Early detection of hepatocellular carcinoma in hepatitis-B-positive renal transplant recipients

Hepatitis B virus and renal transplantation

Hepatitis B virus (HBV) infection remains an important cause of liver disease in the renal transplant (RT) population, potentially diminishing survival. Consequences of HBV infection after RT include progression to decompensated cirrhosis and an increased risk of hepatocellular carcinoma. Although precautions initially recommended by the Centers for Diseases Control and Prevention 30 years ago have substantially reduced HBV transmission within hemodialysis units, acute HBV outbreaks continue to be reported in patients with chronic kidney disease on maintenance hemodialysis. In addition, immigration from areas of high HBV prevalence implies that HBV-infected organs with chronic kidney disease will continue to enter the RT pool. Fortunately, the advent of oral therapy for HBV infection now reduces the risk of HBV progression post-RT.

Hepatocellular Carcinoma After Renal Transplantation: The Long-Term Impact of Cirrhosis on Chronic Hepatitis B Virus Infection

Hepatocellular carcinoma (HCC) is the most common posttransplantation malignancy in hepatitis B virus (HBV) endemic areas. The aim of this study was to review the significant effect of liver cirrhosis on the outcome of renal allograft recipients with chronic hepatitis B. We performed a retrograde analysis of the clinical presentations of 66 hepatitis B surface antigen-positive kidney allograft recipients during the past 25 years with a mean follow-up of 76 months. Seven patients were diagnosed with HCC. The patients were subgrouped into cirrhotic versus noncirrhotic liver cohorts. Among renal allograft recipients with HBV infection, patients with cirrhotic livers had a higher risk of HCC (P = .003) and mortality (P = .025) than those with a noncirrhotic liver. The outcome was poor among the cirrhotic liver group. Pretransplantation liver biopsy may be indicated for the recipient candidate with HBV infection. Liver cirrhosis may be an exclusion criterion for the renal transplant waiting list due to the high incidence of HCC and the poor patient survival.

Viral nephropathy

Viral infections can cause many glomerular diseases. The diagnostic criteria for virus-related nephropathy include detailed clinical and laboratory data, and tissue molecular analysis. Several mechanisms are involved in the pathogenesis of virus-related nephropathy, including tropism of the virus in the kidney, induction of abnormal immune complexes, direct cytopathogenic effects, and multiorgan failure. Hepatitis B virus is associated with membranous nephropathy and mesangiocapillary glomerulonephritis in endemic areas. Hepatitis C virus causes various forms of glomerulonephritis, including cryoglobulinemia-mediated glomerulonephritis. Infection with HIV is associated with a collapsing focal segmental glomerulosclerosis, a distinctive disease that affects mainly Africans and African Americans. In the course of HIV infection, other types of immune complex glomerulonephritis can occur, most frequently in whites. Recent reports indicate a role for parvovirus B19 in 'idiopathic' collapsing focal segmental glomerulosclerosis. Both hantaviruses, and coronaviruses associated with severe acute respiratory syndrome, can lead to acute renal failure. Renal biopsy followed by appropriate serological and molecular testing is essential for defining virus-related glomerular lesions and guiding prognostic and therapeutic evaluation.

Management of hepatocellular carcinoma in renal transplant recipients

BACKGROUND AND OBJECTIVE

In Hong Kong where hepatitis B virus (HBV) infection is endemic, hepatocellular carcinoma (HCC) accounts for 20% of all malignant transformations in renal transplant recipients. The aim of the present study was to review the management and outcome of HCC in renal transplant recipients at a specialized surgical center.

METHOD

A retrospective analysis on the data collected prospectively in a tertiary referral center.

RESULTS

From January 1991 to December 2002, five renal transplant recipients were diagnosed to have primary HCC and received treatment in our center. There were four men and one woman with a median age of 47 (range, 38-68) years. Four of them had cadaveric renal transplantation whereas one had live donor transplantation. All of them were HBV carriers. The median tumor size was 3.5 cm (range, 1.8-8 cm). All tumors, except one, were diagnosed in sub-clinical stage by surveillance serum alpha-fetoprotein assay and percutaneous ultrasonography. Four patients were treated with surgical resection and one received transarterial oily chemoembolization (TOCE) as their primary treatments. There was one peri-operative death and the remaining three surgically treated patients were alive 4, 62, and 64 months after the resection. One patient developed recurrence 18 months after curative resection and was treated with TOCE. The patient with unresectable disease was alive for 50 months after the initial diagnosis. The surgical resection and overall survival rates of these patients were better than the published results.

CONCLUSION

Early detection with regular serum alpha-fetoprotein assay and ultrasonographic study, vigilant care in the peri-operative period, long-term follow-up for detection and treatment of recurrence, as well as close collaboration between renal physicians and liver surgeons may improve the outcome of treatment of HCC in renal transplant recipients.

Aggressive hepatocellular carcinoma complicating pregnancy after autologous bone marrow transplantation for non-Hodgkin's lymphoma

In the Asia-Pacific region, autologous and allogeneic bone marrow transplantation (BMT) in patients infected with the hepatitis B virus (HBV) may be complicated by fatal hepatic failure due to viral reactivation. Survivors may suffer from accelerated hepatitis and cirrhosis. We report the first case of hepatocellular carcinoma (HCC) after autologous BMT for mediastinal B cell lymphoma. The tumor developed rampantly during a planned pregnancy 5 years after BMT. Less than 40 cases of HCC complicating pregnancy have been reported, and outcome is invariably poor. Immunosuppression and HBV reactivation after autologous BMT, as well as immune tolerance and hormonal changes associated with pregnancy may contribute to the rapid tumor growth. Biochemical and radiological surveillance for HCC should be strengthened in HBV carriers after BMT, especially in patients with the histology of chronic liver disease, or biochemical/ virological evidence of increased HBV activity.

Selective internal radiation therapy by yttrium-90 microspheres for hepatocellular carcinoma after renal transplantation

We report a HBsAg-positive patient who developed hepatocellular carcinoma (HCC) 7 years after cadaveric kidney transplantation. The tumor was unresectable because of coexisting cirrhosis. Selective internal radiation (SIR) therapy, a novel therapy with the technique recently perfected, was used. Yttrium-90 microspheres were given via an angiographic catheter under fluoroscopy guidance. Serum alpha-fetal protein (AFP) was normalized within 2 wk. A follow-up abdominal CT scan revealed significant necrosis of the tumor and compensatory hypertrophy of non-diseased liver. The treatment was well tolerated except for transient liver function deterioration. The patient enjoyed 15 months of symptom-free survival before she died of liver failure. Practical aspects and potential applications of SIR therapy in this group of patients are discussed.

Long-term impact of hepatitis B, C virus infection on renal transplantation

Chronic liver disease and its complications are major problems in renal transplant recipients. Our aim was to elucidate the influence of hepatitis B, C virus infection on the long-term outcome of renal transplantation. Four hundred and seventy-seven patients who received renal transplantation between January 1984 and December 1999, and who were followed up at our hospital were enrolled. HBsAg was detected by the RIA method and anti-HCV Ab was assayed by the second-generation RIA kit. SGOT/ SGPT were checked every 3 months. Hepatoma was diagnosed by dynamic CT scan, elevated alpha-fetoprotein, hypervascularity by angiography and confirmed by pathological examination. The prevalence of HBV, HCV, coinfected HBV/HCV was 9.9% (n = 47), 28.5% ( n = 136), 3.1% (n = 15), respectively. The incidences of hepatoma in the HBV-/HCV-, HBV-/HCV+, HBV+/HCV-, HBV+/HCV+ groups were 1.4% (n = 4), 4.4% (n = 6), 6.4% (n = 3), 6.7% (n = 1), respectively (p = 0.114). The incidences of liver cirrhosis/hepatic failure were 3.2% (n = 9), 6.6% (n = 9), 21.3% (n = 10), 20% (n = 3), respectively (p < 0.001). The frequencies of chronic liver disease were 10.4% (n = 29), 45.6% (n = 62), 66% (n = 31), 80% (n = 12), respectively (p < 0.001). Patient and graft survival rates were lower in the HBV-infected group than in the other groups. Cox regression analysis revealed that HBV infection is likely an independent risk factor for patient mortality although the statistical significance was only borderline. Patients with HBV as well as HCV infection were not at risk of graft loss according to this model of analysis. Patients with HBV infection showed higher incidences of hepatoma, hepatic failure, graft failure and death. Therefore, HBV-infected patients who are candidates for renal transplantation should be carefully evaluated. It seems that HCV infection has little influence on the outcome of renal transplant recipients. A longer period of follow-up is needed to clarify the impact of HCV on renal transplant recipients.