Six Minute Walk Test to assess functional capacity in chronic liver disease patients

AIM: To examine the utility of Six Minute Walk Test (6MWT) in patients with chronic liver disease (CLD).

METHODS: Two hundred and fifty subjects between the ages of 18 and 80 (mean 47) years performed 6MWT and the Six Minute Walk Distance (6MWD) was measured.

RESULTS: The subjects were categorized into four groups. Group A (n = 45) healthy subjects (control); group B (n = 49) chronic hepatitis B patients; group C (n = 54) chronic hepatitis C patients; group D (n = 98) liver cirrhosis patients. The four groups differed in terms of 6MWDs (P < 0.001). The longest distance walked was 421 ± 47 m by group A, then group B (390 ± 53 m), group C (357 ± 72 m) and group D (306 ± 111 m). The 6MWD correlated with age (r = -0.482, P < 0.01), hemoglobin (r = +0.373, P < 0.001) and albumin (r = +0.311, P < 0.001) levels. The Child-Pugh classification was negatively correlated with the 6MWD in cirrhosis (group D) patients (r = -0.328, P < 0.01). At the end of a 12 mo follow-up period, 15 of the 98 cirrhosis patients had died from disease complications. The 6MWD for the surviving cirrhotic patients was longer than for non-survivors (317 ± 101 vs 245 ± 145 m, P = 0.021; 95% CI 11-132). The 6MWD was found to be an independent predictor of survival (P = 0.024).

CONCLUSION: 6MWT is a useful tool for assessing physical function in CLD patients. We suggest that 6MWD may serve as a prognostic indicator in patients with liver cirrhosis.

Systemic inflammatory response syndrome strongly affects the prognosis of patients with fulminant hepatitis B

BACKGROUND

Hepatitis B virus infection is the most frequent cause of fulminant hepatic failure. Recently, systemic inflammatory response syndrome has been reported to be important in patients with fulminant hepatic failure. However, prognostic factors for fulminant hepatitis B have not been fully examined. In this study, we analyzed prognostic factors for fulminant hepatitis B in order to accurately identify patients with fatal outcomes.

METHODS

Of 110 consecutive patients with fulminant hepatic failure, 36 (33%) were diagnosed with fulminant hepatitis B. Five of the 36 patients received liver transplants, and we analyzed prognostic factors associated with fatal outcomes in the other 31 patients, who consisted of 15 men and 16 women with a median age of 45 (range, 20-74) years.

RESULTS

Eleven patients (35%) survived without liver transplantation, and the remaining 20 (65%) died. Nonsurvivors were older and had a higher prevalence ratio of systemic inflammatory response syndrome than survivors. Treatments were similar between survivors and nonsurvivors. Using a multivariate Cox proportional hazard model, age (>45 years), systemic inflammatory response syndrome, and ratio of total to direct bilirubin (>2.0) were associated with fatal outcomes. In particular, 1-week and overall survival rates of patients with systemic inflammatory response syndrome at the time of diagnosis were 39% and 8%, respectively, while those of patients without systemic inflammatory response syndrome were 94% and 56%, respectively.

CONCLUSIONS

Systemic inflammatory response syndrome strongly affects the short-term prognosis of patients with fulminant hepatitis B, and patients with systemic inflammatory response syndrome might need urgent liver transplantation.

Worldwide mortality from cirrhosis: an update to 2002

BACKGROUND/AIMS

Cirrhosis mortality has registered large changes over the last few decades.

METHODS

Age-standardized (world standard) cirrhosis mortality rates per 100,000 were computed for 41 countries worldwide over the period 1980-2002 using data from the WHO mortality database.

RESULTS

In the early 1980s, the highest rates were in Mexico, Chile (around 55/100,000 men and over 14/100,000 women), France, Italy, Portugal, Austria, Hungary and Romania (around 30-35/100,000 men and 10-15/100,000 women). Mortality from cirrhosis has been steadily declining in most countries worldwide since the mid or late 1970s (annual percent change, APC, between -5% and -1.5% in the last decade only for both sexes). In southern Europe, rates in the early 2000s were less than halved compared to earlier decades. In contrast, rates have been rising in Eastern European countries to reach extremely high values in the mid 1990s, and declined only thereafter. In the UK rates were still steadily rising (APC around +7% in men and +3% in women from England and Wales, and +9% in men and +7% in women from Scotland).

CONCLUSIONS

Mortality from cirrhosis shows favourable trends in most countries of the world, following the reduction in alcohol consumption and hepatitis B and C virus infection. The steady upward trends observed over more recent calendar periods in the UK and central and eastern European countries are attributed to the persistent increase in the prevalence of alcohol consumption.

Initial load of hepatitis B virus (HBV), its changing profile, and precore/core promoter mutations correlate with the severity and outcome of acute HBV infection

BACKGROUND

The pathogenesis of the fulminant or severe form of acute hepatitis B virus (HBV) infection remains unclear, although both host- and virus-specific factors are considered to have a great impact on the c course. We aimed to define possible viral factors implicated in the severe form of acute HBV infection.

METHODS

We investigated viral factors in 42 patients with acute HBV infection: 11 had fulminant hepatitis (FH); 9 had a severe form of acute hepatitis (SAH), defined as having a prothrombin activity of less than 40% without encephalopathy; and 22 had acute self-limited hepatitis (AH).

RESULTS

Although there was no significant difference in serum HBV DNA levels on admission among the three groups, the level decreased more rapidly in patients with SAH or FH than in those with AH. In patients with SAH or FH, the HBV load on admission was higher in patients who died than in those who recovered (7.0 +/- 1.6 vs 5.6 +/- 1.0 log copies/ml; P=0.0293). In univariate analysis, seronegativity for hepatitis B envelope antigen (HBeAg) and mutations in both the precore (G1896A and/or G1899A) and core promoter (T1753A/C and/or T1754C/G and/or A1762T/G1764A) were associated with FH (odds ratio [OR], 5.60; P=0.0269 and OR, 52.0; P=0.0006; respectively). In multivariate logistic regression analysis, only the presence of precore/core promoter mutations was associated with FH (OR, 42.8; P=0.0020).

CONCLUSIONS

The rapid decrease in viral load in the early phase of acute HBV infection was associated with the severity of the disease. A high viral load on admission and the presence of both precore and core promoter mutations in patients with severe coagulopathy closely correlated with mortality.

Lamivudine plus low-dose hepatitis B immunoglobulin to prevent recurrent hepatitis B following liver transplantation

BACKGROUND AND AIMS

High-dose intravenous hepatitis B immunoglobulin (HBIG) may prevent recurrent hepatitis B virus (HBV) infection, but the cost has limited its widespread use in countries with endemic HBV infection. We report on long-term safety and efficacy of an alternative strategy of very low doses (400-800 IU/month) of intramuscular (IM) HBIG plus lamivudine.

METHODS

Australian and New Zealand patients who received low-dose HBIG plus lamivudine following liver transplantation for HBV-related end-stage liver disease were studied. Prior to transplantation, patients with detectable serum HBV DNA received lamivudine 100 mg daily. Posttransplantation, all patients received lamivudine 100 mg daily plus IM HBIG 400 or 800 IU daily for 1 week then monthly thereafter. Serum HBV DNA levels were measured prior to lamivudine, at transplantation, and at 12 months posttransplantation. Serum titers of antibody to HBV surface antigen were measured at 1, 3, and 12 months posttransplantation.

RESULTS

Between February 1996 and October 2004, 147 patients received low-dose HBIG plus lamivudine. Thirty-one percent were hepatitis B e antigen positive, and 85% were HBV DNA+ prior to transplantation. The median duration of pretransplantation lamivudine was 92 days (range, 1-1775). Median follow-up posttransplantation was 1860 days. Kaplan-Meier patient survival was 92% at 1 year and 88% at 5 years. The actuarial risk of HBV recurrence was 1% at 1 year and 4% at 5 years. Baseline HBV DNA titer was associated with HBV recurrence.

CONCLUSION

Low-dose IM HBIG plus lamivudine provides safe and effective long-term prophylaxis against recurrent HBV at <10% the cost of the high-dose regimen.

Clinical outcome of renal transplantation in patients with positive pre-transplant hepatitis B surface antigen

The clinical outcomes of 2,054 renal recipients were examined retrospectively based on pre-transplant hepatitis B surface antigen (HBsAg) status to investigate the efficacy of lamivudine treatment in HBsAg positive recipients. Pre-transplant HBsAg positivity was documented in 66 recipients. The 10-year patient and graft survival rates in Ag positive group were significantly lower than those of Ag negative group (64.4/36.6% vs. 88.2/70.5%, respectively, P < 0.0001). Since 1997, lamivudine was used when hepatitis B virus polymerase chain reaction (HBV PCR) was positive or when the level of post-transplant viral load rose. Lamivudine given to 27 recipients markedly improved both 10-year patient and graft survivals compared to Ag positive renal recipients who did not take lamivudine (85.3/59.2% vs. 49.9/22.7%, respectively, P < 0.0001). Overall, 13 viral breakthroughs among 24 lamivudine-responsive patients were observed. The cumulative incidence of viral breakthrough at 60 months was 53.3%. Adefovir rescue in three viral breakthroughs patients induces virological response and restoration of liver function. In 10 patients who did not changed to adefovir, 6 patients are alive with elevated liver enzymes. In conclusion, in the era of lamivudine and adefovir, renal transplantation in HBsAg positive end-stage renal disease patients should not be abandoned.

[Hepatitis B in Poland in 2005]

In total 1727 new cases were reported, 91 (5.3%) of which concerned people co-infected with HBV and HCV. The registered incidence, 4.5 per 100,000 population, was 10% higher then in 2004. It is assumed that the increase is connected to the changes in the surveillance system (introduction of European case definitions). Chronic hepatitis accounted for 62% of all cases (incidence 2.8 per 100,000) and acute hepatitis for 38% (incidence 1.7). As in previous years, the incidence in the urban areas (5.1) exceeded the incidence in the rural areas (3.6) and was higher in men (6.1) then in women (3.1). Comparing the incidence across the regions, the rate ratio between the voivodeship with the highest and the lowest incidence (respectively 7.9 in swietokrzyskie and 2.1 in podkarpackie) was 3.8. Overall the most affected age groups were young adults (incidence 6.7 among 20-24 year olds, 5.5 in 30-34 year olds and 5.3 in 25-29 year olds) and the elderly (incidence 6.2 in 65-74 year olds and 5.4 in persons over 74 years of age). Approximately 85% of cases were hospitalised. 85 deaths from hepatitis B were registered in 2005, including 62 from chronic and 23 from acute hepatitis B.

Causes of death after diagnosis of hepatitis B or hepatitis C infection: a large community-based linkage study

BACKGROUND

Hepatitis B and hepatitis C virus infections are common causes of death related to liver disease. In this large study, we aimed to investigate all cause mortality of the viruses in a community-based setting.

METHODS

In the study population, 39,109 people had hepatitis B, 75,834 had hepatitis C, and 2604 had hepatitis B and hepatitis C co-infection, notified to the New South Wales state health department, Australia, between 1990 and 2002. Their data were probabilistically linked to the National Death Index. Standardised mortality ratios for all causes of death were calculated and adjusted for age, sex, and calendar year.

RESULTS

The number of deaths identified by the linkage were 1233 (3.2%) for hepatitis B, 4008 (5.3)% for hepatitis C, and 186 (7.1)% for hepatitis B and C co-infection. Raised risk of liver-related death (standardised mortality ratios 12.2, 95% CI 10.7-13.9; 16.8, 15.4-18.3, and 32.9, 23.1-46.7, for hepatitis B, hepatitis C, and hepatitis B and C co-infected patients, respectively) and drug-induced death (1.4, 1.0-2.0; 19.3, 18.1-20.5; and 24.7, 18.2-33.5, respectively) were detected. In people with hepatitis C, raised risk of dying from drug-related causes was significantly greater than from liver-related causes (p=0.012), with the greatest excess risk in women aged 15-24 years (56.9, 39.2-79.9).

INTERPRETATION

All groups had increased risk of liver-related death compared with the standard population, with the greatest excess in people diagnosed with hepatitis B and hepatitis C co-infection. Our data highlight that young people with hepatitis C and with co-infection face a higher mortality risk from continued drug use than from their infection, whereas the main cause of hepatitis B death was liver related.

Successful Treatment of Hepatitis B Virus Infection With Lamivudine After Heart Transplantation

Patients with hepatitis B virus (HBV) infection have a higher morbidity and mortality after heart transplantation (HT). HBV infection is endemic in Taiwan. We studied the effect of lamivudine treatment of HBV infection after HT. From July 1987 to July 2005, 252 patients underwent HT. All recipients and donors underwent routine screening of hepatitis B surface antigen (HBsAg), hepatitis B e antigen, antibody to hepatitis B surface antigen, antibody to hepatitis B core antigen, antibody to hepatitis B e antigen, and an alanine aminotransferase (ALT) level before HT. When ALT was two times greater than the upper limit of normal or serum bilirubin was higher than 3 mg/dL in HBsAg-positive patients, HBV-DNA were checked by a branched DNA assay or polymerase chain reaction. When HVB-DNA was greater than 100,000 copies/mL, lamivudine (100 mg per day) was prescribed indefinitely. There were 14 patients under lamivudine treatment after HT, among whom, none suffered severe adverse reactions from lamivudine. Four patients died: one due to end-stage cirrhosis while awaiting liver transplantation at 14 months after HT. Two died of sudden death at 54 months and 138 months after HT. Another died of diffuse B cell lymphoma at 62 months after HT. All the survivors have normal ALT and undetectable HBV-DNA after lamivudine treatment. But the YMDD mutant was detected in two patients. With successful treatment of HBV infection in HT, it is not necessary to exclude HBV infection patients from HT.

Native hepatitis B virions and capsids visualized by electron cryomicroscopy

Hepatitis B virus (HBV) infects more than 350 million people, of which one million will die every year. The infectious virion is an enveloped capsid containing the viral polymerase and double-stranded DNA genome. The structure of the capsid assembled in vitro from expressed core protein has been studied intensively. However, little is known about the structure and assembly of native capsids present in infected cells, and even less is known about the structure of mature virions. We used electron cryomicroscopy (cryo-EM) and image analysis to examine HBV virions (Dane particles) isolated from patient serum and capsids positive and negative for HBV DNA isolated from the livers of transgenic mice. Both types of capsids assembled as icosahedral particles indistinguishable from previous image reconstructions of capsids. Likewise, the virions contained capsids with either T = 3 or T = 4 icosahedral symmetry. Projections extending from the lipid envelope were attributed to surface glycoproteins. Their packing was unexpectedly nonicosahedral but conformed to an ordered lattice. These structural features distinguish HBV from other enveloped viruses.

Epidemiology of hepatocellular carcinoma in areas of low hepatitis B and hepatitis C endemicity

Hepatocellular carcinoma (HCC) ranks among the 10 most common cancers worldwide. It evolves from several chronic liver diseases, most of which culminate in cirrhosis. As the most common causes, other than alcoholic cirrhosis, are chronic hepatitis B and C infections, its prevalence worldwide is linked to the prevalence of these two viruses. Thus, the highest rates are in southeast Asia and sub-Saharan Africa, the world's most populous nations, where hepatitis B virus infection is endemic. In most western countries, hepatitis C virus infection is the predominant cause, and hepatitis B-related liver cancer occurs largely among immigrants from countries of high hepatitis B endemicity. In most western countries, the incidence and mortality from HCC is increasing as a consequence of the chronic sequelae of the 'epidemic' of hepatitis C of the 1960-1980s. In the US, modeling of this infection predicts a continued rise in liver cancer over the next decade. Surveillance by the National Cancer Institute and the Centers for Disease Control confirms the increasing incidence of and mortality from HCC to the year 2000, although subsequent analyses suggest a slowing or possibly decline in the rate of increase. Whether this trend will continue requires further evaluation.

Lack of association between acute exposure to ionizing radiation and liver cirrhosis

PURPOSE

Although previous studies have shown significantly increased risks of liver cirrhosis and chronic liver disease for acute radiation exposure among survivors of the atomic bombings of Hiroshima and Nagasaki, Japan, these studies have not taken into account hepatitis B virus (HBV) infections. Because HBV is associated with both A-bomb radiation and liver cirrhosis, our goal was to investigate the relationship of acute ionizing radiation to liver cirrhosis adjusting for HBV, co-occurring primary liver cancer (PLC), and other potential confounders.

MATERIALS AND METHODS

Using a cross-sectional design and pathology review of a cohort of Japanese atomic-bomb survivors, we found that 213 of 335 (63.6%) subjects with PLC and 55 of 776 (7.1%) subjects without PLC had cirrhosis.

RESULTS

We found no association between acute exposure to A-bomb radiation and liver cirrhosis. The adjusted odds ratio of cirrhosis per Sv liver irradiation was 0.59 (95% confidence interval: 0.27 - 1.27). Cirrhosis risks for the highest tertile of radiation exposure (mean exposure 0.7 Sv) were also not elevated (0.8, 0.26 - 2.12 and 0.2, 0.03 - 0.98 among subjects with and without PLC.

CONCLUSIONS

Acute exposure to liver irradiation does not increase risks of liver cirrhosis, regardless of PLC status.

Impact of Lamivudine on the Risk of Liver-Related Death in 2,041 Hbsag- and HIV-Positive Individuals: Results from An Inter-Cohort Analysis

Background

The impact of lamivudine (3TC) as part of combination antiretroviral therapy (cART) on the risk of liver-related death (LRD) in HIV/hepatitis B virus (HBV)-coinfected patients has not been extensively studied.

Methods

We performed an analysis involving HIV/HBV-coinfected patients in 13 cohorts who initiated cART. The end–point was LRD – that is, death with concomitant decompensated liver disease (DLD) or hepatocellular carcinoma – as the main cause. Incidence rates of LRD after initiation of cART were expressed as number of events per 100 person–years of follow–up (PYFU). A Poisson regression model adjusted for cohort, gender, mode of HIV transmission, CD4+ T-cell count at cART initiation, liver disease pre–cART, duration of 3TC before cART, and hepatitis C virus was used to assess the association between use of 3TC and risk of LRD.

Results

We analysed 2,041 patients. Follow–up after starting cART was 7,648 PYFU (5,569 spent on 3TC-containing regimens) with a median per person of 48 months (range: 2–91). Of the total, 217 subjects died; 57 deaths were liver-related resulting in a rate of 7.5 per 1,000 PYFU [95% confidence intervals (CI): 5.6–9.7]. The relative risk of LRD per extra year of 3TC use was 0.73 (95% CI: 0.59–0.90, P=0.004).

Conclusion

The use of 3TC was associated with a reduced risk of LRD over 4 years of follow–up. This study supports the current view that the use of 3TC as part of cART should be considered in patients who are tested positive for HBsAg.

Surveillance of HIV and viral hepatitis by analysis of samples from drug related deaths

OBJECTIVES

To determine the prevalence of antibodies against HIV, hepatitis B (HBV) and hepatitis C (HCV) in postmortem samples from drug related deaths (DRDs) in Denmark.

DESIGN

Prospective cohort study. Postmortem samples tested for anti-HIV, anti-HCV anti-HBc and anti-HBs. Comparison to pre-mortem testing when possible. DRDs were searched for in the national register of drug treatment, national prison registers, and the national infectious disease register.

SETTING

National level.

PARTICIPANTS

Drug related deaths admitted to Danish Institutes of Forensic Medicine during 2004.

MAIN OUTCOME MEASURES

Prevalence of antibodies, injection drug use, drug treatment experience and prevalence of cirrhosis.

RESULTS

Samples for analysis were obtained from 78% (233/299) of DRDs. The prevalences of anti-HIV, anti-HCV and anti-HBc were 4% (9/214), 51% (110/215), and 35% (74/209), indicating a persisting low prevalence of HIV and a declining prevalence of HCV and HBV. Injecting ever was detected among 45% of DRDs and this was associated with a significantly higher prevalence of hepatitis B and C. Among the DRDs 56% received drug treatment and 12% had cirrhosis at autopsy. Evidence of vaccination against HBV was found among 16% (21/128).

CONCLUSIONS

Monitoring of viral hepatitis and HIV among DRDs is feasible, and our survey indicates a falling prevalence among Danish drug users. Surveillance based on drug users in treatment may overestimate the true prevalence.

Bilirubin appears to be the only independent variable affecting mortality on liver transplant waiting list if waiting time exceeds 1 year

BACKGROUND

The Model for End-Stage Liver Disease (MELD) score has been shown to be the best predictor of short-term mortality on the liver transplant waiting list in the United States but waiting time often exceeds 1 year in many countries. We wanted to identify the factors affecting mortality on the liver transplant waiting list in Singapore where waiting time for liver transplant exceeds 1 year.

PATIENTS AND METHODS

All patients who were listed on the liver transplant waiting list in Singapore from January 1997 to December 2003 excluding those who were transplanted were analyzed. MELD was calculated according to the United Network for Organ Sharing formula. Univariate analysis was performed to identify factors affecting mortality on the waiting list and multivariate analysis by logistic regression. Categorical and continuous variables were compared with the chi-square and Mann-Whitney U tests.

RESULTS

There were 48 patients in the study. We found that on univariate analysis, bilirubin, INR, MELD score, and Child's score significantly influenced mortality on the waiting list but on multivariate analysis, bilirubin was the only independent prognostic indicator of mortality on the waiting list (LR = 1.97; 95% confidence interval = 1.08 to 3.61). INR was found to be significantly correlated to bilirubin with Pearson correlation (R = 0.63, P < .001).

CONCLUSION

Bilirubin is the only independent factor affecting mortality on the liver transplant waiting list where waiting time exceeds 1 year.

[Epidemiologic characteristic of hepatitis B in the Splitsko-Dalmatinska County]

Epidemiologic characteristics of hepatitis B virus (HBV) infection in the Split-Dalmatia County and in Croatia as a whole from January 1, 1994 till December 31, 2003 were analyzed. The mean number of hepatitis B cases was 28 (morbidity rate 6.03 per thousand) in the Split-Dalmatia County and 208 (morbidity rate 4.68 per thousand) in Croatia. Over the last five years, there was a marked decrease in the incidence of hepatits B in the Split-Dalmatia County (morbidity rate 1.55 per thousand), whereas its incidence at the national level showed a stable pattern (morbidity rate 4.49 per thousand). In the Split-Dalmatia County, the majority of patients (57.51%) were aged 15-29, which could be attributed to risky sexual contacts and intravenous drug use. The male to female ratio was 2.1(188:93). There was no major incidence fluctuation according to months of year. The hepatitis B mortality rate was 0.24% (5/2079) in Croatia as a whole, whereas no case of HBV lethality was recorded in the Split-Dalmatia County. The significant decrease in the hepatitis B morbidity rate in the Split-Dalmatia County most probably resulted from the comprehensive measures of prevention, especially vaccination, the early introduction of the needle exchange program (1955-1996).

Natural history of compensated cirrhosis in the Child-Pugh class a compared between 490 patients with hepatitis C and 167 with B virus infections

Natural histories of compensated cirrhosis in the Child-Pugh class A were compared between the 490 patients infected with hepatitis C virus (HCV) and 167 patients with hepatitis B virus (HBV) who were followed for more than 1 year up to 20 years without antiviral treatment. Patients with HCV were older (median age: 59 vs. 45 years), less predominantly male (59.0% vs. 76.0%), transfused more frequently (49.2% vs. 9.0%), and had higher aminotransferase as well as lower albumin levels and fewer platelets (P < 0.001 for all). Death was commoner (55.1% vs. 35.9%, P < 0.001) and hepatocellular carcinoma developed more often (53.9% vs. 28.7%, P < 0.001) in patients with HCV than HBV. In multivariate analysis, low albumin levels (hazard ratio: 1.65), alpha-fetoprotein (1.55), alcohol consumption (1.49), age >55 years (1.47), and retention of indocyanine green (1.39) were independent risk factors for the survival in patients with HCV, while male gender (4.43), age >45 years (2.24), retention of indocyanine green (2.14), hepatitis B e antigen (2.11), and low platelet counts (1.91) were in those with HBV. Chances for survival was significantly different (P < 0.001) among patients with HCV having low (number of factors: 0-1), medium (2-3), and high risks (4-5), as well as in those with HBV having low (0-1), medium (2-4), and high risks (5-6). In conclusion, survival and development of hepatocellular carcinoma, and factors for survival, are considerably different between patients with compensated cirrhosis infected with HCV and HBV, which would need to be taken into consideration in their management and planning treatment strategies.

[Clinical evaluation of emergency liver transplantation for patients with benign end-stage liver diseases]

OBJECTIVE

To evaluate the efficacy of emergency liver transplantation in treating patients with benign end-stage liver diseases and explore the possible prognostic factors.

METHOD

The clinic data of 46 cases of recipients who underwent ELT were retrospectively analyzed. clinicopathological variables (including age, gender, etiology, serum creatinine, PT, INR, albumin, total bilirubin) were compared between the survival group (n = 32) and the dead group (n = 14). And the prognostic values of CTP and MELD score were analyzed.

RESULTS

Higher serum creatinine level, MELD score and CTP score were found in the dead group, as compared to those in survival group. The survival rates among CTP or MELD categories showed significant difference. Three-and six months and one year survival rates of total recipients were 73.9% , 71.7% and 69.6% respectively.

CONCLUSION

Emergency liver transplantation is an effective treatment to salvage patients in end-stage. Serum creatinine is the important prognostic factor to the posttransplant survival. MELD score system is more sensitive than CTP classification in predicting the prognosis.

Progress in the control of hepatitis B infection in the Western Pacific Region

Hepatitis B virus infection is a serious problem globally, and particularly in the Western Pacific Region where the population suffers disproportionately from the infection and its sequelae. By 2001, every immunization programme in the Region had included hepatitis B vaccine in their schedule. However, many challenges remain if every one of the 26 million children born in the 37 countries and areas of the Region each year is to be protected against hepatitis B infection. In 2003, the Regional Committee of the World Health Organization's Western Pacific Region resolved to improve hepatitis B control by making it one of two new pillars for strengthening the Expanded Programme on Immunization. The Committee endorsed the strategies of the Regional Plan to improve hepatitis B control through immunization, reducing chronic HBV infection (chronic carriage rate) to less than 1%, and aiming for coverage of at least 80% of the birth cohort in every district with three doses of hepatitis B vaccine by 2005. To help guide this process, an assessment was made of the progress to date, and is reported in this paper. Coverage data used in this evaluation were not independently verified, and could over-estimate progress made in some countries. Whilst there has indeed been great progress in the Region, a number of national programmes still lack the ability to reach all children with immunization services. Other major issues that need to be addressed are the challenges of delivering a timely birth dose, and for certain countries, the affordability of the vaccine over the short- and long-term.

Prevalence of HBV and HCV dual infection in patients on haemodialysis

Hepatitis viral infections are important causes of morbidity and mortality in haemodialysis patients. One hundred and thirty four patients attending haemodialysis unit were screened for the presence of HBV and HCV infections. Eight (5.9%) patients were HCV positive while two (1.4%) patients had HBV infection. A dual infection with both the viruses was observed in five patients (3.7%).

Evidence of multiple hepatitis virus infections in autopsied materials of intravenous drug addicts

Injection of illicit drugs is an important risk factor for acquiring parenterally transmitted viral infections. To investigate the prevalence of viral mono- and co-infections in intravenous drug uses (IDUs) postmortem and to evaluate the risk of potential infection to personnel involved in medicolegal practice a total number of 59 known IDUs were tested during necropsy for serological markers of hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) as well as for the nucleic acids of the hepatitis B and C viruses, and the GB virus C (GBV-C), in blood and in the liver. Our findings showed that 90.2% cases were positive for at least one or more serological markers of the tested viruses. Seroprevalence rates of anti-HCV, HBsAg and anti-HIV were 78.4%, 32.4% and 29.7% respectively. Of the IDUs tested for serological infection markers 43.2% were positive for one, 40.5% for two and 5.4% for all three markers. Viral nucleic acids were detected in the sera of 64.4% and in the liver of 81.4% of the cases. HCV, RNA, GBV-C RNA and HBV DNA were found in 33.9%, 28.8% amd 28.8% of the serum samples and in 67.8%, 35.6% and 28.8% of the liver tissue, respectively. Active viral co-infections or triple infections were detectable in the sera of 20.3% and in the liver of 39% of the case. Results show that the sensitivity of viral nucleic acid testing postmortem strongly depends on the quality and source of material used.

Occupational deaths among healthcare workers

Recent experiences with severe acute respiratory syndrome and the US smallpox vaccination program have demonstrated the vulnerability of healthcare workers to occupationally acquired infectious diseases. However, despite acknowledgment of risk, the occupational death rate for healthcare workers is unknown. In contrast, the death rate for other professions with occupational risk, such as police officer or firefighter, has been well defined. With available information from federal sources and calculating the additional number of deaths from infection by using data on prevalence and natural history, we estimate the annual death rate for healthcare workers from occupational events, including infection, is 17-57 per 1 million workers. However, a much more accurate estimate of risk is needed. Such information could inform future interventions, as was seen with the introduction of safer needle products. This information would also heighten public awareness of this often minimized but essential aspect of patient care.

Natural history of hepatitis B and C in renal allograft recipients

BACKGROUND

In renal allograft recipients, most cases of liver dysfunction are caused by hepatitis B virus and hepatitis C virus (HCV). The natural history of hepatitis C and B was studied in 286 renal allograft recipients who received a kidney allograft between 1972 and 1989 when tests for anti-HCV became available.

METHODS

In all patients, hepatitis B (HB) surface (s) antigen (Ag) was tested before and anti-HCV (by enzyme-linked immunosorbent assay II) after transplantation.

RESULTS

At enrollment in 1989 (5.5+/-4 years after transplantation), 209 patients were anti-HCV positive (C+), 42 patients were HBsAg-positive (B+), and 35 patients were both B+ and C+ (C+B+). One hundred four patients were receiving azathioprine (AZA) and 182 were on cyclosporine A (CsA). Since transplantation, the median follow-up was 18 years in AZA-treated and 13 years in CsA-treated patients. Liver biopsy showed chronic hepatitis in 73 patients, cirrhosis in 20 patients, and fibrosing cholestatic hepatitis in 2 patients. In 34 patients, liver biopsy was repeated, and progression of fibrosis was observed in 24 patients. The 12-year patient survival rate was similar in B+, C+, and B+C+ patients (67%, 78%, and 71%, respectively; P=not significant). Liver-related death was the first cause of death in B+ and B+C+ infected patients (58% and 72%, respectively), whereas cardiovascular disease was the leading cause of death in C+ patients (40%). Multivariate analysis showed that older age (>40 years) (relative risk [RR], 2.8), B+ status (RR, 2.36), and C+ status (RR, 1.65) were independently associated with a worse patient survival.

CONCLUSIONS

In the long term, B+ patients had a higher risk of death related to liver disease than C+ patients, and co-infection did not worsen patient survival.