Use of recombinant factor VIIa to correct the coagulation status of individuals with advanced liver disease prior to a percutaneous liver biopsy

OBJECTIVES

Percutaneous liver biopsies are used to grade and stage liver disease and are also useful in monitoring the progress of liver disease over time as well as the response to medical therapies. The present study was undertaken to assess the effectiveness of recombinant factor VIIa as a means of transiently correcting the coagulopathy, enabling the safe performance of a percutaneous liver biopsy in patients in whom the use of fresh-frozen plasma is not possible without precipitating pulmonary edema or who have a treatment induced (iatrogenic) coagulopathy.

METHODS

The subjects of this report consisted of 18 consecutive individuals with advanced disease induced, and 15 with a therapeutic iatrogenic-induced, coagulopathy. All biopsies were performed by a single hepatologist. Before and 6 h after each biopsy, a prothrombin time and partial thromboplastin time was obtained from each subject. Mean values +/- the standard error of the mean were obtained using the independent samples T-test.

RESULTS

Recombinant factor VIIa had a marked effect in transiently correcting the mean prothrombin time in these subjects allowing for a safe complication free percutaneous biopsy in this high-risk group.

CONCLUSIONS

Recombinant factor VIIa could be used to obtain a clinically indicated liver biopsy in severely ill patients, who without this therapeutic agent, would either not be biopsied or, if biopsied, would require much longer hospitalization and the use of fresh-frozen plasma (with its risks of volume overload and infection).

Gender-incompatible liver transplantation is not a risk factor for patient survival

BACKGROUND/AIMS

Clinical data may be suggestive for differences in patient survival in gender-incompatible orthotopic liver transplantation (OLT), but findings are inconsistent and are putatively linked to circulating hormones. We therefore investigated patient survival as well as metabolism of steroids to identify possible causes of improved graft survival in gender-mismatched OLT.

METHODS

We examined our single-centre database of 1355 recipients of first liver transplants for overall patient survival by non-parametric and parametric analysis of multivariance taking the age of recipient and donor, ischaemia time, underlying liver disease and the time period of transplantation into account. Furthermore, the metabolism of androgens in gender-incompatible OLT was studied in cultures of primary human hepatocytes obtained from male and female patients.

RESULTS

Unlike previous studies we were unable to determine overall significant differences in patient survival in gender-incompatible OLT, even though a statistically significant improved patient survival was observed when male donor livers were transplanted into female recipients in univariant analysis (P=0.047). However, when the overall patient management was taken into account no difference in survival was determined in multivariant analysis. Importantly, the metabolism of testosterone did not differ between male and female hepatocyte cultures, except for the production of 6-alpha-hydroxy-testosterone (P<0.001).

CONCLUSIONS

Taken collectively, clinical observations may tend to suggest a slightly improved patient survival in gender-incompatible OLT but this cannot be explained on the bases of androgen metabolism. Overall, we view gender-incompatible liver transplantation not to be a confounder in patient survival after OLT.

The role of anti-fibrinolytics, rFVIIa and other pro-coagulants: prophylactic versus rescue?

Patients who have liver disease experience an increased risk for bleeding and resulting complications. Diseases affecting the liver can cause a deficiency of pro-coagulant factors or induce a state of increased clot breakdown. Although traditional tests of coagulation, such as prothrombin time or international normalized ratio (INR), may not accurately measure bleeding risk, many studies have assessed measures used to correct an increased INR and minimize adverse outcomes. This article discusses the use of activated factor VIIa and anti-fibrinolytic agents to treat coagulopathy in the setting of liver disease and the potential advantages and disadvantages of these alternatives, and the limitations of the current literature. This article also compares the limitations, risks, and potential benefits of prophylactic therapy to prevent bleeding before invasive procedures with rescue therapy for spontaneous and postprocedure bleeding, and describes the relative advantages and disadvantages of these two approaches.

Patient outcomes in two steroid-free regimens using tacrolimus monotherapy after daclizumab induction and tacrolimus with mycophenolate mofetil in liver transplantation

INTRODUCTION

Long-term steroid administration may predispose liver transplant recipients to infectious and metabolic complications. Maintaining effective immunoprophylaxis while minimizing the negative consequences of steroid therapy could be a key factor in improving clinical outcomes.

METHODS

Six hundred two patients were randomized to receive tacrolimus (TAC) immunosuppression with a single-steroid bolus and two doses of daclizumab (DAC) or mycophenolate mofetil (MMF).

RESULTS

The incidence of biopsy-proven acute rejection was 19.7% in the TAC/DAC group and 16.2% in the TAC/MMF group (ns). Three-month patient and graft survival were similar. Steroid use at month-3 was low at 5.5% in the TAC/DAC group and 3.9% in the TAC/MMF group. Significantly higher incidences of causally related adverse events (AEs) and significantly more dose modifications, interruptions, or discontinuations due to an AE were reported with TAC/MMF. Study withdrawal due to leucopenia was significantly higher with TAC/MMF (0.0% vs. 1.7%. P<or=0.05). AEs were generally reported less frequently in the TAC/DAC group. However, specifically headache and supraventricular arrhythmia were significantly higher with TAC/DAC, whereas leucopenia and bacterial infection were significantly higher with TAC/MMF. Laboratory indices of renal function were similar, and increases in serum lipids were negligible in both groups. Incidences of de novo diabetes mellitus (>or=2 fasting plasma glucose values >or=7.0 mmol/L) were low at 9.5% (TAC/DAC) and 11.0% (TAC/MMF).

CONCLUSION

Both TAC-based regimens allowed optimization of immunoprophylaxis while eliminating some of the negative consequences associated with steroids. Efficacy outcomes were comparable; however, TAC monotherapy after DAC induction was associated with significantly less leucopenia and less bacterial infection than a dual regimen incorporating MMF.

Minimization of steroids in liver transplantation

Because of the markedly improved short-term results of liver transplantation (LT) and persistently high number of long-term complications, the attention of transplant physicians should be focused on minimizing immunosuppressive therapy as much as possible. Steroid-based immunosuppression is responsible for a substantial post-LT morbidity and mortality, hence, minimization of its use is of utmost importance to improve the quality of life of the successfully transplanted liver recipient. This literature review shows that LT can be performed safely with steroid-minimal immunosuppression without compromising graft and patient survival. The tendency in clinical practice is to move more and more from steroid withdrawal to steroid avoidance protocols.

Pathobiology of secondary immune thrombocytopenia

Primary immune thrombocytopenic purpura (ITP) remains a diagnosis of exclusion both from nonimmune causes of thrombocytopenia and immune thrombocytopenia that develops in the context of other disorders (secondary immune thrombocytopenia). The pathobiology, natural history, and response to therapy of the diverse causes of secondary ITP differ from each other and from primary ITP, so accurate diagnosis is essential. Immune thrombocytopenia can be secondary to medications or to a concurrent disease, such as an autoimmune condition (eg, systemic lupus erythematosus [SLE], antiphospholipid antibody syndrome [APS], immune thyroid disease, or Evans syndrome), a lymphoproliferative disease (eg, chronic lymphocytic leukemia or large granular T-lymphocyte lymphocytic leukemia), or chronic infection, eg, with Helicobacter pylori, human immunodeficiency virus (HIV), or hepatitis C virus (HCV). Response to infection may generate antibodies that cross-react with platelet antigens (HIV, H pylori) or immune complexes that bind to platelet Fcgamma receptors (HCV), and platelet production may be impaired by infection of megakaryocyte (MK) bone marrow-dependent progenitor cells (HCV and HIV), decreased production of thrombopoietin (TPO), and splenic sequestration of platelets secondary to portal hypertension (HCV). Sudden and severe onset of thrombocytopenia has been observed in children after vaccination for measles, mumps, and rubella or natural viral infections, including Epstein-Barr virus, cytomegalovirus, and varicella zoster virus. This thrombocytopenia may be caused by cross-reacting antibodies and closely mimics acute ITP of childhood. Proper diagnosis and treatment of the underlying disorder, where necessary, play an important role in patient management.

Transmission of human immunodeficiency virus and hepatitis C virus through liver transplantation

In November 2007, a liver transplant recipient was confirmed to have human immunodeficiency virus (HIV) and hepatitis C (HCV) infection after the organ procurement agency notified our institution that the donor has been HIV and HCV positive. We reviewed medical records and the collected blood sample results for HIV and HCV testing. A 66 year old female with nonalcoholic steatohepatitis cirrhosis underwent liver transplantation. The donor was a male who had sex with men who received multiple blood transfusions during resuscitation. Preoperative testing for HIV and HCV antibodies were negative for both donor and recipient. Ten months later, HIV and HCV were identified with nucleic acid testing in the recipient and in the stored donor sera. This is the first reported case of HIV transmission from solid organ transplantation in 20 years, and the first ever reported case of simultaneously transmitted HIV and HCV. The current case represents a high risk donor with newly-acquired HIV and HCV who transmitted the diseases during the window period of the infections. In this era of organ shortages one option would be avoidance of any high-risk donor organs. Another option would be to continue the use of such organs with appropriate informed consent, acknowledging the limitations of current screening tests for HIV and HCV. This report should serve as a wake-up call to the transplant community to consider revamping organ donor screening for HIV and HCV using nucleic acid testing as well as reconsidering the ongoing use of high-risk donors.

Changing trends in transfusion practice in liver transplantation

PURPOSE OF REVIEW

Prevention of excessive blood loss is an important issue in the perioperative management of liver transplantation. This review describes changing trends in blood products use, risk predicting of blood transfusion, variability in use and practices, as well as transfusion safety during liver transplantation.

RECENT FINDINGS

Over the last 20 years, the average use of blood products per case has considerably decreased. There are marked interinstitutional differences in blood use. Differences in patient population characteristics and surgical techniques are a partial explanation, but differences in transfusion practices probably account for a substantial part of the variability. Recent data have sparked off ongoing controversy relating to volume replacement therapy and its impact on blood loss. New studies emphasize the risks associated with transfusion in liver transplantation.

SUMMARY

Recent studies call for continuing every reasonable effort to minimize the use of blood components and can guide us in new approaches to this vital problem.

The natural history of recurrent hepatitis C and what influences this

1. Liver failure and liver cancer from chronic hepatitis C are the most common indications for liver transplantation and numbers of both are projected to double over the next 20 years. 2. Recurrent hepatitis C infection of the allograft is universal and immediate following liver transplantation and associated with accelerated progression to cirrhosis, graft loss and death. 3. Graft and patient survival is reduced in liver transplant recipients with recurrent HCV infection compared to HCV-negative recipients. 4. The natural history of chronic hepatitis C is accelerated following liver transplantation compared C, with 20% progressing to cirrhosis by 5 years. However, the rate of fibrosis progression is not uniform and may increase over time. 5. The rates of progression from cirrhosis to decompensation and from decompensation to death are also accelerated following liver transplantation. 6. Multiple host, donor and viral factors are associated with rapid fibrosis progression and HCV-related graft failure. 7. Over the last decade, graft and patient survival rates have improved following liver transplantation for non-HCV disease but not for HCV-cirrhosis. This may reflect worsening donor quality and changes in immunosuppression strategies over recent years. 8. Viral eradication by antiviral therapy prevents disease progression and improves survival. 9. The severity of recurrent hepatitis C at one year post-transplant predicts subsequent progression to cirrhosis. Annual protocol biopsies are recommended to help determine need for antiviral therapy. 10. The projected impact of recurrent hepatitis C on graft and patient survival can only be avoided by the development of safe and effective antiviral strategies which can both prevent initial graft infection and eradicate established hepatitis C recurrence.

Dermatomyositis associated with hepatitis B virus-related hepatocellular carcinoma

Dermatomyositis (DM) is an idiopathic inflammatory myopathy (IIM) with typical cutaneous manifestations. It has been proposed that DM may be caused by autoimmune responses to viral infections, and previous studies have also shown that an association between DM and malignancy. However, chronic hepatitis B virus (HBV) infection associated with DM and hepatocellular carcinoma (HCC) is rarely encountered. The authors report a case of DM and HCC in a patient with a HBV infection. A 58-year-old man presented erythematous skin rashes on a sun-exposed area of 2 year's duration, and recent proximal muscle weakness. His medical history revealed that he had a chronic HBV infection. A diagnosis of DM relies on proximal muscle weakness, elevated muscle enzymes, myopathic changes (demonstrated by electromyography), muscle biopsy evidence of myositis, and its characteristic cutaneous findings. A Liver mass in the left lobe visualized by abdominal computed tomography was confirmed histologically as HCC. This case suggests that DM associated with HCC might be caused by a HBV infection.

Benign transient hyperphosphatasemia associated with Epstein-Barr virus enteritis in a pediatric liver transplant patient: a case report

Transient hyperphosphatasemia was found in a 3-year-old male liver transplant recipient. The condition was associated with diarrheal disease due to the Epstein-Barr virus (EBV). Immunosuppression was tapered and valganciclovir prescribed for 3 months, after which the diarrhea resolved and the EBV polymerase chain reaction assays became negative. After 6 months, alkaline phosphatase levels normalized. Isolated elevation of alkaline phosphatase in conjunction with enteric infection is a rare condition. No further diagnostic or therapeutic interventions except treatment of the underlying infection are needed, as this has been shown to be a benign, transient condition.

Low-dose recombinant factor VIIa for trauma patients with coagulopathy

INTRODUCTION

Coagulopathy in injured patients is common and is generally treated with fresh frozen plasma (FFP). Response can be variable, thus complete correction may take hours and require large volumes of fluids. High-dose recombinant factor VIIa (FVIIa, Novoseven, Novo Nordisk, Bagsvaerd, Denmark) has been used off-label to treat severe coagulopathy following trauma. Expense has limited use. Recently, we began administering low dose FVIIa (1.2mg) to patients with mild to moderate coagulopathy after trauma, hypothetising that it would be effective and safe.

PATIENTS AND METHODS

We retrospectively reviewed consecutive patients who received a low dose of 1.2mg of FVIIa over a 2-year period. Factor VIIa is administered after approval by a gatekeeper at the discretion of the treating physician. Demographics, injury and laboratory data were abstracted as were indications for use, source of coagulopathy, effectiveness, and complications. A two-tailed paired t-test was used to determine significant changes in coagulation parameters and blood product utilisation.

RESULTS

Eighty-one patients received 84 low doses of FVIIa. The mean age of the patients was 51 (+/-22) with a mean ISS of 29 (+/-11). Seventy-three per cent were male and 67% had a traumatic brain injury (TBI) as their primary injury. The aetiology of the coagulopathy in the study population included; TBI (40%), warfarin use (22%), and cirrhosis (13%). Mean prothrombin time (PT) fell from 17.0 s (+/-3.2) to 10.6s (+/-1.4) (p<0.0001). All patients had a good clinical response with no bleeding complications. Utilisation of packed red blood cells and fresh frozen plasma were significantly less in the 24h after FVIIa administration as compared to the 24h prior. Subsequent thromboembolic events were observed in 12 of the 81 patients (15%) and included; cerebrovascular accident (CVA) (6), mesenteric thrombosis (2), myocardial infarction (MI) (1), pulmonary embolism/deep venous thrombosis (PE/DVT) (2), and atrial thrombus (1). Only four of these events were thought to be related to the FVIIa administration, with two of the four contributing to a lethal outcome.

CONCLUSIONS

Low dose FVIIa rapidly and effectively treats mild to moderate coagulopathy following injury. This low dose (1.2mg) FVIIa is the smallest available unit dose. It costs approximately the same as 8 units of plasma and may be cost-effective in patients who require high volume factor administration. Low dose FVIIa may be effective in coagulopathic trauma patients who are not in shock but require rapid normalisation of clotting function.

Monitoring peripheral blood CD4+ adenosine triphosphate activity in a liver transplant cohort: insight into the interplay between hepatitis C virus infection and cellular immunity

Peripheral blood CD4+ adenosine triphosphate [ATP (ng/mL)] release [ImmuKnow Immune Cell Function Assay (ATP)] correlates to immunoreactivity. We hypothesized that ATP levels could provide insight into hepatitis C virus (HCV) infection and recurrent liver disease in liver transplantation (LT). We studied our center's LT cohort, in which ATP levels had been measured off protocol from February 2005 through July 2006. Of the 280 LTs performed since 1993, 114 (58.2%) fit the selection criteria, with a mean age of 49 +/- 10 years. LT (alone/combination) indications included HCV (58%), alcoholic liver disease (41%), hepatocellular carcinoma (16%), and other (33%). Four hundred seventy-seven ATP levels were obtained: 3 (1-17) per patient 25 months (4 days to 19 years) from the time from transplantation. Final diagnoses were normal allograft function (n = 166, 35%), recurrent disease (n = 199, 42%), septic event (n = 34, 7%), other (n = 51, 11%), and undetermined (n = 27, 6%). Two hundred eighty-one ATP levels were obtained [3 (1-18) per patient] in 66 HCV(+) patients. Forty-five (68%) developed biopsy-proven recurrent liver disease [188/281 (67%) ATP levels]. The median ATP level (ng/mL) was 162 (1-761); it was lower in HCV(+) patients (151 +/- 109) versus HCV(-) patients (211 +/- 139; P < 0.0001). ATP ranges in HCV(+) patients were stable from the time from transplantation. In HCV(-) patients, ATP ranges were initially high and eventually decreased to HCV(+) levels (P = 0.01). Immunosuppressant levels were low in 62% of HCV(-) patients versus 38% of HCV(+) patients (P = 0.04). In HCV(+) patients, ATP was lower in disease recurrence (139 +/- 97) versus none (181 +/- 141; P = 0.01) with similar immunosuppression, and ATP decreased with grade (P = 0.05) but not stage. Time from transplantation, aspartate aminotransferase/alanine aminotransferase >1, and low ATP were independently associated with recurrent HCV. In conclusion, after LT, global cellular immune function appears depressed at baseline in HCV(+) patients versus HCV(-) patients and more so in HCV(+) recurrent disease.

Bone marrow-derived mesenchymal stem cells are capable of mediating hepatitis B virus infection in injured tissues

We have previously showed that endothelial progenitor cells (EPCs) through uptake of hepatitis B virus (HBV) may play a critical role in mediating extrahepatic HBV diseases. However, it remains to be elucidated whether mesenchymal stem cells (MSCs) are capable of mediating HBV trans-infection into extrahepatic tissues.

METHODS AND RESULTS

In this study, we showed that HBV antigens, HBV DNA and the viral particles were detected in MSCs after 3 days virus challenge. Neither HBV covalently closed circular DNA nor pregenomic RNA were detected in MSCs. Intravenously transplantation of HBV-exposed MSCs into myocardial infarction mouse model resulted in incorporation of HBV into injured heart and other damaged tissues.

CONCLUSION

These results indicate that MSCs could serve as an additional extrahepatic virus reservoir, which may play a role at least in part in mediating HBV trans-infection into the injured tissues through the process of MSCs recruitment.

Use of recombinant activated factor VII in patients without hemophilia: a meta-analysis of randomized control trials

CONTEXT

Benefits of recombinant activated factor VII (rFVIIa) in hemorrhage may be lost because of thromboembolic events (TAE).

METHOD

MEDLINE, EMBASE, BIOSIS, CINAHL, Science Citation Index Expanded, clinicaltrials.gov were searched for placebo controlled trials of rFVIIa in patients without hemophilia. Reports of 22 randomized controlled trials were selected for analysis. Results were pooled using random effects models to calculate the odds ratios (OR) with 95% confidence interval (CI). Subgroup analyses were predetermined.

RESULTS

Among 3184 participants, 478 (15.0%) died and 249 (7.8%) had TAE. Additional blood transfusion was required in 517 (41.2%) of 1256 subjects. Patients receiving rFVIIa were less likely to need additional blood transfusions (OR, 0.54; 95% CI, 0.34-0.86) than patients receiving placebo. Mortality was not increased but may be reduced (OR, 0.88; 95% CI, 0.71-1.09). Reduction in mortality was more likely if rFVIIa was given therapeutically (OR, 0.87; 95% CI, 0.70-1.09) rather than prophylactically (OR, 1.00; 95% CI, 0.37-2.68). Differences in the pooled analysis of TAE were not statistically significant (OR, 1.17; 95% CI, 0.87-1.58) but the incidence of arterial TAE was likely higher in patients receiving rFVIIa (OR, 1.50; 95% CI, 0.93-2.41) although no differences were seen with respect to venous TAE (OR, 0.76; 95% CI, 0.49-1.15).

CONCLUSIONS

Use of rFVIIa reduces the need for blood transfusion and it may reduce mortality, especially if the dose of rFVIIa is limited to therapeutic doses of 90 mug/kg. It does not increase the risk of venous thrombosis but it may increase the risk of arterial thrombosis.

Hepatitis C in ethnic minority populations in England

The aim of the study was to investigate the differing epidemiology of hepatitis C-related end-stage liver disease in ethnic minorities in England. We used Hospital Episode Statistics from 1997/98 to 2004/05 to directly age-standardize numbers of episodes and deaths from hepatitis C-related end-stage liver disease in ethnic groups using the white English population as standard and the age-structured population by ethnic group from the 2001 Census. We estimated the odds of having a diagnosis of end-stage liver disease amongst hepatitis C-infected individuals in each ethnic group compared with whites using logistic regression. The main outcome measures were age-standardized morbidity and mortality ratios and morbidity and mortality odds ratios. Standardized ratios (95% confidence interval) for hepatitis C-related end-stage liver disease ranged from 73 (38-140) in Chinese people to 1063 (952-1186) for those from an 'Other' ethnic group. Amongst individuals with a diagnosis of hepatitis C infection, the odds ratios (95% CI) of severe liver disease were 1.42 (1.13-1.79), 1.57 (1.36-1.81), 2.44 (1.85-3.22), 1.73 (1.36-2.19) and 1.83 (1.08-3.10) comparing individuals of Black African, Pakistani, Bangladeshi, Indian and Chinese origin with whites, respectively. Ethnic minority populations in England are more likely than whites to experience an admission or to die from severe liver disease as a result of hepatitis C infection. Ethnic minority populations may have a higher prevalence of hepatitis C or they may experience a poorer prognosis because of differential access to health services, longer duration of infection or the prevalence of co-morbidities.

Single-center experience: use of recombinant factor VIIa for acute life-threatening bleeding in children without congenital hemorrhagic disorder

Coagulopathy is an important cause of mortality in critically ill children. Traditional therapies to correct coagulopathy lead to great time delays and cause fluid overload in patients. The authors report the effectiveness and safety of the activated recombinant factor VII (rFVIIa) administration in a series of 13 nonhemophiliac children with acute, life-threatening bleeding. In this retrospective study, the records of the patients who were not diagnosed with congenital hemorrhagic disorder and were administered rFVIIa due to any other reason in Ege University Faculty of Medicine, Department of Pediatrics, between February 2002 and February 2007 were reviewed retrospectively. Thirteen nonhemophiliac patients with acute life-threatening bleeding and ages ranging from 2 days to 15 years received rFVIIa over a 5-year period. Three patients were diagnosed with hemaphagocytic lymphohistiocytosis, 4 with prematurity, sepsis, and disseminated intravascular coagulation (DIC), 5 with sepsis, multiple organ dysfunction syndrome, and DIC, and 1 with acute liver failure. Severe bleeding resulted from pulmonary (n = 3), lower gastrointestinal system (n = 2), esophagus varices (n = 1), pulmonary and gastrointestinal system (n = 4), pulmonary, gastrointestinal system, and intracranial hemorrhage (n = 1), and gastrointestinal system and intracranial hemorrhage (n = 2). Median frequency of rFVIIa administration was 3 per patient (range 2-15) and median dose of rFVIIa was 90 microg/kg, ranging from 60 to 135 microg/kg each administration. All of the patients were given fresh frozen plasma and if necessary platelet transfusion (n = 10) or fibrinogen concentrate (n = 3) before administration of rFVIIa. In 6 patients, lack of success to control bleeding by conventional methods was the only cause to start rFVIIa. In 7 patients, the need for volume restriction was also a significant contributing factor in deciding to start rFVIIa. Median PT was 32.9 s (range: 19-65) before rFVIIa administration and it was decreased to 11.6 s (range: 10.7-12.8), 2-3 h after rFVIIa infusion. Bleeding was stopped completely in 10 patients at least for 24 h and decreased in 3 patients 30-45 min after rFVIIa administration. Two patients had thrombotic complications attributed to rFVIIa administration. No other complication was observed in the other patients. In this retrospective study, rFVIIa was found to be effective at controlling severe hemorrhagic symptoms of different etiologies in children without congenital hemorrhagic disorder. In addition to the rapid control of bleeding, administration of this agent improved fluid balance and led to a reduction in blood product requirements in critically ill children. However, survival was still poor (23%), and 2/13 (15.4%) patients developed venous and arterial thrombosis within 3 h of treatment. The authors emphasize that in acquired, acute life-threatening bleeding, simultaneous administration of rFVIIa with conventional treatment may contribute to patient survival. However, the risk of thromboembolism should be considered before this treatment is given.

Formulary management of recombinant factor VIIa at an academic medical center

BACKGROUND

Recombinant human coagulation factor VIIa (rVIIa) is a procoagulant indicated for treatment of bleeding in patients with hemophilia. A large proportion of rVIIa utilization is for off-label administration in nonhemophiliac patients with acute hemorrhage. Concerns of potentially inappropriate use, safety, and cost of rVIIa led to efforts to standardize use of this agent.

OBJECTIVE

To comparatively describe the utilization of rVIIa upon implementation of an evidence-based guideline at a university hospital.

METHODS

With advisory direction from a multidisciplinary task force, an evidence-based guideline for use of rVIIa was developed, approved, and fully implemented. Assessment of appropriateness of use and retrospective review were required for all cases. Effects of these actions were evaluated by auditing and comparing rVIIa use in patients treated in two 6-month observation periods before and after guideline implementation. Outcomes assessed were proportions of patients deemed appropriate to receive rVIIa, compliance with dosing recommendations, and acquisition costs.

RESULTS

Twenty-two and 29 patients were treated in the periods before and after guideline implementation, respectively. Patient characteristics were similar, except more cardiothoracic surgeries were performed in patients treated before implementation of the guideline. Indications for rVIIa use were judged appropriate in 21 (95.5%) before-cases and in all (100%) after-cases. The dose was compliant in 1 (4.6%) before-case and 27 (93.1%) after-cases (p < 0.001). Mean dosages of rVIIa administered were 81.8 microg/kg and 45.3 microg/kg in before- and after-cases, respectively (p < 0.001). During the respective periods of observation, amounts of rVIIa purchased monthly averaged 42.6 mg and 21.8 mg, a 49% difference. Semiannual expenditures for rVIIa decreased approximately $110,000 following guideline implementation. Patient outcomes were similar.

CONCLUSIONS

A guideline based on currently available evidence can serve to sustain the clinical appropriateness of rVIIa therapy and substantially decrease costs.

Laparoscopic cholecystectomy in cirrhotic patients with symptomatic gallstone disease

BACKGROUND

The aim of this study was to evaluate the outcome in patients with liver cirrhosis who underwent laparoscopic cholecystectomy for symptomatic gallstone disease.

METHODS

Retrospective analysis of prospectively collected data of 34 patients operated between March 1998 and April 2006.

RESULTS

There were 19 male and 15 female patients with a median age of 62 years. Cirrhosis aetiology was viral hepatitis in 25 patients, alcohol in 6, primary biliary cirrhosis in 2 and in 1 patient the cause was not identified. Twenty-three were classified as Child-Pugh-Turcotte stage A and 11 as Child-Pugh-Turcotte stage B. The median Model For End-Stage Liver Disease score was 12. Median operating time was 96 min. In three patients there was conversion to open cholecystectomy. Postoperatively, one patient died and six more patients had complications. Median postoperative stay was 3 days. Patients with acute cholecystitis did not have increased morbidity, but had significantly longer hospital stay.

CONCLUSION

Laparoscopic cholecystectomy can be carried out with acceptable morbidity in selected patients with well-compensated Child A and B stages liver cirrhosis. Patients with evidence of significant portal hypertension and severe coagulopathy should avoid surgery.

Chronic hepatitis C in the Hispanic/Latino population living in the United States: a literature review

Advanced practice nurses are faced with the clinical challenge of recognizing risk factors for chronic hepatitis C, not only in the native-born population, but also in the immigrant populations in the United States. Hispanics/Latinos constitute 13% of the U.S. population and are the fastest growing minority in the United States. A greater understanding of chronic hepatitis C in this populace was accomplished by reviewing current literature in the areas of natural history, epidemiology of risk factors, screening practices, and therapy outcomes. This review serves as a foundation for the creation of a culturally competent assessment tool for the screening of chronic hepatitis C in this population. The information from the literature review suggests that Hispanics/Latinos have an overall prevalence rate for chronic hepatitis C of 2.6%; have faster liver fibrosis progression rates; are infected at an earlier age; are more likely to be HIV coinfected; and show significantly higher alanine transaminase, aspartate transaminase, and bilirubin levels. They also have more portal inflammation than do Caucasians and African Americans and a higher prevalence of cirrhosis than do African Americans--more so in Hispanic women than in Hispanic men. Transfusion, tattoos, and iatrogenic transfer are risk factors that need to be assessed.

Racial differences in liver transplantation outcomes in the MELD era

OBJECTIVES

Beginning February 28, 2002, the Model for End-Stage Liver Disease (MELD) score was introduced to better allocate donor livers. Racial differences in orthotopic liver transplantation (OLT) outcomes prior to this time have been attributed to late listing of some racial groups. Racial differences in post-transplant survival in the MELD era have not been previously examined.

METHODS

We performed a retrospective observational cohort study using the United Network for Organ Sharing database for adult liver transplants performed between 2002 and 2006. We examined patient and graft survival at 2 yr and compared disease-specific survival rates among the different races.

RESULTS

A total of 10,409 whites, 1,133 blacks, 1,548 Hispanics, and 765 transplant recipients belonging to other races were included in the study. On multivariate analysis, blacks had lower overall (hazard ratio for death [HR] 1.29, 95% confidence interval [95% CI] 1.10-1.52) and graft (HR 1.38, 95% CI 1.20-1.58) survival at 2 yr compared to whites, while Hispanics had better overall (HR 0.78) and graft (HR 0.82) survival. Compared to whites, blacks transplanted for hepatitis C or HCC had lower survival at 2 yr.

CONCLUSION

In the MELD era, black patients have significantly lower overall and graft survival at 2 yr compared to whites.

Long-term follow-up of a heart transplant recipient with documented seroconversion to HIV-positive status 1 year after transplant

Whether human immunodeficiency virus (HIV) should be an absolute contraindication to heart transplantation has been a topic of recent discussion. There is a paucity of data regarding the expected outcome of heart transplantation in a recipient who is HIV positive. Herein, we report the case and long-term follow-up of a woman who was found to have seroconverted to HIV positive status 1 year after transplant.

The impact of race on liver transplant outcomes in the MELD era: still more questions than answers

Liver transplantation is a life-saving therapy for patients with end-stage liver disease (ESLD); however, donor livers are scarce. Several studies have demonstrated racial disparities in access to liver transplant as well as patient and graft survival after liver transplantation. These studies used data gathered before the model for end-stage liver disease (MELD) was used to determine priority for liver transplant. In this issue of the journal, Drs. Ananthakrishnan and Saeian examine survival after transplant in the MELD era by race and ethnicity, and show that the racial disparities in posttransplant outcomes persist despite MELD. This study provides further evidence that race, which is likely a proxy for a variety of biological and sociological factors, must be considered in any prognostic model for liver transplantation. The impact of race on liver transplantation outcomes should be evaluated further in a well-designed, multicentered, prospective study.

Intensive care of patients with acute liver failure: recommendations of the U.S. Acute Liver Failure Study Group

OBJECTIVE

To provide a uniform platform from which to study acute liver failure, the U.S. Acute Liver Failure Study Group has sought to standardize the management of patients with acute liver failure within participating centers.

METHODS

In areas where consensus could not be reached because of divergent practices and a paucity of studies in acute liver failure patients, additional information was gleaned from the intensive care literature and literature on the management of intracranial hypertension in non-acute liver failure patients. Experts in diverse fields were included in the development of a standard study-wide management protocol.

MEASUREMENTS AND MAIN RESULTS

Intracranial pressure monitoring is recommended in patients with advanced hepatic encephalopathy who are awaiting orthotopic liver transplantation. At an intracranial pressure of > or =25 mm Hg, osmotic therapy should be instituted with intravenous mannitol boluses. Patients with acute liver failure should be maintained in a mildly hyperosmotic state to minimize cerebral edema. Accordingly, serum sodium should be maintained at least within high normal limits, but hypertonic saline administered to 145-155 mmol/L may be considered in patients with intracranial hypertension refractory to mannitol. Data are insufficient to recommend further therapy in patients who fail osmotherapy, although the induction of moderate hypothermia appears to be promising as a bridge to orthotopic liver transplantation. Empirical broad-spectrum antibiotics should be administered to any patient with acute liver failure who develops signs of the systemic inflammatory response syndrome, or unexplained progression to higher grades of encephalopathy. Other recommendations encompassing specific hematologic, renal, pulmonary, and endocrine complications of acute liver failure patients are provided, including their management during and after orthotopic liver transplantation.

CONCLUSIONS

The present consensus details the intensive care management of patients with acute liver failure. Such guidelines may be useful not only for the management of individual patients with acute liver failure, but also to improve the uniformity of practices across academic centers for the purpose of collaborative studies.

Viral-Associated Immune Thrombocytopenic Purpura

Chronic immune thrombocytopenic purpura (CITP) is a diagnosis of exclusion that occurs either de novo or secondary to other underlying disorders. Chronic infection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) are now well-characterized causes of CITP. Between 6% and 15% of patients infected with HIV may develop thrombocytopenia. Patients with CITP with risk factors for HIV infection should be screened for the virus. Treatment of HIV-related CITP should be directed toward antiviral therapy with highly active antiretroviral therapy (HAART) regimens. Hepatitis C viral infection can also be associated with chronic thrombocytopenia, even in the absence of overt liver disease. While HCV-related thrombocytopenia is typically less severe than primary CITP, affected patients are at greater risk of major bleeding. Sustained suppression of HCV virus with interferon-ribavirin therapy can improve platelet counts. Screening for HCV infection should be considered in patients with ITP with risk factors for infection, from regions with high rates of infection or in patients with unexplained mild elevations of liver enzymes.

Statin adverse effects : a review of the literature and evidence for a mitochondrial mechanism

HMG-CoA reductase inhibitors (statins) are a widely used class of drug, and like all medications, have potential for adverse effects (AEs). Here we review the statin AE literature, first focusing on muscle AEs as the most reported problem both in the literature and by patients. Evidence regarding the statin muscle AE mechanism, dose effect, drug interactions, and genetic predisposition is examined. We hypothesize, and provide evidence, that the demonstrated mitochondrial mechanisms for muscle AEs have implications to other nonmuscle AEs in patients treated with statins. In meta-analyses of randomized controlled trials (RCTs), muscle AEs are more frequent with statins than with placebo. A number of manifestations of muscle AEs have been reported, with rhabdomyolysis the most feared. AEs are dose dependent, and risk is amplified by drug interactions that functionally increase statin potency, often through inhibition of the cytochrome P450 3A4 system. An array of additional risk factors for statin AEs are those that amplify (or reflect) mitochondrial or metabolic vulnerability, such as metabolic syndrome factors, thyroid disease, and genetic mutations linked to mitochondrial dysfunction. Converging evidence supports a mitochondrial foundation for muscle AEs associated with statins, and both theoretical and empirical considerations suggest that mitochondrial dysfunction may also underlie many nonmuscle statin AEs. Evidence from RCTs and studies of other designs indicates existence of additional statin-associated AEs, such as cognitive loss, neuropathy, pancreatic and hepatic dysfunction, and sexual dysfunction. Physician awareness of statin AEs is reportedly low even for the AEs most widely reported by patients. Awareness and vigilance for AEs should be maintained to enable informed treatment decisions, treatment modification if appropriate, improved quality of patient care, and reduced patient morbidity.

Hemostasis and hemostatic agents in minimally invasive surgery

As minimally invasive surgery (MIS) has grown in scope and complexity, new challenges have been introduced along the way, including the need for endoscopic hemostatic techniques. Traditional electrical and mechanical means are still the mainstay, but new technologies for hemostasis continue to emerge. Restricted access to the operative site can limit the use of some tools, and yet multiple chemical hemostats and tamponading agents are used in MIS today. Systemic agents also have been developed and have a role in certain MIS circumstances. These products allow surgeons to continue to approach more difficult procedures using minimally invasive techniques. On the horizon are the newer, even less-invasive approaches of natural orifice endoluminal and transluminal surgery, which will increase the difficulties with reliable hemostat agents and delivery mechanisms.

Activated recombinant factor VII in orthotopic liver transplantation

Orthotopic liver transplantation (OLT) is affected by important alterations of hemostasis. The aim of this study was to evaluate the efficacy of recombinant factor VII activated (rFVIIa) to reduce intraoperative bleeding during OLT.

METHODS

Twenty OLT patients were assigned in double-blind way to a rFVIIa group or a control group. Inclusion criteria were hemoglobin > 8 g/dL: INR > 1,5 and fibrinogen > 100 mg/dL. We administered a single bouls of rFVIIa (40 microg/kg) or placebo. We determined INR, partial thromboplastin time, fibrinogen, ATIII, and blood cell counts. Blood products were administered as follows: 4 units of fresh frozen plasma when INR > 1.5, and 1 unit of RBC for Hb < 10 g/dL. The study ended 6 hours after the bolus.

RESULTS

No thromboembolic events occurred. The INR was different between rFVIIa group and the controls at T0 (1.9 vs 1.6 P < .021) and during T1 (1.2 vs 1.6 P < .004). The total transfused red blood cells was 300 mL +/- 133 in rFVIIa group and 570 mL +/- 111 in control group (P < .017). The total fresh frozen plasma was 600 mL +/- 154 in rFVIIa group and 1400 mL +/- 187 in control group (P < .001). Total blood loss was greater in the control group than the rFVIIa group: 1140 mL +/- 112 vs 740 mL +/- 131 (P < .049).

DISCUSSION

The use of rFVIIa during OLT can reduce the risk of bleeding during surgery. The literature has described cases who did not benefit from the treatment. An adequate cut-off of INR, allowed us to treat only patients at greater bleeding risk.

Potential role of recombinant activated factor VII for the treatment of severe bleeding associated with disseminated intravascular coagulation: a systematic review

Recombinant activated factor VII (rFVIIa) is a novel hemostatic agent, originally developed for the treatment of hemorrhage in hemophiliacs with inhibitors, which has been successfully used recently in an increasing number of nonhemophilic bleeding conditions. In the present systematic review we report the existing literature data on the use of this hemostatic agent in severe bleeding, unresponsive to standard treatment, associated with disseminated intravascular coagulation. A total of 99 disseminated intravascular coagulation-associated bleeding episodes treated with rFVIIa were collected from 27 published articles: in the majority of the cases, the underlying disorder complicated by disseminated intravascular coagulation was a postpartum hemorrhage, while in the remaining cases it was a cancer, trauma, sepsis or liver failure. Although limited, the data available suggest that rFVIIa could have a potential role in this clinical setting. Large randomized trials are needed, however, to confirm the preliminary results and to assess the safety and dosing regimens of this agent in refractory bleeding associated with disseminated intravascular coagulation.

Factor VII activado recombinante

Recombinant activated factor VII is a drug that should be considered when there is massive bleeding. Its activation after it is bond to the tissue factor expressed triggers the coagulation cascade by action sequence of the different factors. Since its approval as treatment for bleeding episodes in patients with hemophilia, its indications have been increasing. It is a drug is indicated in non-traumatic intracranial bleeding, in patients with severe multiple traumas, and in those bleeding conditions that may affect patient viability. Although the adverse effects are well characterized, it is still a newly used drug. Thus, the potential risks of its use in each patient must be weighed.

Atopy in children with chronic hepatitis B virus infection

AIM

To investigate whether immune responses against chronic HBV infection in children have an effect on prevalence of allergic diseases and atopy.

METHODS

Children with chronic HBV infection [HBV carriage (group 1) and chronic hepatitis (group 2)] were screened for allergic diseases. The results were compared with age-matched controls (group 3).

RESULTS

The frequencies of doctor-diagnosed 'asthma', 'allergic rhinitis' and 'eczema' were 29.4%, 7.8% and 7.8% in group 1; 7.8%, 5.2% and 5.2% in group 2 and 12.4%, 9% and 2.8% in group 3, respectively. 'History of ever wheezing', doctor-diagnosed 'asthma' and 'eczema' were more common in group 1 than group 3 (p < 0.05 for all parameters), and 'history of ever wheezing' and 'doctor-diagnosed asthma' were more common in group 1 than group 2 (p < 0.05 for al parameters). Atopy was more common in group 1 (35.2%) than both groups 2 (15.7%) and 3 (18%) (p < 0.05 for all parameters). Vertical transmission was more common in patients with versus without atopy in HBV carrier group (33.3% vs. 9%, p < 0.05).

CONCLUSION

Immune responses in chronic HBV infection associated with carrier state may also lead to allergic diseases, which suggests the necessity of following these patients for the allergic diseases along with their viral reactivation.

Haematology

This article examines some of the recent advances in haematology in both the malignant and non-malignant areas of the speciality. Improvements in survival rates after effective chemotherapy now present the haematologist with the challenges of how to minimise therapeutic side effects without affecting outcome and the role of stratification as well as specific monitoring of enzyme activity are discussed. Many treatments for haematological malignancy have significant late effects which are only now becoming a problem--what these are, how to identify them and how they can be limited are examined. The increased knowledge of the altered pathways that lead to malignancy has allowed a whole slew of new therapies to be developed often with excellent results. The role of new iron chelation agents and the so called 'universal haemostatic agent' activated factor VII are also discussed.

Preoperative evaluation of patients with liver disease

Patients with end-stage liver disease often undergo surgery for indications other than liver transplantation. These patients have an increased risk of morbidity and mortality that is related to their underlying liver disease. Assessments of surgical risk provide a basis for discussion of risks and benefits, treatment decision making, and for optimal management of patients for whom surgery is planned. The most useful indicators of surgical risk are indices that predict advanced disease, such as the Child-Turcotte-Pugh score, or those that predict prognosis, such as the Model for End-stage Liver Disease score. Careful preoperative risk assessment, patient selection, and management of various manifestations of advanced disease might decrease morbidity and mortality from nontransplant surgery in patients with liver disease.

Reasons why patients infected with chronic hepatitis C virus choose to defer treatment: do they alter their decision with time?

This study was designed to determine the percentage of treatment-naïve patients infected with chronic hepatitis C virus who make an informed choice to forego (defer) treatment with pegylated interferon regimens in the absence of any medical, psychosocial, or other contraindications, and to reassess their decision by using a questionnaire at least 1 year later. Patient charts dating from 2001 were retrieved and retrospectively analyzed for the following data: patient age, gender, race, hepatitis C viral load, genotype, liver biopsy results, hepatic imaging results, peak alanine aminotransferase (ALT) levels, comorbid conditions, source of infection, estimated duration of infection, and reasons given by the patient for declining pegylated interferon-based treatment at the time of their consultation. A questionnaire survey sought to determine their satisfaction with their initial decision. Of 446 patient charts reviewed, 280 patients were treatment-naïve and were judged to have no contraindications to receiving interferon-based therapy. Of these, 115 (41%) opted to defer treatment and are the subject of this analysis. Women declining therapy outnumbered men by approximately 3 to 2. Middle-aged patients (45-55 years) were most likely to choose expectant therapy compared with older or younger individuals. The proportion of African American patients who deferred therapy (48%) was higher than non-African American patients (36.6%). More than 90% of the patients choosing to be followed were genotype 1. Peak ALT values were normal in 37% and <2X upper limits of normal (ULN) in another 40%. The estimated duration of chronic hepatitis C infection was >16 years in approximately three-quarters of individuals. The most common source of their infection was intravenous drug use followed by transfusion-related. The most common reason for opting not to receive treatment, given by nearly two-thirds of patients, was the asymptomatic nature of their infection coupled with their concern about side effects of the medications. Approximately 10% had unfavorable social situations, including a lack of support or health insurance, that precluded receiving therapy (despite the availability of indigent care programs offered by the pharmaceutical manufacturers). Only five patients (4.3%) cited doubts about efficacy as the main reason that they did not want to be treated. The questionnaire survey at 1 year found that 79% of the patients confirmed their ongoing satisfaction with their initial decision to decline treatment, and another 10.6% indicated that they were still "moderately satisfied" with their decision and unlikely to change it in the near-future. Only six patients (7%) voiced their current dissatisfaction with expectant management and expressed the desire to have a follow-up discussion about treatment options. Of the remaining three patients (3.5%), two had already started treatment and one was deceased (of non-liver-related causes). A significant proportion of patients infected with hepatitis C virus who are otherwise eligible for therapy opt to defer treatment (41% overall in our series, with African American patients deferring in a higher proportion than non-African American patients). Nearly all of our patients were genotype 1 with clinically and histologically mild hepatitis of reasonably long duration. Our questionnaire survey found that most remained satisfied with their decision to defer treatment at the present time. Few patients cited a perceived low rate of efficacy of pegylated interferon and ribavirin therapy as the principal reason that they chose not to initiate treatment.

Prophylactic and therapeutic use of recombinant activated factor VII in patients with cirrhosis and coagulation impairment

Patients with cirrhosis and impaired coagulation often pose major therapeutic problems during bleeding episodes or invasive procedures. Recombinant activated factor VII (rFVIIa), which has been licensed for the treatment of haemophilia patients with factor VIII or IX inhibitors, has been occasionally used in cirrhotic patients. We present five patients with cirrhosis and coagulopathy who received 1-4 recombinant activated factor VII infusions either prophylactically in order to safely undergo an invasive procedure or therapeutically in order to control a severe bleeding episode which did not respond to standard supportive care. In particular, recombinant activated factor VII infusions were given in two patients before a percutaneous liver biopsy, in one patient before teeth extraction and in two patients with haemoperitoneum after an invasive procedure. Infusions of recombinant activated factor VII achieved rapid correction of prothrombin time in all cases allowing the safe performance of invasive procedures or resulting in efficient control of the bleeding episode. In conclusion, recombinant activated factor VII seems to be a rather promising agent for the prevention or treatment of complications of haemostasis impairment in cirrhotic patients. However, its exact role in this setting needs to be evaluated within well-designed, controlled clinical trials.

Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia

BACKGROUND

Recombinant factor VIIa (rFVIIa) is licensed for use in patients with haemophilia and inhibitory allo-antibodies. It is also increasingly being used for off-license indications to prevent bleeding in operations where blood loss is likely to be high, and/or to stop bleeding that is proving difficult to control by other means.

OBJECTIVES

To assess the effectiveness of rFVIIa when used therapeutically to control active bleeding, or prophylactically to prevent (excessive) bleeding in patients without haemophilia.

SEARCH STRATEGY

We searched the Cochrane Injuries Group's Specialised Register, CENTRAL, MEDLINE, EMBASE and other specialised databases up to March 2006. We also searched reference lists of articles and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing rFVIIa with placebo, or one dose of rFVIIa with another, in any patient population with the exception of those with haemophilia. There was no restriction by outcomes examined, but this review focuses on mortality, blood loss or control of bleeding, red cell transfusion requirements, number of patients transfused and thromboembolic adverse events.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed potentially relevant studies for inclusion. Data were extracted and methodological quality was examined. Studies using rFVIIa prophylactically and those using rFVIIa therapeutically have been considered separately. Data were pooled using fixed and random effects models, but random effects models were preferred because of the variability in clinical features of the included studies.

MAIN RESULTS

Thirteen trials met the inclusion criteria; all were placebo-controlled double-blind RCTs. Six trials involving 724 participants examined the prophylactic use of rFVIIa; 379 received rFVIIa. There were no outcomes by which any observed advantage, or disadvantage, of rFVIIa over placebo could not have been observed by chance alone. There were trends in favour of rFVIIa for a number of outcomes, particularly the number of participants transfused, pooled RR 0.85 (95% CI 0.72 to 1.01) but this was balanced by a trend against rFVIIa with respect to thromboembolic adverse events, pooled RR 1.25 (95% CI 0.76 to 2.07). Seven trials involving 1214 participants examined the therapeutic use of rFVIIa; 687 received rFVIIa. There were no outcomes where any observed advantage, or disadvantage, of rFVIIa over placebo could not have been observed by chance alone. There was a trend in favour of rFVIIa for reducing mortality, RR 0.82 (95% CI 0.64 to 1.04), although no other clear trends in favour of rFVIIa were noted for other desired outcomes. Interpretation of these results must take into account one study which could not be included in the quantitative summary but which showed results strongly in favour of rFVIIa for the treatment of intra-cerebral haemorrhage. There was a trend against rFVIIa with respect to thromboembolic adverse events; the RR 1.50 (95% CI 0.86 to 2.62).

AUTHORS' CONCLUSIONS

Although rFVIIa has a role in the management of patients with haemophilia, its effectiveness as a more general haemostatic drug, either prophylactically or therapeutically, remains uncertain. Its effectiveness as a therapeutic agent, particularly for intra-cerebral haemorrhage, looks more encouraging than prophylactic use. The use of rFVIIa outside its current licensed indications should be very limited and its wider use await the results of ongoing and possibly newly commissioned RCTs. In the interim, rFVIIa use should be restricted to clinical trials.

Infection of hepatitis B virus in extrahepatic endothelial tissues mediated by endothelial progenitor cells

BACKGROUND

Hepatitis B virus (HBV) replication has been reported to be involved in many extrahepatic viral disorders; however, the mechanism by which HBV is trans-infected into extrahepatic tissues such as HBV associated myocarditis remains largely unknown.

RESULTS

In this study, we showed that human cord blood endothelial progenitor cells (EPCs), but not human umbilical vein endothelial cells (HUVECs) could be effectively infected by uptake of HBV in vitro. Exposure of EPCs with HBV resulted in HBV DNA and viral particles were detected in EPCs at day 3 after HBV challenge, which were peaked around day 7 and declined in 3 weeks. Consistently, HBV envelope surface and core antigens were first detected in EPCs at day 3 after virus challenge and were retained to be detectable for 3 weeks. In contrast, HBV covalently closed circular DNA was not detected in EPCs at any time after virus challenge. Intravenous transplantation of HBV-treated EPCs into myocardial infarction and acute renal ischemia mouse model resulted in incorporation of HBV into injured heart, lung, and renal capillary endothelial tissues.

CONCLUSION

These results strongly support that EPCs serve as virus carrier mediating HBV trans-infection into the injured endothelial tissues. The findings might provide a novel mechanism for HBV-associated myocarditis and other HBV-related extrahepatic diseases as well.

Treating hepatitis C in African Americans

BACKGROUND

The epidemiology, natural history and response to therapy of chronic hepatitis C differs significantly between African Americans and other ethnic populations. The reasons for these differences are not entirely clear but include mode of transmission, viral kinetics, immune responsiveness, and demographics.

OBJECTIVE

Review of the peer-reviewed literature and expert opinion from 1990 to 2005 regarding features of hepatitis C virus (HCV) infection in African Americans, differences in presentation and response to therapy, and treatment recommendations.

RESULTS

The epidemiology of HCV infection in African Americans appears to be predominantly associated with socio-economic status and high-risk behaviors. However, disease course, response to treatment, and virologic outcome may be a function of race. African Americans may clear HCV less efficiently than other ethnic groups, although impaired immune responsivity may also lead to decreased necro-inflammatory activity and progression to cirrhosis. Therapy-naive African Americans have lower sustained virologic response rates to this treatment than other populations.

CONCLUSIONS

Strategies to improve outcomes in African Americans include higher doses of current medications, medications with fewer adverse events, and new experimental molecular therapies.