[Epidemiological and clinical significance of hepatitis B and C marker detection in blood of patients and donors]

During the assessment of 118 299 patients from hospital n. a. A.A.Vishnevskiy (2001-2005) anti-HCV was found out in 3.6%, HbsAg in 1.94%. By comparison with data of 1992-1994 (hospital n. a. N.N.Burdenko) the indices of disclosure of anti-HCV in in-patients fell 2 times, HbsAg 6.4 times. During this period, diverse changes of frequency of detection of markers in blood-donors took place: HbsAg--reduction, anti-HCV-elevation. During 2001-2005 reduction of frequency of detection of anti-HCV was noted in in-patients and blood donors, but reduction of frequency of detection of HbsAg only in blood donors. The frequency of detection of hepatitis C, B markers in blood donors during the last 10-15 years is correlated with the incidence of virus cirrhosis. Dynamic changes or stability of frequency of detection of hepatitis C, B markers in blood donors and in-patients during current period is correlated with the score of virus cirrhosis mortality.

[Prognosis comparison in middle and later stage severe hepatitis B patients treat with plasma exchange or unified medicine therapy]

OBJECTIVE

To observe the influence on the prognosis of the patients with severe hepatitis B in middle and later stage treated with plasma exchange or unified medicine therapy, and search the therapy methods on the middle and later stage severe hepatitis B.

METHODS

To observe the liver function, complications and prognosis of the patients treated with plasma exchange on the basis of unified medicine therapy. To compare with that of the corresponding period patients with unified medicine therapy and analysis the clinical data with statistics methods.

RESULTS

36 cases of the plasma exchange group, 18 cases survived and 18 cases died. 32 cases of the unified medicine therapy group, 13 cases survived and 19 cases died. The survival rates between the two groups patients does not appear statistics difference;liver function index (ALT, AST, SB, ALB, TC, ChE) and PT also appear the same results in statistics.

CONCLUSIONS

Compare with unified medicine therapy, plasma exchange on the basis of the unified medicine therapy does not appear to improve survival rate of the patients with the middle and later stage severe hepatitis B. The prognosis of these patients determined by the liver failure extent itself.

[Features of clinical evolution of severe acute viral hepatitis. Series of 72 cases]

The fulminant hepatic failure is a dramatic complication of acute viral hepatitis. Despite therapeutical efforts, the mortality of these forms of acute hepatitis is rated in most studies from 60 to 90%.

MATERIAL AND METHOD

We made a retrospective study that included 2014 patients hospitalized at the Bacau County Hospital from January 1996 to December 2005 with the diagnosis of acute viral hepatitis. Among these, 72 patients presented severe forms of hepatitis.

RESULTS

13 patients presented fulminant hepatic failure. In most cases, etiology was represented by the B-type virus (66.7%). Defining for the fulminant form of hepatitis are the Quick index under 50%, the increase of total serum bilirubine and the leucocitosis associated with neutrophilia.

CONCLUSIONS

Mortality in fulminant forms of hepatitis was of 61.5%, respectively 75% in the case of the B-type viral hepatitis. Key words: SEVERE

Hepatocellular cancer: risk factors and survival in Pacific Islanders compared to Caucasians in Hawaii

BACKGROUND

Hepatocellular cancer (HCC) is increasing in the United States. Although studies indicate that Asian and Pacific Islanders have an especially high incidence, no study has characterized HCC in the subgroup of Pacific Islanders (PI) alone.

OBJECTIVE

To describe risk factors/survival of HCC in PI compared to Caucasians in Hawaii.

PATIENTS

Of 523 HCC patients referred 1993-2008, 72 PI patients were compared to 85 Caucasian patients.

MEASUREMENTS

In this retrospective-cohort study, data collected included demographics, risk factors, tumor characteristics, laboratory studies, treatment and survival. Chi-square analyses and t-tests identified difference between groups. Cox-proportional hazards model determined regression analysis of survival data.

RESULTS

Mean age and sex distribution were not significantly different between groups. PI were more likely to have hepatitis B (36% vs 6%, P<.05), symptoms at presentation (60% vs 40%, P=.003), and larger tumors (P=.02). Caucasians were more likely to have hepatitis C (65% vs 43%, P=.01) and encephalopathy. Mean survival was significantly different between PI and Caucasians (10.9 months vs 43.3 months, P=.01). Multivariate-regression analysis showed late stage III/IV, increased Childs score, hepatitis B infection, and alcohol history associated with decreased survival. PI ethnicity was independently associated with increased hazard ratio. Treatment regardless of modality reduced hazard ratio for survival.

CONCLUSION

PI with HCC were more likely to have hepatitis B, symptoms and larger tumors, though they were just as likely to have their HCC found upon screening. PI ethnicity independently affected survival. Better education of the community/physicians on detection of hepatitis B and recognizing this risk for HCC in PI is needed.

HCV-related mortality among male prison inmates in Texas, 1994-2003

PURPOSE

The prevalence of hepatitis C virus (HCV) infection is high among adult incarcerated populations, but HCV-related mortality data are lacking. The study purpose was to assess HCV-related mortality over time and across racial/ethnic categories from 1994 through 2003 among male prisoners in the Texas Department of Criminal Justice (TDCJ).

METHODS

TDCJ decedent data were linked with Texas Vital Statistics multiple-cause-of-death data. Crude annual HCV death rates, age- and race-adjusted summary rates, and average annual percent changes were estimated. The proportion of deaths due to chronic liver disease/cirrhosis, liver cancer, hepatitis B, and HIV for which HCV was identified as an intervening or contributing cause of death was calculated.

RESULTS

Among Texas male prisoners, HCV death rates were high and increased over the 10-year study period by an average 21% annually, with the largest increase occurring among Hispanic prisoners. HCV was identified as an intervening or contributing cause of death in 15% of chronic liver disease/cirrhosis deaths, 33% of liver cancer deaths, 81% of hepatitis B deaths, and 7% of HIV deaths.

CONCLUSIONS

Because HCV-related deaths among Texas male prisoners are high and increasing, particularly among Hispanics, targeted prevention, screening, and treatment of HCV infections should be among the priorities of U.S. correctional healthcare systems.

Chronic liver allograft dysfunction

Approximately 90% of liver transplant patients are alive after 1 year and 75% after 5 years with the majority leading full and near-normal lives. However, although early mortality rates after transplantation have fallen dramatically over the last 2 decades, the rates of late graft loss and patient death have remained constant. Thus, understanding of the causes of graft and patient failure is essential to improve long-term outcomes. In the early days after liver transplantation, ischemia and reperfusion injuries predominate, with acute cellular rejection relatively common in first 3 months. Thereafter, the causes of graft dysfunction are variable with disease recurrence as a major cause of graft loss. In this review, we discuss causes of graft dysfunction after 6 months.

[Estimation on disease burden related to hepatitis B virus infection in Shandong province of China]

OBJECTIVE

To comprehensively measure the burden of hepatitis B, liver cirrhosis and liver cancer in Shandong province, using disability-adjusted life years (DALYs) to estimate the disease burden attribute to hepatitis B virus (HBV) infection.

METHODS

Based on the mortality data of hepatitis B, liver cirrhosis and liver cancer derived from the third National Sampling Retrospective Survey for Causes of Death during 2004 and 2005, the incidence data of hepatitis B and the prevalence and the disability weights of liver cancer gained from the Shandong Cancer Prevalence Sampling Survey in 2007, we calculated the years of life lost (YLLs), years lived with disability (YLDs) and DALYs of three diseases following the procedures developed for the global burden of disease (GBD) study to ensure the comparability.

RESULTS

The total burden for hepatitis B, liver cirrhosis and liver cancer were 211,616 (39,377 YLLs and 172,239 YLDs), 16,783 (13,497 YLLs and 3286 YLDs) and 247,795 (240,236 YLLs and 7559 YLDs) DALYs in 2005 respectively, and men were 2.19, 2.36 and 3.16 times as that for women, respectively in Shandong province. The burden for hepatitis B was mainly because of disability (81.39%). However, most burden on liver cirrhosis and liver cancer were due to premature death (80.42% and 96.95%). The burden of each patient related to hepatitis B, liver cirrhosis and liver cancer were 4.8, 13.73 and 11.11 respectively.

CONCLUSION

Hepatitis B, liver cirrhosis and liver cancer caused considerable burden to the people living in Shandong province, indicating that the control of hepatitis B virus infection would bring huge potential benefits.

Nucleotide analogs for patients with HBV-related hepatocellular carcinoma increase the survival rate through improved liver function

BACKGROUND AND AIM

This study evaluated the outcomes of antiviral therapy with nucleotide analogs for hepatitis B virus infection-related hepatocellular carcinoma.

METHODS

Thirty patients orally received nucleotide analogs and, as a matched control group, 20 patients who were not treated with nucleotide analogs were selected. We compared changes in liver function, HCC recurrence and survival rate between both groups.

RESULTS

In the nucleotide analog group, serum albumin, AST and ALT were significantly improved compared with baseline values. The Child-Pugh score was significantly decreased in the nucleotide analog group. Furthermore, of the 36 patients curatively treated with the initial treatment, more patients in the nucleotide analog group improved or maintained their Child-Pugh score at the time of recurrent HCC than in the control group (p=0.023). The cumulative recurrent-free survival rate of HCC did not significantly differ between the two groups; however, the cumulative survival rates of not only curative-treated patients but also all patients in the nucleotide analog group were significantly higher than those of patients in the control group (p=0.047 and p=0.02, respectively).

CONCLUSION

The results suggest that nucleotide analog treatment increases the survival rate in patients with HCC by contributing to the improvement of remnant liver function.

[Long-term survival after liver transplantation for benign end-stage liver disease in adults]

OBJECTIVE

To evaluate the long-term survival rates of the adults with benign end-stage liver disease (BELD) after liver transplantation (LT) and the causes of death.

METHODS

The common causes of late death (after more than 1 year) after LT were retrospectively analyzed in 203 consecutive patients with BELD who underwent LT from Oct. 2003 to May.2006.

RESULTS

The 1, 2 and 3-year survival rates were 88.7%, 85.5%, and 81.2% respectively. The 2-year and 3-year survival rates of the patients with HBV-related liver disease were 88.4% and 84.5% respectively, not significantly different from those of patients with non-HBV-related liver disease (75.6% and 64.0% respectively, P = 0.144). 165 recipients survived for more than 1 year and 21 recipients died during the period between 12 and 48 months after LT with a mean of (22.7 +/- 6.6) months. The common causes of late death included related to infectious complications (4.8%, 8/165), biliary tract complications (3.6%, 6/165), HBV re-infection (1.8%, 3/165), chronic rejection (1.2%, 2/165), renal functional lesion (0.6%, 1/165), and hepatic arterial complication (0.6%1/165).

CONCLUSION

Satisfactory long-term survival can be achieved in most adult recipients with BELD after LT and the major causes that influence the long-term survival are infectious complications, biliary tract complications, and HBV re-infection. Prevention of these complications, rational use of immunosuppressant, and regular follow-up are essential to improve long-term survival.

Deaths due to bloodborne infections and their sequelae among health-care workers

BACKGROUND

The odds of dying from bloodborne infections among health-care workers has not been well studied.

METHODS

Using data from the National Occupational Mortality Surveillance (NOMS) system, a matched case-control design was employed to examine the relationship between health-care employment and death from HIV, hepatitis B (HBV), hepatitis C (HCV; non-A/non-B viral hepatitis), liver cancer, and cirrhosis from 1984 to 2004. We examined the whole health-care industry and specific health-care occupations.

RESULTS

From 1984 to 2004, NOMS captured 248,550 deaths from bloodborne pathogens and their sequelae. Employment in the health-care industry was associated with increased risk of death from HIV (MOR = 2.27; 95% confidence interval [CI] = 2.11-2.44), HBV (MOR = 1.98; CI = 1.58-2.48), and cirrhosis (MOR = 1.09; CI = 1.04-1.15) among males, and death from HCV among both males (MOR = 1.46; CI = 1.22-1.75) and females (MOR = 1.22; CI = 1.05-1.40). Nursing was the occupation with the highest MORs among males for HIV and HBV, but female nurses were at decreased risk of dying from HIV (MOR = 0.69; CI = 0.57-0.83).

CONCLUSIONS

Employment in the health-care industry was found to be associated with deaths from several bloodborne pathogens and their sequelae among males, but only with HCV among females from 1984 to 2004 in this exploratory study.

Management of chronic hepatitis B

OBJECTIVES

Synthesize evidence of the natural history of chronic hepatitis B (CHB) and effects and harms of antiviral drugs on clinical, virological, histological, and biochemical outcomes.

DATA SOURCES

MEDLINE, electronic databases, and manual searches of systematic reviews.

REVIEW METHODS

We included original observational studies to assess natural history and randomized controlled trials (RCTs) of adults with CHB published in English to assess treatment effects and harms if they reported mortality, incidence of hepato-cellular carcinoma (HCC), cirrhosis or failure, HBeAg or HBsAg, viral load (HBV DNA), alanine aminotransferase (ALT) levels, histological necroinflammatory and fibrosis scores, and adverse events after interferon alfa-2b, pegylated interferon alfa 2-a, lamivudine, adefovir, entecavir, tenovir or telbivudine. We excluded pregnant women, transplant patients, and individuals undergoing cancer chemotherapy. We calculated relative risk or absolute risk differences at end of treatment and post-treatment.

RESULTS

Observational studies (41 publications) suggested that male gender, coinfection with hepatitis C, D, or HIV, increased HBV DNA, and cirrhosis were associated with increased risk of HCC and death. Drugs did not reduce death, liver failure, or HCC in 16 RCTs not designed to test long-term clinical outcomes. Evidence from 93 publications of 60 RCTs suggested drug effects on viral load or replication, liver enzymes, and histology at end of treatment and lasting from 3 to 6 months off treatment. No one treatment improved all outcomes and there was limited evidence on comparative effects. Two RCTs suggested interferon alfa-2b increased CHB solution versus placebo. Interferon alfa-2b or lamivudine improved off treatment HBV DNA and HBeAg clearance and seroconversion and ALT normalization. Adefovir improved off treatment ALT normalization and HBV DNA clearance. Pegylated interferon alfa 2-a versus lamivudine improved off-treatment HBV DNA and HBeAg clearance and seroconversion, ALT normalization and liver histology. Lamivudine combined with interferon alfa-2b versus lamivudine improved off treatment HBV DNA clearance and HBeAg seroconversion and reduced HBV DNA mutations. Pegylated interferon alfa 2-a plus lamivudine improved off treatment HBV DNA and HBeAg clearance and seroconversion and ALT normalization compared to lamivudine but not pegylated interferon alfa 2-a monotherapy. Adverse events were common but generally mild and did not result in increased treatment discontinuation. Longer hepatitis duration, male gender, baseline viral load and genotype, HBeAg, and histological status may modify treatment effect on intermediate outcomes. Adefovir and pegylated interferon alfa 2-a with lamivudine improved off treatment viral clearance in HBeAg negative patients. There was insufficient evidence to determine if biochemical, viral, or histological measures are valid surrogates of treatment effect on mortality, liver failure, or cancer.

CONCLUSION

Adults with CHB have an increased risk of death, hepatic decompensation, and HCC. Mono or combined drug therapy improves selected virological, biochemical, and histological markers with no consistent effects on all examined outcomes. Patient and disease characteristics may modify treatment-induced intermediate outcomes. Evidence was insufficient to assess treatment effect on clinical outcomes, predict individualized patient response, or determine if intermediate measures are reliable surrogates. Future research should assess long-term drug effects on clinical outcomes and among patient subpopulations.

Hepatitis B immunoglobulin and Lamivudine improve hepatitis B-related outcomes after liver transplantation: meta-analysis

BACKGROUND & AIMS

HBV recurrence increases morbidity and mortality in HBsAg+ patients undergoing liver transplantation. We aimed to estimate the relative efficacy of combined therapy with hepatitis B immunoglobulin (HBIG) and lamivudine (LAM) versus HBIG monotherapy for preventing HBV-related morbidity and mortality in this setting.

METHODS

We performed a meta-analysis of clinical trials that met the prespecified criteria and provided data for risk estimation of HBV recurrence in HBsAg+ liver transplant patients receiving HBIG and LAM versus HBIG alone. Databases searched until May 2007 included MEDLINE (Ovid), PubMed, Embase, Toxnet, Scopus, and Web of Science. Literature search and data extraction were conducted independently by 2 study investigators; then 2 other investigators reviewed and screened eligible studies. Odds ratios (ORs) for the risk reduction with HBIG and LAM versus HBIG alone were calculated by using a random-effects model.

RESULTS

Two prospective and 4 retrospective studies were included in the meta-analysis. The OR showing risk reduction in HBV recurrence with HBIG and LAM (n = 193) versus HBIG alone (n = 124) was 0.08 (95% confidence interval [CI], 0.03-0.21). HBV-related death and all-cause mortality could only be assessed in 3 studies each. The ORs showing HBV-related death and all-cause mortality reduction with HBIG and LAM versus HBIG alone were 0.08 (95% CI, 0.02-0.33) and 0.02 (95% CI, 0.06-0.82), respectively.

CONCLUSIONS

Although this meta-analysis was limited by small studies and varying levels of immunosuppression, it is apparent that adding LAM to HBIG improved HBV-related morbidity and mortality in HBsAg+ recipients of liver transplants.

[The effect of hepatitis B virus infection on the outcome of hematopoietic stem cell transplantation]

OBJECTIVE

To evaluate the effect of hepatitis B virus (HBV) infection on the outcome of hematopoietic stem cell transplantation (HSCT).

METHODS

Among 279 patients with blood diseases underwent HSCT from 2001 to 2006, clinical data of 43 patients with HBV were analyzed retrospectively.

RESULTS

(1) There was no significant difference in the engraftment of hematopoietic stem cells between HBV infected group and control group. (2) In all the HLA-matched allogeneic HSCTs, the incidence rates of hepatic veno-occlusive disease (HVOD) (31.8%), hepatic complications (72.7%) and fatal hepatic lesion (27.3%) were all significantly higher in HBV group than those in control group (P < 0.05). (3) Through univariate analysis, the risk factors of hepatic complications in HBV group were: pretransplant hepatic dysfunction; progression phase of primary disease; allo-HSCT; having used cyclosporine as graft-versus-host disease (GVHD) prophylaxis drug. Donor's age older than 25; pretransplant hepatic dysfunction; progression phase of primary disease; total body irradiation (TBI) conditioning regimen; TBI abdomen dosage was over 7 Gy etc. were the risk factors of HVOD. However, pretransplant hepatic dysfunction; progression phase of primary disease were among the risk factors causing fatal hepatic lesion. (4) The mortality rate in HBV group (51.2%) was significantly higher than that in the control group (23.9%). The major causes of death were multiple organ failure (MOF) and liver function failure (LF). Deterioration of LF was occurred in patients with allo-HSCT during immunosuppressive agent tapered off. (5) The accumulated survival rate in HBV group was significantly lower than that in the control group (P = 0.023).

CONCLUSION

Donors and recipients infected with HBV were not contradictive to HSCT. The proper time of HSCT and suitable HSCT schedule could control some of the transplantation risk factors and might be helpful in reducing the mortality rate and improving the quality of life through enhancing the curative effect.

Development of a survival evaluation model for liver transplant recipients with hepatocellular carcinoma secondary to hepatitis B

AIM

To develop a model using easily obtainable, objective, verifiable preoperative parameters, to help evaluate post transplant survival probability for hepatocellular carcinoma (HCC) patients with hepatitis B.

METHODS

We retrospectively examined a cohort of 150 consecutive primary cadaveric liver transplants with HCC in our center over 6 years. Thirteen preoperative biochemical parameters and six tumor-related factors were analyzed to identify their correlation with post transplant survival using the Cox proportional-hazards regression model. The predictive power of a new model and the model for end stage liver disease was compared by the receiver operating characteristic curve.

RESULTS

In univariate analysis, the factors significantly associated with post transplant survival were serum concentrations of albumin, total bilirubin, alkaline phosphatase, alpha-fetoprotein, gamma-glutamyltransferase, aspartate aminotransferase, sodium, tumor diameter and the number of tumor nodules. Multivariate analysis showed alpha-fetoprotein, serum sodium, alkaline phosphatase and the number of tumor nodules were significantly associated with the post transplant outcome. Based on the four variables, we established a new model with a c-statistic of 0.72 which was significantly greater than 0.50 (P = 0.001), and the c-statistic of MELD was 0.59 (P = 0.146).

CONCLUSION

The new model based on four objective tumor-related parameters has the capacity to evaluate the risk of post transplant mortality for HCC patients with hepatitis B.

[Hepatitis B in Poland in 2006]

A total of 1,693 of hepatitis B cases (including 59 cases of co-infections with HCV) were reported in Poland in 2006, with incidence rate 4.4 per 100,000 population. Regionally the incidence varied from 1.7 per 100,000 in lubuskie voivodeship to 10.5 in łódzkie. In total number of registered cases 70% were new chronic ones (incidence 3.1 per 100,000; regionally ranged from 0.4 in podlaskie voivodeship to 8.8 in łódzkie), and only 30% acute cases (incidence 1.3; regionally ranged from 0.6 in zachodniopomorskie voivodeship to 2.1 in slaskie). The highest reported incidence (both acute and chronic) was observed in age group 35-39 years (6.3 per 100,000) but the highest incidence of chronic form was among 15-19 (4.8) years old and acute form among 60-64 years old (2.4). The total incidence in the urban areas (4.8) was higher than in rural areas (3.8) and also was higher in men (6.0) than in women (2.9). This situation we could observe in previous year. In total 68.3% of patients were hospitalized and the percentage varied regionally from 39.5% in lubelskie voivodeship to 100.0% in podkarpackie. There were 64 deaths attributed to hepatitis B in 2006 including 8 deaths of acute and 56 of chronic hepatitis B.

[Liver transplantation for patients infected with both HIV and HCV or HIV and HBV]

Human immunodeficiency virus infection (HIV) has been considered until recently as a contraindication for liver transplantation. This was due to the poor spontaneous prognosis of HIV infection. The advent of highly active antiretroviral drugs (HAART) was a therapeutic breakthrough, and the prognosis has been dramatically improved. 30 % and 10 % of HIV infected patients are coinfected with hepatitis C virus (HCV) and with hepatitis B virus (HBV), respectively. The progression of chronic hepatitis B and C seems more rapid in coinfected patients, and a high number of patients will develop life-threatening liver cirrhosis. There are numerous potential problems raised by liver transplantation in HIV infected patients: (1) the potential risk of needlestick injury during this type of hemorrhagic surgery at high risk of bleeding; (2) the timing for liver transplantation; (3) the risk of interference between HAART and calcineurin inhibitors; (4) The risk of HBV and HCV recurrence post-transplant. Since 1999, a program of liver transplantation has been started in patients coinfected with HIV and HBV or HCV with the support of the Agence Nationale de Recherche contre le Sida et les Hépatites virales (ANRS). The first results showed that liver transplantation in HIV-HCV and HIV-HBV infected patients is feasible, achieving 2-year survival of 70 % and 100 %, respectively. There was no acceleration of HIV disease after transplantation. HBV recurrence was well prevented by the combination of anti-HBs immunoglobulins plus nucleoside and nucleotide analogues effective against HBV. The main problem is HCV recurrence, which is more rapid and more severe in HIV coinfected patients than in HCV monoinfected patients. Understanding HCV recurrence mechanisms, and preventing and treating of HCV recurrence are major future challenges.

Comparison of surgical outcomes for small hepatocellular carcinoma in patients with hepatitis B versus hepatitis C: a Chinese experience

BACKGROUND

Although both hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are well recognized risk factors for hepatocellular carcinoma (HCC), little is known with respect to how HBV and HCV infection affect HCC recurrence in postoperative HCC Chinese patients. The objective of this study was to determine if differences exist in preoperative characteristics and postoperative HCC recurrence in patients with different HBV and HCV infection status.

METHODS

The study population consisted of 413 patients undergoing a curative resection at Tianjin Cancer Hospital for small HCC (< or =3 cm) from January 1997 to December 2003. The patients were divided into four groups: HCV only (n = 75), HBV only (n = 251), HBV and HCV (n = 33), and neither HBV nor HCV (NBNC, n = 54). The preoperative status and postoperative HCC recurrence were recorded. Survival analyses were used to assess the impact of HBV/HCV status on HCC recurrence.

RESULTS

Patients with HCV had a significant association with older age, lower mean preoperative platelet counts and albumin levels, higher mean prothrombin time, alanine aminotransferase and total bilirubin levels and multinodular tumors during diagnosis. Patients with HCV also had significantly less differentiated tumors and a higher incidence of vascular invasion and cirrhosis when compared to the other groups. During the follow-up, the HCV group showed a higher incidence of intrahepatic recurrence and multiple recurrent lesions than the other patients.

CONCLUSIONS

Patients with HCV infection tended to be older, and were characterized by more severe cirrhosis and higher incidence of tumor multicentricity. The statistically significant determinants for reoccurrence in patients with small HCC were HCV infection, presence of vascular invasion and multiple tumors.

Milk thistle for alcoholic and/or hepatitis B or C virus liver diseases

BACKGROUND

Alcohol and hepatotoxic viruses cause the majority of liver diseases. Randomised clinical trials have assessed whether extracts of milk thistle, Silybum marianum (L) Gaertneri, have any effect in patients with alcoholic and/or hepatitis B or C virus liver diseases.

OBJECTIVES

To assess the beneficial and harmful effects of milk thistle or milk thistle constituents versus placebo or no intervention in patients with alcoholic liver disease and/or viral liver diseases (hepatitis B and hepatitis C).

SEARCH STRATEGY

The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and full text searches were combined (July 2007). Manufacturers and researchers in the field were contacted.

SELECTION CRITERIA

Only randomised clinical trials in patients with alcoholic and/or hepatitis B or C virus liver diseases (acute and chronic) were included. Interventions encompassed milk thistle at any dose or duration versus placebo or no intervention. The trials could be double blind, single blind, or unblinded. The trials could be unpublished or published and no language limitations were applied.

DATA COLLECTION AND ANALYSIS

The primary outcome measure was mortality. Binary outcomes are reported as relative risks (RR) with 95% confidence interval (CI). Subgroup analyses were performed with regard to methodological quality.

MAIN RESULTS

Eighteen randomised clinical trials assessed milk thistle in 1088 patients with alcoholic and/or hepatitis B or C virus liver diseases. The methodological quality was low: only 28.6% of the trials reported high methodological quality characteristics. Milk thistle versus placebo or no intervention had no significant effect on mortality (RR 0.78, 95% CI 0.53 to 1.15), complications of liver disease (RR 0.95, 95% CI 0.83 to 1.09), or liver histology. Liver-related mortality was significantly reduced by milk thistle in all trials (RR 0.50, 95% CI 0.29 to 0.88), but not in high-quality trials (RR 0.57, 95% CI 0.28 to 1.19). Milk thistle was not associated with a significantly increased risk of adverse events (RR 0.83, 95% CI 0.46 to 1.50).

AUTHORS' CONCLUSIONS

Our results question the beneficial effects of milk thistle for patients with alcoholic and/or hepatitis B or C virus liver diseases and highlight the lack of high-quality evidence to support this intervention. Adequately conducted and reported randomised clinical trials on milk thistle versus placebo are needed.