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Hashem M, Medhat MA, Abdeltawab D, Makhlouf NA. Expanding the liver donor pool worldwide with hepatitis C infected livers, is it the time? World J Transplant 2024; 14:90382. [DOI: 10.5500/wjt.v14.i2.90382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/29/2024] [Accepted: 04/12/2024] [Indexed: 06/13/2024] Open
Abstract
Liver transplantation (LT) provides a life-saving option for cirrhotic patients with complications and hepatocellular carcinoma. Despite the increasing number of liver transplants performed each year, the number of LT candidates on the waitlist remains unchanged due to an imbalance between donor organ supply and the demand which increases the waitlist time and mortality. Living donor liver transplant had a great role in increasing the donor pool and shortened waitlist time for LT candidates. Nevertheless, further strategies can be implemented to increase the pool of potential donors in deceased donor LT, such as reducing the rate of organ discards. Utilizing hepatitis C virus (HCV) seropositive liver grafts is one of the expanded donor organ criteria. A yearly increase of hundreds of transplants is anticipated as a result of maximizing the utilization of HCV-positive organs for HCV-negative recipients. Direct-acting antiviral therapy's efficacy has revolutionized the treatment of HCV infection and the use of HCV-seropositive donors in transplantation. The American Society of Transplantation advises against performing transplants from HCV-infected liver donors (D+) into HCV-negative recipient (R-) unless under Institutional Review Board-approved study rules and with full informed consent of the knowledge gaps associated with such transplants. Proper selection of patients to be transplanted with HCV-infected grafts and confirming their access to direct-acting antivirals if needed is important. National and international consensuses are needed to regulate this process to ensure the maximum benefit and the least adverse events.
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Affiliation(s)
- Mai Hashem
- Fellow of Tropical Medicine and Gastroenterology, Assiut University Hospital, Assiut 71515, Egypt
| | - Mohammed A Medhat
- Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Doaa Abdeltawab
- Department of Tropical Medicine and Gastroenterology, Al-Rajhi Liver Hospital, Assiut University, Assiut 71515, Egypt
| | - Nahed A Makhlouf
- Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
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2
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Raoufinia R, Arabnezhad A, Keyhanvar N, Abdyazdani N, Saburi E, Naseri N, Niazi F, Niazi F, Namdar AB, Rahimi HR. Leveraging stem cells to combat hepatitis: a comprehensive review of recent studies. Mol Biol Rep 2024; 51:459. [PMID: 38551743 DOI: 10.1007/s11033-024-09391-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 02/27/2024] [Indexed: 04/02/2024]
Abstract
Hepatitis is a significant global public health concern, with viral infections being the most common cause of liver inflammation. Antiviral medications are the primary treatments used to suppress the virus and prevent liver damage. However, the high cost of these drugs and the lack of awareness and stigma surrounding the disease create challenges in managing hepatitis. Stem cell therapy has arisen as a promising therapeutic strategy for hepatitis by virtue of its regenerative and immunomodulatory characteristics. Stem cells have the exceptional capacity to develop into numerous cell types and facilitate tissue regeneration, rendering them a highly promising therapeutic avenue for hepatitis. In animal models, stem cell therapy has demonstrated worthy results by reducing liver inflammation and improving liver function. Furthermore, clinical trials have been undertaken to assess the safety and effectiveness of stem cell therapy in individuals with hepatitis. This review aims to explore the involvement of stem cells in treating hepatitis and highlight the findings from studies conducted on both animals and humans. The objective of this review is to primarily concentrate on the ongoing and future clinical trials that assess the application of stem cell therapy in the context of hepatitis, including the transplantation of autologous bone marrow-derived stem cells, human induced pluripotent stem cells, and other mesenchymal stem cells. In addition, this review will explore the potential merits and constraints linked to stem cell therapy for hepatitis, as well as its prospective implications in the management of this disease.
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Affiliation(s)
- Ramin Raoufinia
- Department of Medical Genetics and Molecular Medicine, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Basic Medical Sciences, Neyshabur University of Medical Sciences, Neyshabur, Iran
| | - Ali Arabnezhad
- Department of Pharmacognosy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Neda Keyhanvar
- Department of Biochemistry & Biophysics, University of California San Francisco, San Francisco, CA, 94107, USA
| | - Nima Abdyazdani
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ehsan Saburi
- Department of Medical Genetics and Molecular Medicine, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nima Naseri
- Department of Biochemistry, School of medicine, Hamadan University of medical sciences, Hamadan, Iran
| | - Fereshteh Niazi
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Faezeh Niazi
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Beheshti Namdar
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamid Reza Rahimi
- Department of Medical Genetics and Molecular Medicine, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
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3
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Boyarsky BJ, Strauss AT, Segev DL. Transplanting Organs from Donors with HIV or Hepatitis C: The Viral Frontier. World J Surg 2021; 45:3503-3510. [PMID: 33471156 DOI: 10.1007/s00268-020-05924-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2020] [Indexed: 12/21/2022]
Abstract
A wide gap between the increasing demand for organs and the limited supply leads to immeasurable loss of life each year. The organ shortage could be attenuated by donors with human immunodeficiency virus (HIV) or hepatitis C virus (HCV). The transplantation of organs from HIV+ deceased donors into HIV+ individuals (HIV D+ /R+) was initiated in South Africa in 2010; however, this practice was forbidden in the USA until the HIV Organ Policy Equity (HOPE) Act in 2013. HIV D+/R+ transplantation is now practiced in the USA as part of ongoing research studies, helping to reduce waiting times for all patients on the waitlist. The introduction of direct acting antivirals for HCV has revolutionized the utilization of donors with HCV for HCV-uninfected (HCV-) recipients. This is particularly relevant as the HCV donor pool has increased substantially in the context of the rise in deaths related to drug overdose from injection drug use. This article serves to review the current literature on using organs from donors with HIV or HCV.
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Affiliation(s)
- Brian J Boyarsky
- Department of Surgery, Epidemiology Research Group in Organ Transplantation, Johns Hopkins University School of Medicine, 2000 E Monument St, Baltimore, MD, 21205, USA
| | - Alexandra T Strauss
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Epidemiology Research Group in Organ Transplantation, Johns Hopkins University School of Medicine, 2000 E Monument St, Baltimore, MD, 21205, USA. .,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA.
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4
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Bethea E, Arvind A, Gustafson J, Andersson K, Pratt D, Bhan I, Thiim M, Corey K, Bloom P, Markmann J, Yeh H, Elias N, Kimura S, Dageforde LA, Cuenca A, Kawai T, Safa K, Williams W, Gilligan H, Sise M, Fishman J, Kotton C, Kim A, Marks C, Shao S, Cote M, Irwin L, Myoung P, Chung RT. Immediate administration of antiviral therapy after transplantation of hepatitis C-infected livers into uninfected recipients: Implications for therapeutic planning. Am J Transplant 2020; 20:1619-1628. [PMID: 31887236 PMCID: PMC8005111 DOI: 10.1111/ajt.15768] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/04/2019] [Accepted: 12/22/2019] [Indexed: 01/25/2023]
Abstract
The practice of transplanting hepatitis C (HCV)-infected livers into HCV-uninfected recipients has not previously been recommended in transplant guidelines, in part because of concerns over uncontrolled HCV infection of the allograft. Direct-acting antivirals (DAAs) provide an opportunity to treat donor-derived HCV-infection and should be administered early in the posttransplant period. However, evidence on the safety and efficacy of an immediate DAA treatment approach, including how to manage logistical barriers surrounding timely DAA procurement, are required prior to broader use of HCV-positive donor organs. We report the results of a trial in which 14 HCV-negative patients underwent successful liver transplantation from HCV-positive donors. Nine patients received viremic (nucleic acid testing [NAT]-positive) livers and started a 12-week course of oral glecaprevir-pibrentasvir within 5 days of transplant. Five patients received livers from HCV antibody-positive nonviremic donors and were followed using a reactive approach. Survival in NAT-positive recipients is 100% at a median follow-up of 46 weeks. An immediate treatment approach for HCV NAT-positive liver transplantation into uninfected recipients is safe and efficacious. Securing payer approval for DAAs early in the posttransplant course could enable need-based allocation of HCV-positive donor organs irrespective of candidate HCV status, while averting chronic HCV allograft infection.
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Affiliation(s)
- Emily Bethea
- Harvard Medical School, Boston, Massachusetts,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts,Massachusetts General Hospital Transplant Center, Boston, Massachusetts
| | - Ashwini Arvind
- Harvard Medical School, Boston, Massachusetts,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Jenna Gustafson
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts,Massachusetts General Hospital Transplant Center, Boston, Massachusetts
| | - Karin Andersson
- Harvard Medical School, Boston, Massachusetts,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts,Massachusetts General Hospital Transplant Center, Boston, Massachusetts
| | - Daniel Pratt
- Harvard Medical School, Boston, Massachusetts,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts,Massachusetts General Hospital Transplant Center, Boston, Massachusetts
| | - Irun Bhan
- Harvard Medical School, Boston, Massachusetts,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts,Massachusetts General Hospital Transplant Center, Boston, Massachusetts
| | - Michael Thiim
- Harvard Medical School, Boston, Massachusetts,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts,Massachusetts General Hospital Transplant Center, Boston, Massachusetts
| | - Kathleen Corey
- Harvard Medical School, Boston, Massachusetts,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts,Massachusetts General Hospital Transplant Center, Boston, Massachusetts
| | - Patricia Bloom
- Harvard Medical School, Boston, Massachusetts,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts,Massachusetts General Hospital Transplant Center, Boston, Massachusetts
| | - Jim Markmann
- Harvard Medical School, Boston, Massachusetts,Massachusetts General Hospital Transplant Center, Boston, Massachusetts,Transplant Surgery Division, Massachusetts General Hospital, Boston Massachusetts
| | - Heidi Yeh
- Harvard Medical School, Boston, Massachusetts,Massachusetts General Hospital Transplant Center, Boston, Massachusetts,Transplant Surgery Division, Massachusetts General Hospital, Boston Massachusetts
| | - Nahel Elias
- Harvard Medical School, Boston, Massachusetts,Massachusetts General Hospital Transplant Center, Boston, Massachusetts,Transplant Surgery Division, Massachusetts General Hospital, Boston Massachusetts
| | - Shoko Kimura
- Harvard Medical School, Boston, Massachusetts,Massachusetts General Hospital Transplant Center, Boston, Massachusetts
| | - Leigh Anne Dageforde
- Harvard Medical School, Boston, Massachusetts,Transplant Surgery Division, Massachusetts General Hospital, Boston Massachusetts
| | - Alex Cuenca
- Harvard Medical School, Boston, Massachusetts,Transplant Surgery Division, Massachusetts General Hospital, Boston Massachusetts
| | - Tatsuo Kawai
- Harvard Medical School, Boston, Massachusetts,Transplant Surgery Division, Massachusetts General Hospital, Boston Massachusetts
| | - Kassem Safa
- Harvard Medical School, Boston, Massachusetts,Massachusetts General Hospital Transplant Center, Boston, Massachusetts,Nephrology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Winfred Williams
- Harvard Medical School, Boston, Massachusetts,Nephrology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Hannah Gilligan
- Harvard Medical School, Boston, Massachusetts,Nephrology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Meghan Sise
- Harvard Medical School, Boston, Massachusetts,Nephrology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Jay Fishman
- Harvard Medical School, Boston, Massachusetts,Massachusetts General Hospital Transplant Center, Boston, Massachusetts,Infectious Diseases Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Camille Kotton
- Harvard Medical School, Boston, Massachusetts,Massachusetts General Hospital Transplant Center, Boston, Massachusetts,Infectious Diseases Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Arthur Kim
- Harvard Medical School, Boston, Massachusetts,Infectious Diseases Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Christin Marks
- Harvard Medical School, Boston, Massachusetts,Massachusetts General Hospital Division of Pharmacy, Boston Massachusetts
| | - Sarah Shao
- Massachusetts General Hospital Transplant Center, Boston, Massachusetts,Massachusetts General Hospital Division of Pharmacy, Boston Massachusetts
| | - Mariesa Cote
- Massachusetts General Hospital Division of Pharmacy, Boston Massachusetts
| | - Linda Irwin
- Massachusetts General Hospital Transplant Center, Boston, Massachusetts
| | - Paul Myoung
- Massachusetts General Hospital Transplant Center, Boston, Massachusetts
| | - Raymond T. Chung
- Harvard Medical School, Boston, Massachusetts,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts,Massachusetts General Hospital Transplant Center, Boston, Massachusetts
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5
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Bethea ED, Samur S, Kanwal F, Ayer T, Hur C, Roberts MS, Terrault N, Chung RT, Chhatwal J. Cost Effectiveness of Transplanting HCV-Infected Livers Into Uninfected Recipients With Preemptive Antiviral Therapy. Clin Gastroenterol Hepatol 2019; 17:739-747.e8. [PMID: 30138735 PMCID: PMC6382534 DOI: 10.1016/j.cgh.2018.08.042] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/26/2018] [Accepted: 08/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Guidelines do not recommend transplanting hepatitis C virus (HCV)-infected livers into HCV-uninfected recipients. Direct-acting antivirals (DAAs) can be used to treat donor-derived HCV infection. However, the added cost of DAA therapy is a barrier. We evaluated the cost effectiveness of transplanting HCV-positive livers into HCV-negative patients with preemptive DAA therapy. METHODS A previously validated Markov-based mathematical model was adapted to simulate a virtual trial of HCV-negative patients on the liver transplant waitlist. The model compared long-term clinical and economic outcomes in patients willing to accept only HCV-negative livers vs those willing to accept any liver (HCV negative or HCV positive). Recipients of HCV-positive livers received 12 weeks of preemptive DAA therapy. The model incorporated data from the United Network for Organ Sharing and published sources. RESULTS For patients with a model for end-stage liver disease (MELD) score ≥ 22, accepting any liver vs waiting for only HCV-negative livers was cost effective, with incremental cost-effectiveness ratios ranging from $56,100 to $91,700/quality-adjusted life-year. For patients with a MELD score of 28 (the median MELD score of patients undergoing transplantation in the United States), accepting any liver was cost effective at an incremental cost-effectiveness ratio of $62,600/quality-adjusted life year. In patients with low MELD scores, which may not accurately reflect disease severity, accepting any liver was cost effective, irrespective of MELD score. CONCLUSIONS Using a Markov-based mathematical model, we found transplanting HCV-positive livers into HCV-negative patients with preemptive DAA therapy to be a cost-effective strategy that could improve health outcomes.
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Affiliation(s)
- Emily D. Bethea
- Massachusetts General Hospital Institute for Technology Assessment, Boston, MA,Harvard Medical School, Boston, MA,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA
| | - Sumeyye Samur
- Massachusetts General Hospital Institute for Technology Assessment, Boston, MA,Harvard Medical School, Boston, MA
| | - Fasiha Kanwal
- Department of Medicine, Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX,Houston Veterans Affairs Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Turgay Ayer
- Department of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Chin Hur
- Massachusetts General Hospital Institute for Technology Assessment, Boston, MA,Harvard Medical School, Boston, MA,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA
| | - Mark S. Roberts
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA,University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Norah Terrault
- University of California San Francisco Medical Center, San Francisco, CA
| | - Raymond T. Chung
- Harvard Medical School, Boston, MA,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA
| | - Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts.
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6
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Chhatwal J, Samur S, Bethea ED, Ayer T, Kanwal F, Hur C, Roberts MS, Terrault N, Chung RT. Transplanting hepatitis C virus-positive livers into hepatitis C virus-negative patients with preemptive antiviral treatment: A modeling study. Hepatology 2018; 67:2085-2095. [PMID: 29222916 PMCID: PMC5991982 DOI: 10.1002/hep.29723] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 10/30/2017] [Accepted: 12/07/2017] [Indexed: 12/11/2022]
Abstract
UNLABELLED Under current guidelines, hepatitis C virus (HCV)-positive livers are not transplanted into HCV-negative recipients because of adverse posttransplant outcomes associated with allograft HCV infection. However, HCV can now be cured post-LT (liver transplant) using direct-acting antivirals (DAAs) with >90% success; therefore, HCV-negative patients on the LT waiting list may benefit from accepting HCV-positive organs with preemptive treatment. Our objective was to evaluate whether and in which HCV-negative patients the potential benefit of accepting an HCV-positive (i.e., viremic) organ outweighed the risks associated with HCV allograft infection. We developed a Markov-based mathematical model that simulated a virtual trial of HCV-negative patients on the LT waiting list to compare long-term outcomes in patients: (1) willing to accept any (HCV-negative or HCV-positive) liver versus (2) those willing to accept only HCV-negative livers. Patients receiving HCV-positive livers were treated preemptively with 12 weeks of DAA therapy and had a higher risk of graft failure than those receiving HCV-negative livers. The model incorporated data from published studies and the United Network for Organ Sharing (UNOS). We found that accepting any liver regardless of HCV status versus accepting only HCV-negative livers resulted in an increase in life expectancy when Model for End-Stage Liver Disease (MELD) was ≥20, and the benefit was highest at MELD 28 (0.172 additional life-years). The magnitude of clinical benefit was greater in UNOS regions with higher HCV-positive donor organ rates, that is, Regions 1, 2, 3, 10, and 11. Sensitivity analysis demonstrated that model outcomes were robust. CONCLUSION Transplanting HCV-positive livers into HCV-negative patients with preemptive DAA therapy could improve patient survival on the LT waiting list. Our analysis can help inform clinical trials and minimize patient harm. (Hepatology 2018;67:2085-2095).
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Affiliation(s)
- Jagpreet Chhatwal
- Massachusetts General Hospital Institute for Technology Assessment, Boston, MA,Harvard Medical School, Boston, MA,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA
| | - Sumeyye Samur
- Massachusetts General Hospital Institute for Technology Assessment, Boston, MA,Harvard Medical School, Boston, MA
| | - Emily D. Bethea
- Massachusetts General Hospital Institute for Technology Assessment, Boston, MA,Harvard Medical School, Boston, MA,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA
| | - Turgay Ayer
- Department of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Fasiha Kanwal
- Department of Medicine, Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX,Houston Veterans Affairs Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Chin Hur
- Massachusetts General Hospital Institute for Technology Assessment, Boston, MA,Harvard Medical School, Boston, MA,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA
| | - Mark S. Roberts
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA,University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Norah Terrault
- University of California San Francisco Medical Center, San Francisco, CA
| | - Raymond T. Chung
- Harvard Medical School, Boston, MA,Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA
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7
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Huang F, Voelk C, Trampisch M, Rowland L, Schultz A, Sabo JP. Pharmacokinetic Interaction between Faldaprevir and Cyclosporine or Tacrolimus in Healthy Volunteers: A Prospective, Open-Label, Fixed-Sequence, Crossover Study. Basic Clin Pharmacol Toxicol 2018; 123:84-93. [PMID: 29427400 DOI: 10.1111/bcpt.12980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 01/31/2018] [Indexed: 12/14/2022]
Abstract
Faldaprevir (FDV) is a potent, orally administered inhibitor of hepatitis C virus. In this single-centre, open-label, fixed-sequence, crossover study of 32 healthy adult male and female volunteers, subjects received either a single dose of cyclosporine (CsA) 50 mg (N = 16) or tacrolimus (TAC) 0.5 mg (N = 16), followed by a washout of at least 14 days. Each subject then received a loading dose of FDV 240 mg followed by 120 mg FDV once daily for 6 days. FDV 120 mg was then co-administered with an additional single dose of CsA (50 mg) or TAC (0.5 mg), followed by an additional 6 days of FDV 120 mg once daily. Intensive blood sampling was performed to assess the PK interaction potential. Assessment of relative BA indicated that exposure to CsA co-administered with FDV was similar to CsA alone. However, the AUCτ,ss and Cmax,ss of FDV were increased by 23% and 41%, respectively, when FDV was co-administered with CsA. Exposure to TAC was slightly increased (AUC0-∞ increased by 27%, no change in Cmax ) when TAC was co-administered with FDV. In contrast, exposure to FDV co-administered with TAC was similar to FDV alone. No unexpected safety findings arose from the trial. The limitations of the study (use of single, low dose of TAC and CsA, and only healthy volunteers in the trial) are discussed.
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Affiliation(s)
- Fenglei Huang
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Claudia Voelk
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | | | - Lois Rowland
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Armin Schultz
- CRS Clinical Research Services Mannheim GmbH, Mannheim, Germany
| | - John P Sabo
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
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8
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Feng H, Caro L, Fandozzi CM, Guo Z, Talaty J, Wolford D, Panebianco D, Iwamoto M, Butterton JR, Yeh WW. Pharmacokinetic Interactions Between Elbasvir/Grazoprevir and Immunosuppressant Drugs in Healthy Volunteers. J Clin Pharmacol 2018; 58:666-673. [DOI: 10.1002/jcph.1052] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 11/07/2017] [Indexed: 11/10/2022]
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9
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Predictors of hepatitis C virus recurrence after living donor liver transplantation: Mansoura experience. Arab J Gastroenterol 2017; 18:151-155. [PMID: 28958486 DOI: 10.1016/j.ajg.2017.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 06/22/2017] [Accepted: 09/05/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND STUDY AIMS Hepatitis C virus (HCV)-related cirrhosis is the leading cause of liver transplantation (LT). All patients who undergo LT with detectable serum HCV-RNA experience graft reinfection, which is the most frequent cause of graft loss and death in these patients. We estimated the rate of HCV recurrence and evaluated the current therapeutic regimens. PATIENTS AND METHODS The records of consecutive 325 living donor LT (LDLT) surgeries performed between May 2004 and August 2014 were retrospectively analysed; 207 of them were followed-up throughout the study. Clinical, laboratory, radiological and histopathological examinations were performed thoroughly. Patients received treatment in the form of either pegylated interferon (PEG-IFN) or sofosbuvir, both in combination with ribavirin. RESULTS In total, 90.3% of recipients who were transplanted because of HCV-related end-stage liver disease experienced recurrence due to the virus. The donor age was older in the HCV recurrent group versus the non-recurrence group (28.7±7.1 versus 22.6±2.6years: p≤0.001), warm ischaemia time was prolonged (46.1±18.1 versus 28.6±4.1min: p≤0.001), median cold ischaemia time was 40.0 (10-175) versus 22.5 (15-38) min (p≤0.001) and basal PCR was 414000 (546-116000000) versus 10766 (1230-40000) (p≤0.001). Sustained virological response was achieved in 95.4% of patients treated with a combination of a fixed daily dose of 400mg sofosbuvir with ribavirin and in 65.1% of those who were treated with PEG-IFN with ribavirin. CONCLUSIONS Older donor age and prolonged warm ischaemia time are independent predictors of HCV recurrence after LDLT, and early treatment with the direct-acting sofosbuvir is helpful in resolving the problem of post-LT HCV recurrence.
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10
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Bowring MG, Kucirka LM, Massie AB, Luo X, Cameron A, Sulkowski M, Rakestraw K, Gurakar A, Kuo I, Segev DL, Durand CM. Changes in Utilization and Discard of Hepatitis C-Infected Donor Livers in the Recent Era. Am J Transplant 2017; 17:519-527. [PMID: 27456927 PMCID: PMC5266634 DOI: 10.1111/ajt.13976] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 07/12/2016] [Indexed: 01/25/2023]
Abstract
The impact of interferon (IFN)-free direct-acting antiviral (DAA) hepatitis C virus (HCV) treatments on utilization and outcomes associated with HCV-positive deceased donor liver transplantation (DDLT) is largely unknown. Using the Scientific Registry of Transplant Recipients, we identified 25 566 HCV-positive DDLT recipients from 2005 to 2015 and compared practices according to the introduction of DAA therapies using modified Poisson regression. The proportion of HCV-positive recipients who received HCV-positive livers increased from 6.9% in 2010 to 16.9% in 2015. HCV-positive recipients were 61% more likely to receive an HCV-positive liver after 2010 (early DAA/IFN era) (aRR:1.45 1.611.79 , p < 0.001) and almost three times more likely to receive one after 2013 (IFN-free DAA era) (aRR:2.58 2.853.16 , p < 0.001). Compared to HCV-negative livers, HCV-positive livers were 3 times more likely to be discarded from 2005 to 2010 (aRR:2.69 2.993.34 , p < 0.001), 2.2 times more likely after 2010 (aRR:1.80 2.162.58 , p < 0.001) and 1.7 times more likely after 2013 (aRR:1.37 1.682.04 , p < 0.001). Donor HCV status was not associated with increased risk of all-cause graft loss (p = 0.1), and this did not change over time (p = 0.8). Use of HCV-positive livers has increased dramatically, coinciding with the advent of DAAs. However, the discard rate remains nearly double that of HCV-negative livers. Further optimization of HCV-positive liver utilization is necessary to improve access for all candidates.
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Affiliation(s)
- Mary G Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lauren M Kucirka
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore MD
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore MD
| | - Xun Luo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mark Sulkowski
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Katie Rakestraw
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ahmet Gurakar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Irene Kuo
- Department of Epidemiology and Biostatistics, George Washington University School of Public Health, Washington, DC
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore MD,Scientific Registry of Transplant Recipients, Minneapolis, MN
| | - Christine M Durand
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Garcia JHP, Araújo Filho AHD, Braga LLBC, Viana CFG, Rocha TDS, Pereira KB. PEGYLATED INTERFERON AND RIBAVIRIN FOR TREATMENT OF RECURRENT HEPATITIS C AFTER LIVER TRANSPLANTATION: a single-liver transplant center experience in Brazil. ARQUIVOS DE GASTROENTEROLOGIA 2016; 52:216-21. [PMID: 26486290 DOI: 10.1590/s0004-28032015000300012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 04/27/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Treatment of hepatitis C virus infection in post-transplantation patients is a challenge due to poor tolerance and low success rates. OBJECTIVE To determine the response rate to pegylated interferon and ribavirin in post-liver transplant patients with hepatitis C recurrence. METHODS Between 18 May 2002 and 18 December 2011, 601 patients underwent liver transplantation at our service (Hospital Universitário Walter Cantídio, University of Ceará), 176 (29.2%) of whom were hepatitis C virus positive. Forty received antiviral therapy and were included in this cohort study. Twenty-eight (70%) completed the treatment protocol, which consisted of pegylated interferon and ribavirin for 48 weeks. RESULTS The sustained virological response rate was 55% according to intention-to-treat analysis. Recipient age and exposure to antiviral drugs prior to liver transplantation were associated with sustained virological response in the multivariate analysis. Patients were followed for 57 months on the average. Survival at 1 and 5 years was 100% in responders, versus 100% and 78%, respectively, in non-responders. CONCLUSION Sustained virological response rates were satisfactory in our series of liver transplantation patients, and decreased with increasing recipient age. Non-exposure to antiviral drugs prior to liver transplantation was positively associated with sustained virological response. The overall survival of responders and non-responders was similar.
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Optimizing outcome of recurrent hepatitis C virus genotype 4 after living donor liver transplantation: moving forward by looking back. Transplant Proc 2015; 46:822-7. [PMID: 24767357 DOI: 10.1016/j.transproceed.2013.11.152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 11/08/2013] [Accepted: 11/27/2013] [Indexed: 12/16/2022]
Abstract
PURPOSE Recurrence of HCV after LDLT is almost universal. Different factors affect response to treatment. Few data are available regarding outcome of recurrent HCV genotype 4. The purpose of this study is to improve outcome of recurrent HCV genotype 4 after LDLT. METHODS An IRB approved chart review of 243 patients transplanted for ESLD, HCV genotype 4 over 4 years were reviewed. Protocol liver biopsies were taken 6 months after transplant. Patients received pegylated interferon and ribavirin in case of histological recurrence. Five patients had FCH were excluded. RESULTS Thirty-seven patients were included. Sustained Virological Response (SVR) was achieved in 29 (78.3%). Patients with Metavir fibrosis stage (F0) and (F1) had SVR in 5/5 (100%) and 20/24 (83.3%). Two patients with F1 had to stop treatment because of thrombocytopenia and 2 were non responders. Three out of 6 patients (50%) with (F2) had SVR, 2 were non responders and one had to discontinue treatment because of severe depression. One of 2 patients (50%) with F3 had SVR and the other patient decompensated within 4 months before treatment and died. CONCLUSION Protocol biopsies allow early detection of inflammatory changes in the graft before fibrosis occurs. Early treatment of recurrent HCV genotype 4 after LDLT results in better response.
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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.
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Affiliation(s)
- M Shah
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Cambridge, Cambridge University Hospitals, Cambridge, UK
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Hulskotte E, Gupta S, Xuan F, van Zutven M, O'Mara E, Feng HP, Wagner J, Butterton J. Pharmacokinetic interaction between the hepatitis C virus protease inhibitor boceprevir and cyclosporine and tacrolimus in healthy volunteers. Hepatology 2012; 56:1622-30. [PMID: 22576324 DOI: 10.1002/hep.25831] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 05/04/2012] [Indexed: 02/06/2023]
Abstract
UNLABELLED The hepatitis C virus protease inhibitor boceprevir is a strong inhibitor of cytochrome P450 3A4 and 3A5 (CYP3A4/5). Cyclosporine and tacrolimus are calcineurin inhibitor immunosuppressants used to prevent organ rejection after liver transplantation; both are substrates of CYP3A4. This two-part pharmacokinetic interaction study evaluated boceprevir with cyclosporine (part 1) and tacrolimus (part 2). In part 1, 10 subjects received single-dose cyclosporine (100 mg) on day 1, single-dose boceprevir (800 mg) on day 3, and concomitant cyclosporine/boceprevir on day 4. After washout, subjects received boceprevir (800 mg three times a day) for 7 days plus single-dose cyclosporine (100 mg) on day 6. In part 2A, 12 subjects received single-dose tacrolimus (0.5 mg). After washout, they received boceprevir (800 mg three times a day) for 11 days plus single-dose tacrolimus (0.5 mg) on day 6. In part 2B, 10 subjects received single-dose boceprevir (800 mg) and 24 hours later received boceprevir (800 mg) plus tacrolimus (0.5 mg). Coadministration of boceprevir with cyclosporine/tacrolimus was well tolerated. Concomitant boceprevir increased the area under the concentration-time curve from time 0 to infinity after single dosing (AUC(inf) ) and maximum observed plasma (or blood) concentration (C(max) ) of cyclosporine with geometric mean ratios (GMRs) (90% confidence interval [CI]) of 2.7 (2.4-3.1) and 2.0 (1.7-2.4), respectively. Concomitant boceprevir increased the AUC(inf) and C(max) of tacrolimus with GMRs (90% CI) of 17 (14-21) and 9.9 (8.0-12), respectively. Neither cyclosporine nor tacrolimus coadministration had a meaningful effect on boceprevir pharmacokinetics. CONCLUSION Dose adjustments of cyclosporine should be anticipated when administered with boceprevir, guided by close monitoring of cyclosporine blood concentrations and frequent assessments of renal function and cyclosporine-related side effects. Administration of boceprevir plus tacrolimus requires significant dose reduction and prolongation of the dosing interval for tacrolimus, with close monitoring of tacrolimus blood concentrations and frequent assessments of renal function and tacrolimus-related side effects.
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Berenguer M, Ortíz-Cantó C, Abellán JJ, Aguilera V, Rubín A, Prieto M, López-Labrador FX. Hepatitis C virus viral kinetics during α-2a or α-2b pegylated interferon plus ribavirin therapy in liver transplant recipients with different immunosuppression regimes. J Clin Virol 2012; 53:231-8. [PMID: 22222052 DOI: 10.1016/j.jcv.2011.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 11/09/2011] [Accepted: 12/08/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Predictors of sustained virological response (SVR) to antiviral therapy post-liver transplantation (LT) for chronic hepatitis C are needed. In non-transplanted patients, viral kinetics can predict SVR. OBJECTIVES To determine the early viral kinetics in LT recipients with different immunosuppression (tacrolimus - Tac- vs. cyclosporine - CsA-) during treatment with peg-IFN+RBV. STUDY DESIGN Prospective pilot study in HCV-1b infected patients: (LT CsA n=8; Tac n=8; non-LT n=4), treated with IFN α-2a vs. α-2b (180 μg or 1.5 μg/kg, respectively) once weekly plus weight-based RBV. Median CsA or Tac baseline trough levels were 141 and 7.70 ng/mL, respectively. HCV-RNA was quantified before treatment and after 3, 6, 12h; days 1-6; and weeks 4, 12, 24, 48 and 78 (follow-up). RESULTS Different kinetics were observed: early viral load declines with shoulder phase (n=12), delayed monophasic without first phase (n=5, all CsA), and biphasic (n=1) or flat (n=1), without influence of IL28B rs12979860 donor/recipient alleles. In LT, median declines (log(10)UI/mL) at week 4 were -3.62 and -1.49 for Tac vs. CsA; and -2.10 vs.-1.50 for IFN α-2a vs. α-2b (NS), with a trend for faster declines in Tac patients. Generalized additive models suggested a cut-off for predicting response in LT patients of 30 days for Tac, but beyond day 40 for CsA. CONCLUSION In LT, the viral kinetics during peg-IFN+RBV treatment is delayed. HCV-RNA at 48 h. may not be predictive of response, and CsA-immunosupressed patients with delayed monophasic declines may potentially achieve ETVR and SVR despite unfavourable or absent early viral load declines.
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Affiliation(s)
- Marina Berenguer
- Hepatology-Liver Transplantation Unit, Digestive Medicine Service, Hospital Universitari La Fe, Spain
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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.
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Marino M, Iemmolo RM, Montalti R, Bertolotti M, Di Benedetto F, De Ruvo N, Cautero N, Guerrini G, De Blasiis MG, Gerunda GE. Predictive factors of lack of response to antiviral therapy among in patients with recurrent hepatitis C after liver transplantation. Transplant Proc 2010; 42:1223-5. [PMID: 20534266 DOI: 10.1016/j.transproceed.2010.03.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The current therapy for hepatitis C recurrence after liver transplantation OLT is based on interferon (IFN) and ribavirin (RBV) in monotherapy or combination. The rate of sustained virological response (SVR) varies between 10% and 45%. We have retrospectively analyzed factors that could predict SVR after antiviral therapy. We analyzed 42 patients who completed a cycle of therapy with natural or pegylated IFN plus RBV. There were 15 (35.7%) patients who obtained an SVR. The following factors were significantly associated with a lack of SVR: donor age >or=50 years (P = .046); donor body mass index (BMI) > 27 (P = .016); genotype 1 versus 2 to 3 (P = 0.010), aspartate transferase (AST) before therapy >or= 140 U/L (P = .046), alanine transferase before therapy >or= 280 U/L (P = .055), use of natural IFN versus pegylated IFN (P = .016). The only factors remaining after multivariate analysis were: donor BMI, AST before therapy and genotype. Our data confirmed that genotype 1 was associated with poorer outcomes; other additional parameters can influence the response to antiviral therapy.
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Affiliation(s)
- M Marino
- Chirurgia Trapianti di Fegato e Multiviscerale, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
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Berenguer M, Aguilera V, Prieto M, Ortiz C, Rodríguez M, Gentili F, Risalde B, Rubin A, Cañada R, Palau A, Rayón JM. Worse recent efficacy of antiviral therapy in liver transplant recipients with recurrent hepatitis C: impact of donor age and baseline cirrhosis. Liver Transpl 2009; 15:738-46. [PMID: 19562707 DOI: 10.1002/lt.21707] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We hypothesized that antiviral efficacy [sustained virologic response (SVR)] has improved in recent years in the transplant setting. Our aim was to assess whether the efficacy of pegylated interferon (PegIFN)-ribavirin (Rbv) has improved over time. One hundred seven liver transplant patients [74% men, 55.5 years old (range: 37.5-69.5), 86% genotype 1a or 1b] were treated with PegIFN-Rbv for 355 (16-623) days at 20.1 (1.7-132.6) months after transplantation. Tacrolimus was used in 61%. Sixty-seven percent had baseline F3-F4 (cirrhosis: 20.5%). Donor age was 49 (12-78) years. SVR was achieved in 39 (36.5%) patients, with worse results achieved in recent years (2001-2003: n = 27, 46.5%; 2004: n = 23, 43.5%; 2005: n = 21, 35%; 2006 to January 2007: n = 36, 24%; P = 0.043). Variables associated with SVR in the univariate analysis included donor age, baseline viremia and cirrhosis, bilirubin levels, rapid virologic response and early virologic response (EVR), premature discontinuation of PegIFN or Rbv, and accumulated Rbv dose. In the multivariate analysis, the variables in the model were EVR [odds ratio (OR): 0.08, 95% confidence interval (CI): 0.016-0.414, P = 0.002] and donor age (OR: 1.039, 95% CI: 1.008-1.071, P = 0.01). Variables that had changed over time included donor age, baseline viremia, disease severity (cirrhosis, baseline bilirubin, and leukocyte and platelet counts), interval between transplantation and therapy, and use of growth factors. In the multivariate analysis, variables independently changing were donor age (OR: 1.041, 95% CI: 1.013-1.071, P = 0.004), duration from transplantation to antiviral therapy (OR: 1.001, 95% CI: 1.000-1.001, P = 0.013), and baseline leukocyte count (OR: 1.000, 95% CI: 1.000-1.000, P = 0.034). In conclusion, the efficacy of antiviral therapy with PegIFN-Rbv has worsened over time, at least in our center. The increase in donor age and greater proportion of patients treated at advanced stages of disease are potential causes.
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Affiliation(s)
- Marina Berenguer
- Hepatogastroenterology Service, Hospital Universitari La Fe, Valencia, Spain.
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A Novel Immunosuppressive Strategy Combined with Preemptive Antiviral Therapy Improves the Eighteen-Month Mortality in HCV Recipients Transplanted with Aged Livers. Transplantation 2008; 86:1666-71. [DOI: 10.1097/tp.0b013e31818fe505] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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20
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Berenguer M. Systematic review of the treatment of established recurrent hepatitis C with pegylated interferon in combination with ribavirin. J Hepatol 2008; 49:274-87. [PMID: 18571272 DOI: 10.1016/j.jhep.2008.05.002] [Citation(s) in RCA: 295] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The aim of our study was to conduct a systematic review of studies evaluating antiviral therapy with pegylated interferon (PEG-IFN) alfa in combination with ribavirin for the management of recurrent hepatitis C after liver transplantation. Data sources included electronic databases and a manual search. Studies evaluating the efficacy and tolerability of PEG-IFN alfa with ribavirin in patients with recurrent hepatitis C were selected for inclusion. The information extracted from each of the selected publications included study design details, patient characteristics, treatment regimens and efficacy and tolerability end points. Nineteen studies including 611 patients were identified. PEG-IFN alfa-2b was used in 16 studies. The mean rate of SVR was 30.2% (range, 8-50%). Dose reduction and discontinuation of treatment were common in these studies (73% and 27.6%, respectively). The lack of an early virologic response (EVR) at 3 months of therapy was the most frequently described predictive factor of nonresponse. Treatment discontinuation and dose reductions due to adverse events were frequent and possibly represent important obstacles to attainment of SVR. EVR at 3 months of treatment should be considered an important predictor of treatment outcome.
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Affiliation(s)
- Marina Berenguer
- Hepatogastroenterology Service, Hospital La Fe, Valencia, Spain and CIBEREHD, Spain.
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Berenguer M, Palau A, Aguilera V, Rayón JM, Juan FS, Prieto M. Clinical benefits of antiviral therapy in patients with recurrent hepatitis C following liver transplantation. Am J Transplant 2008; 8:679-87. [PMID: 18294165 DOI: 10.1111/j.1600-6143.2007.02126.x] [Citation(s) in RCA: 237] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Pegylated interferon (pegIFN) and ribavirin eradicates hepatitis C virus (HCV) in one third of liver recipients with recurrent disease. Side effects are frequent and potentially life threatening. Our aim was to define the long-term benefits of antiviral therapy in recurrent HCV. Eighty-nine (89) recipients (genotype 1: 86.5%) were treated with IFN (n = 31) or pegIFN (n = 58) plus ribavirin and 75 untreated contemporaneous disease-matched controls. The major end point was survival from transplantation. Survival, progression to cirrhosis and clinical decompensation since start of therapy were compared between sustained virologic responders (SVRs) and nonresponders (NRs). Results revealed 44 patients died during the follow-up (20% treated vs. 35% controls; p = 0.05). Patient survival was higher in treated compared to controls (7 years: 74% vs. 62%; p = 0.04). Among treated patients, an SVR was achieved in 37% (IFN 16% vs. peg-IFN 48%; p = 0.03). About 2/33 SVRs and 16/56 NRs died (p = 0.01) due to HCV-disease (56%), IFN-induced rejection (11%), both causes (11%) or others (22%). Five-year survival was greater in SVRs than in NRs (93% vs. 69%, p = 0.032). In patients without baseline cirrhosis, progression to cirrhosis occurred more frequently in NRs (27/42 vs. 6/16; p = 0.06). The 5-year risk of graft decompensation was higher in NRs (33% vs. 16%; p = 0.04). Antiviral therapy is associated with improved long-term outcome in recurrent HCV.
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Affiliation(s)
- M Berenguer
- Hepatogastroenterology Service, Hospital la Fe, Valencia, Spain.
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Abstract
Recurrence of the original liver disease following liver transplantation is a typical complication in viral hepatitis. Recent advances, particularly the development of strategies to prevent or effectively treat hepatitis B, have led to substantial improvements in the post-transplantation outcome of hepatitis B candidates. While the efficacy of antivirals to treatrecurrent hepatitis C has improved in recent years, there is as yet no therapy to universally prevent recurrent infection, and tolerability of antivirals remains a matter of concern.
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Affiliation(s)
- Marina Berenguer
- Ciberehd and Department of Medicine, Medical University in Valencia, Spain
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Abstract
Hepatitis C virus (HCV) is a leading cause of chronic hepatitis, with 170 to 190 million people infected worldwide. The treatment of choice for patients who have HCV-related cirrhosis with or without hepatocellular carcinoma is liver transplantation. Virologic recurrence is constant after transplantation and results in chronic hepatitis in the vast majority. HCV infection now can be cured in a substantial proportion of liver transplant recipients. This review highlights the available strategies to improve outcome, including modification of factors that affect disease progression and the efficacy of antiviral therapy.
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Affiliation(s)
- Marina Berenguer
- Universidad de Medicina, Hospital Universitario La Fe, Servicio de Medicina Digestiva, Ciberehd, Avda Campanar 21, Valencia, 46009 Spain.
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Hepatitis C virus in liver transplantation: impact and treatment of hepatitis C virus recurrence. Curr Opin Organ Transplant 2006. [DOI: 10.1097/mot.0b013e3280106c3d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Berenguer M. [Management of hepatitis C virus infection in liver transplantation]. GASTROENTEROLOGIA Y HEPATOLOGIA 2006; 29:422-7. [PMID: 16938259 DOI: 10.1157/13091455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Because of graft reinfection and recurrence of the primary disease in the graft, patients who undergo transplantation due to cirrhosis caused by chronic hepatitis C virus (HCV) infection have a poorer long-term prognosis than non-HCV-infected transplant recipients. Apart from antiviral therapy, which can occasionally eradicate HCV infection before transplantation, there are no effective measures to prevent graft reinfection. Pre-transplantation antiviral therapy, however, is of limited applicability with currently available drugs. After liver transplantation, 2 options can be used to prevent graft loss due to HCV progression: early treatment in the first 4-6 weeks when there is still no evidence of histological injury and treatment of established HCV infection. Early antiviral therapy is limited not only by its scarce applicability but also by poor tolerability and limited effectiveness (sustained virological response in approximately 20-30% of patients). Treatment of established HCV infection, especially in patients with evidence of disease progression in biopsy, is the most cost-effective alternative with an efficacy of around 35-45% when pegylated interferon combined with ribavirin is used. Adverse effects, such as cytopenia and even induction of rejection, are the main limitation and lead to premature withdrawal in 30% of patients.
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Affiliation(s)
- Marina Berenguer
- Servicio de Medicina Digestiva. Hospital Universitario La Fe. Valencia. España.
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Berenguer M, Palau A, Fernandez A, Benlloch S, Aguilera V, Prieto M, Rayón JM, Berenguer J. Efficacy, predictors of response, and potential risks associated with antiviral therapy in liver transplant recipients with recurrent hepatitis C. Liver Transpl 2006; 12:1067-76. [PMID: 16622844 DOI: 10.1002/lt.20737] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
There are unresolved issues regarding sustained virological response (SVR), tolerance and risk of rejection following antiviral therapy in liver transplantation (LT). The aim of our study was to determine efficacy, rejection risk and factors associated with SVR. HCV-infected LT patients with at least 6 months of follow-up following end-of-therapy (EOT) received combination therapy of ribavirin (Rbvr) + standard (n = 31)/pegIFN (n = 36) between 1999 and 2004 (95% genotype 1). An EOT and SVR was obtained in 46% and 33%, respectively. Type of antiviral therapy, use of erythropoietin, compliance, and early virologic response (EVR) were predictive of SVR, but only the latter remained in the multivariate analysis. Premature discontinuation, not impacted by the use of erythropoietin or GCSF, occurred in 40% patients. None of the variables predicted rejection (acute n = 2, chronic n = 4). A SVR occurred in 3/4 patients with chronic rejection. In conclusion, the efficacy of pegIFN-Rbvr is similar to the non-transplant population. An EVR at 3 months is useful to predict lack of response. The type of calcineurin inhibitor and history of prior non-response to IFN before LT do not influence the outcome of therapy. Severe rejection may lead to graft loss, a complication difficult to predict.
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Affiliation(s)
- Marina Berenguer
- HepatoGastroenterology Service, Hospital Universitari La Fe, Valencia, Spain.
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Mukherjee S, Lyden E. Impact of pegylated interferon alpha-2B and ribavirin on hepatic fibrosis in liver transplant patients with recurrent hepatitis C: an open-label series. Liver Int 2006; 26:529-35. [PMID: 16761996 DOI: 10.1111/j.1478-3231.2006.01261.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Patients with recurrent hepatitis C virus (HCV) are often treated with interferon-based therapy in an attempt to eradicate HCV and prevent cirrhosis requiring retransplantation. We describe our experience with pegylated interferon and ribavirin and the impact of this therapy on hepatic fibrosis. METHODS Patients were treated with pegylated interferon alpha-2b 1.5 mcg/kg/week and ribavirin 800 mg/day for 6-12 months according to genotype. HCV ribonucleic acid (HCV RNA) was repeated at 3 months, end of treatment (EOT) and 6 months after EOT for patients HCV RNA negative at EOT. Liver biopsies were performed prior to treatment and at EOT. RESULTS Thirty nine patients were eligible. Twenty two completed treatment and 17 (43.6%) were intolerant. Eleven of 22 (50%) patients who completed treatment developed sustained viral response (SVR). Two patients intolerant to treatment also developed SVR. Serial biopsies were performed in 17 patients and refused in five. Improved fibrosis scores were present in four patients (non-responders, n = 2), unchanged in 10 (non-responders, n = 4), and worse in three (all non-responders). CONCLUSIONS Side effects are an important limiting factor in recurrent HCV treatment with SVR only 33.3% in an intention-to-treat analysis. However, improved or stable fibrosis scores were also demonstrated in 66.7% of non-responders. This suggests failure to eradicate HCV should not necessarily lead to treatment discontinuation as a subgroup of patients may benefit from maintenance therapy.
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Affiliation(s)
- Sandeep Mukherjee
- Medicine/Section of Gastroenterology, University of Nebraska Medical Center, Omaha, NE 68198-3285, USA.
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