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Background and Aim: reduction in calcineurin inhibitor levels is considered crucial to decrease the incidence of kidney dysfunction in liver transplant (LT) recipients. The aim of this study was to evaluate the safety and impact of everolimus plus reduced tacrolimus (EVR + rTAC) vs. mycophenolate mofetil plus tacrolimus (MMF + TAC) on kidney function in LT recipients from Spain., Methods: the REDUCE study was a 52-week, multicenter, randomized, controlled, open-label, phase 3b study in de novo LT recipients. Eligible patients were randomized (1:1) 28 days post-transplantation to receive EVR + rTAC (TAC levels ≤ 5 ng/mL) or to continue with MMF + TAC (TAC levels = 6-10 ng/mL). Mean estimated glomerular filtration rate (eGFR), clinical benefit in renal function, and safety were evaluated., Results: in the EVR + rTAC group (n = 105), eGFR increased from randomization to week 52 (82.2 [28.5] mL/min/1.73 m2 to 86.1 [27.9] mL/min/1.73 m2) whereas it decreased in the MMF + TAC (n = 106) group (88.4 [34.3] mL/min/1.73 m2 to 83.2 [25.2] mL/min/1.73 m2), with significant (p < 0.05) differences in eGFR throughout the study. However, both groups had a similar clinical benefit regarding renal function (improvement in 18.6 % vs. 19.1 %, and stabilization in 81.4 % vs. 80.9 % of patients in the EVR + rTAC vs. MMF + TAC groups, respectively). There were no significant differences in the incidence of acute rejection (5.7 % vs. 3.8 %), deaths (5.7 % vs. 2.8 %), and serious adverse events (51.9 % vs. 44.0 %) between the 2 groups., Conclusion: EVR + rTAC allows a safe reduction in tacrolimus exposure in de novo liver transplant recipients, with a significant improvement in eGFR but without significant differences in renal clinical benefit 1 year after liver transplantation.

Systemic lupus erithematosus (SLE) is an autoimmune disease with multiorgan involvement caused principally by vasculitis of small vessels. The gastrointestinal tract is one of the most frequently affected by SLE, with abdominal pain as the most common symptom. An early diagnosis and treatment of lupus enteritis is essential to avoid complications like hemorrhage or perforation, with up to 50 % of mortality rate. However, differential diagnosis sometimes is difficult, especially with other types of gastrointestinal diseases as digestive involvement of antiphospholipid syndrome (APS), moreover when both entities may coexist. We describe the case of a patient with both diseases that was diagnosed with lupus enteritis and treated with steroid therapy; the patient had an excellent response.

Background: Surgical management of acute appendicitis with appendiceal abscess or phlegmon remains controversial. We studied the results of initial conservative treatment (antibiotics and percutaneous drainage if necessary, with or without interval appendectomy) compared with immediate surgery., Methods: We undertook an observational, retrospective cohort study of patients with a clinical and radiological diagnosis of acute appendicitis with an abscess or phlegmon, treated in our hospital between January 1997 and March 2009. Patients younger than 14, with severe sepsis or with diffuse peritonitis were excluded. A study group of 15 patients with acute appendicitis complicated with an abscess or phlegmon underwent conservative treatment. A control group was composed of the other patients, who all underwent urgent appendectomy, matched for age and later randomized 1:1. The infectious risk stratification was established with the National Nosocomial Infections Surveillance System (NNIS) index. Dependent variables were hospital stay and surgical site infection. Analysis was with SPSS, with p < 0.05 considered significant., Results: Interval appendectomy was performed in 7 study group patients. Surgical site infection episodes were more frequent in the control group (6 vs. 0, p < 0.001). A greater percentage of high risk patients (NNIS ≥ 2) was identified in the control group (80 vs. 28.7%, p < 0.03), mostly related with contaminated or dirty procedures in this group (p < 0.001). No significant difference between groups was found in hospital stay., Conclusion: Initial conservative treatment should be considered the best therapeutic choice for acute appendicitis with abscess or phlegmon.

The molecular basis of porphyria cutanea tarda is defective activity of hepatic uroporphyrinogen decarboxylase. A common characteristic is liver dysfunction than goes from cirrhosis to hepatocellular carcinoma. A high prevalence of hepatitis C virus markers has been demonstrated. We study a patient with PCT and hepatitis C virus markers that finally develops to hepatocellular carcinoma without previous cirrhosis. Previous studies with association of PCT and hepatitis C virus markers, have found liver diseases ranging from cirrhosis to hepatocellular carcinoma. The importance of this study is the absence of cirrhosis.

Controversy remains about the best treatment for patients with esophagogastric variceal bleeding. In spite of different therapeutic alternatives and recent progress, such as liver transplantation of TIPS, many patients will finally be treated by standard surgery. With the aim to know the results of surgery in shunting vs non-shunting procedures, we have analyzed a recent and consecutive series of 68 cirrhotics patients operated on for variceal hemorrhage. According to the surgical technique there were three groups: I) 30 patients underwent a total portacaval shunt; II) 18 cases with an azygosportal disconnection; III) 20 patients with a partial portacaval shunt (8-10 mm H-portacaval PTFE graft). All groups were homogeneous considering age, sex etiology, Child-Pugh grade and timing of surgery (elective vs urgent). The complications and mortality rates were similar for the three groups. The overall operative mortality was 10%, and 5% in selected cases (Child-Pugh A-B, non urgent cases). With a follow-up for I, II and III group of 47, 44 and 27 months respectively, chronic encephalopathy have been seen in 61%, 15% and 15% respectively (p < .05). No patient in group I has rebled, and only one case in the II and III groups had a recurrence of hemorrhage. The actuarial three years survival was 76%, 86% and 85% (p NS), and the five year survival was 41% vs 86% for the groups I and II respectively (p < .05). In conclusion, in selected cases, surgery gives excellent immediate and long term results. In patients with variceal bleeding and failure of first line treatments, such as sclerosis or pharmacology, the partial H-portacaval shunt and non-shunting procedures are good alternatives, with low incidence of rebleeding and chronic encephalopathy.