patients were considered: coinfected patients were prospectively evaluated in the gastroenterology clinic at "Hospital Nossa Senhora da Conceição", Porto Alegre, RS, Brazil (group 1 - 385 patients), and monoinfected patients by human immunodeficiency virus based on the review of the charts from the infectious diseases clinic (group 2 - 198 patients). Demographic (gender, race, age) CD4 and CD8 cell count, CD4/CD8 index and human immunodeficiency virus viral load were evaluated. A 5% significance level was adopted. RESULTS: There were no difference between the parameters evaluated: mean CD4 count (374,7 ± 215,7 x 357,5 ± 266,0), CD8 (1.512,4 ± 7.274,6 x 986,7 ± 436,4) and HIV viral load (83.744,2 ± 190.292,0 x 104.464,0 ± 486.880,5) respectively in both groups evaluated, as well as the proportion of patients with CD4/CD8 rate below 1. CONCLUSION: Coinfection by both viruses did not have a negative impact in relation to monoinfection by human immunodeficiency virus, and the immune profile was similar in all groups.

RACIONAL: Considerando a imunossupressão dos pacientes com doença hepática crônica, sua resposta à vacinação é discutida na literatura. OBJETIVOS: Avaliar a resposta à vacina anti-hepatite B em pacientes com hepatite crônica pelo vírus C. MÉTODOS: Estudo prospectivo avaliando 85 pacientes com infecção pelo vírus C (46,8 ± 9,4 anos, 44,7% homens) e 46 adultos saudáveis (36,7 ± 11,1 anos, 39,1% homens). Carga viral foi determinada através do b-DNA em 74 pacientes e o genótipo foi determinado por seqüenciamento em 73 pacientes. Todos os pacientes e os adultos saudáveis receberam três doses da vacina Engerix B® IM (aos 0, 30 e 180 dias). Resposta sorológica à vacina foi dividida em três categorias: soroproteção, quando anti-HBs era >"100 mUI/mL; soroconversão, quando anti-HBs era 10-99 mUI/mL e não-reagente, quando anti-HBs era <10 mUI/mL. RESULTADOS: A resposta da vacina anti-hepatite B em 1 mês após a dose 3 foi soroproteção em 37,7%, soroconversão em 17,6% e não-reagente em 44,7% entre os pacientes, e 84,8%, 13,0% e 2,2%, respectivamente em adultos saudáveis. O número de respostas não-reagentes foi significativamente maior em pacientes com doença hepática crônica. Sessenta e cinco pacientes com hepatite crônica foram comparados a 20 cirróticos compensados em relação à resposta à vacina, mas nenhuma diferença foi observada. A resposta à vacina nos pacientes com genótipos 2 ou 3 (n = 40) foi melhor do que naqueles com genótipo 1 (n = 33). A resposta não foi relacionada com a concentração de VHC-RNA. CONCLUSÃO: O número de não-respondedores foi maior em pacientes com infecção crônica pelo vírus C, independentemente do "status" histológico e da carga viral. É sugerido que tais pacientes deveriam receber uma dose dupla de vacina, particularmente aqueles com genótipo 1.

BACKGROUND: Considering the immunosuppression of patients with chronic liver disease, their response to vaccination is discussed in literature. AIMS: To evaluate the response of hepatitis B vaccine in patients with chronic hepatitis C virus infection. METHODS: This is a prospective study in which 85 patients with chronic hepatitis C virus infection (46.8 ± 9.4 years, 44.7% males) and 46 healthy adults (36.7 ± 11.1 years; 39.1% males) were evaluated. Confirmation of hepatitis C virus was obtained by the technique of polymerase chain reaction. Viral load was determined by the branched DNA method in 74 patients, and genotype was determined by sequencing in 73 patients. All patients and healthy adults received three doses of Engerix B® vaccine IM (at 0, 30 and 180 days). Serological responses to the vaccine were divided into three categories: seroprotection, when anti-HBs was >100 mUI/mL; seroconversion, when anti-HBs was 10-99 mUI/mL, and non-reagent, when anti-HBs was <10 mUI/mL. RESULTS: The response of hepatitis B vaccine as determined 1 month following dose 3 was seroprotection in 37.7%, seroconversion in 17.6% and non-reagent in 44.7% among patients and 84.8%, 13.0%, 2.2%, respectively in healthy adults. The number of non-reagent responses was significantly higher among those patients with chronic liver disease. Sixty-five patients with chronic hepatitis were compared to 20 compensated cirrhotic patients in concern to the response to vaccine, but no difference was found. The response to vaccine in patients with genotypes 2 or 3 (n = 40) was better than in those with genotype 1 (n = 33). Response was not related to serum HCV-RNA concentration. CONCLUSION: The number of non-responders was higher in patients with chronic hepatitis C virus infection, irrespective of histological status and viral load. It is suggested that such patients should receive a double dose of vaccine, particularly the ones with genotype 1.