Budd Chiari syndrome defines an obstruction of the hepatic venous outflow. Primary causes include pro-coagulant states resulting in venous thrombosis, while secondary Budd Chiari syndrome appears in conditions associated with extrinsic compression of the hepatic veins or tumor invasion. Clinical presentation is greatly varied, from incidentally discovered asymptomatic thrombosis to fulminant liver failure due to hepatic congestion. Abdominal ultrasonography is the key diagnostic tool of Budd Chiari syndrome. This pictorial essay aims to show the ultrasonographic aspect of Budd-Chiari syndrome associated with other medical conditions (abdominal malignancy, hematologic disorders and abdominal surgery).
Background: This is a real-world evidence study that aims to analyze the efficacy, tolerability and safety profile of paritaprevir/ombitasvir/ritonavir and dasabuvir, in patients with renal impairment. Methods: We conducted an observational prospective study, on 232 patients with chronic kidney disease, undergoing treatment with paritaprevir/ombitasvir/ritonavir and dasabuvir, for chronic hepatitis C infection -genotype 1b. Renal and liver function were assessed at the beginning of therapy, monthly during treatment and three months after therapy completion. Results: All patients achieved sustained virologic response. Common side effects were nausea, fatigue and headache. Close monitoring of tacrolimus blood levels and dose reduction was required in kidney transplant recipients. Conclusions: HCV therapy in the setting of renal dysfunction has always been a challenging topic. Direct-acting antivirals have shown promising effects, demonstrating good tolerance and efficacy in patients with HCV infection and renal impairment. Sustained virologic response within our study population was 100%.
Context. Hepatitis C and diabetes represent important health problems globally. The new-onset diabetes after transplantation is a particular entity that appears due to the use of immunosuppression among transplanted patients.Objective. We aim to describe the clinical and biological aspects of severe hyperglycemia in a kidney transplant recipient undergoing Interferon-free therapy for chronic hepatitis C, discussing the interference of different factors with the glucose metabolism.Design. The occurrence of diabetes in a patient with history of renal transplantation and Interferon-free treated hepatitis C was studied from both clinical and paraclinical points of view.Subjects and methods. When presenting to the hospital, extensive blood tests were performed on the patient, revealing significant hyperglycemia and an elevated level of blood tacrolimus. Creatinine clearance was calculated. ECG presented T-wave alterations. Intensive insulin protocol was applied, the case being managed in a multidisciplinary approach.Results. Blood glucose and tacrolimus were slowly normalized, under therapy. The antiviral treatment was continued, with the achievement of sustained virologic response.Conclusions. Diabetes mellitus can have many causes, hepatitis C and transplantation both having an impact on glucose metabolism. The association of the three entities should be carefully managed, due to its enhancing effect on morbidity and mortality.
Background and Objectives: Cirrhotic cardiomyopathy is a chronic cardiac dysfunction associated with liver cirrhosis, in patients without previous heart disease, irrespective of the etiology of cirrhosis. Electrocardiography (ECG) is an important way to evaluate patients with cirrhosis and may reveal significant changes associated with liver disease. Our study aimed to evaluate ECG changes in patients with diagnosed liver cirrhosis and compare them to patients with chronic hepatitis. Materials and Methods: We evaluated laboratory findings and ECG tracings in 63 patients with cirrhosis and 54 patients with chronic hepatitis of viral etiology. The end points of the study were prolonged QT interval, QRS hypovoltage and T-peak-to-T-end decrease. We confirmed the diagnosis of cirrhotic cardiomyopathy using echocardiography data. Results: Advanced liver disease was associated with prolonged QT intervals. Also, QRS amplitude was lower in patients with decompensated cirrhosis than in patients with compensated liver disease. We found an accentuated deceleration of the T wave in patients with cirrhosis. These findings correlated to serum levels of albumin, cholesterol and ammonia. Conclusions: ECG changes in liver cirrhosis are frequently encountered and are important noninvasive markers for the presence of cirrhotic cardiomyopathy. Author Contributions: Conceptualization, L.I., C.D.; methodology, A.Z., N.B.; software, A.M.S., N.B.; validation, C.D.; formal analysis, L.T., A.M.S.; data curation, A.Z., N.B.; writing-original draft preparation, L.T., A.Z.; writing-review and editing, L.I., N.B.; visualization, A.M.S.; supervision, L.I., N.B.; project administration, L.I., C.D. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Conflicts of Interest:The authors declare no conflict of interest.
A 66-year old woman with chronic HCV hepatitis was being evaluated for antiviral therapy. On admission we observed a reddish indurated cutaneous lesion of about 1.5/2cm affecting the nose. Laboratory tests revealed proteinuria (5g/ 24 hours), mild hepatocytolysis, RNA-HCV level of 900,000UI/ml and positive serum cryoglobulins. Biopsy from the cutaneous lesion revealed circumscribed non-caseating granulomas composed of epithelioid cells, with Langhans giant cells and without necrosis, located in the superficial dermis (Fig.1, H&E x20). The CT scan of the thorax revealed multiple mediastinal adenopathies, but no pulmonary lesions; cytology after broncho-alveolar lavage evidenced lymphocytic alveolitis. The serum level of angiotensin converting enzyme was 48.9 U/ml (normal 15-20 U/ml). The diagnosis established was of stage I sarcoidosis with cutaneous manifestation. A liver biopsy, revealed mild steatosis and a METAVIR score of A2 F2 (Fig.2, H&Ex20). No granulomas were found in the biopsy.We performed a kidney biopsy to investigate the nephrotic syndrome. Optic microscopy showed thickening of the capillary walls. Ultrastructural studies by electron microscopy showed a thickened basement membrane, with dense epi-membrane deposits, the "dome and spike" aspect. The diagnosis was of membranoproliferative glomerulonephritis (MPGN).Kidney disease due to chronic HCV infection occurs mostly in association with type II cryoglobulinemia. Kidney biopsy frequently shows type I MPGN. In our patient, a type II MPGN was diagnosed [1].Sarcoidosis could appear after interferon and ribavirin treatment for HCV; only rarely has been HCV-induced sarcoidosis reported [2][3][4]. Our patient did not require systemic treatment for sarcoidosis. Local corticosteroid application was recommended. IMAGE OF THE ISSUEWe started pulse therapy with metyl-prednisolone for the nephrotic syndrome, which was followed by a remarkable decrease of proteinuria [5]. After six cycles, we initiated the Peginterferon and ribavirin treatment. Sustained virologic response was achieved. The patient is presently under follow-up, which includes monitoring of proteinuria, serum liver enzymes and pulmonary ventilatory function.
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