151
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Piano S, Tonon M, Angeli P. Predicting Outcomes of Liver Transplantation in Patients With Nonalcoholic Steatohepatitis: Pretransplant Renal Function Is Key. Liver Transpl 2019; 25:362-364. [PMID: 30657244 DOI: 10.1002/lt.25413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 01/14/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padua, Padua, Italy
| | - Marta Tonon
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padua, Padua, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padua, Padua, Italy
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152
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Dismuke-Greer CE, Syn WK. Coming Complications of Nonalcoholic Fatty Liver Disease: Time to GNASH Your Teeth. Dig Dis Sci 2019; 64:606-608. [PMID: 30560337 DOI: 10.1007/s10620-018-5426-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Clara E Dismuke-Greer
- Health Equity and Rural Outreach Innovation Center, Ralph H Johnson VAMC, Charleston, SC, USA.,Division of Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Wing-Kin Syn
- Section of Gastroenterology, Ralph H Johnson VAMC, Charleston, SC, USA. .,Division of Gastroenterology and Hepatology, Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA.
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153
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Strauss E. CHRONIC HEPATITIS C IS STILL A PROBLEM FOR THE PUBLIC HEALTH CARE SYSTEM IN BRAZIL. ARQUIVOS DE GASTROENTEROLOGIA 2019; 55:321-323. [PMID: 30785512 DOI: 10.1590/s0004-2803.201800000-90] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Edna Strauss
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brasil
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154
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Adam R, Karam V, Cailliez V, O Grady JG, Mirza D, Cherqui D, Klempnauer J, Salizzoni M, Pratschke J, Jamieson N, Hidalgo E, Paul A, Andujar RL, Lerut J, Fisher L, Boudjema K, Fondevila C, Soubrane O, Bachellier P, Pinna AD, Berlakovich G, Bennet W, Pinzani M, Schemmer P, Zieniewicz K, Romero CJ, De Simone P, Ericzon BG, Schneeberger S, Wigmore SJ, Prous JF, Colledan M, Porte RJ, Yilmaz S, Azoulay D, Pirenne J, Line PD, Trunecka P, Navarro F, Lopez AV, De Carlis L, Pena SR, Kochs E, Duvoux C. 2018 Annual Report of the European Liver Transplant Registry (ELTR) - 50-year evolution of liver transplantation. Transpl Int 2019; 31:1293-1317. [PMID: 30259574 DOI: 10.1111/tri.13358] [Citation(s) in RCA: 280] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 06/19/2018] [Accepted: 09/22/2018] [Indexed: 02/07/2023]
Abstract
The purpose of this registry study was to provide an overview of trends and results of liver transplantation (LT) in Europe from 1968 to 2016. These data on LT were collected prospectively from 169 centers from 32 countries, in the European Liver Transplant Registry (ELTR) beginning in 1968. This overview provides epidemiological data, as well as information on evolution of techniques, and outcomes in LT in Europe over more than five decades; something that cannot be obtained from only a single center experience.
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Affiliation(s)
- René Adam
- Paul Brousse Hospital, Univ Paris-Sud, Inserm U935, Villejuif, France
| | - Vincent Karam
- Paul Brousse Hospital, Univ Paris-Sud, Inserm U935, Villejuif, France
| | - Valérie Cailliez
- Paul Brousse Hospital, Univ Paris-Sud, Inserm U935, Villejuif, France
| | | | | | - Daniel Cherqui
- Paul Brousse Hospital, Univ Paris-Sud, Inserm U935, Villejuif, France
| | | | | | | | | | | | | | | | - Jan Lerut
- Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Lutz Fisher
- Universitatsklinikum Hamburg Eppendorf, Hamburg, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Robert J Porte
- University Medical Center Groningen, Groningen, The Netherlands
| | | | | | | | | | - Pavel Trunecka
- Transplant Center, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | | | | | | | | | - Eberhard Kochs
- Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Munich, Germany
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155
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Vitale A, Donato MF. From individual to population-based benefit of split liver transplantation. Dig Liver Dis 2019; 51:181-182. [PMID: 30553748 DOI: 10.1016/j.dld.2018.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 11/04/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Alessandro Vitale
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
| | - Maria Francesca Donato
- Transplant Hepatology Unit, Division of Gastroenterology and Hepatology, IRCCS Cà Granda Maggiore Hospital Policlinico and RC "A. M. and A. Migliavacca" Center for the Study of Liver Disease, University of Milan, Milan, Italy
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156
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Bertot LC, Adams LA. Trends in hepatocellular carcinoma due to non-alcoholic fatty liver disease. Expert Rev Gastroenterol Hepatol 2019; 13:179-187. [PMID: 30791782 DOI: 10.1080/17474124.2019.1549989] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide and is associated with hepatocellular carcinoma (HCC), the most frequent malignant liver tumor. The increasing prevalence of obesity and diabetes is influencing the epidemiology of HCC with the most dramatic increases in NAFLD-related HCC seen in Western countries. Although cirrhosis is the major risk factor for HCC in NAFLD, there is increasing recognition that NAFLD-HCC occurs in the absence of cirrhosis. Areas covered: The epidemiology of NAFLD related HCC and its impact on changing the incidence of HCC globally. We overview risk factors for NAFLD-HCC in the presence and absence of cirrhosis and examine trends in liver transplantation (LT) related to NAFLD-HCC. Expert commentary: The incidence of NAFLD-related cirrhosis will continue to rise globally in parallel with risk factors of obesity and diabetes. Consequently, NAFLD-related HCC will become an increasingly important cause of liver-related morbidity and mortality and a common indication for LT worldwide. Further identification of risk factors for NAFLD-HCC and effective treatments for NAFLD are required to reduce this future burden of disease.
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Affiliation(s)
| | - Leon A Adams
- a Medical School , University of Western Australia , Nedlands , Australia.,b Department of Hepatology and Liver Transplant Unit , Sir Charles Gairdner Hospital , Nedlands , Australia
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157
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Calzadilla-Bertot L, Jeffrey GP, Jacques B, McCaughan G, Crawford M, Angus P, Jones R, Gane E, Munn S, Macdonald G, Fawcett J, Wigg A, Chen J, Fink M, Adams LA. Increasing Incidence of Nonalcoholic Steatohepatitis as an Indication for Liver Transplantation in Australia and New Zealand. Liver Transpl 2019; 25:25-34. [PMID: 30609187 DOI: 10.1002/lt.25361] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/25/2018] [Indexed: 02/07/2023]
Abstract
The worldwide increase in obesity and diabetes has led to predictions that nonalcoholic steatohepatitis (NASH) will become the leading indication for orthotopic liver transplantation (OLT). Data supporting this prediction from outside the United States are limited. Thus, we aimed to determine trends in the frequency of NASH among adults listed and undergoing OLT in Australia and New Zealand (ANZ) from 1994 to 2017. Data from the ANZ Liver Transplant Registry were analyzed with patients listed for fulminant liver failure, retransplantation, or multivisceral transplants excluded. Nonparametric trend, Spearman rank correlation, and regression analysis were used to assess trends in etiologies of liver disease over time. Of 5016 patient wait-list registrants, a total of 3470 received an OLT. The percentage of patients with NASH activated for OLT increased significantly from 2.0% in 2003 to 10.9% in 2017 (trend analyses; P < 0.001). In 2017, NASH was the third leading cause of chronic liver disease (CLD) among wait-list registrants behind chronic hepatitis C virus (HCV; 29.5%) and alcohol (16.1%). Similarly, significant increases over time in the percentage of patients undergoing OLT were observed for HCV and NASH (all trend analyses; P < 0.001) but with significant reductions in primary sclerosing cholangitis and cryptogenic cirrhosis (both P < 0.05). By 2017, NASH was the third leading cause of liver disease among patients undergoing OLT (12.4%) and behind chronic HCV (30.2%) and alcohol (18.2%). NASH also became the third most frequent etiology of CLD in patients transplanted (13.8%) with concomitant hepatocellular carcinoma by 2017. In conclusion, NASH is increasing as a primary etiology of liver disease requiring listing and liver transplantation in ANZ.
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Affiliation(s)
| | - Gary P Jeffrey
- Medical School, University of Western Australia, Nedlands, Australia.,Liver Transplant Unit, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Bryon Jacques
- Liver Transplant Unit, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Geoffrey McCaughan
- Australian National Liver Transplant Unit, Centenary Institute, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Michael Crawford
- Australian National Liver Transplant Unit, Centenary Institute, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Peter Angus
- The Austin Hospital, Melbourne, Victoria, Australia
| | - Robert Jones
- The Austin Hospital, Melbourne, Victoria, Australia
| | - Edward Gane
- Auckland City Hospital, Auckland, New Zealand
| | | | | | | | - Alan Wigg
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - John Chen
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Michael Fink
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Leon A Adams
- Medical School, University of Western Australia, Nedlands, Australia.,Liver Transplant Unit, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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158
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Ioannou GN, Feld JJ. What Are the Benefits of a Sustained Virologic Response to Direct-Acting Antiviral Therapy for Hepatitis C Virus Infection? Gastroenterology 2019; 156:446-460.e2. [PMID: 30367836 DOI: 10.1053/j.gastro.2018.10.033] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 09/26/2018] [Accepted: 10/03/2018] [Indexed: 02/06/2023]
Abstract
Direct-acting antiviral (DAA) regimens are safe and effective at eradicating hepatitis C virus (HCV) infection. Unfortunately, DAAs remain expensive, so treatment of all HCV-infected patients would substantially affect health care costs. It is therefore important to continue to assess the hepatic and extrahepatic benefits of a DAA-induced sustained virologic response (SVR). A DAA-induced SVR reduces a patient's risk of cirrhosis and hepatocellular carcinoma and extrahepatic manifestations of HCV infection; there are also data to indicate that an SVR can reduce mortality. SVR is a relevant clinical end point, but further analyses are required to confirm its importance among diverse HCV-infected populations and to document the public health benefits of HCV elimination at the population level. We review the evidence for the benefits associated with SVRs in different clinical settings and challenges to data collection.
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Affiliation(s)
- George N Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, Washington; Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, Washington; Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington.
| | - Jordan J Feld
- Toronto Centre for Liver Disease, University Health Network, Sandra Rotman Centre for Global Health, University of Toronto, Toronto, Ontario, Canada
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159
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Iavarone M, Invernizzi F. Liver transplant for hepatocellular carcinoma: A heavyweight therapeutic option in need of a new policy on liver graft allocation. Dig Liver Dis 2018; 50:1351-1352. [PMID: 30316790 DOI: 10.1016/j.dld.2018.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/17/2018] [Accepted: 09/18/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Massimo Iavarone
- CRC "A. M. & A. Migliavacca" Center for the Study of Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Maggiore Hospital, University of Milan, Milan, Italy.
| | - Federica Invernizzi
- CRC "A. M. & A. Migliavacca" Center for the Study of Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Maggiore Hospital, University of Milan, Milan, Italy
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160
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Younossi Z, Papatheodoridis G, Cacoub P, Negro F, Wedemeyer H, Henry L, Hatzakis A. The comprehensive outcomes of hepatitis C virus infection: A multi-faceted chronic disease. J Viral Hepat 2018; 25 Suppl 3:6-14. [PMID: 30398294 DOI: 10.1111/jvh.13005] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 08/16/2018] [Indexed: 02/06/2023]
Abstract
Treatment of hepatitis C virus (HCV) infection has been revolutionized with the introduction of pangenotypic, interferon- and ribavirin-free regimens associated with high cure rates and a low side effect profile. Additionally, there is evidence that HCV cure reduces HCV complications, improves patient-reported outcomes and is cost-saving in most western countries in the long term. This is a review of the comprehensive burden of HCV and the value of eliminating HCV infection. With the introduction of the interferon-free all-oral, once a day pill treatment regimen for the cure of HCV, the potential to eliminate HCV by 2030 has become a possibility for some regions of the world. Nevertheless, there are barriers to screening, linkage to care, and treatment in many countries that must be overcome in order to reach this goal. In conclusion, globally, work must continue to ensure national policies are in place to support screening, linkage to care and affordable treatment in order to eliminate HCV.
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Affiliation(s)
- Zobair Younossi
- Department of Medicine, Inova Fairfax Hospital, Falls Church, Virginia.,Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia
| | - Georgios Papatheodoridis
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens Laiko, Athens, Greece
| | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, AP HP Hôpital La Pitié-Salpêtrière, Paris, France.,CNRS UMR 7087, INSERM UMR S-959, DHU I2B, Sorbonne Université, Paris, France
| | | | | | - Linda Henry
- Center for Outcomes Research in Liver Disease, Washington D.C
| | - Angelos Hatzakis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School of National and Kapodistrian University of Athens, Athens, Greece.,Hepatitis B and C Public Policy Association, L-2453 , Luxembourg
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161
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Toniutto P, Bitetto D, Fornasiere E, Fumolo E. Challenges and future developments in liver transplantation. MINERVA GASTROENTERO 2018; 65:136-152. [PMID: 30303340 DOI: 10.23736/s1121-421x.18.02529-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Liver transplantation (LT) has become the treatment of choice for a wide range of liver diseases in both adult and pediatric patients. Until recently, the largest proportion of LT in adults, were performed in patients with hepatitis C (HCV) related cirrhosis. The recent availability of safe and effective direct antiviral agents to cure HCV infection in almost all patients whatever the HCV genotype and severity of liver disease, will reduce the need for LT in this category of recipients. Thus, it is presumed that in the next 1 to 2 decades HCV related liver disease will diminish substantially, whereas non-alcoholic steato-hepatitis (NASH) will correspondingly escalate as an indication for LT. The greatest challenges facing LT remain the limited supply of donor organs, and the need for chronic immunosuppression, which represent the true obstacles to the greater application and durable success of the LT procedure. This review aimed to highlight, in different sections, the main open issues and future developments in LT. These will be focused to explore current and future strategies to maximize the use of limited organs, to offer an update on potential new approaches to immunosuppression and to imagine new indications for LT when the number of patients awaiting transplants for HCV related liver disease is reduced.
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Affiliation(s)
- Pierluigi Toniutto
- Unit of Hepatology and Liver Transplantation, Department of Medical Area (DAME), University of Udine, Udine, Italy -
| | - Davide Bitetto
- Unit of Hepatology and Liver Transplantation, Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Ezio Fornasiere
- Unit of Hepatology and Liver Transplantation, Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Elisa Fumolo
- Unit of Hepatology and Liver Transplantation, Department of Medical Area (DAME), University of Udine, Udine, Italy
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162
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Terrault NA, Pageaux GP. A changing landscape of liver transplantation: King HCV is dethroned, ALD and NAFLD take over! J Hepatol 2018; 69:767-768. [PMID: 30104027 DOI: 10.1016/j.jhep.2018.07.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 07/22/2018] [Indexed: 12/04/2022]
Affiliation(s)
- Norah A Terrault
- Gastroenterology/Hepatology, University of California San Francisco, CA, USA.
| | - Georges-Philippe Pageaux
- Hepatology and Liver Transplantation Unit, CHU Saint Eloi, Montpellier University, 34295 Montpellier, France.
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163
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Calleja JL, Macias J, Forns X, Garcia F, Berenguer M, Garcia Deltoro M, Buti M, Granados R, Carrion JA, Morano L, Fernandez I, Coste P, Pineda JA. Guidelines on treatment of hepatitis C virus infection. Spanish Association for the Study of the Liver (AEEH). GASTROENTEROLOGIA Y HEPATOLOGIA 2018; 41:597-608. [PMID: 30270150 DOI: 10.1016/j.gastrohep.2018.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 07/27/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Jose L Calleja
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, Instituto de Investigación Puerta de Hierro, Universidad Autónoma de Madrid, Majadahonda, Madrid, España.
| | - Juan Macias
- Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario de Valme, Sevilla, España; Grupo para el Estudio de las Hepatitis Víricas, Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica, Madrid, España
| | - Xavier Forns
- Servicio de Hepatología, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Universidad de Barcelona, Barcelona, España
| | - Federico Garcia
- Grupo para el Estudio de las Hepatitis Víricas, Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica, Madrid, España; Unidad de Gestión Clínica de Microbiología, Hospital Universitario San Cecilio, Instituto de Investigación Biosanitaria (ibs), Red de Investigación en SIDA (Retic ISCiii RD16/0025), Granada, España
| | - Marina Berenguer
- Unidad de Hepatología, Hospital Universitari i Politécnic La Fe, IIS La Fe, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Universidad de Valencia, Valencia, España
| | - Miguel Garcia Deltoro
- Grupo para el Estudio de las Hepatitis Víricas, Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica, Madrid, España; Servicio de Enfermedades Infecciosas, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - Maria Buti
- Servicio de Hepatología, Hospital Universitario Vall d'Hebron, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, España
| | - Rafael Granados
- Grupo para el Estudio de las Hepatitis Víricas, Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica, Madrid, España; Servicio de Medicina Interna, Unidad de Enfermedades Infecciosas, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, España
| | - Jose A Carrion
- Sección de Hepatología, Servicio de Digestivo, Hospital del Mar, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Universitat Autònoma de Barcelona, Barcelona, España
| | - Luis Morano
- Grupo para el Estudio de las Hepatitis Víricas, Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica, Madrid, España; Unidad de Patología Infecciosa, Hospital Universitario Álvaro Cunqueiro, Instituto de Investigación Sanitaria Galicia Sur (IISGS), Universidad de Santiago de Compostela, Vigo, Pontevedra, España
| | | | - Pablo Coste
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Puerta de Hierro, Instituto de Investigación Puerta de Hierro, Universidad Autónoma de Madrid, Majadahonda, Madrid, España
| | - Juan A Pineda
- Unidad de Enfermedades Infecciosas y Microbiología, Hospital Universitario de Valme, Sevilla, España; Grupo para el Estudio de las Hepatitis Víricas, Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica, Madrid, España
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