Liver disease as a major cause of death among HIV infected patients: role of hepatitis C and B viruses and alcohol

BACKGROUND/AIMS

We analyzed the characteristics of HIV infected patients who died from liver disease, focusing on hepatitis virus co-infection.

METHODS

One-hundred and eighty-five French hospital departments involved in HIV/AIDS management prospectively notified all deaths occurring in 2000. Patients whose hepatitis C (HCV) and hepatitis B (HBV) serostatus was known were classified as being infected by HCV alone, HBV alone (HBsAg positive), both HCV and HBV, or neither HCB nor HBV.

RESULTS

Among 822 HIV infected patients, 29% were infected by HCV alone, 8% by HBV alone, and 4% by both HCV and HBV. The most frequent causes of death were liver disease (31% of cases) and AIDS (29%) among HIV-HCV co-infected patients, and AIDS (38%) and liver disease (22%) among HIV-HBV co-infected patients. Liver disease was a more frequent cause of death among patients co-infected by both HCV and HBV (44% of cases). Hepatocellular carcinoma was present in 15% of patients who died from liver disease, and was associated with HBV co-infection. Nearly half the patients who died from liver disease had more than 200 CD4/mm3.

CONCLUSIONS

Liver disease is now a leading cause of death among HIV-HCV co-infected patients and is becoming an important cause of death among HIV-HBV co-infected patients. The risk of death from liver disease is highest in patients co-infected by both HCV and HBV.

Prevention of hepatitis B virus reinfection after orthotopic liver transplantation

OBJECTIVE

We discuss the prevention of hepatitis B virus reinfection following orthotopic liver transplantation.

METHODS

Sixty-eight cases of chronic fulminant hepatitis B, the end stage of liver cirrhosis and liver carcinoma complicated with HBV cirrhosis, were given antiviral drugs pre- and posttransplantation to prevent hepatitis B virus reinfection. Lamivudine was administered to two cases and lamivudine + HBIG to 63 cases. Adefovir + HBIG was administered to three cases. The serum HBV, HBV DNA, liver biopsy immunohistochemistry and clinical examinations were performed.

RESULTS

One of two cases given lamivudine developed reinfection with serum HBSAg, HbeAb, HBcAb, HBV DNA, and positive and liver biopsy immunohistochemistry showing HBSAg phenotype. Two of the 63 cases given lamivudine + HBIG developed reinfection with serum HBSAg, HBeAb, HBcAb positive and liver biopsy immunohistochemistry showing HBSAg phenotype. The serum HBV DNA was positive in one of the two cases. Three cases given adefovir developed no reinfection with HBV.

CONCLUSION

Orthotopic liver transplantation is an effective treatment for HBV infection; lamivudine + HBIG or adefovir + HBIG prevent hepatitis B virus reinfection.

[Therapy of hepatitis B and hepatitis C coinfection in HIV patients]

Hepatitis coinfection represents a major risk for end stage liver disease in HIV-positive patients. For this reason, categorically every patient should be evaluated in respect to a specific treatment for hepatitis. The immunological benefit of HAART for hepatitis/HIV coinfected patients is not only a reduction of the risk for HIV disease, but also the reduction of the risk for liver associated diseases and outweighs the drawbacks of a potential hepatotoxicity of HAART. Thus, HAART should not be withheld from a patient because of hepatitis coinfection. When cirrhosis is present, semiannual prophylactic checkups are recommended to monitor the occurrence of hepatocellular carcinoma.

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 (December 2003). 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

Thirteen randomised clinical trials assessed milk thistle in 915 patients with alcoholic and/or hepatitis B or C virus liver diseases. The methodological quality was low: only 23% of the trials reported adequate allocation concealment and only 46% were considered adequately double-blinded. 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.

Clinical significance of hepatic derangement in severe acute respiratory syndrome

AIM: Elevation of alanine aminotransferase (ALT) level is commonly seen among patients suffering from severe acute respiratory syndrome (SARS). We report the progression and clinical significance of liver derangement in a large cohort of SARS patient.

METHODS: Serial assay of serum ALT was followed in patients who fulfilled the WHO criteria of SARS. Those with elevated ALT were compared with those with normal liver functions for clinical outcome. Serology for hepatitis B virus (HBV) infection was checked. Adverse outcomes were defined as oxygen desaturation, need of intensive care unit (ICU) and mechanical ventilation and death.

RESULTS: Two hundred and ninety-four patients were included in this study. Seventy (24%) patients had elevated serum ALT on admission and 204 (69%) patients had elevated ALT during the subsequent course of illness. Using peak ALT > 5×ULN as a cut-off and after adjusting for potential confounding factors, the odds ratio of peak ALT > 5×ULN for oxygen desaturation was 3.24 (95%CI 1.23-8.59, P = 0.018), ICU care was 3.70 (95%CI 1.38-9.89, P = 0.009), mechanical ventilation was 6.64 (95%CI 2.22-19.81, P = 0.001) and death was 7.34 (95%CI 2.28-24.89, P = 0.001). Ninety-three percent of the survived patients had ALT levels normalized or were on the improving trend during follow-up. Chronic hepatitis B was not associated with worse clinical outcomes.

CONCLUSION: Reactive hepatitis is a common complication of SARS-coronavirus infection. Those patients with severe hepatitis had worse clinical outcome.

Survival in patients with HIV infection and viral hepatitis B or C: a cohort study

AIM

To assess survival in patients with HIV and viral hepatitis co-infection.

METHODS

A prospective university clinic cohort of 472 patients with HIV infection who were followed for 8343 patient-months. The outcome measures were the survival from HIV or liver disease assessed by the Kaplan-Meier method. Multivariable analysis using a Cox regression model identified variables associated with mortality.

RESULTS

Patients were divided into four subgroups: HIV/hepatitis B virus (HBV) (n = 72), HIV/hepatitis C virus (HCV) (n = 256), multiple hepatitides (n = 18) and HIV alone (n = 126). One hundred and thirty-four patients (28.4%) died during follow-up. Liver mortality was noted in 55 patients, representing 12% of the cohort and 41% of the total mortality. Survival curves were similar in patients with HIV alone and those with any viral hepatitis co-infection. Liver deaths were more common in patients with multiple hepatitides (28%) HIV/HBV (15%), HIV/HCV co-infection (13%) versus HIV alone (6%). Liver mortality was comparable in HIV/HBV as in HIV/HCV co-infected patients and was not associated with gender, ethnicity, age, or mode of infection. HIV deaths were similar in patients co-infected with viral hepatitis compared with those with HIV alone. In patients with viral hepatitis co-infection, initial CD4 cell count > 200 x 10(6) cells/l and use of highly active antiretroviral therapy (HAART) were associated with significantly reduced liver mortality.

CONCLUSIONS

Patients with HIV and viral hepatitis had greater liver mortality than patients with HIV alone, but had comparable HIV mortality. Co-infection with hepatitis B is associated with hepatic outcomes similar to hepatitis C. Control of immunosuppression with HAART and CD4 counts > 200 x 10(6) cells/l are associated with better hepatic outcomes and should be the first priority in patients with HIV and viral hepatitis.

Factors associated with fulminant liver failure during an outbreak among injection drug users with acute hepatitis B

Death related to acute hepatitis B occurs in approximately 1% of patients. We investigated an outbreak of hepatitis B virus (HBV) infections among injection drug users (IDUs) resulting in several deaths. We conducted a case-control study of fulminant (case patients) and nonfulminant (control patients) HBV infections. We directly sequenced the entire HBV genome from fulminant and nonfulminant cases. From October 1998 to July 2000, 21 acute HBV infections, including 10 fulminant hepatitis B cases, were identified. The median age was 30 (range, 18-49) years, 12 (57%) were female, 20 (95%) were American Indians, and 20 (95%) reported injecting illicit drugs. All patients with fulminant hepatitis B died (case-fatality rate = 47.6%). Case patients (n = 5) and control patients (n = 9) were similar with respect to age, sex, race, and hepatitis C virus serostatus. All case patients used acetaminophen during their illness compared with 44% of control patients (P =.08). Compared with control patients, case patients lost more weight in the 6 months before illness (P =.04); during their illness, they used more alcohol (P =.03) and methamphetamine (P =.04). All 9 isolates sequenced were genotype D, shared 99.7% homology, and included mutations previously described in association with fulminant hepatitis B. In conclusion, a high prevalence of exposure to factors potentiating hepatic damage with acute hepatitis B contributed to the outbreak's high mortality rate; mutations present in the outbreak strain might also have been a factor. Improved vaccination coverage among IDUs has the potential to prevent similar outbreaks in the future.

Survival after transfusion as assessed in a large multistate US cohort

BACKGROUND

The only survival and mortality data on a general population of transfused patients in the United States is more than two decades old. More contemporary data are needed to reflect more current patient populations and transfusion practices.

STUDY DESIGN AND METHODS

Data were extracted from Constella Health Strategies Sciences' managed-care administrative claims database that contains private health care claims. Patients were selected if they had at least one professional or facility claim indicating transfusion in 1995. Only the first transfusion in the time period was included so that each patient was counted only once and all claims were unduplicated. Survival for five years after transfusion was the primary outcome measure.

RESULTS

A total of 6779 patients were included in the analysis. A total of 4658 (69%) patients were alive 1 year after transfusion, 4056 (60%) were alive at 2 years, and 3092 (46%) were alive 5 years after transfusion. Overall annual mortality was 31 percent in Year 1 after transfusion, 14 percent in Year 2, and 10 percent in each of Years 3 through 5. Transfusion mortality was much higher in recipients older than age 65 at the time of transfusion, who comprised 60 percent of transfused patients.

CONCLUSION

These data from the mid 1990s can be used in models of the effectiveness of risk reduction interventions and in models of the disease consequences of infections transmitted through blood transfusions.

The role of psychosocial factors in the progression of hepatocellular carcinoma

The number of deaths per year from hepatocellular carcinoma (HCC) exceeds 250000, placing it sixth as the cause of death from cancer worldwide. The primary etiology of most cases of HCC in the US is hepatitis B and/or C. Extensive research has demonstrated that the relationship between hepatitis B infection and the progression to HCC is mediated by the immune system. A substantial, but unrelated literature, describes the relationship between psychosocial factors (e.g., stress, psychiatric morbidity), immune system reactivity, and disease progression in patients with cancer. However, the role of these factors in the progression of HBV-HCC has not been explored. An understanding of the relationship among virology, immunology, and behavior in the development and recurrence of HCC may provide alternative methods for secondary prevention of HCC (e.g., behavioral) until a vaccine and/or pharmacological treatments are developed, feasible, and affordable.

Hepatitis B virus reactivation after fludarabine-based regimens for indolent non-Hodgkin's lymphomas: high prevalence of acquired viral genomic mutations

BACKGROUND AND OBJECTIVES

Chemotherapy can cause hepatitis flare-up through viral reactivation in patients who have had contact with hepatitis viruses. Few data are available on the genotype of the reactivated viruses.

DESIGN AND METHODS

In 40 consecutive adult patients with indolent non-Hodgkin's lymphoma (NHL) receiving fludarabine-based front-line chemotherapy, we performed a prospective study on viral hepatitis reactivation and analyzed the genotype of the reactivated viruses. Before chemotherapy, 4 patients were healthy carriers of hepatitis B surface antigen (HBsAg), 2 had HB core antigen antibodies (anti-HBc), 6 anti-HBs and 6 anti-HCV; 22 were seronegative.

RESULTS

Hepatitis flare-up occurred in the 4 HBsAg-positive patients and in 1 anti-HBc-positive patient at a median of 1 month (range 1-4) after chemotherapy, when the CD4/CD8 ratio was still inverted. HBV reactivation was documented in all 5 instances (HBV-DNA 2-8 x 10(6) copies/mL). Two of the 5 patients responded to lamivudine, whereas 1 died of acute liver failure and 2 had persistent severe hepatitis. HBV genome sequencing at hepatitis flare-up showed that deviation from the closest related published sequences was 1.0% and 1.1% in the 2 lamivudine-responsive patients, and 1.5%, 1.8% and 1.7% in the 3 lamivudine-resistant patients. The polymerase open reading frame (ORF) and the HBs ORF of lamivudine-resistant strains contained several novel amino acid substitutions.

INTERPRETATION AND CONCLUSIONS

These results suggest that fludarabine treatment of HBV-infected patients is frequently associated with acute hepatitis due to viral reactivation, and that lamivudine may be less effective in this situation than in other settings of immunocompromised hosts because of the emergence of resistant mutant strains.

Diabetes mellitus is a recurrence-independent risk factor in patients with hepatitis B virus-related hepatocellular carcinoma undergoing resection

OBJECTIVES

The prognostic impact of diabetes mellitus and its association with virological factors on patients with hepatocellular carcinoma (HCC) are unclear. This study aimed to investigate the outcome in HCC patients undergoing resection with and without diabetes mellitus and the interaction with hepatitis B virus (HBV) and hepatitis C virus (HCV).

METHODS

A total of 239 HCC patients were included. Survival and tumour recurrence were analysed according to the status of diabetes mellitus and viral hepatitis.

RESULTS

Diabetic patients tended to have an overall decreased survival compared with non-diabetic patients in 32 +/- 19 months of follow-up. A total of 113 (47%) patients developed tumour recurrence during the follow-up period. No significant difference of tumour recurrence between diabetic and non-diabetic patients, or between patients seropositive and seronegative for HBV surface antigen (HBsAg), was noted. Stratified analysis showed that diabetic patients with HBV but not with HCV infection had a poor long-term outcome. In the HBV group, the one-, three- and five-year survival rates were 83%, 51% and 41% versus 90%, 78% and 73% in diabetic and non-diabetic patients, respectively, compared with 90%, 83% and 42% versus 91%, 73% and 73% in the HCV group with and without diabetes mellitus, respectively. Cox multivariate analysis disclosed that diabetic patients seropositive for HBsAg had a significantly poor survival.

CONCLUSIONS

Diabetes mellitus does not affect the long-term survival in HCV-related HCC but is a recurrence-independent poor prognostic factor for HBV-related HCC.

[Epidemiologic and clinical aspects of acute hepatitis B in the past decade]

To study the clinical and epidemiological aspects of acute B hepatitis during the last 11 years. We retrospectively studied 1712 patient files, admitted in the Department of Infectious Diseases Iaşi, with acute B hepatitis between 1992-2002. The majority of the patients (69%) had an urban origin. Teenagers and young adults were predominantly affected (59% had between 15 and 34 years). A point of entry of the pathogen was identified only in 20% of the patients. The mean incubation period was 4 month. 24% of the patients had a prolonged form of the disease (over 30 days of jaundice). A fulminant evolution was noted in 1.2% of cases. Extrahepatic involvement was described in 25% of the patients. The global mortality was 1.15%. The number of patients with acute B hepatitis decreased by half during the last 11 years.

Fibrosis and inflammatory activity in noncancerous tissue and mitotic index of cancer tissue in patients with hepatocellular carcinoma: relationship to clinicopathological factors and prognosis after hepatic resection

This study was designed to provide a histopathological analysis focusing on fibrosis (staging) and necroinflammatory reaction (grading, hepatitis activity index: HAI) in noncancerous liver tissue, and mitotic index (MI) in cancerous liver tissue to predict prognosis in 81 patients with chronic hepatitis or cirrhosis who underwent hepatectomy for hepatocellular carcinoma (HCC). The incidence of grade 2/3 and higher HAI was higher in patients with viral hepatitis C. The incidence of grade 2/3 was associated with vascular invasion of HCC, postoperative liver dysfunction, and cancer recurrence. Higher MI (> or = 5) was significantly associated with vascular invasion, poor histological differentiation, and recurrence rate (P < 0.05). Multivariate analysis showed that higher grade was the factor strongly associated with cancer recurrence (odds ratio: 10.621, P = 0.006). Higher MI correlated with overall patient survival (P < 0.05) by univariate analysis. Grading and MI are the useful prognostic markers for predicting tumor recurrence and patient survival.

A longitudinal study of children who received renal transplants 10-20 years ago

BACKGROUND

We have previously reported on our 10-year experience of renal transplantation in children in the cyclosporine era, that is, from December 1981 until December 1991. In this paper, we report on the same children observed for another 10 years.

METHODS

Of 53 children who received a renal transplant between 1981 and 1991, 47 survived and were observed for 10 to 20 years. Immunosuppression consisted of cyclosporine, prednisolone, and azathioprine. Yearly clinical examinations were performed.

RESULTS

Overall, actual patient survival is 91%, 89%, and 89%, and actual graft survival 85%, 77%, and 66% at 1, 5, and 10 years, respectively. No patients have died during the last 10 years. Twenty-six grafts were lost over 20 years. Thirteen of those were lost during the present follow-up (10-20 years): 11 in chronic rejection and 2 because of development of renal cell carcinoma. No other malignancies were noted. Mean glomerular filtration rate decreased from 58+/-19 at 1 year (n=42) to 44+/-16 mL/min/1.73 m2 body surface area at 10 (n=33) years. Hypertension was treated in 46%, 40%, and 66% of the children at 1, 5, and 10 years, respectively; two of them showed left ventricular hypertrophy 10 years after transplant. Minor cataracts without visual disturbance were found in 45% of patients. All children except three with mental retardation are, or have been, attending normal day care or normal school.

CONCLUSION

Social integration is good, and severe complications are scarce, even when renal transplantation occurred at a very young age.

Case fatality rate of acute viral hepatitis in Italy: 1995-2000. An update

BACKGROUND

Fulminant hepatic failure is the most serious complication of viral hepatitis. Although this event occurs rarely, it may be fatal.

AIMS

To evaluate the case fatality rate (several deaths divided by number of cases x 100) for each viral hepatitis type in Italy from 1995 to 2000.

PATIENTS

Acute hepatitis cases identified by the surveillance system for acute viral hepatitis, which covers approximately 58% of the Italian population.

RESULTS

Twenty-five deaths (0.1%) occurred among the 18 460 acute viral hepatitis cases observed from 1995 to 2000, a rate threefold lower than the 0.3% reported during the period 1985-1994. The highest case fatality rate (0.4%) was seen for acute hepatitis B (18 deaths among 4257 cases). Only one death (0.01%) occurred among the 11 063 acute hepatitis A cases and two deaths (0.1%) among the 1536 acute hepatitis C cases. No deaths were observed among the 309 acute hepatitis A cases superimposed on chronic HBsAg carriers and the 166 superimposed on chronic HCV carriers. Intravenous drug use (22.2% of cases) and other parenteral exposures (22.2% of cases) were the most frequent non-mutually exclusive sources of infection reported by subjects who died of acute hepatitis B.

CONCLUSIONS

Analysis of surveillance system data from 1995 to 2000 indicates that, in Italy, deaths due to acute viral hepatitis are rare, but most commonly observed with acute hepatitis B. There is no evidence that acute hepatitis A may be fatal in chronic HBsAg or HCV carriers. The overall better survival rate may probably reflect improvements in the treatment of fulminant hepatitis in the last few years in Italy.

Comparison of clinical features and survival of patients with hepatitis B- and hepatitis C-associated hepatocellular carcinoma in Thailand

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are leading causes hepatocellular carcinoma (HCC) worldwide. The aim of this study was to determine whether differences do exist between HBV- and HCV-associated HCC in terms of clinical, pathologic features and prognosis among Thai patients. The authors retrospectively reviewed the clinical data of 188 patients with pathologically proven HCC, who were admitted to Chulalongkorn Hospital between January 1997 and December 1999. Of these cases, there were 105 patients (55.9%) with hepatitis B surface antigen (HbsAg) positive, 19 patients (10.1%) with anti-HCV positive, and 2 patients (1.0%) with both markers positive. The authors found that the mean age of patients with HBsAg positive was significantly lower than that of anti-HCV positive (49.2 +/- 12.7 and 58.3 +/- 8.9 years, respectively, p = 0.003). In contrast, the mean serum alpha-fetoprotein level of HBsAg positive group was significantly higher than that of anti-HCV positive group (48,583.6 +/- 109,494.1 and 2,022.7 +/- 4,869.1 IU/ml, respectively, p = 0.001). However, there was no difference between the two groups in terms of the severity of underlying liver disease, tumor histology and morphology, clinical staging, and the overall survival rate of the patients. The authors concluded that, among Thai populations, the majority of clinical features and survival of HBV-associated HCC did not differ from those with HCV-associated HCC.

Molecular Adsorbent Recirculating System: clinical experience in patients with liver failure based on hepatitis B in China

The aim of this study is to evaluate the effect of treatment with the Molecular Adsorbent Recirculating System (MARS) on liver failure based on HBV. In 25 patients (median age, 36.3 years, range, 22-67 years, bilirubin level > 255 micro mol/l) admitted with liver failure based on HBV, the 6-8h MARS intermittent treatments were performed without any adverse events, A significant decrease in bilirubin, ammonia and urea levels were observed (P < 0.05). All patients achieved a remarkable neurologic recovery, particularly 2 HE-III and 3 HE-IV patients regained normal consciousness, respectively. The survival rate for the patients whose treatments kept to the MARS art strategy was 76.9% (10/13), while the others only had the survival rate of 16.7% (2/12) due to their giving up sequential MARS treatments after the first time. The rebounding rate of the bilirubin level in the patients after a single MARS treatment was significantly lower than that of patients, who underwent a single plasma-exchange treatment (P < 0.01). It is concluded that MARS method can contribute to the optimistic treatment of liver failure patients based on HBV which being the major epidemic liver disease in China.

Mortality of hepatitis B surface antigen-positive blood donors in England and Wales

BACKGROUND

Large population-based cohort studies in areas of high hepatitis B virus (HBV) prevalence have provided the evidence establishing hepatitis B surface antigen (HBsAg) carriage as a risk factor for hepatocellular carcinoma (HCC) and liver disease. Fewer studies have examined this in Western countries, where both HBV infection and carriage are less common and transmission patterns differ. This is the only prospective population-based study to examine this relationship in Europe.

METHODS

In all, 2681 male and 977 female blood donors in England and Wales, found to be HBsAg positive during routine blood-donation screening, were followed up from recruitment in 1970-1982 to December 1999 and their cause-specific mortality was analysed. This was compared with that of the general population of England and Wales.

RESULTS

During a mean of 22 years of follow-up, 17.4% of the 420 deaths were due to HCC or liver disease. There were 20 deaths from HCC in male HBsAg carriers, representing a significantly high standardized mortality ratio (SMR) compared to the male population of England and Wales of 26 (SMR = 26.26; 95% CI: 16.04- 40.54). The HCC incidence rate in males was 33.5 per 100 000 person years and 4.4 per 100 000 person years in females. Men had 8.5 (SMR = 8.50; 95% CI: 6.25- 11.31) and women had 3.9 times the risk of death from liver disease (SMR = 3.89; 95% CI: 1.26-9.09). The risk of circulatory disease deaths was reduced in both males and females. There was a significant increased risk of non-Hodgkins lymphoma that was not apparent in the first decade of follow-up. The increased risk of HCC and liver disease in men fell with follow-up.

CONCLUSION

Hepatitis B surface antigen carriage is a significant risk factor in England and Wales for both liver disease and HCC mortality. However, this risk has declined with duration of follow-up. This could be due to natural reversion to HBsAg negativity or as a result of treatment and avoidance of other risk factors. The increased risk of non-Hodgkins lymphoma seen in longer follow-up is likely to be related to HIV infection acquired subsequent to recruitment.

Increased mortality after liver transplantation for hepatocellular carcinoma in hepatitis B-associated cirrhosis

Transplant patients suffering from hepatocellular carcinoma in cirrhosis are selected according to tumor nodule number and diameter. Vascular invasion and histopathological grading are predictive of outcome. The prognostic influence of hepatitis B-cirrhosis has been investigated after resection and after local tumor treatment, but not after transplantation. Of the 1,188 transplantations performed between 1989 and 2000, 120 were on patients with hepatocellular carcinoma in cirrhosis (HCC) (follow-up: 57 months; 1-140 months). Within this group, 25 patients (21%) suffered from hepatitis B. Pre-transplant selection criteria were a maximum diameter of 5 degrees cm in uni-nodular tumors, or 3 degrees cm for two to three tumor nodules. The rate of tumors with 2-3 tumor nodules was increased in the hepatitis-B group (52% vs. 29%; P<0.05). Other tumor characteristics did not differ. In the hepatitis-B group, more patients died post-transplantation (44% vs.22%; P<0.05). This difference was due to unspecific causes, not to tumor recurrence or re-infection. These findings may be indicative of a more complicated course in patients suffering from hepatitis B in general.

Lamivudine Therapy for Decompensated Liver Cirrhosis Related to Hepatitis B Virus Infection

Chronic hepatitis B virus (HBV) infection is the major cause of chronic liver disease worldwide. Although the clinical course of HBV infection varies widely, the prognosis of decompensated liver cirrhosis is quite poor and the 5-year survival rate has been estimated to be only 14-35%. While the ultimate treatment of decompensated cirrhosis is orthotopic liver transplantation (OLT), recent studies have suggested that lamivudine can also improve the clinical outcomes in this group of patients. Lamivudine rapidly suppresses HBV replication and can improve several parameters of liver function tests and afford prolonged periods of pretransplantation survival. However, the proportion of clinical improvement as defined by a decrease in Child-Pugh score as well as the prolonged survival rate varied widely from study to study. These discrepancies might result from differences in the severity of cirrhosis at entry, the presence of active viral replication or inflammation, and the proportions of patients who received OLT during the study period. Overall, about half of the patients achieved a clinical improvement with lamivudine therapy. However, data are still lacking on whether lamivudine can prolong survival before OLT and even replace OLT. Most of the deaths or clinical improvement occurred or started to occur within the first 6 months of treatment. Therefore, OLT should be actively considered in patients with risk factors for early mortality or those without clinical improvement within the first 6 months of lamivudine treatment.