Incidence of De Novo Nonmelanoma Skin Tumors After Liver Transplantation for Alcoholic and Nonalcoholic Liver Diseases

INTRODUCTION

Skin tumors are the most common malignancies after orthotopic liver transplantation (OLT). They have been related to sunlight exposure, tobacco consumption, and immunosuppression. The aim of this study was to compare the incidence of de novo skin tumors (nonmelanoma) in patients who underwent liver transplantation for alcoholic cirrhosis versus nonalcoholic diseases.

PATIENTS AND METHODS

Between April 1986 and July 2004, we performed 1000 OLT in a population of 888 recipients. This study was performed in a sample of 701 adult recipients who survived >2 months after transplantation: 276 patients (39.4%) underwent OLT for alcoholic cirrhosis (AC-group), and 425 (60.6%) for nonalcoholic disease (N-AC). The overall incidence of de novo skin tumors was 3.5% (25 tumors): 5.4% (15 tumors) in the AC-group and 2.4% (10 tumors) in the N-AC group (P = .027). Two patients developed two tumors. There were 19 men and 4 women, mean age at OLT of 54.4 +/- 6.8 years (range, 40 to 66 years). The mean time from OLT to tumor diagnosis was 66.1 +/- 51.4 months (range, 3 to 165 months): 56.4 +/- 44.4 months in the AC-group versus 80.6 +/- 59.8 months in the N-AC group (P = NS). Histologically, 17 tumors (68%) were basal cell carcinomas and eight tumors (32%) were squamous cell carcinomas (P = .128). Fourteen patients (60.8%) were smokers: 11 patients (84.6%) in the AC-group versus 3 patients (30%) in the N-AC group (P = .012). All the patients underwent tumor resection, with only one patient dying, because of lymph node invasion of the neck.

CONCLUSION

There was a higher incidence of de novo skin tumors among patients who smoked who underwent OLT for alcoholic cirrhosis.

First Spanish series of intestinal transplantation in adult recipients

BACKGROUND

short-bowel transplantation has experienced a substantial growth worldwide following improved results from the late 1990's on, and its coverage by Medicare. According to the International Registry (1985-2005), a total of 1,292 intestinal transplants for 1,210 patients in 65 hospitals across 20 countries have been carried out thus far.

OBJECTIVE

to know short-term (6 months) results regarding patient and graft survival from the first Spanish series of intestinal transplants in adult recipients.

MATERIAL AND METHODS

we present our experience in the assessment of 20 potential candidates to short-bowel transplantation between June 2004 and October 2005. Of these, 10 patients were rejected and 4 were transplanted, which makes up the sample of our study.

RESULTS

to this date 5 transplants have been carried out in 4 patients (2 retransplants, 2 desmoid tumors, 1 short bowel syndrome after excision as a result of mesenteric ischemia). Upon study completion and after a mean follow-up of 180 days (range 90-190 days) all recipients are alive, and all grafts but one (75%) are fully operational, with complete digestive autonomy. All patients received induction with alemtuzumab except one, who received thymoglobulin; in all induction was initiated with no steroids.

CONCLUSIONS

intestinal transplantation represents a therapeutic option that is applicable in our setting and valid for recipients with an indication who have no other feasible alternative to keep their intestinal failure under control.

Uric acid and anti-TNF antibody improve mitochondrial dysfunction in ob/ob mice

The mechanisms responsible for low mitochondrial respiratory chain (MRC) activity in the liver of patients with nonalcoholic steatohepatitis are unknown. In this study, we examined the cause of this dysfunction in ob/ob mice. Forty-six mice were distributed in six groups: group I: C57BL/6J mice; group II: C57BL/6J Lep(-/-) mice (ob/ob); group III, ob/ob mice treated with manganese [III] tetrakis (5,10,15,20 benzoic acid) porphyrin (MnTBAP); group IV, ob/ob mice treated with IgG1 immunoglobulin; group V, ob/ob mice treated with anti-TNF antibody; group VI: ob/ob mice treated with uric acid. In liver tissue, we measured MRC activity, fatty acid beta-oxidation, tumor necrosis factor (TNF), inducible nitric oxide synthase (iNOS), 3-tyrosine-nitrated proteins, 3-tyrosine-nitrated mitochondrial proteins, including cytochrome c and ND4 subunit of complex I. MRC activity was decreased in ob/ob mice. TNF levels, iNOS protein expression, and tyrosine nitrated proteins were markedly increased in the liver of ob/ob mice. In these animals, mitochondrial proteins were markedly tyrosine nitrated, particularly the ND4 subunit of complex I and cytochrome c. Treatment of these animals with uric acid, a peroxynitrite scavenger, anti-TNF antibody, or MnTBAP decreased tyrosine nitrated proteins, improved the activity of MRC complexes, and led to a marked regression of hepatic steatosis and inflammation. In conclusion, MRC dysfunction and liver lesions found in ob/ob mice are likely to reflect the tyrosine nitration of mitochondrial proteins by peroxynitrite or a peroxynitrite-derivate radical. Increased hepatic TNF and iNOS expression might enhance peroxynitrite formation and inhibition of MRC complexes.

Factors associated with the presence of nonalcoholic steatohepatitis in patients with chronic hepatitis C

OBJECTIVES

The aim of this study was to identify factors associated with the presence of nonalcoholic steatohepatitis (NASH) in patients with chronic hepatitis C (CHC).

METHODS

We studied 98 patients with CHC [47 with NASH (group HCV/NASH), 51 without NASH (group HCV)] and 85 with NASH not infected with hepatitis C virus (HCV) (group NASH). We determined factors associated with the presence of NASH in patients with hepatitis C.

RESULTS

Group HCV/NASH patients resembled those with NASH. Body mass index (BMI) was higher in group HCV/NASH than in group HCV, but was similar to group NASH. Most HCV/NASH patients had risk factors for NASH. In patients infected with HCV, NASH and NASH-related lesions were independently associated with BMI, while steatosis score was associated with HCV genotype 3 and BMI. Fibrosis stage was independently associated with steatosis, necroinflammatory activity index, and NASH lesions.

CONCLUSION

While HCV genotype 3 infection and BMI are associated with the presence of steatosis in CHC, BMI is the only factor independently associated with the presence of NASH in these patients. We suggest that overweight-related factors might induce NASH in CHC patients.

Pseudomyxoma peritonei: a clinicopathologic analysis and follow-up of 21 patients

BACKGROUND/AIMS

Pseudomyxoma peritonei is an uncommon disease characterized by the presence of mucinous peritoneal implants associated with an abdominal neoplasm. Our objective is to consider the characteristics of this entity in our western Mediterranean urban population.

METHODOLOGY

All cases diagnosed with pseudomyxoma peritonei by our hospital during a period of 16 years were reviewed. Data from their clinical records and the biopsy samples were analyzed.

RESULTS

We found 21 cases of pseudomyxoma peritonei with a male/female ratio of 10/11 and a mean age of 59 years. The predominant presentation symptom was abdominal pain (17 cases, 6 of them with acute abdomen). The most frequent primary site of origin of the pseudomyxoma was the appendix (10 cases). The histologic diagnosis was malignant (associated with carcinoma) in 17 cases and indeterminate behavior in 4. The follow-up was available for 15 patients (mean follow-up of 41 months), while six patients have been lost. Nine patients have died during the follow-up and the other 6 patients are still alive after follow-up.

CONCLUSIONS

Laparotomy is the main tool for diagnosing pseudomyxoma peritonei. The appendix is the most frequent primary site of origin of pseudomyxoma peritonei, followed by bowel; the latter being more important than previously described. In most cases the histology is malignant. The prognosis is bad with a mortality greater than 60% at 5 years.

Safe endoscopic resection of gangliocytic paraganglioma of the major duodenal papilla

A case of gangliocytic paraganglioma of the papilla of Vater in a 76-year-old man with a history of recurrent obstructive jaundice is presented. This is the first case of gangliocytic paraganglioma of the major papilla successfully resected by endoscopic ampullectomy.

Tissue CA-19.9 content in colorectal adenomas and its value in the assessment of dysplasia

BACKGROUND

occasionally, the risk of malignant transformation may be difficult to establish in adenomatous polyps due to the fact that they contain areas with variable grades of dysplasia. A measurement of tissue tumor markers may be useful to recognize these adenomas.

OBJECTIVES

the aims of this study were: to established firstly the relationship between carbohydrate antigen 19.9 (CA-19.9) content in the colorectal mucosa and the characteristics of polyps, and secondly, the diagnostic value of the formers measurement.

PATIENTS AND METHODS

tissue CA-19.9 concentration was measured in 155 colorectal samples obtained from 145 patients (21 normal mucosa; 113 adenomatous polyps; 21 adenocarcinoma). Cytosol CA-19.9 content was determined by enzyme-linked immunoadsorbant assay, and the measurement of this protein was achieved by quantitative assay. Tissue samples were also processed for histological examination.

RESULTS

we demonstrated that CA-19.9 levels in adenomatous polyps and adenocarcinomas were significantly higher than in the normal mucosa. These levels varied significantly according to polyp size, histological type, and grade of dysplasia. CA-19.9 contents were higher in polyps with a high risk of malignant transformation than in those with a low risk of severe dysplasia. The cut-off value 214 U/mg of protein properly differentiated both types of risk. The area under the receiver operating characteristic (ROC) curves showed that cytosol CA-19.9 levels allow classifying polyps according to their histological features.

CONCLUSIONS

we concluded that the measurement of CA-19.9 content in adenomatous polyps may be useful to classify these tumors and confirm the feasibility to separate adenomas into two groups: low and high risk of malignant change.

Focal hyperplastic hepatocellular nodules in hepatic venous outflow obstruction: a clinicopathological study of four patients and 24 nodules

AIMS

In hepatic venous outflow obstruction (Budd-Chiari syndrome), focal hepatocellular nodules are occasionally discovered showing variable morphology. These could be interpreted either as neoplastic (adenoma), regenerative (large regenerative nodule) or reactive to abnormal vasculature (focal nodular hyperplasia). The aim of this study was to investigate their histogenesis and to determine their morphological characteristics in order to provide diagnostic criteria.

MATERIAL AND METHODS

Twenty-four hepatocellular nodules were studied, which were found in three explanted livers and in one additional autopsied liver from four patients with Budd-Chiari syndrome. As controls, we employed three explanted livers without nodules from patients who also suffered from Budd-Chiari syndrome. We attempted to classify the nodules morphologically as either adenoma-like, large regenerative nodule or focal nodular hyperplasia-like, using criteria from the literature.

RESULTS

Out of the four cases, we observed two nodules in each of two livers, five in the third one and up to 15 in the remaining one. The size of the nodules ranged from 4 to 25 mm. Eleven nodules could be categorized as large regenerative nodules (two of them with a central scar), seven as focal nodular hyperplasia-like and six as adenoma-like. Some large regenerative nodules showed proliferated arteries with muscular hyperplasia similar to that seen in focal nodular hyperplasia. In the individual livers we could find nodules of various categories. Patchy or diffuse monoacinar regeneration was seen in most cases (six out of seven cases) in the macroscopically non-nodular liver parenchyma. In addition, thrombotic obstruction of portal vein branches was present in all except one of the nodular cases, but in none of the controls. Thus, it appears that portal venous obstructions are frequently, but not invariably associated with the development of nodules.

CONCLUSIONS

The hepatocellular nodules seen in livers from patients with Budd-Chiari syndrome share morphological characteristics with large regenerative nodules, focal nodular hyperplasia and hepatocellular adenomas. Their multiplicity, the existence of mixed lesions, the frequent hepatocellular regenerative background as well as the frequently associated portal venous obstructions suggest that these nodules are regenerative in nature and conditioned by an uneven blood perfusion throughout the liver. In their differential diagnosis, the clinicopathological context in which they occur is of paramount importance and should allow recognition that those resembling adenomas may not be true neoplasms.

Defective hepatic mitochondrial respiratory chain in patients with nonalcoholic steatohepatitis

Mitochondrial dysfunction might play a central role in the pathogenesis of nonalcoholic steatohepatitis (NASH). The aims of this study were to evaluate whether free fatty acid (FFA) transport into the mitochondria or the activity of mitochondria respiratory chain (MRC) complexes are impaired in NASH. In patients with NASH and control subjects, we measured free carnitine, short-chain acylcarnitine (SCAC) and long-chain acylcarnitine (LCAC) esters, carnitine palmitoyltransferase (CPT) activity, and MRC enzyme activity in liver tissue as well as serum concentration of tumor necrosis factor alpha (TNF-alpha), homeostatic metabolic assessment of insulin resistance (HOMA(IR)), and body mass index (BMI). In patients with NASH, the LCAC/free carnitine ratio was significantly increased and the SCAC/free carnitine ratio was decreased. In patients with NASH, the activity of the MRC complexes was decreased to 63% +/- 20% (complex I), 58.5% +/- 16.7% (complex II), 70.6% +/- 10.3% (complex III), 62.5% +/- 13% (complex IV), and 42.4% +/- 9.1% (adenosine triphosphate synthase) of the corresponding control values. Activity of these complexes correlated significantly with serum TNF-alpha and HOMA(IR). Serum TNF-alpha (36.3 +/- 23.1 pg/mL), HOMA(IR) (4.5 +/- 2.38), and BMI (29.9 +/- 3.5 kg/m(2)) values were significantly increased in patients with NASH. In conclusion, activities of MRC complexes were decreased in liver tissue of patients with NASH. This dysfunction correlated with serum TNF-alpha, insulin resistance, and BMI values.

Defective hepatic mitochondrial respiratory chain in patients with nonalcoholic steatohepatitis

Mitochondrial dysfunction might play a central role in the pathogenesis of nonalcoholic steatohepatitis (NASH). The aims of this study were to evaluate whether free fatty acid (FFA) transport into the mitochondria or the activity of mitochondria respiratory chain (MRC) complexes are impaired in NASH. In patients with NASH and control subjects, we measured free carnitine, short-chain acylcarnitine (SCAC) and long-chain acylcarnitine (LCAC) esters, carnitine palmitoyltransferase (CPT) activity, and MRC enzyme activity in liver tissue as well as serum concentration of tumor necrosis factor alpha (TNF-alpha), homeostatic metabolic assessment of insulin resistance (HOMA(IR)), and body mass index (BMI). In patients with NASH, the LCAC/free carnitine ratio was significantly increased and the SCAC/free carnitine ratio was decreased. In patients with NASH, the activity of the MRC complexes was decreased to 63% +/- 20% (complex I), 58.5% +/- 16.7% (complex II), 70.6% +/- 10.3% (complex III), 62.5% +/- 13% (complex IV), and 42.4% +/- 9.1% (adenosine triphosphate synthase) of the corresponding control values. Activity of these complexes correlated significantly with serum TNF-alpha and HOMA(IR). Serum TNF-alpha (36.3 +/- 23.1 pg/mL), HOMA(IR) (4.5 +/- 2.38), and BMI (29.9 +/- 3.5 kg/m(2)) values were significantly increased in patients with NASH. In conclusion, activities of MRC complexes were decreased in liver tissue of patients with NASH. This dysfunction correlated with serum TNF-alpha, insulin resistance, and BMI values.

Colorectal cancer relapse: allelic alterations associated with tumour marker overexpression

The objective of the present study was to assess the prognostic value of allelic alterations in comparison with clinical prognostic factors (age and gender, clinical stage, lymph node involvement, tissue tumour marker expression) and clinical outcomes (disease relapse and overall survival time) in colorectal cancer patients. Polymerase chain reaction was performed on the DNA of 72 colorectal samples (from 36 colorectal cancer patients) using primers D17S513 and D17S514. Carbohydrate antigen 19-9 (CA 19-9) marker was determined in tumour sections by enzyme immunoassay. Tumours were considered to exhibit allelic alterations if the microsatellite region adjacent to the p53 locus in chromosome 17 either gained or lost repeated sequences. Allelic alterations were detected in 44% of tumour samples. Patients with more than 3 involved lymph nodes had more frequent allelic alterations (p < 0.002). The allelic alteration status was compared with tumour CA 19-9 expression, which showed statistically significantly higher values within the allelic alterations group (p < 0.005). Multivariate analyses confirmed that tumours with allelic alterations had a higher probability of disease relapse (odds ratio 7.3, p = 0.01). This is the first report showing an association between allelic alteration and overexpression of a tissue tumour marker protein and established risk factors. These results could be considered useful additional prognostic information for colorectal cancer.

Kaposi's visceral sarcoma in liver transplant recipients

We report three cases of Kaposi's sarcoma after orthotopic liver transplantation performed for cirrhosis related to hepatitis C virus (one case), ethanol (one case), or both (one case). All patients displayed disease within the first year after liver transplantation, and only in one case was the diagnosis obtained before the patient died. All three patients were on tacrolimus-steroid therapy, and in one case mycophenolate mofetil was added to treat acute persistent rejection.

An unusual expression of hyperplastic gastropathy (Menetrier type) in twins

Menetrier's disease is an uncommon condition of unknown aetiology. We describe two cases of male identical twins with haematemesis aged 29 and 35 years that exhibited a similar and particular form of this hyperplastic gastropathy. Their stomachs showed confluent polypoid mucosal projections affecting mainly the gastric fundus and the antrum. To the best of our knowledge, only four previous cases have been reported in a familial setting, and this is the first documented example of an occurrence in twins. These two cases suggest the possibility of a genetic predisposition for this condition.

Porphyria cutanea tarda as a predictor of poor response to interferon alfa therapy in chronic hepatitis C

BACKGROUND

Porphyria cutanea tarda (PCT) is sometimes associated with hepatitis C virus chronic infection. The aim of this study was to describe the effect of interferon alfa (IFN-alpha) in the treatment of patients with chronic hepatitis C and PCT.

METHODS

We treated a total of 66 patients with chronic hepatitis C with IFN-alpha 2b (5 MU t.i.w.) for 12 months. Twenty-two of these patients suffered from PCT as well. These patients differed from patients without PCT in that they were men, past history of alcohol abuse and HFE gene mutations were more common and the source of infection was almost always unknown.

RESULTS

Sustained virologic response was obtained in 19.7% of the 66 treated patients, 27.3% in the non-PCT group and 4.5% in the PCT group (P < 0.05). This difference could not be ascribed to the difference in sex of patients, history of alcohol abuse, HCV genotype or iron status.

CONCLUSION

Multivariate logistic regression analysis revealed that PCT is independently and significantly associated with non-sustained response to IFNalpha therapy. In conclusion, patients with chronic hepatitis C and PCT rarely responded to IFNalpha treatment.

Clinicopathological features of nine cases of non-cirrhotic portal hypertension: current definitions and criteria are inadequate

AIMS

The clinicopathological features of nine patients with non-cirrhotic portal hypertension were studied and an attempt was made to apply the descriptive criteria of experts to the morphological alterations of the livers in order to classify them adequately.

METHODS AND RESULTS

Clinical and biochemical data and the alterations in livers resected at transplantation (n=7) or at autopsy (n=2) were gathered in five males and four females (ages 15-78 years) without aetiological factors for chronic hepatic disease who had oesophageal varices and splenomegaly in the absence of typical cirrhosis. Noting the luminal obstruction of the three hepatic vascular trees, hyperplastic nodule size and distribution, and the density of fibrosis, an attempt was made to assign each case to one of the following diagnostic categories: idiopathic portal hypertension, diffuse nodular regenerative hyperplasia, partial nodular transformation and incomplete septal cirrhosis. When a case could not be categorized into one of these groups, it was listed as non-cirrhotic irregular architectural transformation. Only three cases could be assigned to one pure diagnostic category (two diffuse nodular regenerative hyperplasias and one incomplete septal cirrhosis). Three other cases could not be classified due to the heterogeneity of their lesions. In the remaining three cases, the hepatic morphology was a mixture of hilar partial nodular transformation combined with another abnormal architectural pattern in the peripheral parenchyma: diffuse nodular regenerative hyperplasia in two cases and idiopathic portal hypertension in the other. In seven cases, old thromboses in the hilar portal tree were observed. Stenoses were observed in some of the arterial branches in five cases and in some hepatic venous branches in four. However, no obstructions could be discovered in small or large portal veins in the two classical diffuse nodular regenerative hyperplasia cases.

CONCLUSIONS

The hepatic morphology in this group of non-cirrhotic portal hypertension patients was an abnormal remodelling of the liver associated with the frequent development of irregular hyperplastic nodules and frequent obstructions of the pre- and intrahepatic vascular lumens. It was very difficult to apply the nomenclature proposed by international experts.

Porphyria cutanea tarda as a Predictor of Poor Response to Interferon Alfa Therapy in Chronic Hepatitis C

BACKGROUND

Porphyria cutanea tarda (PCT) is sometimes associated with hepatitis C virus chronic infection. The aim of this study was to describe the effect of interferon alfa (IFN-a) in the treatment of patients with chronic hepatitis C and PCT.

METHODS

We treated a total of 66 patients with chronic hepatitis C with IFN-a 2b (5 MU t.i.w.) for 12 months. Twenty-two of these patients suffered from PCT as well. These patients differed from patients without PCT in that they were men, past history of alcohol abuse and HFE gene mutations were more common and the source of infection was almost always unknown.

RESULTS

Sustained virologie response was obtained in 19.7% of the 66 treated patients, 27.3% in the non-PCT group and 4.5% in the PCT group (P < 0.05). This difference could not be ascribed to the difference in sex of patients, history of alcohol abuse, HCV genotype or iron status.

CONCLUSION

Multivariate logistic regression analysis revealed that PCT is independently and significantly associated with non-sustained response to IFNa therapy. In conclusion, patients with chronic hepatitis C and PCT rarely responded to IFNa treatment.

Autoimmune enteropathy in an adult with autoimmune multisystemic involvement

We describe the case of a 58-year-old woman with autoimmune enteropathy associated with thyroiditis, gastritis, transitory neutropenia, sicca syndrome and severe axonal polyneuropathy of autoimmune origin. Enterocyte autoantibodies were not detected. However, predisposition to autoimmune disease was indicated by the presence of high titres of anti-gastric parietal cell, anti-thyroglobulin, anti-thyroid peroxidase and anti-neutrophil antibodies. CD4+ and CD8+ lymphocytes were equally distributed in the lamina propria of the small intestine, but CD8+ cells were highly represented among intraepithelial lymphocytes.

Chronic hepatitis C and autoimmune cholangitis: a case study and literature review

We present a case of a chronic hepatitis C with damage of bile ducts resembling primary biliary cirrhosis. The immunological profile (negative antimitochondrial antibodies and positive anti-nuclear antibody) was characteristic of the autoimmune cholangitis. One year of treatment with ursodeoxycholic acid returned the liver tests to the normal range but the liver lesions remained unchanged.

Long-term biliary complications after liver surgery leading to liver transplantation

Chronic biliary obstruction with repeated bouts of cholangitis adversely affects quality of life and may lead to secondary biliary cirrhosis with liver failure. We reviewed our experience with chronic biliary complications after surgical treatment of various diseases that at the end needed a liver transplantation. Twelve patients with previous biliary surgery developed secondary biliary cholangitis, secondary biliary cirrhosis, or both. Seven had surgery for liver hydatid disease by Echinococcus granulosus, another four had complicated biliary surgery unrelated to hydatid disease, and one had a history of a traffic accident with liver trauma and hepatectomy with chronic biliary fistula. The repeated cholangitis attacks and in two cases of hydatid disease the development of biliary-bronchial fistulas made these patients' lives miserable. All had had previous surgical procedures that made the transplantation procedure more difficult. Nevertheless, patient survival and graft actuarial survival after liver replacement were 75.0% and 69.2%, respectively, at 5 years.

Fibrosing cholestatic hepatitis-like syndrome in hepatitis B virus-negative and hepatitis C virus-negative renal transplant recipients

Cholestatic hepatitis and diffuse liver fibrosis have been described in immunosuppressed patients with hepatitis B virus or hepatitis C virus infection as fibrosing cholestatic hepatitis (FCH). FCH is characterized by cholestasis, with only a modest increase in aminotransferase levels. The pathologic picture typically shows periportal and perisinusoidal fibrosis, scarce mixed infiltrates, hepatocellular ballooning, and histologic cholestasis. We report two patients with diffuse fibrosis and cholestasis quite similar to the histologic picture of FCH, but in whom neither hepatitis B virus nor hepatitis C virus infection could be shown, highlighting the potential contribution of cytomegalovirus infection and azathioprine toxicity in the development of this severe complication of solid-organ transplantation.

Liver transplantation and hepatitis C virus. Results in a Spanish center since 1989

BACKGROUND/AIMS

Hepatitis C-related liver disease is the main indication for liver transplantation in many centers. Viral RNA remains after transplantation in almost 100% of the patients, and more recent reports show a graft hepatitis rate of about 90%. The progression of this hepatitis seems to be quicker than in the nontransplant setting.

METHODOLOGY

From June 1989 to October 2000, 197 adult patients had 213 for HCV-related liver disease at our institution. Basal immunosuppression consisted of a triple therapy with cyclosporine, azathioprine and steroids, or dual therapy with tacrolimus and steroids. None of the patients was treated with antivirals after liver transplantation.

RESULTS

Pure HCV-related cirrhosis was the indication for liver transplantation in 114 patients, another 14 with hepatocellular carcinoma, 8 associated metabolic diseases, 43 high alcohol intake, 4 hepatitis B, 5 cholestatic diseases, and 3 other diseases. Six patients out of the 197 transplanted in this period were already grafted before this time, and had their first retransplantation of the liver after 1989 (their first liver transplantation was done when HCV was not known). Sixteen additional retransplantation procedures were done in the period considered. Hepatitis was diagnosed in 84.3% of the grafts biopsied later than 90 days after liver transplantation (118/140), and in 92.9% if it was done after one year (92/99). Cirrhosis was diagnosed in 21 grafts at a mean time of 1004.7 days, 21.2% of the grafts biopsied after 1 year and 28.6% after 2 years. Nine grafts in 8 patients were diagnosed as fibrosing cholestatic hepatitis. Patient actuarial survival was 80.9%, 69.7%, 67.5% and 50.6% at 1, 3, 5 and 10 years. Liver failure and hepatoma recurrence were the cause of death in 42.4% of the patients. Actuarial graft survival was 75.2%, 64.9%, 63.5% and 48.6% at 1, 3, 5 and 10 years, and was significantly affected by Child stage (B vs. C, P = 0.004). When compared to 228 non-HCV- infected patients with chronic parenchymatous disease, these had an almost significantly better patient survival (P = 0.0577), but a nonsignificant difference in graft survival. Graft loss related to liver causes was 17.6% in HCV+ patients 14.6% in HCV- patients. Liver causes of death were 14.0% in HCV+ patients and 4.8% in HCV-patients (P = 0.002).

CONCLUSIONS

HCV infected liver transplantation recipients present very often graft hepatitis, which may progress to advanced stages in a quite short interval. Mid-term patient and graft survival is comparable to those of non-HCV recipients, but causes of death related directly to liver disease are more common in HCV+. This makes one think that long-term prognosis (more than 10 or 15 years) will be worse in HCV patients.