1
|
Sanghi V, Romero-Marrero C, Flocco G, Graham RP, Abduljawad B, Niyazi F, Asfari MM, Hashimoto K, Eghtesad B, Menon KVN, Aucejo FN, Lopez R, Yerian LM, Allende DS. The spectrum of histopathological findings after SVR to DAA for recurrent HCV infection in liver transplant recipients. Virchows Arch 2021; 480:335-347. [PMID: 34498114 DOI: 10.1007/s00428-021-03191-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/07/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
Sustained virological response (SVR) to the treatment of recurrent HCV in liver transplant recipients has excellent clinical outcomes; however, little is known about the effects on allograft histology. The study aimed to assess the histology of the allograft liver. In this single-center, retrospective cohort study, patients with recurrent hepatitis C (HCV) in allograft liver who were cured with antiviral therapy between 2010 and 2016 were identified. Biopsies were reviewed by two liver pathologists blinded to the treatment and SVR status. Paired analysis was performed to compare pre- and post-treatment histological features. Of the 62 patients analyzed, 22 patients received PEGylated interferon/ribavirin (IFN) therapy, while 40 patients received direct-acting antiviral agents (DAA). The mean age was 57 years, 24% were female, and 79% were Caucasian. RNA in situ hybridization testing for HCV and HEV was negative in all the tested patients. Significant reduction in the inflammatory grade of post-treatment biopsy specimens was noted in all subjects (n = 57; p < 0.001) and in the IFN group (n = 21; p = 0.001) but not in the DAA group (p = 0.093). Of all subjects, 21% had worsening stage, 31% had improvement, and 48% had no change in stage. Of the treatment groups, 27% in the IFN and 17% in the DAA groups had worsening stage; however, the results were not statistically significant in all subjects or by treatment modality. Persistent inflammatory infiltrates and fibrosis was noted in allograft tissue of patients cured with DAA. Significant improvement in grade was noted in the IFN group, without a significant change in stage.
Collapse
Affiliation(s)
- Vedha Sanghi
- Department of Gastroenterology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Carlos Romero-Marrero
- Department of Gastroenterology and Hepatology, Memorial Healthcare System, Hollywood, FL, USA
| | - Gianina Flocco
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rondell P Graham
- Department of Gastroenterology & Liver Pathology, Mayo Clinic, Rochester, MN, USA
| | - Baraa Abduljawad
- Department of Critical Care Medicine/Transplant Hepatology, Cleveland Clinic Foundation, Abu Dhabi, United Arab Emirates
| | - Fadi Niyazi
- Department of Gastroenterology, Hepatology and Nutrition, University of Iowa, Iowa City, IA, USA
| | - Mohammad M Asfari
- Department of Gastroenterology, Hepatology and Nutrition, Augusta University, Augusta, GA, USA
| | - Koji Hashimoto
- Department of Surgery - Liver Transplantation, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bijan Eghtesad
- Department of Surgery - Liver Transplantation, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - K V Narayanan Menon
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Federico N Aucejo
- Department of Surgery - Liver Transplantation, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rocio Lopez
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lisa M Yerian
- Department of Gastrointestinal and Hepatobiliary Pathology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daniela S Allende
- Department of Gastrointestinal and Hepatobiliary Pathology, Cleveland Clinic Foundation, Cleveland, OH, USA.
| |
Collapse
|
2
|
Baganate F, Beal EW, Tumin D, Azoulay D, Mumtaz K, Black SM, Washburn K, Pawlik TM. Early mortality after liver transplantation: Defining the course and the cause. Surgery 2018; 164:694-704. [DOI: 10.1016/j.surg.2018.04.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 03/31/2018] [Accepted: 04/10/2018] [Indexed: 02/07/2023]
|
3
|
Mansour M, Hill L, Kerr J. Safety and effectiveness of direct acting antivirals for treatment of hepatitis C virus in patients with solid organ transplantation. Transpl Infect Dis 2018; 20:e12972. [PMID: 30080955 DOI: 10.1111/tid.12972] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/22/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The direct acting antivirals (DAAs) for treatment of hepatitis C virus (HCV) infection have sustained virologic response (SVR) rates of greater than 90% in most patients. However, data evaluating DAA use in transplant patients are limited. The goal of this study was to evaluate the effectiveness and safety of HCV treatment in this high-risk population. METHODOLOGY This single-center retrospective study included liver, kidney, lung, and/or heart transplant patients who were treated for HCV infection with DAAs. The primary objective was to identify drug-drug interactions between DAAs and immunosuppressants by comparing immunosuppression dosages and levels at baseline and week 4 of HCV treatment. As secondary objectives, we described the percentage of patients with new or worsening rejection and/or graft dysfunction during HCV treatment, and the percentage of study patients who achieved SVR. RESULTS Of the 108 patients included, the majority had liver (76%) or kidney (13%) transplants. Simeprevir plus sofosbuvir was the most commonly prescribed HCV treatment (33.9%) and tacrolimus was the most common immunosuppressant (91%). We did not detect a statistically significant difference in immunosuppression dosages or levels during HCV treatment. Furthermore, only one patient (<1%) experienced rejection and five patients (4.6%) had six episodes of graft dysfunction while on DAAs. Efficacy was high with 98% of patients achieving SVR. CONCLUSION DAAs appear to be safe and effective for HCV treatment in patients with a history of liver and/or kidney transplantation. More data are needed to evaluate DAAs in lung and/or heart transplant patients.
Collapse
Affiliation(s)
- Marlina Mansour
- Department of Pharmacy Services, UC San Diego Health, La Jolla, California
| | - Lucas Hill
- Department of Hepatology, UC San Diego Health, San Diego, California
| | - Janice Kerr
- Abdominal Transplantation, UC San Diego Health, La Jolla, California
| |
Collapse
|
4
|
Gubay F, Staunton R, Metzig C, Abubakar I, White PJ. Assessing uncertainty in the burden of hepatitis C virus: Comparison of estimated disease burden and treatment costs in the UK. J Viral Hepat 2018; 25:514-523. [PMID: 29274178 PMCID: PMC5947569 DOI: 10.1111/jvh.12847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 11/23/2017] [Indexed: 12/15/2022]
Abstract
Hepatitis C virus (HCV) is a major and growing public health concern. We need to know the expected health burden and treatment cost, and understand uncertainty in those estimates, to inform policymaking and future research. Two models that have been important in informing treatment guidelines and assessments of HCV burden were compared by simulating cohorts of individuals with chronic HCV infection initially aged 20, 35 and 50 years. One model predicts that health losses (measured in quality-adjusted life-years [QALYs]) and treatment costs decrease with increasing initial age of the patients, whilst the other model predicts that below 40 years, costs increase and QALY losses change little with age, and above 40 years, they decline with increasing age. Average per-patient costs differ between the models by up to 38%, depending on the patients' initial age. One model predicts double the total number, and triple the peak annual incidence, of liver transplants compared to the other model. One model predicts 55%-314% more deaths than the other, depending on the patients' initial age. The main sources of difference between the models are estimated progression rates between disease states and rates of health service utilization associated with different disease states and, in particular, the age dependency of these parameters. We conclude that decision-makers need to be aware that uncertainties in the health burden and economic cost of HCV disease have important consequences for predictions of future need for care and cost-effectiveness of interventions to avert HCV transmission, and further quantification is required to inform decisions.
Collapse
Affiliation(s)
- F. Gubay
- MRC Centre for Outbreak Analysis and Modelling and NIHR Health Protection Research Unit in Modelling MethodologySchool of Public HealthImperial College LondonLondonUK
| | - R. Staunton
- MRC Centre for Outbreak Analysis and Modelling and NIHR Health Protection Research Unit in Modelling MethodologySchool of Public HealthImperial College LondonLondonUK
| | - C. Metzig
- MRC Centre for Outbreak Analysis and Modelling and NIHR Health Protection Research Unit in Modelling MethodologySchool of Public HealthImperial College LondonLondonUK
- Department of MathematicsImperial College LondonLondonUK
| | - I. Abubakar
- Institute for Global HealthUniversity College LondonLondonUK
- Medical DirectoratePublic Health EnglandLondonUK
- MRC Clinical Trials UnitUniversity College LondonLondonUK
| | - P. J. White
- MRC Centre for Outbreak Analysis and Modelling and NIHR Health Protection Research Unit in Modelling MethodologySchool of Public HealthImperial College LondonLondonUK
- Modelling and Economics UnitNational Infection ServicePublic Health EnglandLondonUK
| |
Collapse
|
5
|
Hepatitis C following liver transplantation: current approach and future research opportunities. Curr Opin Infect Dis 2018; 29:346-52. [PMID: 27191202 DOI: 10.1097/qco.0000000000000274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The treatment of hepatitis C virus infection (HCV) in liver transplant recipients was very limited until direct-acting antivirals became widely available. We review the current approach to HCV treatment following liver transplantation and future research opportunities. RECENT FINDINGS Current treatment of HCV infection with all oral new direct-acting antivirals in the postliver transplant setting is easier, shorter, tolerable, and more effective with high-sustained virological response rates. However, some challenges remain, including the optimal timing of therapy, drug-drug interactions, renal insufficiency, and HIV coinfection. SUMMARY Patients with recurrent HCV following liver transplant will significantly benefit from all oral new direct acting antivirals. Ongoing studies will determine the optimal timing and combination in this unique population.
Collapse
|
6
|
Oya Y, Sugawara Y, Watanabe T, Yoshimaru Y, Honda M, Hashimoto S, Yoshii D, Isono K, Hayashida S, Yamamoto H, Tanaka M, Sasaki Y, Inomata Y. Ledipasvir and sofosbuvir for recurrent hepatitis C after liver transplantation. Biosci Trends 2016; 10:496-499. [PMID: 27990005 DOI: 10.5582/bst.2016.01223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Management of recurrent hepatitis C following liver transplantation still remains a challenge. Here, we report five patients who achieved viral responses following combined treatment with ledipasvir and sofosbuvir. All the patients received tacrolimus for immunosuppression. No dose adjustment was made before the ledipasvir and sofosbuvir therapy. All completed the intended 12-week treatment course with the full dose of ledipasvir and sofosbuvir. There were no significant adverse events greater than grade 2. During the study period, no acute rejection episodes were detected. The trough levels of tacrolimus were maintained stably. Hepatitis C virus RNA was not detected at week 12 in any of the patients. Based on the findings from this pilot study, combined ledipasvir and sofosbuvir therapy for 12 weeks is effective and safe for living - donor liver transplantation recipients with recurrence of hepatitis C virus.
Collapse
Affiliation(s)
- Yuki Oya
- Departments of Transplantation/Pediatric Surgery and Gastroenterology and Hepatology, Postgraduate School of Life Science, Kumamoto University
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Perspectives on treating hepatitis C infection in the liver transplantation setting. Curr Opin Organ Transplant 2016; 21:111-9. [PMID: 26927201 DOI: 10.1097/mot.0000000000000288] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW This article reviews treatment options of the approved and soon-to-be approved direct-acting antiviral (DAA)-based therapies in the transplant setting. RECENT FINDINGS DAA-based therapies have been shown to be effective and safe in achieving viral eradication in the majority of pre- and postliver transplant (LT) populations. Treatment decisions are guided by hepatitis C virus (HCV) genotype, the degree of renal dysfunction, and severity of cirrhosis. The addition of ribavirin is frequently needed to achieve highest viral eradication rates. Viral eradication pre-LT has been associated with fewer portal hypertensive complications and improved survival and effectively prevents recurrent HCV post-LT. For those with shorter time to LT, an alternative strategy is treatment with DAAs up to the time of LT to reduce the risk of post-LT recurrence. Therapies should be considered for all post-LT patients with recurrent HCV given the risk of accelerated disease progression. The sustained virological response rates among LT recipients parallel those of nontransplant patients. SUMMARY With broader application of DAA therapy in the transplant setting, improved graft and patient survival and simplified post-LT management are likely. The availability of high potency DAA therapy with excellent safety profiles has transformed the HCV-infected LT population into a group that is no longer 'difficult-to-treat.'
Collapse
|
8
|
Piñero F, Fauda M, Quiros R, Mendizabal M, González-Campaña A, Czerwonko D, Barreiro M, Montal S, Silberman E, Coronel M, Cacheiro F, Raffa P, Andriani O, Silva M, Podestá LG. Predicting early discharge from hospital after liver transplantation (ERDALT) at a single center: a new model. Ann Hepatol 2016; 14:845-55. [PMID: 26436356 DOI: 10.5604/16652681.1171770] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND & RATIONALE Limited information related to Liver Transplantation (LT) costs in South America exists. Additionally, costs analysis from developed countries may not provide comparable models for those in emerging economies. We sought to evaluate a predictive model of Early Discharge from Hospital after LT (ERDALT = length of hospital stay ≤ 8 days). A predictive model was assessed based on the odds ratios (OR) from a multivariate regression analysis in a cohort of consecutively transplanted adult patients in a single center from Argentina and internally validated with bootstrapping technique. RESULTS ERDALT was applicable in 34 of 289 patients (11.8%). Variables independently associated with ERDALT were MELD exception points OR 1.9 (P = 0.04), surgery time < 4 h OR 3.8 (P = 0.013), < 5 units of blood products consumption (BPC) OR 3.5 (P = 0.001) and early weaning from mechanical intubation OR 6.3 (P = 0.006). Points in the predictive scoring model were allocated as follows: MELD exception points (absence = 0 points, presence = 1 point), surgery time < 4 h (0-2 points), < 5 units of BPC (0-2 points), and early weaning (0-3 points). Final scores ranged from 0 to 8 points with a c-statistic of 0.83 (95% CI 0.77-0.90; P < 0.0001). Transplant costs were significantly lower in patients with ERDALT (median $23,078 vs. $28,986; P < 0.0001). Neither lower patient and graft survival, nor higher rates of short-term re-hospitalization and acute rejection events after discharge were observed in patients with ERDALT. In conclusion, the ERDALT score identifies patients suitable for early discharge with excellent outcomes after transplantation. This score may provide applicable models particularly for emerging economies.
Collapse
Affiliation(s)
- Federico Piñero
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Martín Fauda
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Rodolfo Quiros
- Internal Medicine, Infectious Diseases and Statistics. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Manuel Mendizabal
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Ariel González-Campaña
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Demian Czerwonko
- Intensive Care Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Mariano Barreiro
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Silvina Montal
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Ezequiel Silberman
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Matías Coronel
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Fernando Cacheiro
- Department of Anesthesiology. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Pía Raffa
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Oscar Andriani
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Marcelo Silva
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| | - Luis G Podestá
- Hepatology and Liver Transplant Unit. Hospital Universitario Austral, Buenos Aires, Argentina
| |
Collapse
|
9
|
EXP CLIN TRANSPLANTExp Clin Transplant 2016; 14. [DOI: 10.6002/ect.2015.0284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
10
|
Peyton A, Bhamidimarri KR. Hepatitis C treatment in liver transplant setting. Clin Liver Dis (Hoboken) 2015; 5:145-149. [PMID: 31040972 PMCID: PMC6490518 DOI: 10.1002/cld.475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 02/28/2015] [Accepted: 03/08/2015] [Indexed: 02/04/2023] Open
Affiliation(s)
- Adam Peyton
- From the Division of HepatologyUniversity of Miami–Miller School of MedicineMiamiFL
| | | |
Collapse
|
11
|
Edeghere O, Verlander NQ, Aboulhab J, Costella A, Harris HE, Balogun MA, Ramsay ME. Retrospective cohort study of liver transplantation in the United Kingdom between 1994 and 2010: the impact of hepatitis C infection. Public Health 2015; 129:509-16. [PMID: 25726124 DOI: 10.1016/j.puhe.2015.01.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 01/05/2015] [Accepted: 01/21/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND Liver transplantation is an important and established treatment option for chronic hepatitis C virus (HCV) related end-stage liver disease (HCV-related ESLD). This study describes trends in elective liver transplantation among persons with HCV-related ESLD. STUDY DESIGN Retrospective cohort. METHODS Analyses of United Kingdom (UK) Transplant Registry data for the period 1994 to 2010, with follow-up information extending to 2011. RESULTS Annual registrations for liver transplantation increased linearly and alcoholic liver cirrhosis (2075, 24%) and HCV-related ESLD (1213, 14%) were the most common indications. HCV-related ESLD patients were mainly aged 40-49 years (32%) and 50-59 years (43%); males (76%); and of white ethnicity (74%). Overall, 75% (956/1213) received a liver transplant with a linear increase over the period (OR 1.11, 95% CI 1.08, 1.13). Pre transplant mortality was unchanged (adjusted OR 1.0, 95% CI 0.96, 1.05) and post-transplant mortality decreased in both HCV-related (adjusted OR 0.77, 95% CI 0.68, 0.88) and non-HCV-related ESLD (adjusted OR 0.82, 95% CI 0.75, 0.89) patients. CONCLUSION The increase in demand for and receipt of liver transplants among persons with HCV-related ESLD requires coordinated efforts to increase not only organ donation, but investment in HCV prevention programmes and improved access to hepatitis C treatment services.
Collapse
Affiliation(s)
- O Edeghere
- Field Epidemiology Service, Public Health England, UK.
| | - N Q Verlander
- Statistics, Modelling and Economics Department, Centre for Infectious Disease Surveillance and Control, Public Health England, UK
| | | | - A Costella
- Immunisation, Hepatitis and Blood Safety Department, Centre for Infectious Disease Surveillance and Control, Public Health England, UK
| | - H E Harris
- Immunisation, Hepatitis and Blood Safety Department, Centre for Infectious Disease Surveillance and Control, Public Health England, UK
| | - M A Balogun
- Immunisation, Hepatitis and Blood Safety Department, Centre for Infectious Disease Surveillance and Control, Public Health England, UK
| | - M E Ramsay
- Immunisation, Hepatitis and Blood Safety Department, Centre for Infectious Disease Surveillance and Control, Public Health England, UK
| |
Collapse
|
12
|
Shah M, Shankar A, Gee I, Nash K, Hoare M, Gibbs P, Davies S, Alexander GJM. A retrospective 15-year review: survival advantage after switching to sirolimus in hepatitis C virus infected liver graft recipients. Aliment Pharmacol Ther 2015; 41:379-92. [PMID: 25496225 DOI: 10.1111/apt.13049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 11/05/2014] [Accepted: 11/21/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND The use of sirolimus-based immune suppression in liver transplantation, particularly in hepatitis C virus (HCV)-infected recipients, remains contentious. There is some evidence that sirolimus retards hepatic fibrosis, is renal sparing and may be of benefit in preventing hepatocellular carcinoma (HCC) recurrence. Sirolimus has not been adopted by many transplant centres because of persistent concerns regarding an increased risk of hepatic artery thrombosis, graft loss and death with de novo sirolimus. AIM To review the impact of switching to sirolimus monotherapy in HCV-infected liver recipients with respect to survival, graft loss and hepatic fibrosis. METHODS A retrospective review of 190 patients from a single centre undergoing first liver transplantation for HCV over 15 years. 113 patients were switched from calcineurin inhibitor (CNI)-based therapy to low-dose sirolimus monotherapy at a median of 15 months after transplantation for HCV-related fibrosis (72%), renal impairment (14%) or high-risk HCC (5%). RESULTS Patients switched to sirolimus had improved survival (P < 0.001) and slower progression to cirrhosis (P = 0.001). In patients with HCC (n = 91), sirolimus duration rather than strategy was an independent predictor of survival (P = 0.001) and extended time to HCC recurrence (33 vs. 16 months). Patients switched for renal dysfunction showed improvement in serum creatinine (140-108 μmol/L, P = 0.001). Those remaining on CNI-therapy were more likely to develop post-transplant diabetes (P = 0.03). CONCLUSION These data suggest selective switching to low-dose sirolimus monotherapy in HCV-positive liver recipients improves clinical outcome.
Collapse
Affiliation(s)
- M Shah
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Cambridge, Cambridge University Hospitals, Cambridge, UK
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Abstract
Chronic HCV infection is the leading indication for liver transplantation. However, as a result of HCV recurrence, patient and graft survival after liver transplantation are inferior compared with other indications for transplantation. HCV recurrence after liver transplantation is associated with considerable mortality and morbidity. The development of HCV-related fibrosis is accelerated after liver transplantation, which is influenced by a combination of factors related to the virus, donor, recipient, surgery and immunosuppression. Successful antiviral therapy is the only treatment that can attenuate fibrosis. The advent of direct-acting antiviral agents (DAAs) has changed the therapeutic landscape for the treatment of patients with HCV. DAAs have improved tolerability, and can potentially be used without PEG-IFN for a shorter time than previous therapies, which should result in better outcomes. In this Review, we describe the important risk factors that influence HCV recurrence after liver transplantation, highlighting the mechanisms of fibrosis and the integral role of hepatic stellate cells. Indirect and direct assessment of fibrosis, in addition to new antiviral therapies, are also discussed.
Collapse
|
14
|
Increased uptake and new therapies are needed to avert rising hepatitis C-related end stage liver disease in England: modelling the predicted impact of treatment under different scenarios. J Hepatol 2014; 61:530-7. [PMID: 24824282 DOI: 10.1016/j.jhep.2014.05.008] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 02/28/2014] [Accepted: 05/03/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS Hepatitis C (HCV) related disease in England is predicted to rise, and it is unclear whether treatment at current levels will be able to avert this. The aim of this study was to estimate the number of people with chronic HCV infection in England that are treated and assess the impact and costs of increasing treatment uptake. METHODS Numbers treated were estimated using national data sources for pegylated interferon supplied, dispensed, or purchased from 2006 to 2011. A back-calculation approach was used to project disease burden over the next 30 years and determine outcomes under various scenarios of treatment uptake. RESULTS 5000 patients were estimated to have been treated in 2011 and 28,000 in total from 2006 to 2011; approximately 3.1% and 17% respectively of estimated chronic infections. Without treatment, incident cases of decompensated cirrhosis and hepatocellular carcinoma were predicted to increase until 2035 and reach 2290 cases per year. Treatment at current levels should reduce incidence by 600 cases per year, with a peak around 2030. Large increases in treatment are needed to halt the rise; and with more effective treatment the best case scenario predicts incidence of around 500 cases in 2030, although treatment uptake must still be increased considerably to achieve this. CONCLUSIONS If the infected population is left untreated, the number of patients with severe HCV-related disease will continue to increase and represent a substantial future burden on healthcare resources. This can be mitigated by increasing treatment uptake, which will have the greatest impact if implemented quickly.
Collapse
|
15
|
Akamatsu N, Sugawara Y, Kokudo N, Eguchi S, Fujiwara T, Ohdan H, Nagano H, Taketomi A, Kitagawa Y, Shimada M, Ku Y, Yanaga K, Shirabe K, Ikegami T, Mizokami M, Takeuchi M, Maehara Y. Outcomes of living donor liver transplantation for hepatitis C virus-positive recipients in Japan: results of a nationwide survey. Transpl Int 2014; 27:767-74. [PMID: 24684710 DOI: 10.1111/tri.12329] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 02/17/2014] [Accepted: 03/28/2014] [Indexed: 02/06/2023]
Abstract
A nationwide survey of living donor liver transplantation (LDLT) for hepatitis C virus (HCV)-positive recipients was performed in Japan. A total of 514 recipients are reported and included in the study. The cumulative patient survival rate at 5 and 10 years was 72% and 63%, respectively. Of the 514 recipients, 142 patients (28%) died until the end of the observation, among which the leading cause was recurrent hepatitis C (42 cases). According to Cox regression multivariate analysis, donor age (>40), non-right liver graft, acute rejection episode, and absence of a sustained virologic response were independent prognostic factors. Of the 514 recipients, 361 underwent antiviral treatment mainly with pegylated-interferon and ribavirin (preemptive treatment in 150 patients and treatment for confirmed recurrent hepatitis in 211). The dose reduction rate and discontinuation rate were 40% and 42%, respectively, with a sustained virologic response rate of 43%. In conclusion, patient survival of HCV-positive recipients after LDLT was good, with a 10-year survival of 63%. Right liver graft might be preferable for HCV-positive recipients in an LDLT setting.
Collapse
Affiliation(s)
- Nobuhisa Akamatsu
- Division of Artificial Organ and Transplantation, Department of Surgery, University of Tokyo, Tokyo, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Staatz CE, Tett SE, Hollenbeak CS, Khan A, Kadry Z. Pharmacology and toxicology of mycophenolate in organ transplant recipients: an update. Arch Toxicol 2014; 24:640-50. [PMID: 24792322 DOI: 10.1111/j.1432-2277.2011.01250.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This review aims to provide an update of the literature on the pharmacology and toxicology of mycophenolate in solid organ transplant recipients. Mycophenolate is now the antimetabolite of choice in immunosuppressant regimens in transplant recipients. The active drug moiety mycophenolic acid (MPA) is available as an ester pro-drug and an enteric-coated sodium salt. MPA is a competitive, selective and reversible inhibitor of inosine-5'-monophosphate dehydrogenase (IMPDH), an important rate-limiting enzyme in purine synthesis. MPA suppresses T and B lymphocyte proliferation; it also decreases expression of glycoproteins and adhesion molecules responsible for recruiting monocytes and lymphocytes to sites of inflammation and graft rejection; and may destroy activated lymphocytes by induction of a necrotic signal. Improved long-term allograft survival has been demonstrated for MPA and may be due to inhibition of monocyte chemoattractant protein 1 or fibroblast proliferation. Recent research also suggested a differential effect of mycophenolate on the regulatory T cell/helper T cell balance which could potentially encourage immune tolerance. Lower exposure to calcineurin inhibitors (renal sparing) appears to be possible with concomitant use of MPA in renal transplant recipients without undue risk of rejection. MPA displays large between- and within-subject pharmacokinetic variability. At least three studies have now reported that MPA exhibits nonlinear pharmacokinetics, with bioavailability decreasing significantly with increasing doses, perhaps due to saturable absorption processes or saturable enterohepatic recirculation. The role of therapeutic drug monitoring (TDM) is still controversial and the ability of routine MPA TDM to improve long-term graft survival and patient outcomes is largely unknown. MPA monitoring may be more important in high-immunological recipients, those on calcineurin-inhibitor-sparing regimens and in whom unexpected rejection or infections have occurred. The majority of pharmacodynamic data on MPA has been obtained in patients receiving MMF therapy in the first year after kidney transplantation. Low MPA area under the concentration time from 0 to 12 h post-dose (AUC0-12) is associated with increased incidence of biopsy-proven acute rejection although AUC0-12 optimal cut-off values vary across study populations. IMPDH monitoring to identify individuals at increased risk of rejection shows some promise but is still in the experimental stage. A relationship between MPA exposure and adverse events was identified in some but not all studies. Genetic variants within genes involved in MPA metabolism (UGT1A9, UGT1A8, UGT2B7), cellular transportation (SLCOB1, SLCO1B3, ABCC2) and targets (IMPDH) have been reported to effect MPA pharmacokinetics and/or response in some studies; however, larger studies across different ethnic groups that take into account genetic linkage and drug interactions that can alter a patient's phenotype are needed before any clinical recommendations based on patient genotype can be formulated. There is little data on the pharmacology and toxicology of MPA in older and paediatric transplant recipients.
Collapse
Affiliation(s)
- Christine E Staatz
- School of Pharmacy, The University of Queensland, Brisbane, QLD, 4072, Australia,
| | | | | | | | | |
Collapse
|
17
|
Harada N, Tamura S, Sugawara Y, Togashi J, Ishizawa T, Kaneko J, Aoki T, Sakamoto Y, Hasegawa K, Tanaka T, Yamashiki N, Kokudo N. Impact of donor and recipient single nucleotide polymorphisms of IL28B rs8099917 in living donor liver transplantation for hepatitis C. PLoS One 2014; 9:e90462. [PMID: 24599320 PMCID: PMC3944011 DOI: 10.1371/journal.pone.0090462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 01/31/2014] [Indexed: 02/06/2023] Open
Abstract
Single nucleotide polymorphisms of interleukin-28B (IL28B) rs8099917 are reported to be associated with virologic clearance in interferon-and ribavirin -based treatment for hepatitis C virus (HCV)-infected patients. We examined virologic response in accordance with IL28B polymorphisms in our living donor liver transplantation series under a preemptive interferon and RBV treatment approach. Adequate DNA samples from both the recipient and donor for the study of single nucleotide polymorphisms of IL28B were available from 96 cases and were the subjects of the present study. Various clinical factors related with virologic response including early virologic response (EVR) and sustained virologic response (SVR) were examined. Totally 51% presented with EVR and 44% achieved SVR. Presence of the major allele (TT) in either the recipient or the donor corresponded to SVR of 53% and 48%. Presence of the minor allele (TG or GG) corresponded to SVR of 26% and 32%. Multivariate analysis revealed that genotype of HCV or EVR, but not IL28B polymorphisms in either the recipient or donor, was an independent factor for achieving SVR. When virologic response to treatment was incorporated into analysis, the impact of IL28B polymorphism on virological clearance remained relative to other factors and was not significantly independent.
Collapse
Affiliation(s)
- Nobuhiro Harada
- Division of Artificial Organ and Transplantation, The University of Tokyo Hospital, Tokyo, Japan
| | - Sumihito Tamura
- Division of Artificial Organ and Transplantation, The University of Tokyo Hospital, Tokyo, Japan
| | - Yasuhiko Sugawara
- Division of Artificial Organ and Transplantation, The University of Tokyo Hospital, Tokyo, Japan
- Organ Transplantation Service, The University of Tokyo Hospital, Tokyo, Japan
| | - Junichi Togashi
- Division of Artificial Organ and Transplantation, The University of Tokyo Hospital, Tokyo, Japan
| | - Takeaki Ishizawa
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Junichi Kaneko
- Division of Artificial Organ and Transplantation, The University of Tokyo Hospital, Tokyo, Japan
| | - Taku Aoki
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Tomohiro Tanaka
- Organ Transplantation Service, The University of Tokyo Hospital, Tokyo, Japan
| | - Noriyo Yamashiki
- Organ Transplantation Service, The University of Tokyo Hospital, Tokyo, Japan
| | - Norihiro Kokudo
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, The University of Tokyo Hospital, Tokyo, Japan
- Organ Transplantation Service, The University of Tokyo Hospital, Tokyo, Japan
| |
Collapse
|
18
|
Younossi ZM, Kanwal F, Saab S, Brown KA, El-Serag HB, Kim WR, Ahmed A, Kugelmas M, Gordon SC. The impact of hepatitis C burden: an evidence-based approach. Aliment Pharmacol Ther 2014; 39:518-31. [PMID: 24461160 DOI: 10.1111/apt.12625] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 10/11/2013] [Accepted: 12/30/2013] [Indexed: 12/08/2022]
Abstract
BACKGROUND Infection with the hepatitis C virus (HCV) has been considered a major cause of mortality, morbidity and resource utilisation in the US. In addition, HCV is the main cause of hepatocellular cancer (HCC) in the US. Recent developments in the diagnosis and treatment of HCV, including new recommendations pertaining to screening for HCV by the Centers for Disease Control and Prevention and newer treatment regimens with high efficacy, short duration and the potential for interferon-free therapies, have energised the health care practitioners regarding HCV management. AIM To assess the full impact of HCV burden on clinical, economic and patient-reported outcomes. METHODS An expert panel was convened to assess the full impact of HCV burden on a number of important outcomes using an evidence-based approach predicated on Grading of Recommendations Assessment, Development and Evaluation methodology. The literature was summarised, graded using an evidence-based approach and presented during the workshop. Workshop presentations were intended to review recent, relevant evidence-based literature and provide graded summary statements pertaining to HCV burden on topics including the relationships between HCV and the development of important outcomes. RESULTS The associations of HCV with cirrhosis, HCC, liver-related mortality, type 2 diabetes mellitus, rheumatological diseases and quality of life impairments are supported by strong evidence. Also, there is strong evidence that sustained viral eradication of HCV can improve important outcomes such as mortality and quality of life. CONCLUSIONS The current evidence suggests that HCV has been associated with tremendous clinical, economic and quality of life burden.
Collapse
Affiliation(s)
- Z M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA; Department of Medicine, Center for Liver Disease, Inova Fairfax Hospital, Falls Church, VA, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
19
|
El Awady MK, Bader El Din NG, Abdel Aziz Riad M, Omran MH, Abdelhafez TH, Elbaz TM, Hunter SS, Dawood RM, Abdel Aziz AO. Predictors of disease recurrence post living donor liver transplantation in end stage chronic HCV patients. DISEASE MARKERS 2014; 2014:202548. [PMID: 24695489 PMCID: PMC3948502 DOI: 10.1155/2014/202548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 12/14/2013] [Accepted: 12/24/2013] [Indexed: 12/22/2022]
Abstract
HCV recurrence represents a universal phenomenon after liver transplantation. In this study Fifty HCV patients who underwent living donor liver transplantation were enrolled and factors that may accelerate HCV reinfection of the allograft such as donor's age and degree of liver steatosis, recipient's age, gender, BMI, MELD score, liver functions, HCV viral load, type of immunosuppressive drug, and genetic polymorphisms of IL28B, OAS, and IL1B were studied. The results of disease-free survival (DFS) rates showed inverse correlation with the recipient's postoperative levels of ALT, AST, ALP (P < 0.001, <0.001, and 0.006 resp.) as well as pre- and postoperative titers of HCV RNA (P < 0.003 and <0.001 resp.). Recipient's IL28B SNP was a significant factor in predicting postoperative DFS (P < 0.025). However, SNPs in OAS and IL1B genes had no apparent correlation with DFS. Cox proportional hazards model revealed that patients with elevated levels of ALT, preoperative viral titers, IL28B CT, and IL28B TT were 8.28, 4.22, 3.35, and 1.36 times, respectively, more likely to develop recurrence. In conclusion IL28B SNP, ALT level, and preoperative HCV titer besides proper choice of immunosuppressant are helpful for predicting posttransplant HCV recurrence and DFS.
Collapse
Affiliation(s)
- Mostafa K. El Awady
- Department of Microbial Biotechnology, National Research Center, Dokki, Cairo, 12622, Egypt
| | - Noha G. Bader El Din
- Department of Microbial Biotechnology, National Research Center, Dokki, Cairo, 12622, Egypt
| | | | - Moataza H. Omran
- Department of Microbial Biotechnology, National Research Center, Dokki, Cairo, 12622, Egypt
| | - Tawfeek H. Abdelhafez
- Department of Microbial Biotechnology, National Research Center, Dokki, Cairo, 12622, Egypt
| | - Tamer Mahmoud Elbaz
- Department of Tropical Medicine, Kasr El Aini, Cairo University, Cairo, Egypt
| | | | - Reham M. Dawood
- Department of Microbial Biotechnology, National Research Center, Dokki, Cairo, 12622, Egypt
| | | |
Collapse
|
20
|
Gelley F, Gámán G, Gerlei Z, Zádori G, Görög D, Kóbori L, Fehérvári I, Schuller J, Szőnyi L, Nagy P, Doros A, Fazakas J, Lengyel G, Schaff Z, Kiss A, Sárváry E, Nemes B. Hepatitis C virus recurrence after liver transplantation in Hungary. Trends over the past 10 years. Orv Hetil 2013; 154:1058-66. [DOI: 10.1556/oh.2013.29647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Management of hepatitis C virus recurrence is a challenge after liver transplantation. Aim: The aim of the authors was to analyse the outcome of liver transplantation performed in hepatitis C virus positive patients during the past ten years and to compare recent data with a previous report of the authors. Method: The authors retrospectively evaluated the data (donors, recipients, perioperative characteristics, patient and graft survival, serum titer of hepatitis C virus RNA, histology) of 409 patients who underwent liver transplantation between 2003 and 2012. Results: 156 patients were transplanted due to hepatitis C virus associated liver cirrhosis (38%). Worse outcome was observed in these patients in comparison to hepatitis C virus negative recipients. The cumulative patient survival rates at 1, 5, and 10 year were 80%, 61%, 51% in the hepatitis C virus positive group and 92%, 85%, 79% in the hepatitis C virus negative group, respectively (p<0.001). The cumulative graft survival rates at 1, 5 and 10 year were 79%, 59% and 50% in hepatitis C virus positive and 89%, 80% and 70% in hepatitis C virus negative patients (p<0.001). Hepatitis C virus recurrence was observed in the majority of the patients (132 patients, 85%), mainly within the first year (83%). The authors observed recurrence within 6 months in 71 patients (56%), and within 3 months in 26 patients (20%). The mean hepatitis C virus recurrence free survival was 243 days. Higher rate of de novo diabetes was detected in case of early recurrence. The cumulative patient survival rates at 1, 3, 5, 10 years were 98%, 89.5%, 81% and 65% when hepatitis C virus recurrence exceeded 3 months and 64%, 53%, 30.5% and 30.5% in patients with early recurrence (p<0.001). Conclusions: Poor outcome of liver transplantation in hepatitis C virus positive patients is still a challenge. Hepatitis C virus recurrence is observed earlier after liver transplantation in comparison with a previous report of the authors. De novo diabetes occurs more frequently in case of early recurrence. Despite an immediate start of antiviral treatment, early recurrence has a significant negative impact on the outcome of transplantation. Orv. Hetil., 2013, 154, 1058–1066.
Collapse
Affiliation(s)
- Fanni Gelley
- Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest
| | - György Gámán
- Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest
| | - Zsuzsanna Gerlei
- Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest
| | - Gergely Zádori
- Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest
| | - Dénes Görög
- Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest
| | - László Kóbori
- Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest
| | - Imre Fehérvári
- Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest
| | - János Schuller
- Egyesített Szent István és Szent László Kórház – Rendelőintézet Hepatológiai Osztály Budapest
| | - László Szőnyi
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Gyermekgyógyászati Klinika, Általános Belgyógyászati és Gasztroenterológiai Osztály Budapest
| | - Péter Nagy
- Semmelweis Egyetem, Általános Orvostudományi Kar I. Patológiai és Kísérleti Rákkutató Intézet Budapest
| | - Attila Doros
- Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest
| | - János Fazakas
- Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest
| | - Gabriella Lengyel
- Semmelweis Egyetem, Általános Orvostudományi Kar II. Belgyógyászati Klinika Budapest
| | - Zsuzsa Schaff
- Semmelweis Egyetem, Általános Orvostudományi Kar II. Patológiai Intézet Budapest
| | - András Kiss
- Semmelweis Egyetem, Általános Orvostudományi Kar II. Patológiai Intézet Budapest
| | - Enikő Sárváry
- Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest
| | - Balázs Nemes
- Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest
| |
Collapse
|
21
|
Allam SR, Krüger B, Mehrotra A, Schiano T, Schröppel B, Murphy B. The association of IL28B polymorphism and graft survival in patients with hepatitis C undergoing liver transplantation. PLoS One 2013; 8:e54854. [PMID: 23382988 PMCID: PMC3559776 DOI: 10.1371/journal.pone.0054854] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 12/17/2012] [Indexed: 12/16/2022] Open
Abstract
Hepatitis C virus (HCV) infection is the leading cause of liver transplantation (LT) in Western countries. Polymorphism in the IL28B gene region has a major impact on the natural history and response to antiviral treatment in HCV. We investigated whether IL28B polymorphism was associated with graft survival in patients with or without HCV undergoing LT. 1,060 adult patients (age >18 years) underwent LT between years 2000 and 2008. Patients with previous LT, living donor LT and patients dying or requiring retransplants within 30 days of LT were excluded. DNA samples of 620 (84%) recipients and 377 (51%) donors were available for genotyping of IL28B rs12979860C>T. Donor IL28B genotypes had no significant differences in graft survival irrespective of HCV status. There was no difference in graft outcome in the non-HCV cohort (n = 293) based on recipient IL28B genotype. In the HCV group (n = 327), recipients with CC or CT genotype had better graft survival compared to TT genotype (62% vs. 48%, p = 0.02). HCV recipients with CC or CT genotype had delayed time to clinically relevant HCV recurrence compared to TT (10.4 vs. 6.7 months, p = 0.002). The beneficial effect of the CC/CT genotype on HCV recurrence and graft survival was independent of antiviral treatment. In conclusion, our study demonstrated that in contrast to donor IL28B genotype recipient IL28B was associated with graft survival and clinically relevant HCV recurrence in HCV infected recipients. No effect of IL28B genotype was manifest in non-HCV LT recipients.
Collapse
Affiliation(s)
- Sridhar R. Allam
- Division of Nephrology, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Bernd Krüger
- V. Medizinische Klinik, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim der Universität Heidelberg, Mannheim, Germany
| | - Anita Mehrotra
- Division of Nephrology, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Thomas Schiano
- Division of Liver Diseases, Mount Sinai School of Medicine, New York, New York, United States of America
- Recanati Miller Transplantation Institute, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Bernd Schröppel
- Division of Nephrology, Mount Sinai School of Medicine, New York, New York, United States of America
| | - Barbara Murphy
- Division of Nephrology, Mount Sinai School of Medicine, New York, New York, United States of America
| |
Collapse
|
22
|
Living-donor liver transplantation and hepatitis C. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2013; 2013:985972. [PMID: 23401640 PMCID: PMC3564275 DOI: 10.1155/2013/985972] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 01/01/2013] [Indexed: 12/19/2022]
Abstract
Hepatitis-C-virus- (HCV-) related end-stage cirrhosis is the primary indication for liver transplantation in many countries. Unfortunately, however, HCV is not eliminated by transplantation and graft reinfection is universal, resulting in fibrosis, cirrhosis, and finally graft decompression. In areas with low deceased-donor organ availability like Japan, living-donor liver transplantation (LDLT) is similarly indicated for HCV cirrhosis as deceased-donor liver transplantation (DDLT) in Western countries and accepted as an established treatment for HCV-cirrhosis, and the results are equivalent to those of DDLT. To prevent graft failure due to recurrent hepatitis C, antiviral treatment with pegylated-interferon and ribavirin is currently considered the most promising regimen with a sustained viral response rate of around 30% to 35%, although the survival benefit of this regimen remains to be investigated. In contrast to DDLT, many Japanese LDLT centers have reported modified treatment regimens as best efforts to secure first graft, such as aggressive preemptive antiviral treatment, escalation of dosages, and elongation of treatment duration.
Collapse
|
23
|
|
24
|
Preemptive antiviral treatment for hepatitis C virus after living donor liver transplantation. Transplant Proc 2012; 44:791-3. [PMID: 22483497 DOI: 10.1016/j.transproceed.2012.01.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Recurrence following liver transplantation for hepatitis C virus (HCV), which is universal, affects long-term outcomes. Treatment with interferon (IFN) and ribavirin (RBV), the only widely available options at this time, have been faced with low tolerability and overall unsatisfactory results in deceased donor liver transplantation (DDLT). However, its place after living donor liver transplantation (LDLT) remains a matter of debate. Since most LDLT cases are performed in a planned manner at a lower Model for End-stage Liver Disease (MELD) score compared to DDLT, we have aggressively applied preemptive INF/RBV in our series. PATIENTS AND METHODS We studied 122 adult recipients who underwent LDLT for HCV-related end-stage liver disease. The preemptive IFN/RBV protocol initiated treatment promptly after improvement in the patient's general condition with a low-dose IFN alpha2b and RBV (400 mg/d) followed by a gradual increase in the INFalpha2b dosage. Finally, we applied pegylated IFN (1.5 ug/kg/wk) and RBV (800 mg/d). The treatment was continued for 12 months after serum HCV-RNA became negative, which was defined as the end-of-treatment response (ETR). The response was considered to be a sustained viral response (SVR) if there were negative serologic results without antiviral treatment for another 6 months. Splenectomy was performed at the time of LDLT to improve tolerability to INF/RBV. The median age of the patients was 55 yrs (range = 23-66), with male dominance (87 males and 35 females). Median MELD score was 14 (range = 6-48). The series included 72 patients with hepatocellular carcinomas, and six with HIV coinfections. In 98 cases, HCV genotype was 1b. RESULTS Overall survival at 5 years was 79%. Cumulative response rates under the protocol were ETR 56% and SVR 44% at 5 years. CONCLUSIONS Preemptive IFN/RBV therapy after LDLT for HCV is feasible with acceptable outcomes.
Collapse
|
25
|
Berenguer M, Pons JA. Rabbit anti-thymocyte globulin in liver transplantation: all that glitters is not gold, but 1000 patients are so many to dazzle. Liver Transpl 2012; 18:755-60. [PMID: 22431230 DOI: 10.1002/lt.23432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
26
|
Berenguer M, Charco R, Manuel Pascasio J, Ignacio Herrero J. Spanish society of liver transplantation (SETH) consensus recommendations on hepatitis C virus and liver transplantation. Liver Int 2012; 32:712-31. [PMID: 22221843 DOI: 10.1111/j.1478-3231.2011.02731.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 11/23/2011] [Indexed: 02/06/2023]
Abstract
In November 2010, the Spanish Society of Liver Transplantation (Sociedad Española de Trasplante Hepático, SETH) held a consensus conference. One of the topics of debate was liver transplantation in patients with hepatitis C. This document reviews (i) the natural history of post-transplant hepatitis C, (ii) factors associated with post-transplant prognosis in patients with hepatitis C, (iii) the role of immunosuppression in the evolution of recurrent hepatitis C and response to antiviral therapy, (iv) antiviral therapy, both before and after transplantation, (v) follow-up of patients with recurrent hepatitis C and (vi) the role of retransplantation.
Collapse
Affiliation(s)
- Marina Berenguer
- Spanish Society of Liver Transplantation (Sociedad Española de Trasplante Hepático, SETH)
| | | | | | | |
Collapse
|
27
|
Giannelli V, Giusto M, Farcomeni A, Ponziani FR, Pompili M, Viganò R, Iemmolo RM, Donato MF, Rendina M, Toniutto P, Pasulo L, Morelli MC, De Martin E, Miglioresi L, Di Paolo D, Fagiuoli S, Merli M. Treatment of hepatitis C recurrence is less successful in female than in male liver transplant recipients. Transpl Int 2012; 25:448-54. [PMID: 22353419 DOI: 10.1111/j.1432-2277.2012.01440.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
It has been recently suggested that the risk of graft loss after liver transplantation (LT) may increase in female HCV patients. The aim of the study was to examine gender differences in HCV therapy tolerance and outcome in LT patients treated for HCV recurrence. A retrospective study was conducted on liver recipients with HCV recurrence, who were given antiviral therapy from 2001 to 2009 in 12 transplant centers in Italy. Sustained virological response (SVR), adherence-to-therapy, and side effects were evaluated. A multivariate logistic regression model was used after adjusting for possible confounders. The data regarding 342 treated patients were analyzed. SVR was reported in 38.8% of patients. At baseline, male and female did not differ in HCV viral load, histology, or rate of diabetes. SVR was lower in females than in males (29.5% vs. 42.1%; P=0.03). Adherence-to-therapy was also lower in females than in males 43.4% vs. 23.8%; P=0.001); anemia was the main reason for lower adherence. In a multivariate analysis in patients Genotype1, female gender (P<0.04), early virological response (P<0.0001), and adherence to therapy (P<0.0001) were independent predictors for SVR. In conclusion, female gender represents an independent negative prognostic factor for the outcome of HCV antiviral therapy after LT.
Collapse
Affiliation(s)
- Valerio Giannelli
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Abstract
Hepatitis-C-virus- (HCV-) related end-stage cirrhosis is the primary indication for liver transplantation in many countries. Unfortunately, however, HCV is not eliminated by transplantation and graft reinfection is universal, resulting in fibrosis, cirrhosis, and finally graft decompensation. The use of poor quality organs, particularly from older donors, has a highly negative impact on the severity of recurrence and patient/graft survival. Although immunosuppressive regimens have a considerable impact on the outcome, the optimal regimen after liver transplantation for HCV-infected patients remains unclear. Disease progression monitoring with protocol biopsy and new noninvasive methods is essential for predicting patient/graft outcome and starting antiviral treatment with the appropriate timing. Antiviral treatment with pegylated interferon and ribavirin is currently considered the most promising regimen with a sustained viral response rate of around 30% to 35%, although the survival benefit of this regimen remains to be investigated. Living-donor liver transplantation is now widely accepted as an established treatment for HCV cirrhosis and the results are equivalent to those of deceased donor liver transplantation.
Collapse
|
29
|
Kawahara T, Asthana S, Kneteman NM. m-TOR inhibitors: what role in liver transplantation? J Hepatol 2011; 55:1441-51. [PMID: 21781947 DOI: 10.1016/j.jhep.2011.06.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 06/28/2011] [Accepted: 06/29/2011] [Indexed: 12/11/2022]
Abstract
The development of calcineurin inhibitors (CNIs) led to marked improvements in patient and graft survival after liver transplantation (LTx). We have been left, however, with a dependence on immunosuppressive agents with nephrotoxicity, neurotoxicity, adverse impacts on cardiac risk profile, and risk for malignancy. These challenges need to be met against a dominance of hepatitis C virus (HCV) and hepatocellular carcinoma (HCC) as indications for liver transplant. Unmet needs for immunosuppression (IS) in LTx include: (1) Effective drugs that avoid CNIs toxicities. (2) Agents without adverse impact on HCV recurrence. (3) Compounds that minimize risk of HCC recurrence. New immunosuppressives will need to address the above needs while supporting patient and graft survival equivalent to those achievable with CNIs, ideally without important new toxicities. Two new classes of agents are currently in advanced clinical development: belatacept, and the mammalian target of rapamycin inhibitors (m-TORi). This manuscript will review evidence for a role for m-TORi in LTx in a range of clinical scenarios including patients with CNI nephrotoxicity or neurotoxicity, patients at risk of (or with) HCV recurrence, and patients at risk of HCC recurrence.
Collapse
Affiliation(s)
- Toshiyasu Kawahara
- Division of Transplantation, Department of Surgery, University of Alberta, Canada
| | | | | |
Collapse
|
30
|
O'Leary JG, Trotter JF, Neri MA, Jennings LW, McKenna GJ, Davis GL, Klintmalm GB. Effect of tacrolimus on survival in hepatitis C-infected patients after liver transplantation. Proc (Bayl Univ Med Cent) 2011; 24:187-91. [PMID: 21738288 DOI: 10.1080/08998280.2011.11928712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The observation that cyclosporine inhibits HCV replication in vitro has led some programs to use cyclosporine as the calcineurin inhibitor (CNI) of choice after orthotopic liver transplantation (OLT). Previous studies comparing outcomes with different CNIs used small HCV cohorts or had short-term follow-up. We examined patient survival and fibrosis progression in all HCV-infected adult primary OLT recipients from 1995 to 2004 at the Annette C. and Harold C. Simmons Transplant Institute (n = 516). Patients were categorized by their CNI on day 7 post-OLT, and they were excluded if they died before day 14. Patient and donor age, sex, race, and prevalence of cytomegalovirus infection post-OLT were similar in the tacrolimus and cyclosporine patients. As expected, acute cellular rejection and steroid-resistant rejection were less common in tacrolimus-treated patients. Although no difference in 1-year survival was seen, tacrolimus patients (n = 268) had superior 5-year survival compared to cyclosporine patients (n = 248) (75% vs. 67%; P = 0.02). Fibrosis progression was no different between the groups. In our retrospective analysis of 516 post-OLT patients, tacrolimus improved long-term survival compared to cyclosporine in HCV-infected patients, although it did not impact HCV fibrosis progression.
Collapse
|
31
|
DiMartini A, Dew MA, Chaiffetz D, Fitzgerald MG, deVera ME, Fontes P. Early trajectories of depressive symptoms after liver transplantation for alcoholic liver disease predicts long-term survival. Am J Transplant 2011; 11:1287-95. [PMID: 21645258 PMCID: PMC4133126 DOI: 10.1111/j.1600-6143.2011.03496.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Although it is well known that depression is associated with poorer medical outcomes, the association between depression- and liver transplant (LTX)-specific outcomes has not been investigated. We identified three trajectories of depressive symptoms evolving within the first post-LTX year in a cohort of 167 patients transplanted for alcoholic cirrhosis: a group with consistently low depression levels at all time points (group 1, n = 95), a group with initially low depression levels that rose over time (group 2, n = 41), and a group with consistently high depression levels (group 3, n = 31). Controlling for medical factors associated with poorer survival, recipients with increasing depression or persisting depression were more than twice as likely to die (all cause mortality) within the subsequent years. At 10 years post-LTX the survival rate was 66% for the low depression group, but only 46% and 43%, respectively, for the increasing depression and high depression groups. Except for a paradoxically higher percentage of malignancies in the low depression group, the causes of death and other specific LTX outcomes were not different between groups. Whether treatment of depression will improve survival rates is an area for research.
Collapse
Affiliation(s)
- A. DiMartini
- Department of Psychiatry, University of Pittsburgh Medical Center, PA,Department of Transplantation Surgery, University of Pittsburgh Medical Center, PA,University of Pittsburgh Medical Center, PA,The University of Pittsburgh Medical School, PA,Corresponding author: Andrea DiMartini,
| | - M. A. Dew
- Department of Psychiatry, University of Pittsburgh Medical Center, PA,Department of Psychology, University of Pittsburgh Medical Center, PA,Department of Epidemiology, University of Pittsburgh Medical Center, PA,Department of Biostatistics, University of Pittsburgh Medical Center, PA
| | | | - M. G. Fitzgerald
- Department of Psychiatry, University of Pittsburgh Medical Center, PA,University of Pittsburgh Medical Center, PA
| | - M. E. deVera
- Department of Transplantation Surgery, University of Pittsburgh Medical Center, PA,University of Pittsburgh Medical Center, PA,The University of Pittsburgh Medical School, PA
| | - P. Fontes
- Department of Transplantation Surgery, University of Pittsburgh Medical Center, PA,University of Pittsburgh Medical Center, PA,The University of Pittsburgh Medical School, PA
| |
Collapse
|
32
|
Nellore A, Fishman JA. NK cells, innate immunity and hepatitis C infection after liver transplantation. Clin Infect Dis 2011; 52:369-77. [PMID: 21217184 DOI: 10.1093/cid/ciq156] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Liver transplantation in patients with active hepatitis C virus (HCV) infection is followed by almost universal recurrence of viral infection. The control of HCV infection has been characterized largely in terms of the HCV-specific function of T-lymphocytes and the adaptive immune response. Emerging data suggest that components of the innate immune system, including natural killer cells, have a central role in determining the nature of posttransplant HCV infection and the likelihood of response to antiviral therapy. This review examines the emerging evidence implicating innate immunity in the pathogenesis of posttransplant HCV infections and the potential therapeutic implications of these observations.
Collapse
Affiliation(s)
- Anoma Nellore
- Infectious Disease Division and Transplant Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA
| | | |
Collapse
|
33
|
Bueno J, Barret JP, Serracanta J, Arnó A, Collado JM, Valles C, Colominas MJ, Diez Y, Pont T, Salamero P, Martinez-Ibañez V. Logistics and strategy of multiorgan procurement involving total face allograft. Am J Transplant 2011. [PMID: 21443675 DOI: 10.1111/j.1600-6143.2011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The face is the latest body structure to be added to the field of transplantation and the learning curve is ongoing. In the scenario of multiorgan recovery, the face is a nonvital 'organ' structure compared with other life-saving organs. To date, the face has been the first 'organ' to be procured in a multiorgan procurement. A technique for simultaneous recovery of the whole face, heart, lungs, liver, pancreas and kidneys is described. Thirty professionals participated in the procedure, of whom 13 were surgeons. No tracheotomy was performed. A mask of the donor's face was made from a mold impression. Duration of the procedure from skin incision to the end of surgery was 7.3 h. The face was perfused with Wisconsin solution through a cannula inserted into the aortic arch between the origin of the brachiocephalic arterial trunk and the left subclavian artery. Blood requirements consisted of 4 units of packed red blood cells. After the procedure, the mask was placed on the donor's face. All recovered grafts functioned immediately. In summary, simultaneous multiorgan procurement including the whole face is feasible, effective and saves time without jeopardizing life-saving organs and without the need for tracheotomy.
Collapse
Affiliation(s)
- J Bueno
- Pediatric Liver Transplantation Unit, Hospital Universitario Valle de Hebron, Autonomous University of Barcelona, Barcelona, Spain.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Dickson RC, Pungpapong S, Keaveny AP, Taner CB, Ghabril M, Aranda-Michel J, Satyanarayana R, Bonatti H, Kramer DJ, Nguyen JH. Improving graft survival for patients undergoing liver transplantation. Clin Transplant 2011; 25:E345-55. [DOI: 10.1111/j.1399-0012.2011.01428.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
|
35
|
The impact of sirolimus on hepatitis C recurrence after liver transplantation. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2011; 25:28-34. [PMID: 21258665 DOI: 10.1155/2011/201019] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND While some immunosuppression strategies may accelerate hepatitis C virus (HCV) recurrence after liver transplantation (LT), the impact of sirolimus (SRL) is not known. OBJECTIVE To assess the risk of biopsy-proven HCV recurrence and patient survival using known and suspected risk factors for HCV recurrence as covariates. METHODS A retrospective analysis of 141 consecutive patients, including 88 who received de novo SRL therapy, who had undergone a first LT for HCV cirrhosis was conducted. Known and suspected risk factor covariates including transplant era, donor and recipient age, Model for End-stage Liver Disease score, cold ischemia time, immunosuppressive drugs and steroid treatment rejection rates were used in the assessment. RESULTS Overall, 72.3% of the cohort developed biopsy-proven HCV recurrence. The incidence of HCV recurrence was not significantly different for patients treated with SRL (75% versus 69.8%; P=0.5). There was no difference found for time to recurrence, nor did mean activity or fibrosis scores differ at the time of initial recurrence. However, on follow-up using serial biopsies in patients with recurrence, the mean activity and fibrosis scores were significantly lower in the SRL group. Donor age and acute rejection episodes were the only factors affecting the HCV recurrence rate (expB 1.02 [95% CI 1.01 to 1.03]); P=0.03; and expB 2.8 [95% CI 1.8 to 4.3]; P<0.01], respectively). SRL treatment did not alter patient survival rates. Among patients treated with SRL-based immunosuppression, higher drug area under the curve levels were associated with a trend to lower disease activity and fibrosis at diagnosis; however, higher SRL levels were associated with shorter recurrence-free survival (P=0.038). CONCLUSION Results of the present analysis suggest that de novo SRL-based immunosuppression can be safely used in patients undergoing LT for HCV-associated liver disease; however, SRL-based immunosuppression did not significantly affect the timing or severity of post-transplant HCV recurrence. HCV recurrence in SRL-treated patients had lower progressive activity and fibrosis levels on serial biopsy.
Collapse
|
36
|
Antiviral treatment for hepatitis C virus infection after liver transplantation. HEPATITIS RESEARCH AND TREATMENT 2010; 2010:475746. [PMID: 21151523 PMCID: PMC2989693 DOI: 10.1155/2010/475746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Revised: 08/13/2010] [Accepted: 10/06/2010] [Indexed: 12/16/2022]
Abstract
A significant proportion of patients with chronic hepatitis C virus (HCV) infection develop liver cirrhosis and complications of end-stage liver disease over two to three decades and require liver transplantation, however, reinfection is common and leads to further adverse events under immunosuppression. Pretransplant antiviral or preemptive therapy is limited to mildly decompensated patients due to poor tolerance. The mainstay of management represents directed antiviral therapy after evidence of recurrence of chronic hepatitis C. Combined pegylated interferon and ribavirin therapy is the current standard treatment with sustained viral response rates of 25% to 45%. The rate is lower than that in the immunocompetent population, partly due to the high prevalence of intolerability. To date, there is no general consensus regarding the antiviral treatment modality, timing, or dosing for HCV in patients with advanced liver disease and after liver transplantation. New anti-HCV drugs to delay disease progression or to enhance viral clearance are necessary.
Collapse
|
37
|
Lee WC, Wu TJ, Chou HS, Lee CF, Chan KM, Cheng SS. Flexible and individualized treatment to achieve sustained viral response for recurrent hepatitis C in liver transplant recipients. J Viral Hepat 2010; 17:770-7. [PMID: 20337926 DOI: 10.1111/j.1365-2893.2009.01233.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Hepatitis C recurrence after liver transplantation is universal and is a major cause of long-term graft failure. Improving the effectiveness of recurrent hepatitis C treatment is extremely important. We studied 35 anti-hepatitis C virus (HCV)-positive patients who underwent liver transplantation. Among the 35 patients, 25 patients had recurrent hepatitis C and received antiviral treatment. HCV RNA load after liver transplantation was increased by 3.68-fold. The antiviral treatment regimen comprised pegylated-interferon (180 μg) every 2 weeks and ribavirin at a dose of 200-400 mg every day. The treatment duration was flexible and individualized, and depended on viral response to treatment. The dosage of tacrolimus was decreased gradually to minimize immunocompromise. Median (interquartile) serum level of tacrolimus was 6.9 (6-8.9) ng/mL at initiation of treatment and 3.8 (3.6-5) ng/mL at the end of treatment. One patient (4.0%) was withdrawn from the study, and three patients (12%) died of infection during treatment. At end of treatment, 18 of 25 patients (72%) were negative for serum HCV RNA. After an additional 6 months following the end of treatment, 16 of the 25 patients (64%) had sustained viral response (SVR) and only two patients had HCV relapse. The 1-year, 3-year and 5-year survival rates were 91.4%, 84.5% and 84.5% for all patients and 88.0%, 82.8% and 82.8% for the 25 patients who received antiviral therapy. In conclusion, recurrent HCV infection is an important issue in liver transplantation. The flexible regimen of antiviral therapy and individualized immunosuppressive agents that was applied in this study achieved a SVR rate of 64%.
Collapse
Affiliation(s)
- W-C Lee
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital, Chang-Gung Transplantation Institute, Chang-Gung University Medical School, Taoyuan, Taiwan.
| | | | | | | | | | | |
Collapse
|
38
|
Dhillon N, Walsh L, Krüger B, Ward SC, Godbold JH, Radwan M, Schiano T, Murphy BT, Schröppel B. A single nucleotide polymorphism of Toll-like receptor 4 identifies the risk of developing graft failure after liver transplantation. J Hepatol 2010; 53:67-72. [PMID: 20400193 DOI: 10.1016/j.jhep.2009.12.044] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 12/05/2009] [Accepted: 12/29/2009] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS While studies in animal models have linked Toll-like receptor (TLR) 4 signaling to the pathophysiology of ischemia/reperfusion (IR) injury and liver fibrosis, the relevance of TLR4 activation after human liver transplantation is unknown. The TLR4 single nucleotide polymorphism (SNP) D299G is situated within the extracellular domain and diminishes receptor binding to danger-associated molecular patterns. METHODS We studied the influence of TLR4 D299G on IR injury and graft survival in 430 deceased donor LT recipients. Compared with livers expressing wild-type (WT) alleles, livers with a TLR4 loss-of-function allele were significantly more likely to have initial good graft function (IGGF) (OR 2.20, p=0.01). In contrast, there was no effect of recipient TLR4 genotype on the rate of IGGF. RESULTS The effect of TLR4 D299G on long-term graft survival was analyzed based on hepatitis C virus (HCV) serostatus. In HCV infected recipients, multivariate Cox regression analysis demonstrated a significant association between the presence of recipient, but not donor TLR4 D299G and long-term graft failure (HR 2.48, CI 1.28-4.81; p=0.007). There was no difference in graft survival between TLR4 mutant and WT recipients among non-HCV infected recipients. CONCLUSIONS Collectively, these results demonstrate the differential effects of donor and recipient TLR4 signaling in human liver transplantation. Donor TLR4 contributed to sterile injury following cold preservation and the recipient TLR4 genotype was linked with poor allograft survival among HCV infected recipients.
Collapse
Affiliation(s)
- Navdeep Dhillon
- Division of Nephrology, Mount Sinai School of Medicine, New York, NY 10029, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Karasu Z, Akay S, Yilmaz F, Akarca U, Ersoz G, Gunsar F, Kilic M. A pilot study: longer duration of posttransplant hepatitis C virus therapy may increase the sustained response rate. Transplant Proc 2010; 41:3806-9. [PMID: 19917392 DOI: 10.1016/j.transproceed.2009.06.212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Revised: 04/01/2009] [Accepted: 06/01/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although end of treatment virological responses are similar in posttransplant patients with recurrent chronic hepatitis C virus infection and nontransplant patients, the sustained virological response rate is lower in the posttransplant setting. We investigated the efficacy of a longer duration (3 years) of therapy. METHODS Thirteen patients with biopsy-proven recurrent hepatitis C were included in the study. In the first year of therapy, all patients were treated with a standard regimen of interferon alpha 2b 3MU 3 times in a week plus ribavirin (800 to 1000 mg/d). After the availability of pegylated interferon, patients were converted to pegylated interferon (1.5 microg/kg body weight). Hepatitis C virus RNA was evaluated at months 3, 6, 9, 12, 24, 36, and 42. If hepatitis C virus RNA was negative at month 12, the patients continued treatment for 36 months. RESULTS Hepatitis C virus RNA was negative in six patients at 12 months, including two who became hepatitis C virus RNA negative after 3 months; two, after 6 months; and two, after 12 months of therapy. Those six continued treatment completing 3 years of treatment with a sustained virological response. Four of those six patients with sustained virological response required colony-stimulating factors during treatment. CONCLUSION Although the hepatitis C virus RNA status of patients at 12 weeks is a good marker to predict a sustained virological response in the nontransplant setting, it is not valid in posttransplant patients. A prolonged duration of therapy for patients who are viral responders at 12 months may prevent recurrence and increase the sustained virological response rate.
Collapse
Affiliation(s)
- Z Karasu
- Department of Gastroenterology, Ege University, Izmir, Turkey
| | | | | | | | | | | | | |
Collapse
|
40
|
Dhillon N, Walsh L, Krüger B, Mehrotra A, Ward SC, Godbold J, Radwan M, Schiano T, Murphy B, Schröppel B. Complement component C3 allotypes and outcomes in liver transplantation. Liver Transpl 2010; 16:198-203. [PMID: 20104494 DOI: 10.1002/lt.21972] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The complement system has been implicated in the pathogenesis of liver diseases. Human complement component C3 (C3) exists as 2 allotypes, fast (F) and slow (S). We conducted a study to address the influence of these alleles on ischemia-reperfusion (IR) injury and graft survival in liver transplant recipients. Four hundred thirty patients receiving liver transplants from 2000 to 2004 were included. C3 allotypes of 296 donor-recipient pairs were determined and correlated with clinical outcomes. Four groups were analyzed according to the C3 genotype: C3 SS donor and recipient, C3 FS or C3 FF donor and C3 SS recipient, C3 SS donor and C3 FS or C3 FF recipient, and C3 FS or C3 FF donor and recipient. Baseline characteristics of the 4 groups were similar. The mean follow-up time was 4.3 +/- 2.2 years. The 4 groups had similar rates of IR injury (P = 0.16). The hazard ratios for liver allograft survival in the C3 SS donor and recipient group in comparison with the other 3 groups (C3 FS or C3 FF donor and C3 SS recipient, C3 SS donor and C3 FS or C3 FF recipient, and C3 FS or C3 FF donor and recipient) were not significantly different: 1.13 (P = 0.60), 0.99 (P = 0.97), and 1.02 (P = 0.95), respectively. In conclusion, donor and recipient C3 genotypes are not associated with liver transplantation outcomes.
Collapse
Affiliation(s)
- Navdeep Dhillon
- Division of Nephrology, Mount Sinai School of Medicine, New York, NY 10029, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Tamura S, Sugawara Y, Yamashiki N, Kaneko J, Kokudo N, Makuuchi M. Pre-emptive antiviral therapy in living donor liver transplantation for hepatitis C: observation based on a single-center experience. Transpl Int 2009; 23:580-8. [PMID: 20028490 DOI: 10.1111/j.1432-2277.2009.01023.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Reports of large series in living donor liver transplantation (LDLT) for hepatitis C virus infection (HCV) are scarce. Between 1996 and 2008, 105 LDLTs were performed at the University of Tokyo for HCV. Rapid induction of antiviral treatment with interferon (IFN) and ribavirin (RBV) was attempted per protocol regardless of the clinical presentation of recurrent HCV (pre-emptive treatment approach). Treatment was continued for 12 months after serum HCV-RNA became negative (ETR: end-of-treatment response) and judged as a sustained viral response (SVR) after another 6 months of negative results without treatment. A fixed treatment period was not defined unless an ETR was achieved (no-stopping approach). Flexible dose adjustments were allowed. Ninety-five patients were eligible for pre-emptive therapy. Forty-three (45%) patients experienced an ETR, and 32 (34%) achieved SVR. Nonadherence to full-dose INF and RBV had little impact on the viral response. Evaluation using the Kaplan-Meier method to incorporate the cumulative time-dependent nature of the no-stopping approach estimated SVR rate at 53% by the fifth year. Survival rate at 5 years was 79% for the HCV recipients and did not differ significantly from our non-HCV series. In LDLT for HCV, pre-emptive IFN-RBV-based treatment with the application of no-stopping approach is feasible and effective.
Collapse
Affiliation(s)
- Sumihito Tamura
- Artificial Organ and Transplantation Division, University of Tokyo, Tokyo, Japan
| | | | | | | | | | | |
Collapse
|
42
|
Abstract
BACKGROUND The evaluation of the survival achieved with liver transplantation (LT) compared with remaining on the waiting list, the transplant benefit, should be the underlying principle of organ allocation. METHODS During 2004 to 2007 with an allocation system based on Model for End-Stage Liver Disease (MELD) score with exceptions, we prospectively evaluated the transplant benefit and its relation to the match between recipient and donor characteristics. RESULTS Among 575 patients listed for chronic liver disease, 218 (37.9%) underwent LT and 115 (20%) were removed from the list (76 deaths, 25 tumor progressions, and 14 sick conditions). The 1- and 3-year survival rates on the list were significantly related to MELD score more than or equal to 20 (57% and 33% vs. 88% and 66%, P<0.001) and to its progression during the waiting time, such as s-Na levels less than or equal to 135 mEq/L (73% and 48% vs. 86% and 69%, P<0.001). These two variables had no impact on survival after LT, except in hepatitis C virus positive recipients. The multivariate Cox model confirmed a positive transplant benefit for all cases with MELD score more than or equal to 20 and without hepatocellular carcinoma (HR 2.9; CI 1.3-6.2) independently of the type of donors. Only hepatocellular carcinoma patients with low MELD scores showed a positive transplant benefit (MELD <15; HR 2; CI 1.1-5.1). CONCLUSIONS LT should be reserved for cirrhotic patients with MELD score more than or equal to 20 independently of other recipient and donor matches or for cases with lower MELD score but with hepatocellular carcinoma.
Collapse
|
43
|
Thuluvath PJ, Maheshwari A, Thuluvath NP, Nguyen GC, Segev DL. Survival after liver transplantation for hepatocellular carcinoma in the model for end-stage liver disease and pre-model for end-stage liver disease eras and the independent impact of hepatitis C virus. Liver Transpl 2009; 15:754-62. [PMID: 19562709 DOI: 10.1002/lt.21744] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It has been suggested that hepatitis C virus (HCV) patients with hepatocellular carcinoma (HCC) may have worse outcomes after liver transplantation (LT) because of more aggressive tumor biology. In this study, we determined the post-LT survival of HCC patients with and without HCV using United Network for Organ Sharing data from January 1994 to March 2008. Patients with HCC were stratified into HCV (HCC-HCV) and non-HCV (HCC-non-HCV) groups. In the era before the Model for End-Stage Liver Disease (MELD), there were 1237 HCC patients (780, HCV; 373, non-HCV; 84, unknown HCV status), and during the MELD era, there were 4933 HCC patients (3272, HCV; 1348, non-HCV; 313, unknown). In the pre-MELD era, 5-year graft (58.6% versus 53.7%) and patient (61.7% versus 59.3%) survival rates were marginally higher for HCC-non-HCV patients than for HCC-HCV patients. In the MELD era also, 5-year graft (61.2% versus 55.5%) and patient (63.7% versus 58.2%) survival rates were marginally higher for HCC-non-HCV patients than for HCC-HCV patients. In patients without HCC, pre-MELD and MELD era graft/patient survival rates for non-HCV patients were higher than those for HCV patients. The differences in survival rates for HCC patients with and without HCV were lower than those for non-HCC patients stratified by their HCV status. HCV had no additional negative impact on the post-LT survival of patients with HCC, and this was further confirmed by multivariate analysis. In conclusion, the survival of HCC patients has remained unchanged in the past 2 decades. HCV patients have a lower survival rate than non-HCV patients, regardless of their HCC status, but HCV has no additional negative impact on survival in patients with HCC.
Collapse
Affiliation(s)
- Paul J Thuluvath
- Institute for Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, MD 21229, USA.
| | | | | | | | | |
Collapse
|
44
|
O'Leary JG, Randall H, Onaca N, Jennings L, Klintmalm GB, Davis GL. Post-liver transplant survival in hepatitis C patients is improving over time. Liver Transpl 2009; 15:360-8. [PMID: 19326409 DOI: 10.1002/lt.21691] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Outcomes after orthotopic liver transplantation for chronic hepatitis C have been reported to be worsening over the last 2 decades. We analyzed our center's experience over 15 years to identify trends in post-orthotopic liver transplantation survival in patients with and without hepatitis C virus infection. Patient survival and graft survival among adult primary orthotopic liver transplantation recipients who survived more than 90 days from January 1991 to June 2006 at the Baylor Regional Transplant Institute (n = 1901) were evaluated by Kaplan-Meier analysis. Those with or without hepatitis C virus infection were analyzed by era: era 1, 1991-1994 (n = 473); era 2, 1995-1998 (n = 421); era 3, 1999-2002 (n = 498); and era 4, 2003-2006 (n = 512). Differences in eras with disparate survivals were assessed by univariate and multivariable analysis. Overall, patient survival and graft survival were significantly lower among hepatitis C virus infection recipients compared to those without hepatitis C virus infection (P < 0.001). This difference was dependent on the era of transplantation, with progressive improvement in hepatitis C virus patient (P < 0.001) and graft (P < 0.001) survival in sequential eras. Several factors accounted for this improvement, notably better selection of hepatocellular carcinoma patients and fewer late cytomegalovirus infections. Improvement occurred despite an increase in the ages of both donors and recipients. In conclusion, posttransplant survival after orthotopic liver transplantation for chronic hepatitis C has improved significantly over the last 15 years despite demographic changes in patients and grafts that have been previously shown to impair survival. A major reason for this improvement is better selection of patients with concurrent hepatocellular carcinoma and fewer late cytomegalovirus infections, although other factors may play a role as well.
Collapse
Affiliation(s)
- Jacqueline G O'Leary
- Department of Medicine, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246, USA.
| | | | | | | | | | | |
Collapse
|
45
|
Shankar A, Alexander G. Liver transplantation for liver disease caused by hepatitis C virus infection. Br J Hosp Med (Lond) 2009; 70:95-100. [PMID: 19229150 DOI: 10.12968/hmed.2009.70.2.38908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hepatitis C is an important problem that often requires liver transplantation. However, outcomes have not improved in line with liver transplants for other indications. This article explores the issues surrounding this difficult area of transplant hepatology.
Collapse
Affiliation(s)
- Arun Shankar
- Department of Hepatology, Addenbrooke's Hospital, Cambridge
| | | |
Collapse
|
46
|
Abstract
Recurrent hepatitis C after liver transplantation is a universal phenomenon. Graft reinfection occurs rapidly; once it is established, allograft cirrhosis and decompensation rapidly ensue in many patients. Treatment with pegylated interferon plus ribavirin is the standard of care among nontransplant patients with hepatitis C; however, the applicability of these therapies in liver transplant patients is severely limited. Before transplantation, many patients are simply too ill to endure the long treatment duration necessary to achieve viral eradication; thus, treatment-related toxicity is a frequent barrier to success. Clinical trials in the pretransplantation population have yielded poor outcomes, with sustained virologic response rates only as high as 25%. Early after transplantation, treatment may be initiated prophylactically, or it may be initiated therapeutically in patients with evidence of recurrent disease. In small studies, prophylactic therapy has been associated with sustained virologic response rates lower than 20%, whereas in therapeutic intervention studies, sustained virologic response rates have ranged from 20% to 37%. In the setting of therapeutic intervention, preliminary indications suggest that rapid and early virologic response may become important clinical tools enabling the early identification of patients likely to respond to treatment. Two important clinical trials, PHOENIX (Pegasys and Copegus Administered After Liver Transplantation for Hepatitis C) in the prophylactic setting and PROTECT (Pegylated Interferon Alpha-2b and Ribavirin After Orthotopic Liver Transplantation: Efficacy and Safety in Hepatitis C Recurrence Therapy) in the therapeutic setting, are under way and should further advance our understanding of the management of hepatitis C in patients undergoing liver transplantation.
Collapse
|
47
|
Abstract
PURPOSE OF REVIEW Because the gap between liver organ supply and demand continues to increase, adult living-donor liver transplantation continues to represent a significant pool of organs. RECENT FINDINGS With this in mind, we discuss recent issues in adult living-donor liver transplantation, including issues with donor evaluation and selection, donor liver biopsy, orphan organ allocation, donor morbidity and mortality, outcomes compared with deceased donor liver transplant from time of evaluation, death on the waiting list, and evolving recipient indications for living-donor liver transplantation. SUMMARY Increasing the number of living-donor liver transplants would allow us to expedite transplant, avoid death on the waitlist, and possibly save more lives by expanding the criteria for transplant. These benefits must always be weighed against the potential risks and complications to the donor, which can be significant.
Collapse
|
48
|
Abstract
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.
Collapse
Affiliation(s)
- Edward J Gane
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand.
| |
Collapse
|
49
|
Survival after liver transplantation for hepatitis C is unchanged over two decades in Canada. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2008; 22:153-4. [PMID: 18299733 DOI: 10.1155/2008/127684] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Allograft failure secondary to recurrence of hepatitis C virus (HCV) infection is the most common cause of death and retransplantation among recipients with HCV infection. It has been suggested that patients transplanted for HCV have had worse outcomes in more recent years than in previous years (the 'era effect'). A Canadian transplantation registry database was analyzed to determine the outcomes of patients transplanted over the years for HCV. The results of the present analysis of 1002 patients show that the 'era effect' was not seen in liver transplantation recipients with HCV in Canada, because no survival difference was noted based on the year of transplantation. All groups had overall two-year and five-year survival rates of 76% to 83% and 69% to 72%, respectively. The present study's national results prove continued benefit to transplantation of HCV patients.
Collapse
|
50
|
Hong Z, Smart G, Dawood M, Kaita K, Wen SW, Gomes J, Wu J. Hepatitis C Infection and Survivals of Liver Transplant Patients in Canada, 1997–2003. Transplant Proc 2008; 40:1466-70. [DOI: 10.1016/j.transproceed.2008.03.089] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2007] [Revised: 02/14/2008] [Accepted: 03/11/2008] [Indexed: 01/20/2023]
|