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pero no puede ser excluida&#46; Se han detectado virus en la leche materna&#44; pero en escasa cantidad&#59; este hecho&#44; junto con el pH &#225;cido del est&#243;mago&#44; que inactiva las part&#237;culas virales&#44; hace que el riesgo de transmisi&#243;n sea pr&#225;cticamente inexistente &#40;m&#225;s aun si la carga viral materna es baja y no existen grietas o lesiones en el pez&#243;n&#41;&#46; La mayor&#237;a de los estudios no encuentran relaci&#243;n entre la transmisi&#243;n del VHC y la alimentaci&#243;n&#46; Algunos autores plantean si el hecho de encontrar una primera detecci&#243;n de ARN positivo de forma tard&#237;a &#40;m&#225;s all&#225; del primer mes de vida&#41; podr&#237;a sugerir que la transmisi&#243;n ha ocurrido tras el parto&#44; pero el an&#225;lisis posterior establece que esta evoluci&#243;n sea debe a diferentes patrones de viremia m&#225;s que al momento de la transmisi&#243;n<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">El da&#241;o hep&#225;tico&#44; la adicci&#243;n a drogas por v&#237;a parenteral&#44; el recuento de linfocitos CD4&#44; el peso al nacimiento&#44; el sexo y la edad gestacional se han valorado en m&#250;ltiples estudios&#44; sin mostrar diferencias estad&#237;sticamente significativas en cuanto al riesgo de transmisi&#243;n<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a>&#46; La adicci&#243;n a drogas por v&#237;a parenteral se ha relacionado con la transmisi&#243;n en el subgrupo de mujeres sin coinfecci&#243;n VIH<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46; En 2005 se publica el primer estudio que objetiva que el riesgo de transmisi&#243;n es el doble en ni&#241;as que en ni&#241;os&#44; dato que se puede atribuir a las diferencias hormonales-gen&#233;ticas en la susceptibilidad y respuesta a la infecci&#243;n<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Generalmente&#44; los anticuerpos maternos desaparecen en el ni&#241;o entre los 6 y los 12 meses de vida&#44; pero dado que a veces persisten m&#225;s tiempo&#44; el seguimiento se mantiene hasta los 18 meses de edad&#44; para evitar sobreestimaciones&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">En el Hospital Infantil La Fe de Valencia&#44; 17 ni&#241;os fueron diagnosticados de infecci&#243;n por VHC entre los a&#241;os 1997 y 2004&#46; Durante este periodo se registraron 341 nacimientos de madres con VHC &#40;de 333 mujeres portadoras&#44; con infecci&#243;n aguda o cr&#243;nica&#41;&#46; Coincidiendo con otros estudios<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;13&#44;14</span></a>&#44; corresponde a una tasa de transmisi&#243;n de aproximadamente el 5&#37;&#46; El objetivo de esta revisi&#243;n es valorar los factores de riesgo de transmisi&#243;n vertical de VHC&#44; sobre los que podemos actuar mediante medidas de prevenci&#243;n primaria&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="par0050" class="elsevierStylePara elsevierViewall">Se trata de un estudio retrospectivo&#44; en el que se incluyen los casos de ni&#241;os diagnosticados de infecci&#243;n por VHC desde 1997 hasta 2004 en el Hospital Infantil La Fe &#40;17 casos&#41; &#40;uno de ellos no naci&#243; en este hospital y&#44; por tanto&#44; se ha excluido por la falta de datos de la historia materna&#41;&#46; Por cada caso&#44; se tomaron 3 controles&#44; definidos como mujeres con infecci&#243;n VHC que hab&#237;an sido madres en este periodo sin presentar transmisi&#243;n vertical de la infecci&#243;n&#46; Este estudio fue aprobado por el comit&#233; de &#233;tica e investigaci&#243;n de nuestro hospital&#46; En el periodo de tiempo analizado&#44; 333 mujeres con VHC &#40;portadora&#44; aguda o cr&#243;nica&#41; tuvieron hijos&#46; Uno de los casos y 10 de los controles tuvieron dos hijos en este periodo&#44; por lo que finalmente los controles incluidos fueron 59&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Se analizan&#44; como posibles factores de riesgo&#44; las siguientes caracter&#237;sticas cl&#237;nicas y microbiol&#243;gicas&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8211;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Carga viral VHC&#58; rangos&#58; &#60;<span class="elsevierStyleHsp" style=""></span>500&#46;000&#47;500&#46;000 U&#47;ml-1&#46;000&#46;000&#47;&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;000&#46;000 U&#47;ml</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Genotipo VHC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8211;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Tiempo de evoluci&#243;n VHC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8211;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Afectaci&#243;n de la funci&#243;n hep&#225;tica&#58; hipertransaminasemia&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8211;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Coinfecci&#243;n VIH&#58; carga viral&#44; estadio cl&#237;nico&#44; recuento de linfocitos CD4 &#40;rangos en base a las categor&#237;as de la clasificaci&#243;n CDC&#58;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>200&#47;200-500&#47;&#62;<span class="elsevierStyleHsp" style=""></span>500&#41;&#44; tratamiento antirretroviral&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8211;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Adicci&#243;n a drogas por v&#237;a parenteral&#44; enfermedades de transmisi&#243;n sexual&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8211;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Datos del parto&#58; forma de finalizar la gestaci&#243;n&#58; ces&#225;rea vs parto vaginal&#59; horas de bolsa rota&#59; amniocentesis previa&#44; y monitorizaci&#243;n interna&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8211;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Edad gestacional &#40;a t&#233;rmino&#47;pret&#233;rmino&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8211;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Peso al nacimiento&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8211;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Sexo del reci&#233;n nacido&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8211;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Lactancia materna&#46;</p></li></ul>En nuestro hospital&#44; todos los hijos de madre VHC son controlados en consulta externa de gastroenterolog&#237;a pedi&#225;trica&#46; El seguimiento se realiza mediante estudio de serolog&#237;a y ARN de VHC en las siguientes edades&#58; 1&#44; 3&#44; 6&#44; 9&#44; 12 y 18 meses&#46; Se considera infecci&#243;n por VHC en el ni&#241;o cuando se cumplen &#8805;<span class="elsevierStyleHsp" style=""></span>1 de los siguientes criterios&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8211;</span><p id="par0115" class="elsevierStylePara elsevierViewall">ARN positivo en &#8805;<span class="elsevierStyleHsp" style=""></span>2 muestras separadas al menos 3 meses entre s&#237;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8211;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Serolog&#237;a persiste positiva m&#225;s all&#225; de los 18 meses de edad&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8211;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Seroconversi&#243;n&#58; reaparici&#243;n de anticuerpos o aumento de su t&#237;tulo&#46;</p></li></ul></p><p id="par0130" class="elsevierStylePara elsevierViewall">La infecci&#243;n por VHC queda descartada cuando el ARN es negativo en al menos 2 muestras seguidas y la serolog&#237;a es negativa tras los 18 meses de edad&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">El cribado de la infecci&#243;n VHC se realiza mediante t&#233;cnica de enzimoinmunoensayo &#40;EIA&#41; para la detecci&#243;n de anticuerpos frente al VHC &#40;anti-VHC&#41;&#46; Estas t&#233;cnicas serol&#243;gicas han ido variando en los &#250;ltimos a&#241;os&#44; con el objetivo de mejorar la sensibilidad y la especificidad&#58; a partir del a&#241;o 1993 se empez&#243; a utilizar EIA de tercera generaci&#243;n en microplaca de INNOGENETICS&#46; En la actualidad&#44; se utilizan dos t&#233;cnicas de EIA&#58; una en microplaca &#40;HCV IV de INNOGENETICS<span class="elsevierStyleSup">&#174;</span> de cuarta generaci&#243;n&#41; y otra por quimioluminiscencia de Bayer &#40;Adviacentaur<span class="elsevierStyleSup">&#174;</span>&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">La confirmaci&#243;n serol&#243;gica se realiza mediante el empleo de ant&#237;genos adsorbidos sobre tiras de nitrocelulosa&#46; Desde el a&#241;o 1992 se utiliza la t&#233;cnica INNO-LIA de INNOGENETICS<span class="elsevierStyleSup">&#174;</span>&#58; al principio en su versi&#243;n INNO-LIA II&#44; utilizando 4 ant&#237;genos de la regi&#243;n <span class="elsevierStyleItalic">core</span> del genoma del VHC&#44; otro ant&#237;geno de la regi&#243;n que codifica la prote&#237;na no estructural NS3 y otro de la prote&#237;na no estructural NS4&#46; Posteriormente&#44; aparecieron nuevas generaciones&#44; incluyendo nuevos ant&#237;genos&#44; hasta los empleados en la actualidad&#58; INNO-LIA IV<span class="elsevierStyleSup">&#174;</span>&#44; que incluye dos ant&#237;genos del <span class="elsevierStyleItalic">core&#44;</span> un ant&#237;geno de la regi&#243;n E2&#47;NS1&#44; otro de la regi&#243;n NS3&#44; otro de la regi&#243;n NS4 y un &#250;ltimo ant&#237;geno de la regi&#243;n NS5&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">La detecci&#243;n cualitativa del ARN del VHC se realiza durante los a&#241;os noventa mediante una doble amplificaci&#243;n por reacci&#243;n en cadena de la polimerasa &#40;PCR&#41;&#44; mediante el uso de iniciadores derivados de la regi&#243;n 5&#8217;UTR del genoma viral&#46; La carga viral del VHC se determina mediante 2 m&#233;todos&#58; la prueba del ADN ramificado o bADN &#40;Quantiplex&#8482; HCV RNA 2&#46;0- 3&#46;0&#44; Chiron Corporation&#59; actualmente distribuido por Bayer&#41; &#40;expresa la carga viral en megaequivalenges&#47;ml&#41;&#44; y el Amplicor HCV Monitor&#8482; Test de Roche &#40;expresa la carga viral en copias&#47;ml&#41;&#46; Actualmente&#44; ambas expresan la carga en unidades internacionales por ml &#40;1 U&#47;ml<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#44;2 copias&#47;ml&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">El genotipo VHC se determina mediante el m&#233;todo LiPA<span class="elsevierStyleSup">&#174;</span> &#40;Line Probe Assay&#41;&#44; que permite la detecci&#243;n de los genotipos 1- 6 del VHC mediante la hibridaci&#243;n reversa en tiras de membrana del producto amplificado por PCR&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados</span><p id="par0155" class="elsevierStylePara elsevierViewall">Entre 1997 y 2004&#44; 333 mujeres con infecci&#243;n por VHC fueron madres en el Hospital Infantil La Fe&#46; Diecis&#233;is de estos ni&#241;os &#40;y un ni&#241;o m&#225;s que naci&#243; en otro hospital&#41; fueron diagnosticados en este periodo de infecci&#243;n por VHC &#40;transmisi&#243;n vertical&#41;&#46; Se estudian&#44; de forma retrospectiva&#44; estos 17 casos y 3 controles por cada caso &#40;total 59 controles debido a que 10 de los controles y 1 de los casos fueron madres de 2 hijos&#41;&#46; Las caracter&#237;sticas de esta muestra se resumen en las <a class="elsevierStyleCrossRefs" href="#tbl0005">tablas 1 y 2</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">El an&#225;lisis univariante de los posibles factores de riesgo de transmisi&#243;n vertical de VHC se realiza mediante el test exacto de Fisher en el caso de las variables categ&#243;ricas y por comparaci&#243;n de medias&#47;U de Mann-Whitney cuando se trata de variables cuantitativas &#40;la mayor&#237;a de las variables cuantitativas analizadas se han transformado en categ&#243;ricas por intervalo&#44; por presentar mayor inter&#233;s cl&#237;nico de este modo&#41; &#40;<a class="elsevierStyleCrossRefs" href="#tbl0015">tablas 3 y 4</a>&#41;&#46; Posteriormente se realiza el estudio multivariante mediante regresi&#243;n log&#237;stica de aquellas variables que en el estudio univariante se presentan como posibles factores de riesgo&#44; as&#237; como de aquellas consideradas como tales en la literatura &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Dentro de los antecedentes maternos y sus condiciones serol&#243;gicas&#44; el an&#225;lisis univariante objetiva mayor riesgo de transmisi&#243;n vertical VHC en aquellos hijos de madre con enfermedad de transmisi&#243;n sexual&#44; adictas a drogas por v&#237;a parenteral&#44; coinfectadas por VIH &#40;m&#225;s aun los estadios A1 y C3&#41;&#44; no tratadas con triple terapia antirretroviral&#44; carga viral VHC mayor de 1&#46;000&#46;000 U&#47;l y genotipo VHC 1a y 3a &#40;seguidos del tipo 1b&#41;&#44; pero estas diferencias s&#243;lo fueron estad&#237;sticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;1&#41; para la adicci&#243;n a drogas por v&#237;a parenteral y la falta de terapia antirretroviral&#46; Tras el an&#225;lisis multivariante&#44; se confirma la adicci&#243;n a drogas por v&#237;a parenteral como factor de riesgo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span> 0&#44;039&#41;&#44; sin que la coinfecci&#243;n VIH suponga un factor de confusi&#243;n&#44; y se descarta la significaci&#243;n estad&#237;stica de la falta de tratamiento antirretroviral&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">A diferencia de muchos estudios publicados&#44; no se objetiv&#243; significaci&#243;n estad&#237;stica respecto a la coinfecci&#243;n VIH ni a la carga viral VHC&#46; Este hallazgo en relaci&#243;n con la carga viral podr&#237;a explicarse por la falta de datos en esta categor&#237;a &#40;s&#243;lo hay 14 valores disponibles&#41; probablemente debido a la menor sensibilidad de la prueba en los a&#241;os iniciales de la revisi&#243;n&#44; hecho que a&#250;n m&#225;s justifica la escasez de datos referentes al genotipo&#46; Ni la disfunci&#243;n hep&#225;tica ni el tiempo de evoluci&#243;n de la infecci&#243;n VIH ni el de la hepatitis C mostraron mayor riesgo de transmisi&#243;n&#46; Aquellos con mayor n&#250;mero de linfocitos CD 4&#44; a diferencia de lo esperable&#44; presentaron en nuestro estudio un mayor porcentaje de transmisi&#243;n vertical&#44; sin que esta diferencia fuera estad&#237;sticamente significativa&#44; resultado probablemente debido a que esta variable solo se solicita en pacientes VIH positivas&#44; y los datos son escasos&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Ni el tiempo de evoluci&#243;n de la infecci&#243;n VIH ni el de la hepatitis C representan mayor riesgo&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">En cuanto a las caracter&#237;sticas del parto&#44; ni las horas de bolsa rota ni el menor peso al nacimiento suponen mayor riesgo de transmisi&#243;n&#46; Respecto a la forma de finalizar la gestaci&#243;n&#44; la ces&#225;rea no solo no se muestra como protector&#44; sino incluso supone un mayor riesgo&#44; aunque tampoco de forma significativa&#46; El riesgo es mayor en aquellos en los que se realiz&#243; amniocentesis&#44; monitorizaci&#243;n interna y en las ni&#241;as&#44; pero esta diferencia no presenta significaci&#243;n estad&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;1&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">La lactancia materna no se mostr&#243; como factor de riesgo&#44; sino protector&#44; con un nivel de significaci&#243;n l&#237;mite &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;056&#41; en el an&#225;lisis multivariante&#44; y descartando la infecci&#243;n por VIH y la adicci&#243;n a drogas por v&#237;a parenteral como posibles factores de confusi&#243;n&#46; Las ventajas inmunol&#243;gicas de la leche materna superar&#237;an&#44; por tanto&#44; el escaso riesgo que podr&#237;a suponer la existencia en ella de escasa carga viral VHC&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Las caracter&#237;sticas del estudio hacen que tenga un poder estad&#237;stico del 80&#37;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><p id="par0195" class="elsevierStylePara elsevierViewall">A pesar de que parece importante la relaci&#243;n de la carga viral con el riesgo de transmisi&#243;n vertical del virus de hepatitis C&#44; este efecto no est&#225; claramente establecido&#46; Nuestra revisi&#243;n apoya el hecho&#44; ya objetivado en otros estudios<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;16</span></a>&#44; de que la ausencia de viremia no descarta el riesgo de transmisi&#243;n<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> debido a que la detecci&#243;n de ARN viral puede ser intermitente durante la gestaci&#243;n y a que la sensibilidad de la t&#233;cnica no es del 100&#37; &#40;todav&#237;a menor en los primeros a&#241;os de nuestra revisi&#243;n&#59; y esto justificar&#237;a que el estudio de carga viral no se solicitara en muchos casos&#44; y que fuera negativa en algunos otros&#41;&#46; Por todo ello&#44; los datos al respecto de la carga viral deben ser interpretados con mucha cautela&#46; Aquellas mujeres seropositivas VHC con ARN negativo &#40;comprobado con varias muestras&#41; probablemente correspondan a casos que han aclarado el virus&#46; En este sentido&#44; la coinfecci&#243;n por VIH supone una situaci&#243;n de inmunosupresi&#243;n y&#44; por tanto&#44; de menor capacidad de aclaramiento viral&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">El papel de los diferentes genotipos es dif&#237;cil de establecer&#44; dado que en muchos casos no se ha solicitado o no se ha podido realizar por ser necesario cierto grado de viremia&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">En la mayor&#237;a de estudios publicados se objetiva una clara relaci&#243;n de la transmisi&#243;n con la coinfecci&#243;n VIH&#44; achacada a la inmunosupresi&#243;n&#59; ahora bien&#44; un estudio publicado en 2005 demuestra que la coinfecci&#243;n supone un aumento de riesgo de transmisi&#243;n pero no de forma estad&#237;sticamente significativa<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#44; al igual que ocurre en nuestra revisi&#243;n&#46; Esta diferencia con el resto de estudios publicados puede deberse al efecto del tratamiento antirretroviral&#44; capaz de mejorar la capacidad inmunitaria del organismo para disminuir la carga viral VHC&#46; Estos datos estar&#237;an tambi&#233;n apoyados por los resultados de un metaan&#225;lisis publicado en 2003&#44; ya mencionado&#44; que s&#237; establece la coinfecci&#243;n por el VIH como factor de riesgo en la transmisi&#243;n del VHC&#44; pero pone de manifiesto que su efecto es menos pronunciado cuando solo se incluye a aquellas mujeres con viremia VHC detectable<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">La adicci&#243;n a drogas por v&#237;a parenteral se pone de manifiesto como factor de riesgo de transmisi&#243;n de hepatitis C&#44; incluso tras descartar la posible influencia de la coinfecci&#243;n VIH como factor de confusi&#243;n&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Respecto a las caracter&#237;sticas del parto&#44; el tiempo transcurrido tras la rotura de membranas no ha mostrado ser un factor de riesgo&#59; la ces&#225;rea&#44; lejos de ser protectora&#44; ha mostrado mayor riesgo de transmisi&#243;n&#44; aunque de forma no significativa&#59; por lo que se desestimar&#237;a como forma electiva de finalizar la gestaci&#243;n de mujeres con VHC&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">La relaci&#243;n de la lactancia materna con la transmisi&#243;n de VHC es un tema debatido&#46; Nuestros resultados confirman que la leche materna&#44; a pesar de poder contener virus&#44; no supone mayor riesgo de transmisi&#243;n&#44; es m&#225;s&#44; puede ser protector &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;056&#41;&#46; La escasa carga viral en la leche&#44; su inactivaci&#243;n por el pH &#225;cido del est&#243;mago y los beneficios inmunol&#243;gicos de la lactancia materna justificar&#237;an este resultado&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">La frecuencia de valores perdidos supone una gran limitaci&#243;n de los estudios retrospectivos&#44; dificultando la obtenci&#243;n de hallazgos significativos al respecto de algunas variables&#44; como es el caso de la carga viral&#46; Por tanto&#44; ser&#237;a necesario plantear estudios prospectivos con intenci&#243;n de conocer el papel de estos factores y poder establecer pautas m&#225;s claras de prevenci&#243;n en la transmisi&#243;n de VHC&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Dada la posible evoluci&#243;n a cirrosis o hepatocarcinoma&#44; la infecci&#243;n por el VHC constituye un importante problema de salud&#46; Por tanto&#44; es fundamental el control de su transmisi&#243;n vertical&#44; v&#237;a fundamental de adquirir la infecci&#243;n en la infancia&#46; De los factores analizados&#44; s&#243;lo la adicci&#243;n a drogas por v&#237;a parenteral muestra un aumento de riesgo con significaci&#243;n estad&#237;stica&#46; La influencia de la carga viral no est&#225; clara&#44; ahora bien&#44; se ha demostrado que la ausencia de viremia no descarta la transmisi&#243;n&#44; dado que la detecci&#243;n de ARN viral es intermitente durante la gestaci&#243;n&#46; La coinfecci&#243;n por el VIH no muestra aumento de riesgo estad&#237;sticamente significativo&#46; La ces&#225;rea no supone disminuci&#243;n del riesgo de transmisi&#243;n y&#44; por tanto&#44; no estar&#237;a indicada de forma electiva para finalizar la gestaci&#243;n&#46; La lactancia materna se comporta como factor protector en nuestra revisi&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;056&#41;&#46; Debido a las limitaciones de los estudios retrospectivos&#44; ser&#237;a necesario plantear an&#225;lisis prospectivos para conocer mejor el papel de los posibles factores de riesgo y establecer pautas claras de prevenci&#243;n en la transmisi&#243;n vertical de esta infecci&#243;n&#59; de momento&#44; es fundamental el control evolutivo de todos los hijos de madres con infecci&#243;n por el VHC&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicto de intereses</span><p id="par0235" class="elsevierStylePara elsevierViewall">Los autores declaran que no existe ning&#250;n conflicto de intereses&#46;</p></span></span>"
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            0 => "Abstract"
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          "titulo" => "Conflicto de intereses"
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          "titulo" => "Bibliograf&#237;a"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2011-05-03"
    "fechaAceptado" => "2011-11-13"
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          "identificador" => "xpalclavsec93873"
          "palabras" => array:6 [
            0 => "Ces&#225;rea"
            1 => "Coinfecci&#243;n"
            2 => "Lactancia materna"
            3 => "Transmisi&#243;n vertical"
            4 => "Virus de la hepatitis C"
            5 => "Virus de la inmunodeficiencia humana"
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          "clase" => "keyword"
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          "palabras" => array:5 [
            0 => "Caesarean section"
            1 => "Breast feeding"
            2 => "Hepatitis C virus"
            3 => "HIV-co-infection"
            4 => "Vertical infection transmission"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A pesar de la baja prevalencia infantil de infecci&#243;n por virus hepatitis C &#40;VHC&#41; y su leve cl&#237;nica inicial&#44; la infecci&#243;n cr&#243;nica puede evolucionar a cirrosis y&#47;o hepatocarcinoma&#46; Es fundamental controlar su transmisi&#243;n vertical&#46; Los &#250;ltimos estudios describen hasta 50&#37; de transmisiones intra&#250;tero&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudiamos retrospectivamente 17 casos de infecci&#243;n por VHC en 8 a&#241;os&#44; analizando los factores de riesgo de transmisi&#243;n vertical&#44; para aplicar prevenci&#243;n primaria&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Solo la adicci&#243;n a drogas v&#237;a parenteral muestra riesgo significativo&#44; sin ser la coinfecci&#243;n VIH factor de confusi&#243;n&#46; La carga viral&#44; la coinfecci&#243;n por VIH&#44; la disfunci&#243;n hep&#225;tica y el tiempo de evoluci&#243;n de infecci&#243;n no muestran mayor riesgo&#46; La ces&#225;rea&#44; la amniocentesis y la monitorizaci&#243;n interna pueden ser factores de riesgo &#40;sin significaci&#243;n estad&#237;stica&#41;&#44; pero no las horas de amniorrexis&#46; La lactancia materna muestra protecci&#243;n&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pese a la importancia frecuentemente atribuida&#44; el efecto de la carga viral sobre el riesgo de transmisi&#243;n no est&#225; claramente establecido&#58; la ausencia de viremia no descarta el riesgo de transmisi&#243;n&#44; ya que la detecci&#243;n de ARN viral puede ser intermitente&#44; y por tanto&#44; los datos al respecto deben interpretarse con cautela&#46; La inmunosupresi&#243;n secundaria a la coinfecci&#243;n por VIH supone mayor riesgo de transmisi&#243;n&#44; pero dicho efecto disminuye al mejorar la capacidad inmune gracias al tratamiento antirretroviral&#46; Respecto a las caracter&#237;sticas del parto&#44; el tiempo transcurrido tras la rotura de membranas no ha mostrado ser factor de riesgo&#59; y se desestima la ces&#225;rea como forma &#243;ptima y electiva de finalizar la gestaci&#243;n de estas mujeres&#46; La lactancia materna&#44; lejos de suponer mayor riesgo de transmisi&#243;n&#44; puede ser protectora&#46; La escasa carga viral en la leche&#44; su inactivaci&#243;n por el pH &#225;cido g&#225;strico y sus beneficios inmunol&#243;gicos justificar&#237;an este resultado&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Dadas las limitaciones de los estudios retrospectivos&#44; es necesario plantear an&#225;lisis prospectivos para conocer mejor el papel de los posibles factores de riesgo y establecer pautas claras de prevenci&#243;n&#59; de momento&#44; es fundamental el control evolutivo de todos los hijos de madres con infecci&#243;n por el VHC&#46;</p>"
      ]
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Despite the low prevalence of paediatric HCV infection and its initial mild clinical expressiveness&#44; chronic infection could progress into cirrhosis and&#47;or hepatocarcinoma&#46; It is essential to control vertical transmission&#46; Recent studies show that up to 50&#37; of transmissions occur within the uterus&#46;</p> <span class="elsevierStyleSectionTitle">Material y methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was conducted on 17 cases of &#40;Hepatitis<span class="elsevierStyleHsp" style=""></span>C virus&#41; HCV infection registered over a period of 8 years&#46; Vertical transmission risk factors were analysed&#44; in order to introduce primary prevention&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Only parenteral drug addiction significantly increased the rate of HCV transmission&#59; HIV co-infection was not a confounding factor&#46; HCV viremia&#44; HIV co-infection&#44; liver dysfunction and&#47;or duration of the infection did not appear to affect the rate of transmission&#46; Caesarean section&#44; amniocentesis and internal monitoring may be risk factors &#40;not statistically significant&#41;&#44; but not prolonged vaginal delivery after amniotic membrane rupture&#46; Breastfeeding showed protection&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The effect of viremia on the risk of transmission is not clearly established&#44; despite the importance usually attributed&#46; Lack of viremia does not discount the risk of transmission&#44; due to viral RNA detection can be intermittent&#44; so it should be interpreted cautiously&#46; Immunosuppression secondary to HIV co-infection implies a higher risk of transmission&#44; but this effect decreases by improving immune competence by antiretroviral treatment&#46; With regard to the birth characteristics&#44; time after the rupture of membranes has not shown being a risk factor&#59; being the caesarean not advisable as a good alternative to finish the pregnancy&#46; Breastfeeding does not increase the risk&#44; even it can be protective&#46; This results would be justified by the low viral content of milk&#44; its inactivation by gastric pH and its immunological benefits&#46;</p><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Given that retrospective studies results are limited&#44; prospective studies need to be carried out in order to improve the understanding of the role of possible risk factors and to provide a clear preventive guidelines&#46; At the moment it is essential to control all the children born of mothers with HCV infection&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleBold">Genotipo VHC</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Funci&#243;n hep&#225;tica</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">GPT &#40;UI&#47;l&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">40 U&#47;l</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9&#44;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t  " colspan="3" align="char" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Carga viral VHC &#40;10</span><span class="elsevierStyleSup"><span class="elsevierStyleBold">3</span></span><span class="elsevierStyleBold">U&#47;ml&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">500&#8211;1&#46;000</span>&nbsp;\t\t\t\t\t\t\n
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Original
Estudio retrospectivo de factores de riesgo de transmisión vertical de infección por virus hepatitis C
Retrospective study of risk factors of vertical transmission of hepatitis C virus
P. Madurga Revillaa,
Autor para correspondencia
paumare@hotmail.com

Autor para correspondencia.
, M. Aguar Carrascosab, A. Pereda Pérezc, V. Modesto Alapontd, A. Montañés Sáncheze, E. Torres Martínezb, M. Brugada Montanterb, S. León Cariñenaf
a Unidad de Cuidados Intensivos Pediátricos, Hospital Infantil Miguel Servet, Zaragoza, España
b Servicio de Neonatología, Hospital Infantil La Fe, Valencia, España
c Servicio de Gastroenterología Pediátrica, Hospital Infantil La Fe, Valencia, España
d Unidad de Cuidados Intensivos Pediátricos, Hospital Infantil La Fe, Valencia, España
e Pediatría de atención primaria, Castellón, España
f Servicio de Endocrinología Pediátrica, Hospital Infantil La Fe, Valencia, España
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ahora bien&#44; en 2005 se publica un estudio en el que&#44; a pesar de que se objetiva mayor riesgo de transmisi&#243;n vertical VHC en aquellos casos de coinfecci&#243;n VIH&#44; este efecto no muestra significaci&#243;n estad&#237;stica en el an&#225;lisis multivariante<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; El riesgo de transmisi&#243;n es extremadamente bajo si el ARN viral no es detectable<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a>&#44; pero es posible<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;9-11</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Tradicionalmente se ha considerado que la transmisi&#243;n ocurre en el momento del parto&#44; aunque los &#250;ltimos estudios consideran que hasta el 50&#37; de las transmisiones pueden ocurrir intra&#250;tero<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#46; Cuando la detecci&#243;n de ARN viral es positiva en los primeros 3 d&#237;as de vida&#44; se considera que la transmisi&#243;n ha ocurrido intra&#250;tero<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; Ahora bien&#44; hay casos de negatividad en este primer control de ARN que tambi&#233;n han adquirido la infecci&#243;n intra&#250;tero&#44; pero con niveles de viremia bajos&#44; y no detectables con la t&#233;cnica de PCR empleada<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; Dada la dificultad en la interpretaci&#243;n de la PCR temprana&#44; las conclusiones no est&#225;n claras en cuanto al efecto del modo de finalizar la gestaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46; Existe un peque&#241;o estudio publicado en 2000 que plantea el potencial beneficio de la ces&#225;rea electiva con membranas intactas<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#59; pero este efecto protector de la ces&#225;rea frente al parto vaginal no se ha confirmado en estudios posteriores<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;9</span></a>&#44; incluida una revisi&#243;n Cochrane publicada en 2010<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#44; por lo que la infecci&#243;n por el VHC no es indicaci&#243;n de ces&#225;rea de forma electiva&#46; En este sentido&#44; algunos estudios muestran como factores de riesgo de transmisi&#243;n el tiempo transcurrido desde la rotura de membranas&#44; as&#237; como la monitorizaci&#243;n interna&#44; proponiendo la ces&#225;rea en aquellos casos en los que se prolonga el tiempo tras la rotura de membranas&#44; pero no se establece cu&#225;l es el tiempo l&#237;mite<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">La posibilidad de transmisi&#243;n tras el parto es rara&#44; pero no puede ser excluida&#46; Se han detectado virus en la leche materna&#44; pero en escasa cantidad&#59; este hecho&#44; junto con el pH &#225;cido del est&#243;mago&#44; que inactiva las part&#237;culas virales&#44; hace que el riesgo de transmisi&#243;n sea pr&#225;cticamente inexistente &#40;m&#225;s aun si la carga viral materna es baja y no existen grietas o lesiones en el pez&#243;n&#41;&#46; La mayor&#237;a de los estudios no encuentran relaci&#243;n entre la transmisi&#243;n del VHC y la alimentaci&#243;n&#46; Algunos autores plantean si el hecho de encontrar una primera detecci&#243;n de ARN positivo de forma tard&#237;a &#40;m&#225;s all&#225; del primer mes de vida&#41; podr&#237;a sugerir que la transmisi&#243;n ha ocurrido tras el parto&#44; pero el an&#225;lisis posterior establece que esta evoluci&#243;n sea debe a diferentes patrones de viremia m&#225;s que al momento de la transmisi&#243;n<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">El da&#241;o hep&#225;tico&#44; la adicci&#243;n a drogas por v&#237;a parenteral&#44; el recuento de linfocitos CD4&#44; el peso al nacimiento&#44; el sexo y la edad gestacional se han valorado en m&#250;ltiples estudios&#44; sin mostrar diferencias estad&#237;sticamente significativas en cuanto al riesgo de transmisi&#243;n<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a>&#46; La adicci&#243;n a drogas por v&#237;a parenteral se ha relacionado con la transmisi&#243;n en el subgrupo de mujeres sin coinfecci&#243;n VIH<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46; En 2005 se publica el primer estudio que objetiva que el riesgo de transmisi&#243;n es el doble en ni&#241;as que en ni&#241;os&#44; dato que se puede atribuir a las diferencias hormonales-gen&#233;ticas en la susceptibilidad y respuesta a la infecci&#243;n<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Generalmente&#44; los anticuerpos maternos desaparecen en el ni&#241;o entre los 6 y los 12 meses de vida&#44; pero dado que a veces persisten m&#225;s tiempo&#44; el seguimiento se mantiene hasta los 18 meses de edad&#44; para evitar sobreestimaciones&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">En el Hospital Infantil La Fe de Valencia&#44; 17 ni&#241;os fueron diagnosticados de infecci&#243;n por VHC entre los a&#241;os 1997 y 2004&#46; Durante este periodo se registraron 341 nacimientos de madres con VHC &#40;de 333 mujeres portadoras&#44; con infecci&#243;n aguda o cr&#243;nica&#41;&#46; Coincidiendo con otros estudios<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;13&#44;14</span></a>&#44; corresponde a una tasa de transmisi&#243;n de aproximadamente el 5&#37;&#46; El objetivo de esta revisi&#243;n es valorar los factores de riesgo de transmisi&#243;n vertical de VHC&#44; sobre los que podemos actuar mediante medidas de prevenci&#243;n primaria&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="par0050" class="elsevierStylePara elsevierViewall">Se trata de un estudio retrospectivo&#44; en el que se incluyen los casos de ni&#241;os diagnosticados de infecci&#243;n por VHC desde 1997 hasta 2004 en el Hospital Infantil La Fe &#40;17 casos&#41; &#40;uno de ellos no naci&#243; en este hospital y&#44; por tanto&#44; se ha excluido por la falta de datos de la historia materna&#41;&#46; Por cada caso&#44; se tomaron 3 controles&#44; definidos como mujeres con infecci&#243;n VHC que hab&#237;an sido madres en este periodo sin presentar transmisi&#243;n vertical de la infecci&#243;n&#46; Este estudio fue aprobado por el comit&#233; de &#233;tica e investigaci&#243;n de nuestro hospital&#46; En el periodo de tiempo analizado&#44; 333 mujeres con VHC &#40;portadora&#44; aguda o cr&#243;nica&#41; tuvieron hijos&#46; Uno de los casos y 10 de los controles tuvieron dos hijos en este periodo&#44; por lo que finalmente los controles incluidos fueron 59&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Se analizan&#44; como posibles factores de riesgo&#44; las siguientes caracter&#237;sticas cl&#237;nicas y microbiol&#243;gicas&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8211;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Carga viral VHC&#58; rangos&#58; &#60;<span class="elsevierStyleHsp" style=""></span>500&#46;000&#47;500&#46;000 U&#47;ml-1&#46;000&#46;000&#47;&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;000&#46;000 U&#47;ml</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Genotipo VHC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8211;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Tiempo de evoluci&#243;n VHC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8211;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Afectaci&#243;n de la funci&#243;n hep&#225;tica&#58; hipertransaminasemia&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8211;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Coinfecci&#243;n VIH&#58; carga viral&#44; estadio cl&#237;nico&#44; recuento de linfocitos CD4 &#40;rangos en base a las categor&#237;as de la clasificaci&#243;n CDC&#58;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>200&#47;200-500&#47;&#62;<span class="elsevierStyleHsp" style=""></span>500&#41;&#44; tratamiento antirretroviral&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8211;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Adicci&#243;n a drogas por v&#237;a parenteral&#44; enfermedades de transmisi&#243;n sexual&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8211;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Datos del parto&#58; forma de finalizar la gestaci&#243;n&#58; ces&#225;rea vs parto vaginal&#59; horas de bolsa rota&#59; amniocentesis previa&#44; y monitorizaci&#243;n interna&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8211;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Edad gestacional &#40;a t&#233;rmino&#47;pret&#233;rmino&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8211;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Peso al nacimiento&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8211;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Sexo del reci&#233;n nacido&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8211;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Lactancia materna&#46;</p></li></ul>En nuestro hospital&#44; todos los hijos de madre VHC son controlados en consulta externa de gastroenterolog&#237;a pedi&#225;trica&#46; El seguimiento se realiza mediante estudio de serolog&#237;a y ARN de VHC en las siguientes edades&#58; 1&#44; 3&#44; 6&#44; 9&#44; 12 y 18 meses&#46; Se considera infecci&#243;n por VHC en el ni&#241;o cuando se cumplen &#8805;<span class="elsevierStyleHsp" style=""></span>1 de los siguientes criterios&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8211;</span><p id="par0115" class="elsevierStylePara elsevierViewall">ARN positivo en &#8805;<span class="elsevierStyleHsp" style=""></span>2 muestras separadas al menos 3 meses entre s&#237;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8211;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Serolog&#237;a persiste positiva m&#225;s all&#225; de los 18 meses de edad&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8211;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Seroconversi&#243;n&#58; reaparici&#243;n de anticuerpos o aumento de su t&#237;tulo&#46;</p></li></ul></p><p id="par0130" class="elsevierStylePara elsevierViewall">La infecci&#243;n por VHC queda descartada cuando el ARN es negativo en al menos 2 muestras seguidas y la serolog&#237;a es negativa tras los 18 meses de edad&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">El cribado de la infecci&#243;n VHC se realiza mediante t&#233;cnica de enzimoinmunoensayo &#40;EIA&#41; para la detecci&#243;n de anticuerpos frente al VHC &#40;anti-VHC&#41;&#46; Estas t&#233;cnicas serol&#243;gicas han ido variando en los &#250;ltimos a&#241;os&#44; con el objetivo de mejorar la sensibilidad y la especificidad&#58; a partir del a&#241;o 1993 se empez&#243; a utilizar EIA de tercera generaci&#243;n en microplaca de INNOGENETICS&#46; En la actualidad&#44; se utilizan dos t&#233;cnicas de EIA&#58; una en microplaca &#40;HCV IV de INNOGENETICS<span class="elsevierStyleSup">&#174;</span> de cuarta generaci&#243;n&#41; y otra por quimioluminiscencia de Bayer &#40;Adviacentaur<span class="elsevierStyleSup">&#174;</span>&#41;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">La confirmaci&#243;n serol&#243;gica se realiza mediante el empleo de ant&#237;genos adsorbidos sobre tiras de nitrocelulosa&#46; Desde el a&#241;o 1992 se utiliza la t&#233;cnica INNO-LIA de INNOGENETICS<span class="elsevierStyleSup">&#174;</span>&#58; al principio en su versi&#243;n INNO-LIA II&#44; utilizando 4 ant&#237;genos de la regi&#243;n <span class="elsevierStyleItalic">core</span> del genoma del VHC&#44; otro ant&#237;geno de la regi&#243;n que codifica la prote&#237;na no estructural NS3 y otro de la prote&#237;na no estructural NS4&#46; Posteriormente&#44; aparecieron nuevas generaciones&#44; incluyendo nuevos ant&#237;genos&#44; hasta los empleados en la actualidad&#58; INNO-LIA IV<span class="elsevierStyleSup">&#174;</span>&#44; que incluye dos ant&#237;genos del <span class="elsevierStyleItalic">core&#44;</span> un ant&#237;geno de la regi&#243;n E2&#47;NS1&#44; otro de la regi&#243;n NS3&#44; otro de la regi&#243;n NS4 y un &#250;ltimo ant&#237;geno de la regi&#243;n NS5&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">La detecci&#243;n cualitativa del ARN del VHC se realiza durante los a&#241;os noventa mediante una doble amplificaci&#243;n por reacci&#243;n en cadena de la polimerasa &#40;PCR&#41;&#44; mediante el uso de iniciadores derivados de la regi&#243;n 5&#8217;UTR del genoma viral&#46; La carga viral del VHC se determina mediante 2 m&#233;todos&#58; la prueba del ADN ramificado o bADN &#40;Quantiplex&#8482; HCV RNA 2&#46;0- 3&#46;0&#44; Chiron Corporation&#59; actualmente distribuido por Bayer&#41; &#40;expresa la carga viral en megaequivalenges&#47;ml&#41;&#44; y el Amplicor HCV Monitor&#8482; Test de Roche &#40;expresa la carga viral en copias&#47;ml&#41;&#46; Actualmente&#44; ambas expresan la carga en unidades internacionales por ml &#40;1 U&#47;ml<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#44;2 copias&#47;ml&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">El genotipo VHC se determina mediante el m&#233;todo LiPA<span class="elsevierStyleSup">&#174;</span> &#40;Line Probe Assay&#41;&#44; que permite la detecci&#243;n de los genotipos 1- 6 del VHC mediante la hibridaci&#243;n reversa en tiras de membrana del producto amplificado por PCR&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Resultados</span><p id="par0155" class="elsevierStylePara elsevierViewall">Entre 1997 y 2004&#44; 333 mujeres con infecci&#243;n por VHC fueron madres en el Hospital Infantil La Fe&#46; Diecis&#233;is de estos ni&#241;os &#40;y un ni&#241;o m&#225;s que naci&#243; en otro hospital&#41; fueron diagnosticados en este periodo de infecci&#243;n por VHC &#40;transmisi&#243;n vertical&#41;&#46; Se estudian&#44; de forma retrospectiva&#44; estos 17 casos y 3 controles por cada caso &#40;total 59 controles debido a que 10 de los controles y 1 de los casos fueron madres de 2 hijos&#41;&#46; Las caracter&#237;sticas de esta muestra se resumen en las <a class="elsevierStyleCrossRefs" href="#tbl0005">tablas 1 y 2</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">El an&#225;lisis univariante de los posibles factores de riesgo de transmisi&#243;n vertical de VHC se realiza mediante el test exacto de Fisher en el caso de las variables categ&#243;ricas y por comparaci&#243;n de medias&#47;U de Mann-Whitney cuando se trata de variables cuantitativas &#40;la mayor&#237;a de las variables cuantitativas analizadas se han transformado en categ&#243;ricas por intervalo&#44; por presentar mayor inter&#233;s cl&#237;nico de este modo&#41; &#40;<a class="elsevierStyleCrossRefs" href="#tbl0015">tablas 3 y 4</a>&#41;&#46; Posteriormente se realiza el estudio multivariante mediante regresi&#243;n log&#237;stica de aquellas variables que en el estudio univariante se presentan como posibles factores de riesgo&#44; as&#237; como de aquellas consideradas como tales en la literatura &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Dentro de los antecedentes maternos y sus condiciones serol&#243;gicas&#44; el an&#225;lisis univariante objetiva mayor riesgo de transmisi&#243;n vertical VHC en aquellos hijos de madre con enfermedad de transmisi&#243;n sexual&#44; adictas a drogas por v&#237;a parenteral&#44; coinfectadas por VIH &#40;m&#225;s aun los estadios A1 y C3&#41;&#44; no tratadas con triple terapia antirretroviral&#44; carga viral VHC mayor de 1&#46;000&#46;000 U&#47;l y genotipo VHC 1a y 3a &#40;seguidos del tipo 1b&#41;&#44; pero estas diferencias s&#243;lo fueron estad&#237;sticamente significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;1&#41; para la adicci&#243;n a drogas por v&#237;a parenteral y la falta de terapia antirretroviral&#46; Tras el an&#225;lisis multivariante&#44; se confirma la adicci&#243;n a drogas por v&#237;a parenteral como factor de riesgo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span> 0&#44;039&#41;&#44; sin que la coinfecci&#243;n VIH suponga un factor de confusi&#243;n&#44; y se descarta la significaci&#243;n estad&#237;stica de la falta de tratamiento antirretroviral&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">A diferencia de muchos estudios publicados&#44; no se objetiv&#243; significaci&#243;n estad&#237;stica respecto a la coinfecci&#243;n VIH ni a la carga viral VHC&#46; Este hallazgo en relaci&#243;n con la carga viral podr&#237;a explicarse por la falta de datos en esta categor&#237;a &#40;s&#243;lo hay 14 valores disponibles&#41; probablemente debido a la menor sensibilidad de la prueba en los a&#241;os iniciales de la revisi&#243;n&#44; hecho que a&#250;n m&#225;s justifica la escasez de datos referentes al genotipo&#46; Ni la disfunci&#243;n hep&#225;tica ni el tiempo de evoluci&#243;n de la infecci&#243;n VIH ni el de la hepatitis C mostraron mayor riesgo de transmisi&#243;n&#46; Aquellos con mayor n&#250;mero de linfocitos CD 4&#44; a diferencia de lo esperable&#44; presentaron en nuestro estudio un mayor porcentaje de transmisi&#243;n vertical&#44; sin que esta diferencia fuera estad&#237;sticamente significativa&#44; resultado probablemente debido a que esta variable solo se solicita en pacientes VIH positivas&#44; y los datos son escasos&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Ni el tiempo de evoluci&#243;n de la infecci&#243;n VIH ni el de la hepatitis C representan mayor riesgo&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">En cuanto a las caracter&#237;sticas del parto&#44; ni las horas de bolsa rota ni el menor peso al nacimiento suponen mayor riesgo de transmisi&#243;n&#46; Respecto a la forma de finalizar la gestaci&#243;n&#44; la ces&#225;rea no solo no se muestra como protector&#44; sino incluso supone un mayor riesgo&#44; aunque tampoco de forma significativa&#46; El riesgo es mayor en aquellos en los que se realiz&#243; amniocentesis&#44; monitorizaci&#243;n interna y en las ni&#241;as&#44; pero esta diferencia no presenta significaci&#243;n estad&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;1&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">La lactancia materna no se mostr&#243; como factor de riesgo&#44; sino protector&#44; con un nivel de significaci&#243;n l&#237;mite &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;056&#41; en el an&#225;lisis multivariante&#44; y descartando la infecci&#243;n por VIH y la adicci&#243;n a drogas por v&#237;a parenteral como posibles factores de confusi&#243;n&#46; Las ventajas inmunol&#243;gicas de la leche materna superar&#237;an&#44; por tanto&#44; el escaso riesgo que podr&#237;a suponer la existencia en ella de escasa carga viral VHC&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Las caracter&#237;sticas del estudio hacen que tenga un poder estad&#237;stico del 80&#37;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discusi&#243;n</span><p id="par0195" class="elsevierStylePara elsevierViewall">A pesar de que parece importante la relaci&#243;n de la carga viral con el riesgo de transmisi&#243;n vertical del virus de hepatitis C&#44; este efecto no est&#225; claramente establecido&#46; Nuestra revisi&#243;n apoya el hecho&#44; ya objetivado en otros estudios<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;16</span></a>&#44; de que la ausencia de viremia no descarta el riesgo de transmisi&#243;n<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> debido a que la detecci&#243;n de ARN viral puede ser intermitente durante la gestaci&#243;n y a que la sensibilidad de la t&#233;cnica no es del 100&#37; &#40;todav&#237;a menor en los primeros a&#241;os de nuestra revisi&#243;n&#59; y esto justificar&#237;a que el estudio de carga viral no se solicitara en muchos casos&#44; y que fuera negativa en algunos otros&#41;&#46; Por todo ello&#44; los datos al respecto de la carga viral deben ser interpretados con mucha cautela&#46; Aquellas mujeres seropositivas VHC con ARN negativo &#40;comprobado con varias muestras&#41; probablemente correspondan a casos que han aclarado el virus&#46; En este sentido&#44; la coinfecci&#243;n por VIH supone una situaci&#243;n de inmunosupresi&#243;n y&#44; por tanto&#44; de menor capacidad de aclaramiento viral&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">El papel de los diferentes genotipos es dif&#237;cil de establecer&#44; dado que en muchos casos no se ha solicitado o no se ha podido realizar por ser necesario cierto grado de viremia&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">En la mayor&#237;a de estudios publicados se objetiva una clara relaci&#243;n de la transmisi&#243;n con la coinfecci&#243;n VIH&#44; achacada a la inmunosupresi&#243;n&#59; ahora bien&#44; un estudio publicado en 2005 demuestra que la coinfecci&#243;n supone un aumento de riesgo de transmisi&#243;n pero no de forma estad&#237;sticamente significativa<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#44; al igual que ocurre en nuestra revisi&#243;n&#46; Esta diferencia con el resto de estudios publicados puede deberse al efecto del tratamiento antirretroviral&#44; capaz de mejorar la capacidad inmunitaria del organismo para disminuir la carga viral VHC&#46; Estos datos estar&#237;an tambi&#233;n apoyados por los resultados de un metaan&#225;lisis publicado en 2003&#44; ya mencionado&#44; que s&#237; establece la coinfecci&#243;n por el VIH como factor de riesgo en la transmisi&#243;n del VHC&#44; pero pone de manifiesto que su efecto es menos pronunciado cuando solo se incluye a aquellas mujeres con viremia VHC detectable<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">La adicci&#243;n a drogas por v&#237;a parenteral se pone de manifiesto como factor de riesgo de transmisi&#243;n de hepatitis C&#44; incluso tras descartar la posible influencia de la coinfecci&#243;n VIH como factor de confusi&#243;n&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Respecto a las caracter&#237;sticas del parto&#44; el tiempo transcurrido tras la rotura de membranas no ha mostrado ser un factor de riesgo&#59; la ces&#225;rea&#44; lejos de ser protectora&#44; ha mostrado mayor riesgo de transmisi&#243;n&#44; aunque de forma no significativa&#59; por lo que se desestimar&#237;a como forma electiva de finalizar la gestaci&#243;n de mujeres con VHC&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">La relaci&#243;n de la lactancia materna con la transmisi&#243;n de VHC es un tema debatido&#46; Nuestros resultados confirman que la leche materna&#44; a pesar de poder contener virus&#44; no supone mayor riesgo de transmisi&#243;n&#44; es m&#225;s&#44; puede ser protector &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;056&#41;&#46; La escasa carga viral en la leche&#44; su inactivaci&#243;n por el pH &#225;cido del est&#243;mago y los beneficios inmunol&#243;gicos de la lactancia materna justificar&#237;an este resultado&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">La frecuencia de valores perdidos supone una gran limitaci&#243;n de los estudios retrospectivos&#44; dificultando la obtenci&#243;n de hallazgos significativos al respecto de algunas variables&#44; como es el caso de la carga viral&#46; Por tanto&#44; ser&#237;a necesario plantear estudios prospectivos con intenci&#243;n de conocer el papel de estos factores y poder establecer pautas m&#225;s claras de prevenci&#243;n en la transmisi&#243;n de VHC&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Dada la posible evoluci&#243;n a cirrosis o hepatocarcinoma&#44; la infecci&#243;n por el VHC constituye un importante problema de salud&#46; Por tanto&#44; es fundamental el control de su transmisi&#243;n vertical&#44; v&#237;a fundamental de adquirir la infecci&#243;n en la infancia&#46; De los factores analizados&#44; s&#243;lo la adicci&#243;n a drogas por v&#237;a parenteral muestra un aumento de riesgo con significaci&#243;n estad&#237;stica&#46; La influencia de la carga viral no est&#225; clara&#44; ahora bien&#44; se ha demostrado que la ausencia de viremia no descarta la transmisi&#243;n&#44; dado que la detecci&#243;n de ARN viral es intermitente durante la gestaci&#243;n&#46; La coinfecci&#243;n por el VIH no muestra aumento de riesgo estad&#237;sticamente significativo&#46; La ces&#225;rea no supone disminuci&#243;n del riesgo de transmisi&#243;n y&#44; por tanto&#44; no estar&#237;a indicada de forma electiva para finalizar la gestaci&#243;n&#46; La lactancia materna se comporta como factor protector en nuestra revisi&#243;n &#40;p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;056&#41;&#46; Debido a las limitaciones de los estudios retrospectivos&#44; ser&#237;a necesario plantear an&#225;lisis prospectivos para conocer mejor el papel de los posibles factores de riesgo y establecer pautas claras de prevenci&#243;n en la transmisi&#243;n vertical de esta infecci&#243;n&#59; de momento&#44; es fundamental el control evolutivo de todos los hijos de madres con infecci&#243;n por el VHC&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicto de intereses</span><p id="par0235" class="elsevierStylePara elsevierViewall">Los autores declaran que no existe ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "titulo" => array:5 [
            0 => "Abstract"
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            2 => "Material y methods"
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          "titulo" => "Introducci&#243;n"
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          "titulo" => "Resultados"
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          "titulo" => "Discusi&#243;n"
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          "titulo" => "Conflicto de intereses"
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        9 => array:1 [
          "titulo" => "Bibliograf&#237;a"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-05-03"
    "fechaAceptado" => "2011-11-13"
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          "identificador" => "xpalclavsec93873"
          "palabras" => array:6 [
            0 => "Ces&#225;rea"
            1 => "Coinfecci&#243;n"
            2 => "Lactancia materna"
            3 => "Transmisi&#243;n vertical"
            4 => "Virus de la hepatitis C"
            5 => "Virus de la inmunodeficiencia humana"
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        0 => array:4 [
          "clase" => "keyword"
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          "palabras" => array:5 [
            0 => "Caesarean section"
            1 => "Breast feeding"
            2 => "Hepatitis C virus"
            3 => "HIV-co-infection"
            4 => "Vertical infection transmission"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A pesar de la baja prevalencia infantil de infecci&#243;n por virus hepatitis C &#40;VHC&#41; y su leve cl&#237;nica inicial&#44; la infecci&#243;n cr&#243;nica puede evolucionar a cirrosis y&#47;o hepatocarcinoma&#46; Es fundamental controlar su transmisi&#243;n vertical&#46; Los &#250;ltimos estudios describen hasta 50&#37; de transmisiones intra&#250;tero&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudiamos retrospectivamente 17 casos de infecci&#243;n por VHC en 8 a&#241;os&#44; analizando los factores de riesgo de transmisi&#243;n vertical&#44; para aplicar prevenci&#243;n primaria&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Solo la adicci&#243;n a drogas v&#237;a parenteral muestra riesgo significativo&#44; sin ser la coinfecci&#243;n VIH factor de confusi&#243;n&#46; La carga viral&#44; la coinfecci&#243;n por VIH&#44; la disfunci&#243;n hep&#225;tica y el tiempo de evoluci&#243;n de infecci&#243;n no muestran mayor riesgo&#46; La ces&#225;rea&#44; la amniocentesis y la monitorizaci&#243;n interna pueden ser factores de riesgo &#40;sin significaci&#243;n estad&#237;stica&#41;&#44; pero no las horas de amniorrexis&#46; La lactancia materna muestra protecci&#243;n&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pese a la importancia frecuentemente atribuida&#44; el efecto de la carga viral sobre el riesgo de transmisi&#243;n no est&#225; claramente establecido&#58; la ausencia de viremia no descarta el riesgo de transmisi&#243;n&#44; ya que la detecci&#243;n de ARN viral puede ser intermitente&#44; y por tanto&#44; los datos al respecto deben interpretarse con cautela&#46; La inmunosupresi&#243;n secundaria a la coinfecci&#243;n por VIH supone mayor riesgo de transmisi&#243;n&#44; pero dicho efecto disminuye al mejorar la capacidad inmune gracias al tratamiento antirretroviral&#46; Respecto a las caracter&#237;sticas del parto&#44; el tiempo transcurrido tras la rotura de membranas no ha mostrado ser factor de riesgo&#59; y se desestima la ces&#225;rea como forma &#243;ptima y electiva de finalizar la gestaci&#243;n de estas mujeres&#46; La lactancia materna&#44; lejos de suponer mayor riesgo de transmisi&#243;n&#44; puede ser protectora&#46; La escasa carga viral en la leche&#44; su inactivaci&#243;n por el pH &#225;cido g&#225;strico y sus beneficios inmunol&#243;gicos justificar&#237;an este resultado&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Dadas las limitaciones de los estudios retrospectivos&#44; es necesario plantear an&#225;lisis prospectivos para conocer mejor el papel de los posibles factores de riesgo y establecer pautas claras de prevenci&#243;n&#59; de momento&#44; es fundamental el control evolutivo de todos los hijos de madres con infecci&#243;n por el VHC&#46;</p>"
      ]
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Despite the low prevalence of paediatric HCV infection and its initial mild clinical expressiveness&#44; chronic infection could progress into cirrhosis and&#47;or hepatocarcinoma&#46; It is essential to control vertical transmission&#46; Recent studies show that up to 50&#37; of transmissions occur within the uterus&#46;</p> <span class="elsevierStyleSectionTitle">Material y methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was conducted on 17 cases of &#40;Hepatitis<span class="elsevierStyleHsp" style=""></span>C virus&#41; HCV infection registered over a period of 8 years&#46; Vertical transmission risk factors were analysed&#44; in order to introduce primary prevention&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Only parenteral drug addiction significantly increased the rate of HCV transmission&#59; HIV co-infection was not a confounding factor&#46; HCV viremia&#44; HIV co-infection&#44; liver dysfunction and&#47;or duration of the infection did not appear to affect the rate of transmission&#46; Caesarean section&#44; amniocentesis and internal monitoring may be risk factors &#40;not statistically significant&#41;&#44; but not prolonged vaginal delivery after amniotic membrane rupture&#46; Breastfeeding showed protection&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The effect of viremia on the risk of transmission is not clearly established&#44; despite the importance usually attributed&#46; Lack of viremia does not discount the risk of transmission&#44; due to viral RNA detection can be intermittent&#44; so it should be interpreted cautiously&#46; Immunosuppression secondary to HIV co-infection implies a higher risk of transmission&#44; but this effect decreases by improving immune competence by antiretroviral treatment&#46; With regard to the birth characteristics&#44; time after the rupture of membranes has not shown being a risk factor&#59; being the caesarean not advisable as a good alternative to finish the pregnancy&#46; Breastfeeding does not increase the risk&#44; even it can be protective&#46; This results would be justified by the low viral content of milk&#44; its inactivation by gastric pH and its immunological benefits&#46;</p><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Given that retrospective studies results are limited&#44; prospective studies need to be carried out in order to improve the understanding of the role of possible risk factors and to provide a clear preventive guidelines&#46; At the moment it is essential to control all the children born of mothers with HCV infection&#46;</p>"
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                  \t\t\t\t">18&#44;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">No</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Estadio VIH</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Genotipo VHC</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Funci&#243;n hep&#225;tica</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">GOT &#40;UI&#47;l&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40 U&#47;l&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>40 U&#47;l&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">GPT &#40;UI&#47;l&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40 U&#47;l&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">40 U&#47;l</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#44;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="3" align="char" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Carga viral VHC &#40;10</span><span class="elsevierStyleSup"><span class="elsevierStyleBold">3</span></span><span class="elsevierStyleBold">U&#47;ml&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">500</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12&#44;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#44;494&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">500&#8211;1&#46;000</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">37 SEG</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">37 SEG</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis univariante &#40;test exacto de Fisher&#41; de posibles factores de riesgo de transmisi&#243;n vertical VHC &#40;variables categ&#243;ricas&#41;</p>"
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Información del artículo
ISSN: 16954033
Idioma original: Español
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