dr. abraham katime zúñiga
TRANSCRIPT
![Page 1: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/1.jpg)
![Page 2: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/2.jpg)
Dr. Abraham Katime Zúñiga.
Especialista Medicina Interna – Enfermedades Infecciosas.
Docente Pregrado Universidad Magdalena.
Docente Postgrado Universidad Metropolitana.
Miembro Asociación Colombiana de Infectología (ACIN).
Hepatitis virales en población viviendo con VIH
![Page 4: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/4.jpg)
Disclosures-Biotoscana (Conferencias- Consultoría).
-MSD (Conferencias).
-GSK (Consultoría).
-Abbott (Consultoría).
-Eurofarma (Conferencias).
![Page 5: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/5.jpg)
Caso clínico # 1• Diciembre 2019.• Masculino, 25 años, HSH (vacaciones en Santa Marta) – Medellín. • VIH C3, diagnosticado hace 4 años.• TARV: ABC / 3TC + ATV/r, tolerancia y adherencia 100%.• Carga viral VIH 45 copias/ml – CD4 493 células/uL (Julio 2019).• Cuadro clínico 8 días de evolución: Fiebre – ictericia – diarrea – coluria – malestar general – astenia – adinamia –hiporexia – nauseas – vómitos.• No consume licor desde hace 2 años.• Pareja sexual estable desde hace 3 años.• No recuerda vacunación para VHA – VHB.
![Page 6: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/6.jpg)
Caso clínico # 1• Examen clínico: Ictericia grado III – Hepatomegalia grado II.
• Hemograma: WBC 4000 uL N 50%– L 50% – Plaquetas 150.000 uL
• Química: Creatinina 1 mg/dl– BUN 28 mg/dl– Na 140 mEq/L – K 3,2 mEq/L
ALT 600 UI/L – AST 450 UI/L - Bilirrubina Total 8,3 mg/dl
Que estudio (s) solicitaría para aclarar el diagnostico del paciente?
![Page 7: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/7.jpg)
Caso clínico # 1Que estudio (s) solicitaría para aclarar el diagnostico del paciente?
DIA +8 con respecto al inicio de los síntomas.
Pruebas rápidas:VHB antígeno de superficie negativo.VHC anticuerpos negativos. VHA IgG negativo. VHA IgM negativo.
![Page 8: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/8.jpg)
Caso clínico # 1
![Page 9: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/9.jpg)
https://www.ins.gov.co/buscador-eventos/Informacin%20de%20laboratorio/Guia-Vigilancia-por-Laboratorio-Hepatitis-Virales.pdf
![Page 10: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/10.jpg)
Future Virol. (2012) 7(5), 461–472
![Page 11: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/11.jpg)
Caso clínico # 1
Que estudio (s) solicitaría para aclarar el diagnostico del paciente?
DIA +12 con respecto al inicio de los síntomas.
Pruebas rápidas:VHA IgM positivo.
Se verifico con ELISA.
![Page 12: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/12.jpg)
Caso clínico # 1
Cual seria su recomendación con respecto a la TARV?1. No suspender.2. Modificar a ARV que no sean de metabolismo hepático. 3. Suspender de forma temporal.4. Indicar Monoterapia con Lamivudina por 4 semanas y posteriormente
reiniciar esquema ARV de base.5. Indicar Monoterapia con Efavirenz por 4 semanas y posteriormente
reiniciar esquema ARV de base.
![Page 13: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/13.jpg)
Caso clínico # 1
Cual seria su recomendación con respecto a la TARV?1. No suspender.2. Modificar a ARV que no sean de metabolismo hepático.
3. Suspender de forma temporal.4. Indicar Monoterapia con Lamivudina por 4 semanas y posteriormente
reiniciar esquema ARV de base.5. Indicar Monoterapia con Efavirenz por 4 semanas y posteriormente
reiniciar esquema ARV de base.
![Page 14: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/14.jpg)
Future Virol. (2012) 7(5), 461–472
![Page 15: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/15.jpg)
MIPRES: 50167 - HEPATITIS A, VIRUS COMPLETO INACTIVADO, CODIGO 661 [ANTIGENO DEL VIRUS DE
HEPATITIS A] 1440unidades ELISA/1ml.
HAVRIX 1440 (GlaxoSmithKline).
Dosis: 1 ml IM por 2 dosis, espaciadas 6 a 12 meses, en la región deltoidea o anterolateral superior del muslo.
![Page 16: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/16.jpg)
https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf
![Page 17: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/17.jpg)
Kemper CA, et al; California Collaborative
Treatment Group. Safety and immunogenicity of
hepatitis A vaccine in human immunodeficiency
virus-infected patients: a double-blind,
randomized, placebo-controlled trial. J Infect Dis.
2003 Apr 15;187(8):1327-31.
doi: 10.1086/374562.
Seroconversion was defined as
achieving an anti–hepatitis A virus
antibody titer ≥33 mIU/mL.
![Page 18: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/18.jpg)
Observed immunogenicity of HIV-infected subjects and HIV-uninfected control subjects who received an inactivated hepatitis A vaccine (VAQTA; Merck).
Wallace MR, et al, Safety and Immunogenicity of an Inactivated Hepatitis A Vaccine among HIV-Infected Subjects,
Clinical Infectious Diseases, Volume 39, Issue 8, 15 October 2004, Pages 1207–1213.
https://doi.org/10.1086/424666
Seropositive for HAV antibody ≥10 mIU/mL.e Four weeks after second VAQTA injection.
![Page 19: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/19.jpg)
https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/hepatitis-b-virus-
infection?view=full
Vacunación virus Hepatitis A en pacientes viviendo con VIH
▪ ↓ Respuesta en pacientes VIH con CD4 < 200 células/ mmᶟ
▪ Control de Anticuerpos 1 mes luego de completar esquema de vacunación.
▪ Si VHA Ac IgG son negativos, revacunar con CD4 > 200 células/ mmᶟ (BIII).
Seroconversión
Anti-VHA >10 mUI/mL.
![Page 20: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/20.jpg)
Caso clínico # 2
• Enero 2020.
• Masculino, 35 años, HSH // Venezuela.
• VIH C3, diagnosticado hace 5 años.
• TARV: ABC / 3TC + EFV, 1 año sin ARV.
• No recuerda vacunación para VHA – VHB.
• Paraclínicos de ingreso a programa de atención integral:
Carga viral VIH 65.000 copias/ml –
CD4 193 células/uL –
![Page 21: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/21.jpg)
HBsAg - Anti HBc + Anti HBs -
Caso clínico # 2
![Page 22: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/22.jpg)
1. Infección resuelta (lo más frecuente).
2. Falso positivo, situación frecuente en personas de regiones con baja prevalencia del VHB.
3. Infección aguda, en la cual el anticore IgM explica la positividad del anticore total.
4. Infección crónica con niveles bajos de replicación.
5. Coinfección con VHC o VIH.
Rev Col Gastroenterol vol.33 no.4 Bogotá Oct./Dec. 2018.
https://www.cdc.gov/hepatitis/hbv/pdfs/SerologicChartv8.pdf
https://www.cdc.gov/hepatitis/hbv/hbvfaq.htm#ref10
![Page 23: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/23.jpg)
http://depts.washington.edu/hepstudy/images/hepB/HBVDx_IsoCore_d05.png
Anti HBs
![Page 24: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/24.jpg)
http://depts.washington.edu/hepstudy/images/hepB/HBVDx_IsoCore_d05.png
![Page 25: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/25.jpg)
Hepatitis B oculta• Replicación activa (DNA VHB en hígado y/o sangre).
• HBsAg negativo / Anti-HBc positivo.
• DNA VHB en sangre < 200 UI/ml (1000 copias/ml).
• Asintomática.
• 40-75% de los CHC HBsAg negativo.
Raimondo, G., Locarnini, S., Pollicino, T., Levrero, M., Zoulim, F., Lok, A.S., and the Taormina Workshop on Occult HBV Infection Faculty Members, Update of the
statements on biology and clinical impact of occult hepatitis b virus infection, Journal of Hepatology (2019).
![Page 26: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/26.jpg)
Raimondo, G., Locarnini, S., Pollicino, T., Levrero, M., Zoulim, F., Lok, A.S., and the Taormina Workshop on Occult HBV Infection Faculty
Members, Update of the statements on biology and clinical impact of occult hepatitis b virus infection, Journal of Hepatology (2019).
![Page 27: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/27.jpg)
Raimondo, G., Locarnini, S., Pollicino, T., Levrero, M., Zoulim, F., Lok, A.S., and the Taormina Workshop on Occult HBV Infection Faculty
Members, Update of the statements on biology and clinical impact of occult hepatitis b virus infection, Journal of Hepatology (2019).
![Page 28: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/28.jpg)
Rev Col Gastroenterol vol.33 no.4 Bogotá Oct./Dec. 2018.
Evaluación de anticore positivo. Modificado de: Pondé RA et al. Arch Virol. 2010;155(2):149-58.
![Page 29: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/29.jpg)
https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/hepatitis-b-virus-
infection?view=full
The cut-off of 100 mIU/mL is used in this situation because one study demonstrated that 100% of patients with isolated anti-HBc
who achieved a titer of 100 mIU/mL after a booster dose maintained an anti-HBs response for >18 months as compared to only
23% of those who achieved a titer of 10 to 100 mIU/mL.
![Page 30: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/30.jpg)
Catherine FX, Piroth L. Hepatitis B virus vaccination in HIV-infected people: A review. Hum Vaccin
Immunother. 2017;13(6):1-10. doi:10.1080/21645515.2016.1277844
NR: Non Responders
An anamnestic response is defined by the production of antiHBs > 10 mIU/mL after a
single injection of hepatitis B vaccine, and can rise from 7 to 32.5%
![Page 31: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/31.jpg)
Vacunación Hepatitis B
https://www.who.int/immunization_standards/en/
![Page 32: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/32.jpg)
https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf
![Page 33: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/33.jpg)
Respuesta vacuna VHB
▪ Esquema clásico 20 ug/dosis 0 – 1 – 6 meses.
-VIH 20 a 70%- No VIH 90 a 95%
Catherine FX, Piroth L. Hepatitis B virus vaccination in HIV-infected people: A review. Hum
Vaccin Immunother. 2017;13(6):1-10. doi:10.1080/21645515.2016.1277844
![Page 34: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/34.jpg)
https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/hepatitis-b-virus-
infection?view=full
![Page 35: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/35.jpg)
Catherine FX, Piroth L. Hepatitis B virus vaccination in HIV-infected people: A review. Hum
Vaccin Immunother. 2017;13(6):1-10. doi:10.1080/21645515.2016.1277844
NR: Non Responders
![Page 36: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/36.jpg)
Catherine FX, Piroth L. Hepatitis B virus vaccination in HIV-infected people: A review. Hum Vaccin
Immunother. 2017;13(6):1-10. doi:10.1080/21645515.2016.1277844 NR: Non Responders
![Page 37: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/37.jpg)
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5516a1.htm
Intervalos mínimos entre dosis:
1era y 2da dosis: 4 semanas.
2da y 3era dosis: 8 semanas.
1era y 3era dosis: 16 semanas.
3era dosis, efecto booster.
Aplicación Intramuscular (deltoides).
Glúteos (↓ Inmunogenicidad).
Embarazo y lactancia no son
contraindicación para vacunación VHB.
![Page 38: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/38.jpg)
https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/hepatitis-b-virus-
infection?view=full
Catherine FX, Piroth L. Hepatitis B virus vaccination in HIV-infected people: A review. Hum Vaccin
Immunother. 2017;13(6):1-10. doi: 10.1080/21645515.2016.1277844
Annual antiHBs control is also recommended so that a booster can be given if the antiHBs
titer falls below 10 mIU/mL.
Among persons with HIV infection who did not respond to a primary
3-dose vaccine series with a recombinant vaccine, 25% to 50%
responded to an additional vaccine dose, and 44% to 100%
responded to a 3-dose revaccination series.
![Page 39: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/39.jpg)
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5516a1.htm
![Page 40: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/40.jpg)
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5516a1.htm
https://www.cdc.gov/hepatitis/hbv/hbvfaq.htm#D4
![Page 41: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/41.jpg)
Caso clínico # 3
• Fecha de consulta: 20-01-2020
• HSH, 29 años / Venezuela.
• Ingresa a programa de atención integral B24X.
• Diarrea crónica +/- 1 año.
• Desgaste con perdida de peso +/- 12 kg en 1 año.
• Peso actual: 45 kg.
• Fiebre ocasional.
• Mialgias generalizadas +/- 2 meses.
• Malestar general.
![Page 42: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/42.jpg)
Caso clínico # 3
Paraclínicos ingreso programa B24X - Enero 2020
Paraclínico Reporte
HB 10.5
WBC 2900
PLTS 165000
Creatinina 1
TGO 56
TGP 52
Colesterol total 198
Triglicéridos 192
Glicemia 81
Paraclínico Reporte
PPD 0 mm
CD4 99
Carga viral VIH 74000
HBsAg Positivo
AntiHBc Positivo
AntiHBs 1
Anti VHC Negativo
Anti VHA Positivo
VDRL Negativo
![Page 43: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/43.jpg)
Caso clínico # 3
• Hepatitis B CARGA VIRAL (DNA VHB).
CÓDIGO CUPS 908806.
2900 UI/ML.
• Hepatitis B ANTICUERPOS CENTRAL Ig M (ANTI-CORE HBC-M).
CÓDIGO CUPS 906220.
Negativo.
Diagnostico: VIH C3, coinfección Hepatitis B crónica.
![Page 44: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/44.jpg)
Caso clínico # 3
Esquema antirretroviral – Backbone?
A. ABC/3TC.
B. AZT/3TC.
C. TDF/FTC o TAF/FTC.
![Page 45: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/45.jpg)
Caso clínico # 3
Esquema antirretroviral – Backbone?
A. ABC/3TC.
B. AZT/3TC.
C. TDF/FTC o TAF/FTC.
![Page 46: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/46.jpg)
http://depts.washington.edu/hepstudy/images/hepB/HBV_Rx_Res_d01.png
![Page 47: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/47.jpg)
Journal of Hepatology 2017 vol. 67 / 370–398.
1 yr: 20-25%
![Page 48: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/48.jpg)
https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/hepatitis-b-virus-infection?view=full
Treating HBV Infection - Indication for Therapy:
![Page 49: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/49.jpg)
Tenofovir Alafenamide (TAF)Tenofovir Alafenamide/ Emtricitabine (TAF/FTC)
https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/antiretroviral-dosing-recommendations-patients-renal-or-hepatic?view=full
![Page 50: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/50.jpg)
Journal of Hepatology 2017 vol. 67 / 370–398.
![Page 51: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/51.jpg)
Caso clínico # 4
• Fecha de consulta: 10-01-2020
• HSH, 29 años.
• Trastorno de ansiedad y depresión de base.
• Ingresa a programa de atención integral B24X.
• Diarrea crónica +/- 1 año.
• Desgaste con perdida de peso +/- 22 kg en 1 año.
• Peso actual: 48 kg.
• Fiebre ocasional.
• Malestar general.
![Page 52: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/52.jpg)
Caso clínico # 4Paraclínicos ingreso programa B24X - Enero 2020.
Paraclínico Reporte
HB 11
WBC 3100
Plaquetas 165000
Creatinina 1
TGO 53
TGP 49
Colesterol total 198
Triglicéridos 192
Glicemia 81
Paraclínico Reporte
PPD 0 mm
CD4 104
Carga viral VIH 34000
HBsAg Negativo
AntiHBc Negativo
AntiHBs 22,4
Anti VHC PositivoAnti VHA Positivo
VDRL Negativo
![Page 53: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/53.jpg)
Caso clínico # 4
Paraclínicos ingreso programa B24X - Mayo 2018
Paraclínico Reporte
HB 11
WBC 3100
PLTS 165000
Creatinina 3
TGO 33
TGP 29
Colesterol total 198
Triglicéridos 192
Glicemia 81
Paraclínico Reporte
PPD 0 mm
CD4 104
Carga viral VIH 34000
HBsAg Negativo
HBcT Negativo
AntiHBs 22,4
VHC Ac PositivoVHA Ac Positivo
VDRL Negativo
ESTIMACIÓN DEL FILTRADO GLOMERULAR CKD-EPI: 26,8 mL/min
Preguntas:
A. Se trata de una Infección aguda o crónica por VHC?.
B. Que estudio(s) complementario solicitaría para verificar el diagnostico de Hepatitis C?.- RIBA Hepatitis C.- Carga viral VHC.- Genotipo VHC.- VHC Ac IgM.- VHC Ac IgG.
![Page 54: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/54.jpg)
Anti-HCV HCV RNA (PCR) Interpretation
Negative Negative • No infection
Positive Positive • HCV present (acute or chronicinfection)
Negative Positive • Chronic infection inimmunosuppressed patient• Early infection
Positive Negative • Resolved infection• Treated infection, HCV below
detectable levels (verify withqualitative HCV RNA PCR)• False-positive anti-HCV test (<1%)
Albeldawi M et al. Cleve Clin J Med 2010;77:616-626..
![Page 55: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/55.jpg)
Serologic Pattern of Acute HCV Infection with Recovery
Symptoms +/-
Time after Exposure
Tit
er
anti-HCV
ALT
Normal
0 1 2 3 4 5 6 1 2 3 4
YearsMonths
HCV RNA
https://www.hepatitisc.uw.edu/go/screening-
diagnosis/acute-diagnosis/core-concept/all
Carga viral VHC, es
detectada 1 – 3 semanas.
ANTI VHC +, en el 50-70% de los casos al inicio
de los síntomas.
ANTI VHC +, luego de 12 semanas en >90% de los casos.
ANTI VHC, son detectados a los 6 meses en >97% de los
pacientes infectados.
![Page 56: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/56.jpg)
https://www.ins.gov.co/buscador-eventos/Informacin%20de%20laboratorio/Guia-Vigilancia-por-Laboratorio-Hepatitis-Virales.pdf
![Page 57: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/57.jpg)
Caso clínico # 4
Carga viral VHC 642000 UI/mL.
Solicitaría Genotipo VHC?
![Page 58: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/58.jpg)
Caso clínico # 4
Carga viral VHC 642000 UI/mL.
Genotipo 1b
![Page 59: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/59.jpg)
Caso clínico # 4
Carga viral VHC 642000 UI/mL.
Genotipo 1b
Preguntas:Que tratamiento antiviral de acción directa (VHC) recomendaría en este caso (Colombia)?
A. Elbasvir/GrazoprevirB. Velpatasvir/SofosbuvirC. Sofosbuvir/LedispavirD. Paritaprevir/Ombitasvir/RitonavirE. Tenofovir/Emtricitabina + Atazanavir/Ritonavir.F. ValaciclovirG. AciclovirH. Ganciclovir
![Page 60: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/60.jpg)
EASL Recommendations on Treatment of Hepatitis C 2018. Journal of Hepatology 2018 vol. 69 / 461–511.
![Page 61: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/61.jpg)
BIOTOSCANA MSD
![Page 62: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/62.jpg)
EASL Recommendations on Treatment of Hepatitis C 2018. Journal of Hepatology 2018 vol. 69 / 461–511.
![Page 63: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/63.jpg)
EASL Recommendations on Treatment of Hepatitis C 2018. Journal of Hepatology 2018 vol. 69 / 461–511.
![Page 64: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/64.jpg)
Dosis
1 comprimido administrado por vía oral una vez al día, acompañado o no de alimentos.
12 semanas.
# 84 tabletas.
![Page 65: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/65.jpg)
Caso clínico # 4
Si el paciente presentara insuficiencia renal de base con TFG<30 ml/min, que tratamiento antiviral de acción directa (VHC) recomendaría usted?
A. Elbasvir/GrazoprevirB. Velpatasvir/SofosbuvirC. Sofosbuvir/LedispavirD. Paritaprevir/Ombitasvir/RitonavirE. Tenofovir/Emtricitabina + Atazanavir/Ritonavir.F. ValaciclovirG. AciclovirH. Ganciclovir
![Page 66: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/66.jpg)
Caso clínico # 4Si el paciente presentara insuficiencia renal de base con TFG<30 ml/min, que tratamiento antiviral de acción directa (VHC) recomendaría usted?
A. Elbasvir/GrazoprevirB. Velpatasvir/SofosbuvirC. Sofosbuvir/Ledispavir
D. Paritaprevir/Ombitasvir/RitonavirE. Tenofovir/Emtricitabina + Atazanavir/Ritonavir.F. ValaciclovirG. AciclovirH. Ganciclovir
![Page 67: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/67.jpg)
EASL Recommendations on Treatment of Hepatitis C 2018. Journal of Hepatology 2018 vol. 69 / 461–511.
![Page 68: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/68.jpg)
![Page 69: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/69.jpg)
TFG ≥ 30 ml/min
![Page 70: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/70.jpg)
Caso clínico # 4
• Que terapia antiviral iniciaría primero en este caso:
A. Primero iniciaría tratamiento antiviral de acción directa VHC.
B. Primero iniciaría tratamiento antirretroviral VIH.
C. Se deben iniciar los tratamientos antivirales al mismo tiempo.
D. El tratamiento antiviral de acción directa VHC solo se recomienda cuando los CD4+ aumenten a mas de 200 células.
E. El tratamiento antiviral de acción directa VHC solo se recomienda cuando la carga viral VIH sea menor de 40 copias.
![Page 71: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/71.jpg)
Caso clínico # 4
• Que terapia antiviral iniciaría primero en este caso:
A. Primero iniciaría tratamiento antiviral de acción directa VHC.
B. Primero iniciaría tratamiento antirretroviral VIH.C. Se deben iniciar los tratamientos antivirales al mismo tiempo.
D. El tratamiento antiviral de acción directa VHC solo se recomienda cuando los CD4+ aumenten a mas de 200 células.
E. El tratamiento antiviral de acción directa VHC solo se recomienda cuando la carga viral VIH sea menor de 40 copias.
![Page 72: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/72.jpg)
Caso clínico # 4
Documento de consenso de Gesida/Plan Nacional sobre el Sida respecto al tratamiento antirretroviral en adultos infectados por el virus de la inmunodeficiencia humana. Julio 2020.https://gesida-seimc.org/wp-content/uploads/2020/07/TAR_GUIA_GESIDA_2020_COMPLETA_Julio.pdf
![Page 73: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/73.jpg)
Caso clínico # 4Cual es el único antiviral de acción directa VHC que no presenta interacciones con antirretrovirales?A. SofosbuvirB. ElbasvirC. GrazoprevirD. VelpatasvirE. LedispavirF. ParitaprevirG. Ombitasvir
![Page 74: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/74.jpg)
Caso clínico # 4Cual es el único antiviral de acción directa VHC que no presenta interacciones con antirretrovirales?A. SofosbuvirB. ElbasvirC. GrazoprevirD. VelpatasvirE. LedispavirF. ParitaprevirG. Ombitasvir
![Page 75: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/75.jpg)
EASL Recommendations on Treatment of Hepatitis C 2018. Journal of Hepatology 2018 vol. 69 / 461–511.
*Known or anticipated increase in tenofovir concentrations in regimens containing tenofovir disoproxil fumarate.
Caution and frequent renal monitoring.
![Page 76: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/76.jpg)
Caso clínico # 4Que ARV no indicaría en el paciente teniendo en cuenta interacciones con antivirales de acción directa VHC (función renal normal)A. EfavirenzB. Tenofovir Disoproxil FumaratoC. Elvitegravir/Cobicistat/Emtricitabina/
Tenofovir Alafenamida FumaratoD. Elvitegravir/Cobicistat/Emtricitabina/
Tenofovir Disoproxil FumaratoE. RaltegravirF. DolutegravirG. Atazanavir/RitonavirH. Abacavir
![Page 77: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/77.jpg)
EASL Recommendations on Treatment of Hepatitis C 2018. Journal of Hepatology 2018 vol. 69 / 461–511.
*Known or anticipated increase in tenofovir concentrations in regimens containing tenofovir disoproxil fumarate.
Caution and frequent renal monitoring.
Efavirenz causes a 50% decrease in velpatasvir exposure.
![Page 78: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/78.jpg)
![Page 79: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/79.jpg)
Caso clínico # 5
1 COMPRIMIDO CADA 24 H12 semanas84 días
1 COMPRIMIDO CADA 24 H
ABC/3TC
O
TAF/FTC
INIRAL – DTG – EVG/c - BIC
O
IPIP/r – IP/c
O
INNTRRPV
![Page 80: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/80.jpg)
![Page 81: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/81.jpg)
https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/hepatitis-b-virus-
infection?view=full
![Page 82: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/82.jpg)
Monitoring of Response to Therapy and Adverse Events (Including IRIS)
https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/hepatitis-b-virus-
infection?view=full
![Page 83: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/83.jpg)
https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/hepatitis-b-virus-
infection?view=full
![Page 84: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/84.jpg)
Journal of Hepatology 2017 vol. 67 / 370–398.
![Page 85: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/85.jpg)
https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/antiretroviral-dosing-recommendations-patients-renal-or-hepatic?view=full
Tenofovir Disoproxil Fumarate(TDF)
![Page 86: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/86.jpg)
https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/antiretroviral-dosing-recommendations-
patients-renal-or-hepatic?view=full
![Page 87: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/87.jpg)
https://aidsinfo.nih.gov/guidelines/htmltables/1/7580
Excretion Feces 94%Urine 6%
Excretion Feces 51% Urine 41%
![Page 88: Dr. Abraham Katime Zúñiga](https://reader030.vdocuments.pub/reader030/viewer/2022012622/61a21a6442d11c55c957bc19/html5/thumbnails/88.jpg)
Lancet HIV. 2018 Dec 13. pii: S2352-3018(18)30296-0.