Gastroenterology, hepatology and liver transplant exchanges between the USA and Cuba have mainly consisted of scientific events and short visits. This has facilitated Cuba’s inclusion in recognized scientific organizations, familiarity with Cuba’s biotech products for treatment of liver disease, and access by Cuban professionals to the highest level of scientific information for clinical practice. It has also given health professionals in the US a more accurate picture of Cuba’s health sector. The results of the Global Alcoholic Liver Disease Survey, which included Cuba and was designed and coordinated in the USA, opened doors to joint research and scientific publications. Until now, there have been no protocols for ongoing cooperation to enable bilateral clinical trials or continuing professional development in diagnostic, therapeutic and surgical techniques for hepatology and liver transplantation. There are many mutually beneficial research prospects in these areas. What has been accomplished to date, described in this article, is encouraging and sets the stage for future collaboration.
KEYWORDS Hepatology, liver transplant, health, medicine, science, Cuba, USA
INTRODUCTION Reference values for liver stiffness for healthy individuals vary worldwide. Different optimal cutoff values correspond to the stages of fibrosis in chronic liver disease.
OBJECTIVES Characterize the distribution of liver stiffness in Cuban adults without liver disease and its association with age, serum uric acid and body mass index.
METHODS A cross-sectional study was performed of 110 plasma donors recruited from the Havana Province Blood Bank January 2016 through February 2017. Measurements of liver stiffness were performed using a FibroScan elastography device on the same day of laboratory analyses and abdominal ultrasound. The Pearson coefficient was used to assess correlations, and the reference range was calculated using the mean and its 95% confidence interval.
RESULTS Liver stiffness values observed ranged from 2.2–6.3 kPa. The reference range (95% CI) for the 110 subjects without known liver disease was 4.2–4.6 kPa (mean 4.4). A positive correlation was observed between liver stiffness measurements and body mass index (r = 0.255, p <0.01) and serum uric acid (r = 0.266, p <0.01). There was no correlation between liver stiffness and age. Liver stiffness in women was similar to that of men, 4.3 (2.4–6.1) and 4.5 (2.2–6.3) kPa, respectively (p = 0.086).
CONCLUSIONS Liver stiffness in Cuban adults without liver disease ranges from 2.2–6.3 kPa. The reference range is 4.2–4.6 kPa. Body mass index and serum uric acid levels are positively associated with liver stiffness.
KEYWORDS Liver disease, liver fibrosis, hepatic cirrhosis, hepatic fibrosis, diagnostic imaging, elastography, sonoelastography, elasticity imaging techniques, tissue elasticity imaging, technology assessment, Cuba
CONTRIBUTION OF THIS RESEARCH This is the first Cuban study using FibroScan to measure liver stiffness; its results will enable better assessment of liver disease in clinical practice.
INTRODUCCIÓN La insuficiencia hepática aguda es una enfermedad poco frecuente en pacientes pediátricos y es una de las emergencias médicas más desafiantes debido a su pronóstico y a sus implicaciones terapéuticas. Los mejores resultados globales provienen de estudios multicéntricos en países desarrollados. En Cuba, no hay estudios anteriores sobre esta enfermedad en niños.
OBJETIVOS Se describen las principales características clínicas de niños cubanos tratados en un centro de referencia nacional para la insuficiencia hepática aguda, según la definición dada por los criterios de diagnóstico reconocidos para los pacientes pediátricos.
MÉTODOS Se realizó un estudio en una serie de casos que comprendía los pacientes diagnosticados con insuficiencia hepática aguda tratados entre 2005 y 2011 en el servicio de hepatología y trasplante hepático del Hospital Pediátrico Universitario William Soler en La Habana. Las variables fueron: grupo etario, etiología de la insuficiencia hepática aguda, grado de encefalopatía de origen hepático, variables de la química sanguínea y el resultado clínico (si se recuperaba o no espontáneamente la función hepática). Se evaluaron las asociaciones entre las variables mediante las tablas de contingencia, y se calculó la tasa de letalidad como riesgo relativo con un intervalo de confianza de 95%. Las medias de los resultados de los análisis de laboratorio se compararon con la prueba U de Mann-Whitney.
RESULTADOS La mediana de la edad de los 31 pacientes estudiados (14 niños y 17 niñas) fue de 24 meses (con el rango de 1-180 meses). El tiempo entre el inicio de los síntomas y el diagnóstico de insuficiencia hepática aguda fue de 25.1 días (DE 16.8). La etiología más común fue la infección, que se encontró en el 61.3% de los casos (19/31); los virus no hepatotrópicos, especialmente el citomegalovirus, predominaron en niños pequeños. Hubo recuperación espontánea en 15 pacientes (48.4%), tres (9.7%) recibieron trasplantes y 13 fallecieron, para una tasa de letalidad de 41.9%.El resultado final no estuvo relacionado con la etiología (p = 0.106), pero tenía una relación estadística con el grado de encefalopatía de origen hepático(p <0.01), por lo que el 77.8% de los pacientes (7/9) con encefalopatía de grados III-IV fallecieron, para un riesgo relativo de 4.0 (IC 95% 1.15-13.8), frente al 11.1% (1/9) con encefalopatía de grado II o menos. Los niveles de colesterol fueron significativamente menores en pacientes que no se recuperaron espontáneamente (p <0.01).
CONCLUSIONES Las características clínicas de los pacientes en esta serie de casos fueron similares a los descritos en los países desarrollados. El hecho de que los virus no hepatotrópicos (básicamente el citomegalovirus en niños pequeños) son la causa principal de la insuficiencia hepática aguda en los niños cubanos, plantea la necesidad de realizar estudios epidemiológicos más profundos, e identificar los determinantes subyacentes de este fenómeno.
PALABRAS CLAVE Insuficiencia hepática aguda/etiología, trasplantes, infecciones, citomegalovirus, niños, pediatría, Cuba
INTRODUCTION Acute liver failure is rare in pediatric patients and is one of the most challenging medical emergencies due to its prognostic and therapeutic implications. The best scientific evidence worldwide comes from multicenter studies in developed countries. In Cuba, there are no prior studies of this disorder in children.
OBJECTIVES Describe the main clinical features of Cuban children treated at a national referral center for acute liver failure, as defined by recognized diagnostic criteria for pediatric patients.
METHODS A case series study was conducted comprising patients diagnosed with acute liver failure treated from 2005 to 2011 in the hepatology and liver transplant service at Havana’s William Soler University Children’s Hospital. Variables were age group, etiology of acute liver failure, grade of hepatic encephalopathy, blood chemistry variables, and clinical outcome (whether or not spontaneous recovery of liver function occurred). Associations between variables were assessed using contingency tables, and case fatality was calculated, as well as relative risk with its 95% confidence interval. The Mann-Whitney U test was used to compare means of laboratory test results.
RESULTS Median age of the 31 patients studied (14 boys and 17 girls) was 24 months (range 1–180). Time between symptom onset and diagnosis of acute liver failure was 25.1 days (SD 16.8). Infection was the most common etiology, present in 61.3% of cases (19/31); nonhepatotropic viruses, especially cytomegalovirus, predominated in infants. Spontaneous recovery occurred in 15 patients (48.4%), 3 (9.7%) received transplants, and 13 died, for a case fatality of 41.9%. Outcome was not associated with etiology (p = 0.106), but was statistically associated with degree of hepatic encephalopathy (p <0.01): 77.8% of patients (7/9) with grades III–IV encephalopathy died, for a relative risk of 4.0 (95% CI 1.15–13.8), versus 11.1% (1/9) with grade II or less encephalopathy. Cholesterol levels were significantly lower in patients who failed to recover spontaneously (p <0.01).
CONCLUSIONS Patients’ clinical characteristics in this case series were similar to those described in developed countries.The fact that nonhepatotropic viruses (basically, cytomegalovirus in infants) are the main cause of acute liver failure in Cuban children calls for further epidemiologic study and identification of local underlying determinants of this phenomenon.
KEYWORDS Acute liver failure/etiology, transplants, infections, cytomegalovirus, children, pediatrics, Cuba
