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Arias A.,Complejo Hospitalario la Mancha Centro | Perez-Martinez I.,Hospital Universitario Central Of Asturias | Tenias J.M.,Family and Community Medicine Teaching Unit | Lucendo A.J.,Hospital General Of Tomelloso
Alimentary Pharmacology and Therapeutics | Year: 2016

Background The recognition of eosinophilic oesophagitis (EoE) has risen sharply, but its current epidemiology is still under debate. Aim To estimate accurately the prevalence and incidence rates of EoE, by a systematic review and meta-analysis. Methods MEDLINE, EMBASE and SCOPUS databases were searched for population-based studies on the epidemiology of EoE. Pooled incidence and prevalence rates, male:female and children:adult ratios, and geographical and temporal variations were calculated with random-effects models. Results The search yielded 1334 references; the final quantitative summary included 13 population-based studies from North America, Europe and Australia, with the results showing high heterogeneity. The pooled EoE incidence rate was 3.7/100 000 persons/year [95% confidence interval (CI): 1.7-6.5] and was higher for adults (7; 95% CI: 1-18.3) than for children (5.1; 95% CI: 1.5-10.9). The pooled prevalence of EoE was 22.7 cases/100 000 inhabitants (95% CI: 12.4-36), rising to 28.1 (95% CI: 13-49) when studies with a lower risk of bias were considered; prevalence was higher in adults than in children (43.4; 95% CI: 22.5-71.2 vs. 29.5; 95% CI: 17.5-44.7, respectively), and in American compared to European studies. A steady rise in EoE incidence and prevalence rates was observed upon comparison of studies conducted before and after 2008. No significant publication bias was found. Conclusions Eosinophilic oesophagitis is an increasingly common diagnosis in North America and Europe. The population-based incidence and prevalence of eosinophilic oesophagitis vary widely across individual studies, probably due to variations in diagnosis and risk of bias of research. More prospective, large-scale, multicenter studies are needed to evaluate reported data. © 2015 John Wiley & Sons Ltd.


Lucendo A.J.,Hospital General Of Tomelloso | Arias A.,Complejo Hospitalario La Mancha Centro
Expert Review of Gastroenterology and Hepatology | Year: 2012

Eosinophilic gastroenteritis (EGE) is characterized by dense eosinophilic inflammation of one or several digestive tract sections. The symptoms include abdominal pain, weight loss, vomiting and diarrhea. Biopsy samples taken during endoscopic examination allows the diagnosis of the disease. An infiltration of >30 eosinophils per high-power field in at least five high-power fields, exhibiting signs of eosinophilic degranulation and extending to the muscularis mucosa or submucosa are all histological indications of EGE. EGE is traditionally classified into three forms depending on the depth of inflammation in the wall (mucosal, muscular or serosal). This, together with the digestive tract segments involved, determines the clinical presentation. The natural history of EGE includes three different evolutionary patterns, since patients may suffer a single outbreak, a recurrent course or even chronic disease. Corticosteroids are the most frequently used therapy for EGE; dietary treatments should be also considered. Surgery has been limited to solving obstruction and small bowel perforation. © 2012 Expert Reviews Ltd.


Lucendo A.J.,Hospital General Of Tomelloso | Arias A.,Complejo Hospitalario La Mancha Centro | Molina-Infante J.,Hospital San Pedro Of Alcantara
Clinical Gastroenterology and Hepatology | Year: 2016

Background & Aims: Proton pump inhibitor (PPI) therapy might lead to clinical and histologic remission in a significant proportion of patients with symptomatic esophageal eosinophilia (>15 eos/high-power field). We aimed to evaluate systematically the efficacy of PPI therapy for these patients. Methods: A search in MEDLINE, EMBASE, and SCOPUS databases, and the American Gastroenterological Association Institute, American College of Gastroenterology, and United European Gastroenterology meetings abstract books, was performed. Primary outcomes were clinical response and histologic remission (<15 eos/high-power field) after PPI therapy. Secondary outcomes were the influence on the response to PPIs of age group, study design/quality, PPI type, doses and interval dosing, and pH monitoring results. Data were pooled using a random-effects model. Results: Thirty-three studies (11 prospective studies) comprising 619 patients with symptomatic esophageal eosinophilia (188 children and 431 adults) were included. PPI therapy led to a clinical response in 60.8% (95% confidence interval, 48.38%-72.2%; I2 = 80.2) and histologic remission in 50.5% (95% confidence interval, 42.2%-58.7%; I2 = 67.5) of patients. No differences were observed regarding the study population (children vs adults), the type of publication, or its quality. PPIs were nonsignificantly more effective in prospective studies (52.6% vs 39.1%) administered twice daily compared with once daily (55.9% vs 49.7%), and with pathologic pH monitoring (65.4% vs 49.3%). A significant publication bias in favor of studies reporting histologic responses to PPIs was observed. Conclusions: PPI therapy induces clinicohistologic remission in half of patients with symptomatic esophageal eosinophilia. This finding should be interpreted with caution because of poor-quality evidence, heterogeneity, and publication bias. © 2016 AGA Institute.


Lucendo A.J.,Hospital General Of Tomelloso | Arias A.,Complejo Hospitalario la Mancha Centro | Tenias J.M.,Complejo Hospitalario la Mancha Centro
Annals of Allergy, Asthma and Immunology | Year: 2014

Background The onset of eosinophilic esophagitis (EoE) after oral immunotherapy (OIT) has been repeatedly described in patients with immunoglobulin E (IgE)-mediated food allergy in recent years, but the relation between the 2 conditions has not been fully assessed and quantified.Objective To provide a systematic review of the evidence for an association between OIT and EoE.Methods Electronic searches were performed with keywords relating to EoE and OIT in the MEDLINE, EMBASE, and SCOPUS databases. Summary estimates were calculated. A fixed-effects model was used depending on heterogeneity (I2). Risk of publication bias was assessed by funnel plot analysis and the Egger test.Results The search yielded 118 documents, 15 of which were included in the quantitative summary. Most reported information came from children undergoing peanut, milk, and egg OIT. Significant publication bias in favor of studies reporting the development of EoE after OIT was documented. The overall prevalence of EoE after OIT was 2.7% (95% confidence interval 1.7%-4.0%, I2 = 0%). Differences between medium-to high-quality studies and those of low quality were documented (3.5% vs 2.5%, respectively). EoE often resolved after OIT discontinuation; histologic remission of EoE achieved after allergen immunotherapy also was documented in 2 patients whose topical fluticasone treatment failed.Conclusion New onset of EoE after OIT occurs in up to 2.7% of patients with IgE-mediated food allergy undergoing this treatment strategy. The limited data on the utility of allergen immunotherapy as a therapy for EoE prevent a recommendation for this treatment option. © 2014 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.


Lucendo A.J.,Hospital General Of Tomelloso | Arias A.,Complejo Hospitalario la Mancha Centro | De Rezende L.C.,Hospital General Of Tomelloso | Yague-Compadre J.L.,Complejo Hospitalario la Mancha Centro | And 5 more authors.
Journal of Allergy and Clinical Immunology | Year: 2011

Background: Recent research shows that both pediatric and adult patients with eosinophilic esophagitis (EoE) experience esophageal remodeling marked by increased collagen deposition in which TGF-β plays an important role. However, limited data are available on the intensity and reversibility of fibrous remodeling in adults with EoE. Objective: We sought to analyze differences in collagen deposition in the lamina propria (LP) and profibrogenic cytokine gene expression along with other changes induced by prolonged treatment with fluticasone propionate in adults with EoE. Methods: Ten adults given consecutive diagnoses of EoE were studied prospectively. Deep esophageal biopsy specimens were obtained before and after 1 year of treatment with fluticasone propionate. Collagen deposition in the LP was assessed in tissue sections with the aid of the Masson trichrome technique. IL5, TGFB1, fibroblast growth factor 9 (FGF9), and CCL18 gene expression was quantified through real-time PCR. EoE results were compared among samples from 10 adult patients with gastroesophageal reflux disease and 10 control subjects with healthy esophagi. Results: Patients with EoE showed a significant increase in subepithelial collagen deposition; this correlated positively with eosinophil density in the LP and the patient's age. Prolonged steroid treatment induced a nonsignificant reduction in subepithelial fibrosis, which remained significantly higher than in control subjects. Profibrogenic cytokine gene expression also increased in patients with EoE, with IL5 (P <.001), FGF9 (P = .005), and CCL18 (P =.008) all significantly upregulated. After 1 year of treatment, a reduction was observed in gene expression; for CCL18 expression, this decrease was statistically significant (P <.001). Conclusions: Esophageal remodeling is associated with upregulated gene expression of profibrogenic cytokines in adults with EoE. Prolonged treatment with fluticasone propionate leads to a nonsignificant reduction in subepithelial collagen deposition accompanied by downregulation of profibrogenic cytokine gene expression, with that of CCL18 being especially significant. © 2011 American Academy of Allergy, Asthma & Immunology.


Lucendo A.J.,Hospital General Of Tomelloso | Serrano-Montalban B.,Hospital General Of Tomelloso | Arias A.,Complejo Hospitalario la Mancha Centro | Redondo O.,Complejo Hospitalario la Mancha Centro | Tenias J.M.,Complejo Hospitalario la Mancha Centro
Journal of Pediatric Gastroenterology and Nutrition | Year: 2015

Objectives: Various dietary interventions have been used to treat patients with eosinophilic gastroenteritis (EGE). Concrete evidence as to the effectiveness of such treatments in inducing disease remission is, however, lacking. The aim of the study was to systematically review the efficacy of dietary therapies in inducing EGE remission. Methods: We performed a systematic search for the MEDLINE, EMBASE, and SCOPUS libraries for studies investigating the efficacy of dietary interventions (in both histological and symptomatic remission) for children and adults with EGE and colitis. Results: The search yielded 490 references; 30 were included in the review, with most of these references being "low-quality" individual cases or short case series. No significant publication bias was found. Elemental diets in children were linked to 75.8% of clinical improvement, but few of these patients underwent a histological evaluation. Allergy-testing results have been used scarcely in EGE. Empiric elimination of allergy-associated foods was the most commonly used option. The variable results in terms of symptom relief, however, were scarcely accompanied by histological confirmation. Clinical and methodological heterogeneity hindered the performance of quantitative summaries for the efficacy of dietary therapies in inducing disease remission. Conclusions: Symptomatic improvements reported for dietary treatment in EGE by most of the available literature are questionable because of the lack of objective evaluation of clinical changes and the very limited assessment of histological remission. Because of the relative lack of well-designed, high-quality studies, the unequivocal use of dietary treatment for patients with EGE and colitis cannot be supported. Further research should be undertaken. © 2015 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.


Lucendo A.J.,Hospital General Of Tomelloso | Arias A.,Complejo Hospitalario la Mancha Centro | Tenias J.M.,Complejo Hospitalario la Mancha Centro
Alimentary Pharmacology and Therapeutics | Year: 2014

Background The relationship between eosinophilic oesophagitis (EoE) and coeliac disease (CD) remains controversial, with studies yielding varied results. Aim To systematically review the evidence of a possible association between both diseases. Methods Electronic searches were performed with keywords relating to EoE and CD in the MEDLINE, EMBASE and SCOPUS databases. Summary estimates were calculated. A random-effects model was used depending on heterogeneity (I2). Publication bias was assessed with the aid of funnel plot analysis, along with the Begg-Mazumdar, Harbord and Egger tests. Results The search yielded 197 references; 30 were included in the quantitative summary, with most of these presenting methodological inconsistencies. Significant publication bias in favour of short studies reporting positive associations between both diseases was documented. The prevalence of EoE in CD ranged from 0% to 10.7% (I2 = 78.9%). Prevalence of CD in EoE varied between 0.16% and 57.1% (I2 = 89%). One high-quality, prospective, randomly selected, population-based study documented a 1.1% prevalence of CD, with no patients presenting EoE. Clinical and methodological heterogeneity hindered the performance of quantitative summaries for prevalence data. A gluten-free diet was effective in achieving histological remission of EoE in 32.1% of coeliac patients (95% confidence interval, 14.9-52.2%; I2 = 52.2%), which was similar to that expected for wheat elimination in EoE patients. Conclusions While a lack of valid studies prevents us from completely ruling out a true association between EoE and CD, currently available evidence does not support this hypothesis. Indeed, the only epidemiological study with sufficient validity points to the independence of both diseases. © 2014 John Wiley & Sons Ltd.


Lucendo A.J.,Hospital General Of Tomelloso | Arias A.,Complejo Hospitalario la Mancha Centro | Gonzalez-Cervera J.,Hospital General Of Tomelloso | Mota-Huertas T.,Complejo Hospitalario la Mancha Centro | Yague-Compadre J.L.,Complejo Hospitalario la Mancha Centro
Allergy: European Journal of Allergy and Clinical Immunology | Year: 2013

Background Cow's milk protein, a major food trigger for EoE in both children and adults, should be continuously avoided once identified as such. This study evaluates tolerance of a cow's milk-based extensively hydrolyzed formula (eHF) with regard to disease remission maintenance in adult patients with milk-triggered EoE. Methods Seventeen adult patients in whom cow's milk was consecutively demonstrated to trigger EoE after an empiric six-food elimination diet-based study protocol and who subsequently maintained disease remission were prospectively recruited. They were given 400 ml of a cow's milk-based eHF daily for 8 weeks. Intraepithelial peak eosinophil and blood eosinophil counts, esophageal-related symptoms, serum total and specific IgE to major milk proteins, and eosinophil cationic protein were monitored before and after eHF intake. Results Thirteen male and four female patients aged 17-56 completed the study protocol. 15 patients (88.24%) achieved and maintained EoE remission, while an infiltration of ≥15 eosinophils/hpf reappeared in the remaining two patients. No differences in age, gender, symptoms, and endoscopic appearance at baseline conditions or personal/family allergic background were observed between those patients who tolerated the eHF and those who did not. Symptom scores did not significantly change after eHF intake and were significantly lower than those documented at baseline conditions or after cow's milk challenge. No differences were documented in blood eosinophil counts or serum markers after eHF intake. Conclusion Most adult patients with EoE triggered by cow's milk tolerate a cow's milk-based eHF, thus providing them with a safe, economical alternative to cow's milk. © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.


Arias A.,Complejo Hospitalario la Mancha Centro | Gonzalez-Cervera J.,Hospital General Of Tomelloso | Tenias J.M.,Complejo Hospitalario la Mancha Centro | Lucendo A.J.,Hospital General Of Tomelloso
Gastroenterology | Year: 2014

Background & Aims Various dietary interventions have been used to treat patients with eosinophilic esophagitis (EoE), yielding varied results. This systematic review assesses the efficacy of different dietary therapies in inducing disease remission. Methods We performed a systematic search of the MEDLINE, EMBASE, and SCOPUS databases for studies investigating the efficacy of dietary interventions (reducing infiltration by immune cells <15 eosinophils/high-power field in esophageal biopsies) for pediatric and adult patients with EoE. Summary estimates, including 95% confidence intervals (CI), were calculated for exclusive feeding with amino acid-based elemental formulas, allergy test result-directed food elimination diets, and 6-food elimination diets (SFED). A fixed- or random-effects model was used depending on heterogeneity (I2); publication bias risks were assessed by means of funnel plot analysis. Results The search yielded 581 references; of these, 33 were included in the quantitative summary. We analyzed data on a total of 1317 patients with EoE (1128 children and 189 adults) who received different dietary treatments. Elemental diets were effective for 90.8% of cases (95% CI, 84.7%-95.5%; I2 = 52.3%), SFED for 72.1% (95% CI, 65.8%-78.1%; I 2 = 0), and allergy test result-directed food elimination for 45.5% of cases (95% CI, 35.4%-55.7%; I2 = 75.1%). Additional strategies (elimination of cow's milk, gluten-free diets, and 4-food elimination diet) were also evaluated. Adults vs children had no significant differences in remission after dietary interventions (67.2% vs 63.3%). Conclusions Dietary interventions are effective in producing histologic remission in patients with EoE. Elemental diets and SFEDs were the most effective, achieving <15 eosinophils/high-power field in 90.8% and 72.1% of patients, respectively. © 2014 by the AGA Institute.


Rabih S.A.,Complejo Hospitalario La Mancha Centro | Agudo R.G.,Complejo Hospitalario La Mancha Centro
Nefrologia | Year: 2011

The prevalence of chronic infection with the hepatitis C virus (HCV) in patients with chronic kidney disease is higher than in the general population. The estimated prevalence is 13% in haemodialysis, with wide variations geographically and between units in the same country. A liver biopsy is a useful tool for deciding whether to start antiviral therapy and to exclude concomitant causes of liver dysfunction. Examples of this include nonalcoholic fatty liver disease, whose incidence is on the rise, and haemosiderosis, which may affect the progression of the disease and condition the response to antiviral therapy. In addition, the transjugular route can be used to measure the hepatic venous pressure gradient and confirm the existence of portal hypertension. Chronic hepatitis due to HCV has been shown to reduce survival in haemodialysis, renal transplantation and graft survival. It is the fourth leading cause of death and the leading cause of post-renal transplantation liver dysfunction. HCV behaves as an independent risk factor for the occurrence of proteinuria; it increases the risk of developing diabetes, de novo glomerulonephritis and chronic allograft nephropathy; it leads to a deterioration in liver disease and causes a greater number of infections. An increased frequency of fibrosing cholestatic hepatitis has also been described which, together with the rapid evolution to cirrhosis, can significantly increase morbidity and mortality and lead to the need for liver transplantation. In addition, immunosuppression in renal transplantation predisposes a reactivation of HCV. However, as the pharmacokinetics of interferon and ribavirin is impaired in kidney failure and their use has adverse effects on function and graft survival, a combination therapy is limited to non-transplanted individuals with an estimated glomerular filtration rate greater than 50 ml/min, and with the interferon being used as monotherapy in dialysis. The fact that a quarter of HCVpositive patients evaluated for a renal transplant have bridging fibrosis or cirrhosis in the liver biopsy may renew renal pre-transplant treatment planning.

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