Summary of presentations of the Fourth Course of Continuing Medical Education on Viral Hepatitis.

Between 26 and January 30 was held in the Medical Association of Madrid IV CONTINUING MEDICAL TRAINING COURSE ON VIRAL HEPATITIS. The course, as in other occasions, was led by Professor Juan González-Lahoz and Vincent Soriano, Hospital Carlos III of Madrid. Of note is the extensive participation (more than 200 physicians enrolled) and the quality of the speakers came from pointers hepatology services and / or infectious diseases in Spain.


There are at least 5 hepatotropic virus can infect and inflame the liver tissue: the hepatitis A virus (HAV), B (HBV), C (HCV), D (VHD) and E (HEV). Other viruses such as VHG, viruses and TTS SEN virus can infect the liver, although its pathogenic role is controversial.

HAV and HEV have preferred a fecal-oral transmission and a generally benign course. Today, its incidence in Spain is low due to good hygienic conditions and the existence of a vaccine against HAV andalusia. However, there have been small outbreaks of acute hepatitis A in patients promiscuous homosexual. Furthermore, acute hepatitis E should be considered in travelers and immigrants coming mainly from Southeast Asia.

Viral hepatitis produce greater public health problem in our country are caused by HBV and HCV.

Hepatitis B

Infection occurs through sexual contact, blood or by passage from mother to child. In adults almost always heal themselves, but between 3-5% of cases evolve into chronicity. When infection is acquired in childhood is the rule chronification. Between 15 and 40% of patients with chronic hepatitis B will develop cirrhosis.

It is essential to identify which patients will develop worse and therefore require treatment. The goal of treatment is to prevent viral replication and ideally eradicate the virus. The latter is complex, since the HBV integrates its genetic material into the nucleus of host cells. On the other hand it is known that the viral suppression prevents the progression to cirrhosis and its complications. There is "consensus" that should be addressed to patients with viral loads above 20,000 IU / ml and elevated transaminases, because they have a higher risk of progression.

The drugs currently approved for HBV are:
• Interferons. Achieve higher levels of healing in HBeAg + patients. But they have more side effects and are contraindicated in cirrhotic patients.
• Lamivudine. It was the first approved inhibitor of polymerase. Tolerated very well, but over time it always fails for the emergence of resistance.
• Telvivudina. Share some with lamivudine resistance and also its easy to generate resistance.
• entecavir. More powerful than the previous ones but if there is resistance to lamivudine is necessary to double the dose.
• Adefovir. It is useful for patients who failed previous drug.
• Tenofovir. The last drug approved against HBV and one of the most powerful.

Hepatitis Delta

The HDV is an RNA virus, capable of producing hepatotropic hepatitis, chronic hepatitis and fulminant hepatitis in some cases. It is the least frequent cause of chronic viral hepatitis but produces a severe liver disease. HDV infection occurs only in the context of an HBV infection, either infection or simultaneous coinfection of B and D or D-shaped overinfection affected previous HBsAg carriers. Clinically it is presented in a similar way but evolution and the prognosis is very different. Most of the B and D co-evolve to cure while the delta superinfections progress to chronicity.

Hepatitis C

HCV is characterized by its ability to chronic. About 2% of the Spanish population is infected by this virus and is the leading cause of liver transplantation. The evolution of HCV is usually asymptomatic, but about 20% of patients will develop liver cirrhosis in 20 years.

The treatment of choice is the combination of pegylated interferon (PEG-IFN) and ribavirin (RBV). Genotypes 2 and 3 were treated 6 months get a 80% cure. Genotypes 1 and 4 should be treated 1 years, achieving cure in half the patients. There are currently testing new drugs that inhibit viral enzymes, such as telaprevir, which acts on the protease of HCV and in combination with PEG-IFN and RBV may achieve higher cure rates in patients difficult to treat.

Vaccines against hepatotropic virus

There is now a vaccine against HAV andalusia consisting of inactivated virus. 2 doses are administered intramuscularly at an interval of 6 months and produces a nearly universal immunization.

Against HBV is a vaccine that is produced by genetic recombination. 3 doses are administered and is already included in the pediatric immunization schedule in Spain. This makes for a higher vaccination rates in children, 95% and 80% in adults.

Unfortunately, HCV is not successful to grow in the laboratory. This makes it difficult to investigate, among other things has not yet been able to develop a vaccine.

Vaccination against andalusia andalusia HAV and HBV should always indicated in patients with liver-based, as an acute hepatitis from any of these viruses on a sick liver can be fatal.

Hepatotropic virus coinfection with HIV

Shares with HIV, HBV and HCV transmission routes (especially parenterally) this makes coinfection is relatively frequent. This is an issue of this edge by having a series of special features:

• Since the introduction of highly active against HIV liver disease has become a major cause of morbidity and mortality in these patients.
• The evolution to cirrhosis is accelerated for both HBV and for HCV in HIV + patients.
• The treatment of viral hepatitis is more complex in these patients for drug interactions and hepatotoxicity phenomena.
• Response rates especially HCV with PEG-IFN and RBV are decreased in HIV + patients.