1
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Martinello M, Solomon SS, Terrault NA, Dore GJ. Hepatitis C. Lancet 2023; 402:1085-1096. [PMID: 37741678 DOI: 10.1016/s0140-6736(23)01320-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 05/30/2023] [Accepted: 06/22/2023] [Indexed: 09/25/2023]
Abstract
Hepatitis C virus (HCV) is a hepatotropic RNA virus that can cause acute and chronic hepatitis, with progressive liver damage resulting in cirrhosis, decompensated liver disease, and hepatocellular carcinoma. In 2016, WHO called for the elimination of HCV infection as a public health threat by 2030. Despite some progress, an estimated 57 million people were living with HCV infection in 2020, and 300 000 HCV-related deaths occur per year. The development of direct-acting antiviral therapy has revolutionised clinical care and generated impetus for elimination, but simplified and broadened HCV screening, enhanced linkage to care, and higher coverage of treatment and primary prevention strategies are urgently required.
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Affiliation(s)
- Marianne Martinello
- Viral Hepatitis Clinical Research Program, Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, Prince of Wales Hospital, Sydney, NSW, Australia.
| | - Sunil S Solomon
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Norah A Terrault
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, CA, USA
| | - Gregory J Dore
- Viral Hepatitis Clinical Research Program, Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Department of Infectious Diseases, St Vincent's Hospital, Sydney, NSW, Australia
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2
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Kim D, Cholankeril G, Dennis BB, Alshuwaykh O, Kumari R, Wong RJ, Ahmed A. Trends in the Prevalence of Hepatitis C Virus Infection based on the Insurance Status in the United States from 2013 to 2018. Liver Int 2022; 42:340-349. [PMID: 34817925 DOI: 10.1111/liv.15113] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/19/2021] [Accepted: 11/18/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS With the recent improvement in the treatment of hepatitis C virus (HCV) infection, a better understanding of the infection burden is needed. We aimed to (a) estimate the trends in the national prevalence of HCV infection based on the type of health insurance coverage and (b) identify at-risk populations for HCV infection in the United States (US) general population. METHODS Population-based analyses using the National Health and Nutrition Examination Survey (2013-2018) were performed with a focus on HCV infection. We analysed the prevalence of HCV infection based on the health insurance status before the direct-acting antiviral (DAA) era (2013-2014) and during the DAA era (2015-2018). RESULTS The age-adjusted prevalence of active HCV infection (HCV RNA [+]) was 0.92% (95% confidence interval, 0.71%-1.19%) in the US non-institutionalized civilian population. Although the prevalence of active HCV infection has remained stable, the prevalence of resolved HCV infection has increased after the introduction of DAA. In terms of health insurance coverage, the prevalence of active HCV infection decreased, and the prevalence of resolved HCV infection increased among individuals who had health insurance, especially private health insurance. The independent risk factors of active HCV infection were 40-69 years group, male, less than high school education, unmarried, below poverty status, being born in the US, history of blood transfusion and not having private health insurance. CONCLUSION The burden of active HCV infection has decreased among individuals who had health insurance, especially private health insurance, during the DAA era.
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Affiliation(s)
- Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - George Cholankeril
- Liver Center, Division of Abdominal Transplantation, Michael E DeBakey Department of General Surgery, Baylor College of Medicine, Houston, Texas, USA.,Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Brittany B Dennis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Omar Alshuwaykh
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Radhika Kumari
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA.,Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
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3
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Krassenburg LAP, Zanjir WR, Georgie F, Stotland E, Janssen HLA, Hansen BE, Feld JJ. Evaluation of Sustained Virologic Response as a Relevant Surrogate Endpoint for Long-term Outcomes of Hepatitis C Virus Infection. Clin Infect Dis 2021; 72:780-786. [PMID: 32052014 PMCID: PMC7935378 DOI: 10.1093/cid/ciaa144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 02/11/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The causal link of sustained virologic response (SVR) with outcome has been challenged. With improved SVR rates with direct-acting antivirals (DAAs), the benefit of SVR would be expected to diminish if the association with outcome is not causal. METHODS Data were collected for patients starting treatment with interferon (IFN) or DAAs between June 2006 and December 2016. To control for disease severity, criteria for the IDEAL (Individualized Dosing Efficacy vs. Flat Dosing to Assess Optimal Pegylated Interferon Therapy) trial determined IFN-eligibility. Clinical events were decompensation, hepatocellular carcinoma, liver transplantation, and all-cause mortality. RESULTS In 1078 IDEAL-eligible patients, 1306 treatments occurred (52% IFN, 49% DAAs). Cirrhosis was present in 30% DAAs vs 21% IFN (P < .001). SVR was 97% with DAAs vs 52% with IFN (P < .0001). The 24-month cumulative event-free survival was 99% for IFN and 97% for DAAs with SVR (P = .08) and 96% and 75%, respectively, for non-SVR (P = .01). SVR was associated with improved event-free survival with an adjusted hazard ratio of 0.21 (95% confidence interval, .06-.71; P = .01). Using inverse probability of treatment weighting to match IFN nonresponders with DAA-treated patients, the 24-month event-rate was 1.1% with DAAs compared to 3.4% in IFN nonresponders (P = .005), highlighting the clinical benefit of maximizing SVR. CONCLUSIONS In IFN-eligible patients, SVR is more commonly achieved with DAAs and confers a similar clinical benefit as in those treated with IFN. The reduced event-rate with DAAs compared to IFN, despite similar disease severity, confirm that SVR alters prognosis leading to improved clinical outcomes.
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Affiliation(s)
- Lisette A P Krassenburg
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Wayel R Zanjir
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Firas Georgie
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Emily Stotland
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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4
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Shoreibah M, Romano J, Sims OT, Guo Y, Jones D, Venkata K, Kommineni V, Orr J, Fitzmorris P, Massoud OI. Effect of Hepatitis C Treatment on Renal Function in Liver Transplant Patients. J Clin Transl Hepatol 2018; 6:391-395. [PMID: 30637216 PMCID: PMC6328736 DOI: 10.14218/jcth.2018.00026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/17/2018] [Accepted: 06/23/2018] [Indexed: 12/13/2022] Open
Abstract
Background and Aims: Hepatitis C Virus (HCV) is uniformly recurrent after liver transplant (LT) and recurrence is associated with an increased risk of mortality. Immunosuppressive medications increase the risk of chronic kidney disease, and the presence of chronic kidney disease presents a challenge for HCV treatment in LT recipients. The aim of this study was to assess changes in glomerular filtration rates (GFRs) of LT recipients receiving HCV treatment. Methods: This is a retrospective study of LT patients who received HCV treatment between 2015 and 2016 (n = 60). The outcomes of interest were differences in serum creatinine levels and in GFR, measured at treatment initiation and at 24 weeks after treatment. The average age of the patients was 59 years-old, and 17% were cirrhotic and 67% were treatment-experienced. All patients received sofosbuvir/ledipasvir without ribavirin. Results: All patients achieved sustained virologic response at 12 weeks after treatment (SVR12). At baseline, 55% of patients had GFR <60 mL/min per 1.73 m2. Among those patients, GFR did not change in 18%, 33% had improved GFR, and 48% had worsened GFR. Up to 45% of the patients had a GFR >60 mL/min per 1.73 m2. Among those patients, GFR did not change in 81%, and 19% had worsened GFR. In the entire cohort, 65% of patients had improved or stable GFR and 35% had worsened GFR. The average change in serum creatinine between baseline and 24 weeks was 0.10 (p = 0.18). Conclusions: This study showed improved or unchanged GFR in 65% and worsened GFR in 35% of LT recipients who achieved SVR12. Worsening of GFR was more frequently encountered in those with impaired renal function at baseline. Caution should be used when treating HCV in LT recipients, especially those with baseline status of renal impairment.
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Affiliation(s)
- Mohamed Shoreibah
- Division of Gastroenterology & Hepatology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John Romano
- Department of Internal Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- *Correspondence to: John Romano, Department of Internal Medicine, School of Medicine, University of Alabama at Birmingham, BDB 327, 1808 7 Ave South, Birmingham, AL 35233, USA. Tel: +1-3156574626, E-mail:
| | - Omar T. Sims
- Department of Social Work, College of Arts and Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Center for AIDS Research, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Yuqi Guo
- School of Social Work, University of Alabama, Tuscaloosa, AL, USA
| | - DeAnn Jones
- Department of Pharmacology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Krishna Venkata
- Department of Internal Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vishnu Kommineni
- Department of Internal Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jordan Orr
- Division of Gastroenterology and Hepatology, Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Paul Fitzmorris
- Division of Gastroenterology & Hepatology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Omar I. Massoud
- Division of Gastroenterology & Hepatology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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5
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Taneja S, Duseja A, De A, Kumar V, Ramachandran R, Sharma A, Dhiman RK, Gupta KL, Chawla Y. Successful treatment of chronic hepatitis C infection with directly acting antivirals in renal transplant recipients. Nephrology (Carlton) 2018; 23:876-882. [PMID: 28703905 DOI: 10.1111/nep.13109] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2017] [Indexed: 12/15/2022]
Abstract
AIMS The data regarding the treatment of chronic hepatitis C (CHC) in renal transplant recipients is lacking from the Asia-Pacific region. The aim of the present study was to assess the safety and efficacy of directly acting antivirals (DAAs) in the treatment of CHC infection in renal transplant recipients. METHODS A total of 47 CHC infected renal transplant recipients were enrolled in this real life observational cohort analysis between March 2015 and September 2016. Presence of hepatic fibrosis/cirrhosis was assessed on transient elastography (Fibroscan). Fourteen patients were treated with Sofosbuvir and Ribavirin for 24 weeks. Twenty-two patients received Sofosbuvir and Ledipasvir and 12 patients received Sofosbuvir and Daclatasvir with (n = 3) or without (n = 31) Ribavirin for 12 or 24 weeks depending on genotype and underlying cirrhosis. Data were analyzed for safety and treatment efficacy [sustained virological response at 12 weeks (SVR12)]. RESULTS The median baseline HCV RNA concentration in the whole group was 7.38 × 106 IU/mL (1.23 × 104 -6.36 × 107 ). The SVR12 rates were 100% in all groups except in the Sofosbuvir and Ribavirin group (86%). Transient Elastography revealed minimal or no fibrosis (F0-F1) in 31 (65.96%) patients, moderate fibrosis (F2) in 11 (23.4%) patients and cirrhosis in five (10.64%) patients. The only serious adverse effect was anaemia observed in eight (57%) patients in the Sofosbuvir and Ribavirin group. CONCLUSION DAAs including Sofosbuvir, Daclatasvir and Ledipasvir with or without ribavirin are safe and effective for the treatment of chronic hepatitis C in renal transplant recipients.
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Affiliation(s)
- Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arka De
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivek Kumar
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Ramachandran
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Sharma
- Department of Transplant Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Radha K Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Krishan L Gupta
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Yogesh Chawla
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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6
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Garcia-Pajares F, Tejedor-Tejada J, Torres-Yuste R, Almohalla-Alvárez C, Sánchez-Ocaña R, Peñas-Herrero I, Cimavilla-Román M, de Benito-Sanz M, Sánchez-Martín F, Sánchez-Antolín G. Efficacy of Direct-acting Antivirals to Improve Clinical Condition, Fibrosis, and Liver Function in Liver Transplant Recipients Infected by Hepatitis C. Transplant Proc 2018; 51:74-76. [PMID: 30655151 DOI: 10.1016/j.transproceed.2018.04.088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 04/12/2018] [Accepted: 04/27/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Direct-acting antivirals (DAAs) have revolutionized the treatment of hepatitis C, including transplant recipients with an advanced fibrosis stage. Our aim in this study was to assess the clinical and functional benefits and improvement in liver fibrosis after treatment with DAAs in liver transplant recipients with chronic hepatitis C virus who achieved sustained virologic response (SVR). METHODS We retrospectively analyzed 42 patients who underwent liver transplantation (LT) at our institution and were treated with DAAs from June 2014 to December 2015. Two patients died, so we ultimately included 40 transplant patients with chronic hepatitis C who received DAAs and achieved SVR. We assessed liver function, fibrosis stage, and clinical features at the start of the treatment, and then at 6 and 12 months after SVR. The indication for LT was hepatocellular carcinoma in 8 patients (20%) and Child-Pugh score B/C in 32 patients (80%). RESULTS The DAAs regimens were sofosbuvir plus daclatasvir (45.0%), simeprevir plus sofosbuvir (42.5%), sofosbuvir plus ledipasvir (7.5%), and ombitasvir/paritaprevir/ritonavir (5%). The mean Modified End-stage Liver Disease (MELD) score pretreatment was 10.78, and was 8.46 at 1 year after treatment (P < .05). In addition, fibrosis stage decreased significantly from 14.81 kPa to 9.07 kPa (FibroScan) at 12 months after SVR. Clinically, there was a significant improvement, including control of ascites and chronic hepatic encephalopathy. CONCLUSION DAAs were used successfully in the treatment of hepatitis C after orthotopic liver transplantation and resulted in significant improvement in liver function as measured by MELD score, fibrosis level, and cirrhotic clinical condition, even in patients with very advanced disease.
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Affiliation(s)
- F Garcia-Pajares
- Gastroenterology Service, Liver Transplantation Unit, Hospital Universitario Río Hortega, Valladolid, Spain.
| | - J Tejedor-Tejada
- Gastroenterology Service, Liver Transplantation Unit, Hospital Universitario Río Hortega, Valladolid, Spain
| | - R Torres-Yuste
- Gastroenterology Service, Liver Transplantation Unit, Hospital Universitario Río Hortega, Valladolid, Spain
| | - C Almohalla-Alvárez
- Gastroenterology Service, Liver Transplantation Unit, Hospital Universitario Río Hortega, Valladolid, Spain
| | - R Sánchez-Ocaña
- Gastroenterology Service, Liver Transplantation Unit, Hospital Universitario Río Hortega, Valladolid, Spain
| | - I Peñas-Herrero
- Gastroenterology Service, Liver Transplantation Unit, Hospital Universitario Río Hortega, Valladolid, Spain
| | - M Cimavilla-Román
- Gastroenterology Service, Liver Transplantation Unit, Hospital Universitario Río Hortega, Valladolid, Spain
| | - M de Benito-Sanz
- Gastroenterology Service, Liver Transplantation Unit, Hospital Universitario Río Hortega, Valladolid, Spain
| | - F Sánchez-Martín
- Gastroenterology Service, Liver Transplantation Unit, Hospital Universitario Río Hortega, Valladolid, Spain
| | - G Sánchez-Antolín
- Gastroenterology Service, Liver Transplantation Unit, Hospital Universitario Río Hortega, Valladolid, Spain
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7
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Kwong A, Kim WR, Mannalithara A, Heo NY, Udompap P, Kim D. Decreasing mortality and disease severity in hepatitis C patients awaiting liver transplantation in the United States. Liver Transpl 2018; 24:735-743. [PMID: 29125676 PMCID: PMC5945341 DOI: 10.1002/lt.24973] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/16/2017] [Accepted: 10/13/2017] [Indexed: 12/13/2022]
Abstract
Hepatitis C virus (HCV) infection has been the leading indication for liver transplantation (LT) in the United States. Since 2013, interferon-free antiviral therapy has led to sustained virological response in many LT candidates. We compared the wait-list mortality of HCV patients with that of patients with other chronic liver diseases. Data for primary LT candidates were obtained from the Organ Procurement and Transplantation Network database. Adult wait-list registrants were divided into 3 cohorts: cohort 1 included patients on the waiting list as of January 1, 2004; cohort 2 as of January 1, 2009; and cohort 3 as of January 1, 2014. The primary outcome was wait-list mortality, and the secondary outcome was the rate of change in Model for End-Stage Liver Disease (MELD). Multivariate Cox proportional hazards analysis was performed to evaluate 12-month wait-list mortality. The cohorts included 7627 LT candidates with HCV and 13,748 patients without HCV. Compared with cohort 2, HCV patients in cohort 3 had a 21% lower risk of death (hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.67-0.93). Among patients with non-HCV liver disease, no difference in mortality was seen between cohorts 2 and 3 (HR, 0.97; 95% CI, 0.86-1.09). Among HCV patients, the mean rate of change in MELD decreased from 2.35 per year for cohort 2 to 1.90 per year for cohort 3, compared with 1.90 and 1.66 in cohorts 2 and 3, respectively, among non-HCV patients. In this population-based study, wait-list mortality and progression of disease severity decreased in recent HCV patients for whom direct-acting antiviral agents were available. Liver Transplantation 24 735-743 2018 AASLD.
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Affiliation(s)
- Allison Kwong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, United States
| | - W. Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Ajitha Mannalithara
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Nae-Yun Heo
- Department of Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Prowpanga Udompap
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, United States
| | - Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, United States
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8
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Shafii AE, Harris DD, Baz M. Clearance of Hepatitis C Virus Prior to Lung Transplantation: A Case Report. Transplant Proc 2018; 49:1682-1684. [PMID: 28838464 DOI: 10.1016/j.transproceed.2017.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 06/16/2017] [Indexed: 02/07/2023]
Abstract
Hepatitis C virus (HCV) continues to be considered a relative contraindication to lung transplantation due to concerns of progression of liver disease with the introduction of immunosuppression. Since the recent introduction of effective antiviral therapy for HCV, new approaches in the management of the HCV-positive recipient are being utilized in liver transplantation to clear HCV pre- and post-transplant. Herein, we report use of ledipasvir/sofosbuvir for HCV clearance prior to lung transplantation in a patient with usual interstitial pneumonia. Listing for transplant was delayed until completion of HCV treatment, and he subsequently required extracorporeal membrane oxygenation as a bridge to transplantation due to progressive hypoxia. With antiviral cure rates exceeding 90%, HCV should no longer be considered a relative contraindication to lung transplant, and timing of antiviral treatment should consider the progressive nature of the recipient's lung disease.
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Affiliation(s)
- A E Shafii
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky, Lexington, Kentucky, USA.
| | - D D Harris
- University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - M Baz
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky, Lexington, Kentucky, USA
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9
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Saberi B, Dadabhai AS, Durand CM, Philosophe B, Cameron AM, Sulkowski MS, Gurakar A. Challenges in treatment of hepatitis C among patients with hepatocellular carcinoma. Hepatology 2017; 66:661-663. [PMID: 28211073 DOI: 10.1002/hep.29126] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 02/05/2017] [Accepted: 02/13/2017] [Indexed: 12/21/2022]
Affiliation(s)
- Behnam Saberi
- The Johns Hopkins University School of Medicine, Division of Gastroenterology and Hepatology, Baltimore, MD
| | - Alia S Dadabhai
- The Johns Hopkins University School of Medicine, Division of Gastroenterology and Hepatology, Baltimore, MD
| | - Christine M Durand
- The Johns Hopkins University School of Medicine, Division of Infectious Disease, Baltimore, MD
| | - Benjamin Philosophe
- The Johns Hopkins University, Department of Transplant Surgery, Baltimore, MD
| | - Andrew M Cameron
- The Johns Hopkins University, Department of Transplant Surgery, Baltimore, MD
| | - Mark S Sulkowski
- The Johns Hopkins University School of Medicine, Division of Infectious Disease, Baltimore, MD
| | - Ahmet Gurakar
- The Johns Hopkins University School of Medicine, Division of Gastroenterology and Hepatology, Baltimore, MD
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10
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Bernuth S, Grimm D, Vollmar J, Darstein F, Mittler J, Heise M, Hoppe-Lotichius M, Galle PR, Lang H, Zimmermann T. Efficacy and safety of direct-acting antiviral therapy in previous hard-to-treat patients with recurrent hepatitis C virus infection after liver transplantation: a real-world cohort. Drug Des Devel Ther 2017; 11:2131-2138. [PMID: 28744104 PMCID: PMC5513830 DOI: 10.2147/dddt.s139837] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Recurrent hepatitis C virus (HCV) infection after liver transplantation (LT) has been a frequent and relevant problem in the past two decades. This analysis evaluated the efficacy and safety of new interferon (IFN)-free direct-acting antiviral (DAA) therapies in a large real-world cohort of HCV patients after LT. METHODS We retrospectively analyzed a cohort of 157 patients infected with HCV who underwent deceased donor LT between 1997 and 2014. Patient survival, outcome, and side effects of antiviral therapy were assessed. RESULTS Survival with recurrent HCV genotype 1 (GT1) infection was inferior to other HCV GTs (P=0.01). The overall sustained virological response (SVR) rate with new DAA therapy was 94.6% (n=37). Patients with both GT1 and other GTs reached SVR rates >90%. We noticed a few side effects, mainly caused by ribavirin, and only one discontinuation in DAA-treated patients. CONCLUSION DAA therapy was effective and safe in previous hard-to-treat patients after LT in this real-world cohort.
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Affiliation(s)
| | - Daniel Grimm
- First Department of Internal Medicine, Transplant Hepatology
| | - Johanna Vollmar
- First Department of Internal Medicine, Transplant Hepatology
| | - Felix Darstein
- First Department of Internal Medicine, Transplant Hepatology
| | - Jens Mittler
- General-, Abdominal- and Transplant-Surgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Michael Heise
- General-, Abdominal- and Transplant-Surgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Maria Hoppe-Lotichius
- General-, Abdominal- and Transplant-Surgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Peter R Galle
- First Department of Internal Medicine, Transplant Hepatology
| | - Hauke Lang
- General-, Abdominal- and Transplant-Surgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Tim Zimmermann
- First Department of Internal Medicine, Transplant Hepatology
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11
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Donato MF, Morelli C, Romagnoli R, Invernizzi F, Mazzarelli C, Iemmolo RM, Montalbano M, Lenci I, Bhoori S, Pieri G, Berardi S, Caraceni P, Martini S. Prevention of hepatitis C recurrence by bridging sofosbuvir/ribavirin from pre- to post-liver transplant: a real-life strategy. Liver Int 2017; 37:678-683. [PMID: 27865034 DOI: 10.1111/liv.13322] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 11/12/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS Hepatitis C virus (HCV) re-infection following liver transplant (LT) is associated with reduced graft and patient survival. Before transplant, Sofosbuvir/Ribavirin (SOF/R) treatment prevents recurrent HCV in 96% of those patients achieving viral suppression for at least 4 weeks before transplant. We evaluated whether a bridging SOF-regimen from pre- to post-transplant is safe and effective to prevent HCV recurrence in those patients with less than 4 weeks of HCV-RNA undetectability at the time of transplant. METHODS From July 2014 SOF/R was given in 233 waitlisted HCV cirrhotics with/without hepatocellular carcinoma (HCC) within an Italian Compassionate Program. One hundred patients were transplanted and 31 patients (31%) treated with SOF/R bridging therapy were studied. RESULTS Liver transplant indication in bridge subgroup was HCC in 22 and decompensated cirrhosis in 9. HCV-genotype was 1/4 in 18 patients. SOF 400 mg/day and R (median dosage 800 mg/day) were given for a median of 35 days before LT. At transplant time, 19 patients were still HCV-RNA positive (median HCV-RNA 58 IU/mL). One recipient had a virological breakthrough at week 4 post-transplant; one died, on treatment, 1-month post-transplant for sepsis and 29/31 achieved a 12-week sustained virological response (94%). Acute cellular rejection occurred in three recipients. On September 2016, 30 recipients (97%) were alive with a median follow-up of 18 months (range 13-25). CONCLUSIONS In patients with suboptimal virological response at LT, a bridging SOF/R regimen helps avoiding post-transplant graft reinfection.
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Affiliation(s)
- Maria Francesca Donato
- Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Cristina Morelli
- U.O. Medicina Interna e delle Insufficienze d'Organo-Azienda Ospedaliera-Universitaria, Policlinico S. Orsola-Malpighi di Bologna, Bologna, Italy
| | - Renato Romagnoli
- Liver Transplantation Center, General Surgery Unit 2U, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Federica Invernizzi
- Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Chiara Mazzarelli
- Hepatology Unit and Liver Transplantation Surgery, Niguarda Hospital, Milan, Italy
| | - Rosa Maria Iemmolo
- Liver and Multivisceral Transplant Center, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Marzia Montalbano
- Infectious Diseases and General Surgery, National Institute for Infectious Diseases Spallanzani, Rome, Italy
| | - Ilaria Lenci
- Gastroenterology Unit and Experimental Medicine and Surgery, University of Tor Vergata, Rome, Italy
| | - Sherrie Bhoori
- Surgery and Liver Transplantation Unit, IRCCS National Institute of Cancer, Milan, Italy
| | - Giulia Pieri
- Division of Hepatology, IRCCS AO San Martino IST, Genova, Italy
| | - Sonia Berardi
- U.O. Medicina Interna e delle Insufficienze d'Organo-Azienda Ospedaliera-Universitaria, Policlinico S. Orsola-Malpighi di Bologna, Bologna, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Silvia Martini
- Liver Transplantation Center, Gastrohepatology Unit, AOU Città della Salute e della Scienza di Torino, Turin, Italy
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12
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Indolfi G, D'Antiga L. Treatment of hepatitis C virus infection in children: Time for action. Liver Transpl 2017; 23:427-429. [PMID: 28109055 DOI: 10.1002/lt.24727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/17/2017] [Indexed: 01/13/2023]
Affiliation(s)
- Giuseppe Indolfi
- Paediatric and Liver Unit, Meyer Children's University Hospital of Florence, Florence, Italy
| | - Lorenzo D'Antiga
- Paediatric Hepatology Gastroenterology and Transplantation Hospital Papa Giovanni XXIII, Bergamo, Italy
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13
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Anand AC. Potential Liver Transplant Recipients with Hepatitis C: Should They Be Treated Before or After Transplantation? J Clin Exp Hepatol 2017; 7:42-54. [PMID: 28348470 PMCID: PMC5357718 DOI: 10.1016/j.jceh.2017.01.116] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 12/12/2022] Open
Abstract
Treatment of hepatitis C virus (HCV) with newer directly acting antivirals (DAAs) and lead to sustained viral response (SVR) in majority of patients and SVR has been documented to be associated with reversal of liver cirrhosis. The improved SVR rates and safety profiles of DAAs have led to the treatment of patients with decompensated cirrhosis awaiting liver transplantation (LT). Several clinical trials of DAAs in decompensated HCV patients have recently demonstrated SVR rates above 80%, which have been associated with significant improvements, in the Child-Pugh-Turcotte scores/or model for end-stage liver disease scores in a proportion of patients. Moreover, it has been shown that HCV RNA becomes negative after 2-4 weeks of treatment, and those who are transplanted after becoming HCV RNA negative will be have very low the risk of HCV recurrence after transplantation. Some of the patients may have reached the "point of no return" and may proceed to worsening of decomposition over time. To avoid the risk of worsening, there is an additional option of treating these patients after LT should they develop recurrent HCV infection. Currently there are no guidelines as to select patients who would benefit from treatment prior to LT as opposed to those who will be better off being treated after the transplant surgery. The article discusses a possible approach for such selection.
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Key Words
- CSA, cyclosporine A
- CTP, Child–Turcotte–Pugh staging
- DAA, directly acting antivirals
- DCV, daclatasvir
- DDLT, deceased donor liver transplant
- DSB, dasabuvir
- EBV, elbasvir
- FCH, fibrosing cholestatic hepatitis
- GRZ, grazoprevir
- GT, genotype
- HCV, hepatitis C virus
- IU, international units
- LDLT, living donor liver transplant
- LDV, ledipasvir
- LT, liver transplantation
- MELD, model for end-stage liver disease RNA
- OMB, ombitasvir
- PTV, paritaprevir
- Peg-IFN, pegylated interferon alfa
- RBV, ribavirin
- SMV, simeprevir
- SOF, sofosbuvir
- SVR, sustained virological response, (SVR 12 signifies SVR at 12 weeks)
- TAC, tacrolimus
- VLP, velpatasvir
- decompensated cirrhosis
- directly acting antivirals
- hepatitis C virus infection
- liver transplantation
- rt, ritonavir
- sustained virological response
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Affiliation(s)
- Anil C. Anand
- Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, India
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14
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Chhatwal J, Samur S, Kues B, Ayer T, Roberts MS, Kanwal F, Hur C, Donnell DMS, Chung RT. Optimal timing of hepatitis C treatment for patients on the liver transplant waiting list. Hepatology 2017; 65:777-788. [PMID: 27906468 PMCID: PMC5319880 DOI: 10.1002/hep.28926] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/24/2016] [Indexed: 12/21/2022]
Abstract
The availability of oral direct-acting antivirals has altered the hepatitis C virus (HCV) treatment paradigm for both pre-liver transplant (LT) and post-LT patients. There is a perceived trade-off between pre-LT versus post-LT treatment of HCV-treatment may improve liver function but potentially decrease the likelihood of a necessary LT. Our objective was to identify LT-eligible patients with decompensated cirrhosis who would benefit (and not benefit) from pre-LT treatment based on their Model for End-Stage Liver Disease (MELD) scores. We simulated a virtual trial comparing long-term outcomes of pre-LT versus post-LT HCV treatment with oral direct-acting antivirals for patients with MELD scores between 10 and 40. We developed a Markov-based microsimulation model, which simulated the life course of patients on the transplant waiting list and after LT. Simulation of LT integrated data from recent trials of oral direct-acting antivirals (SOLAR 1 and 2), the United Network for Organ Sharing (UNOS), and other studies. The outcomes of the model included life expectancy, 1-year and 5-year patient survival, and mortality. Model-predicted patient survival was validated with UNOS data. We found that, at the national level, treating HCV before LT increased life expectancy if MELD was ≤27 but could decrease life expectancy at higher MELD scores. Depending on the UNOS region, the threshold MELD score to treat HCV pre-LT varied between 23 and 27 and was lower for UNOS regions 3, 10, and 11 and higher for regions 1, 2, 4, 5, 8, and 9. Sensitivity analysis showed that the thresholds were stable. CONCLUSION Our findings suggest that the optimal MELD threshold below which decompensated cirrhosis patients should receive HCV treatment while awaiting LT is between 23 and 27, depending on the UNOS region. (Hepatology 2017;65:777-788).
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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
| | - Brian Kues
- Department of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Turgay Ayer
- Department of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA
| | - 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
| | - 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
| | - Drew Michael S. Donnell
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Raymond T. Chung
- Harvard Medical School, Boston, MA
- Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, MA
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15
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Levitsky J, Verna EC, O'Leary JG, Bzowej NH, Moonka DK, Hyland RH, Arterburn S, Dvory-Sobol H, Brainard DM, McHutchison JG, Terrault NA. Perioperative Ledipasvir-Sofosbuvir for HCV in Liver-Transplant Recipients. N Engl J Med 2016; 375:2106-2108. [PMID: 27959735 DOI: 10.1056/nejmc1611829] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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16
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Ciesek S, Proske V, Otto B, Pischke S, Costa R, Lüthgehetmann M, Polywka S, Klempnauer J, Nashan B, Manns MP, von Hahn T, Lohse AW, Wedemeyer H, Mix H, Sterneck M. Efficacy and safety of sofosbuvir/ledipasvir for the treatment of patients with hepatitis C virus re-infection after liver transplantation. Transpl Infect Dis 2016; 18:326-32. [PMID: 26988272 DOI: 10.1111/tid.12524] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 01/14/2016] [Accepted: 02/14/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Hepatitis C virus (HCV) infection is associated with a particularly poor outcome after liver transplantation. In December 2014, sofosbuvir/ledipasvir (SOF/LDV) fixed-dose combination (FDC) was approved for HCV genotype 1 and 4 in Europe. In orthotopic liver transplantation (OLT) recipients, the interferon-free treatment of HCV re-infection with novel direct-acting antivirals has been demonstrated to be safe and effective in clinical trials, but real-world data are missing. The aim of this study was to investigate the safety and efficacy of SOF/LDV FDC in OLT recipients in the real-life setting. METHODS All consecutive OLT patients started on SOF/LDV FDC for 12 or 24 weeks at the University Medical Center Hamburg-Eppendorf and Medical School Hannover between October 2014 and August 2015 were retrospectively analyzed (n = 30). The primary efficacy endpoint was sustained virological response (SVR), i.e., absence of viremia 12 weeks after end of treatment (SVR 12). Liver function tests, creatinine, blood count, and HCV RNA (by polymerase chain reaction assay) were determined at each visit. RESULTS SVR was achieved in 29/30 patients (96.67%) treated with SOF/LDV ± ribavirin (RBV) for 12 (n = 4) or 24 weeks (n = 25). Twenty-five patients (86.2%) received RBV. However, in 15 of the 25 patients, RBV administration had to be discontinued because of severe anemia (57.7%). One RBV-treated patient died of a myocardial infarction during antiviral therapy; this event was most likely not directly related to SOF/LDV. Aside from RBV-associated anemia, no severe side effects of the antiviral regimen were observed. CONCLUSION Antiviral treatment with SOF/LDV is highly effective, safe, and well tolerated in OLT recipients. The addition of RBV often results in severe anemia, requiring dose reduction or discontinuation.
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Affiliation(s)
- S Ciesek
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School Hannover, Hannover, Germany.,Integrated Research and Treatment Center - Transplantation (IFB-Tx), Medical School Hannover, Hannover, Germany.,German Center for Infection Research (DZIF), Hannover-Braunschweig site, Hannover, Germany
| | - V Proske
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - B Otto
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,German Center for Infection Research (DZIF), Hamburg-Lübeck-Borstel site, Hamburg, Germany
| | - S Pischke
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,German Center for Infection Research (DZIF), Hamburg-Lübeck-Borstel site, Hamburg, Germany
| | - R Costa
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School Hannover, Hannover, Germany.,German Center for Infection Research (DZIF), Hannover-Braunschweig site, Hannover, Germany
| | - M Lüthgehetmann
- Institute for Medical Microbiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - S Polywka
- Institute for Medical Microbiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Klempnauer
- Integrated Research and Treatment Center - Transplantation (IFB-Tx), Medical School Hannover, Hannover, Germany.,German Center for Infection Research (DZIF), Hannover-Braunschweig site, Hannover, Germany.,General-, Visceral- and Transplant Surgery, Medical School Hannover, Hannover, Germany
| | - B Nashan
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School Hannover, Hannover, Germany.,Integrated Research and Treatment Center - Transplantation (IFB-Tx), Medical School Hannover, Hannover, Germany.,German Center for Infection Research (DZIF), Hannover-Braunschweig site, Hannover, Germany
| | - T von Hahn
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School Hannover, Hannover, Germany.,German Center for Infection Research (DZIF), Hannover-Braunschweig site, Hannover, Germany
| | - A W Lohse
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School Hannover, Hannover, Germany.,German Center for Infection Research (DZIF), Hannover-Braunschweig site, Hannover, Germany.,Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H Mix
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School Hannover, Hannover, Germany.,Integrated Research and Treatment Center - Transplantation (IFB-Tx), Medical School Hannover, Hannover, Germany.,German Center for Infection Research (DZIF), Hannover-Braunschweig site, Hannover, Germany
| | - M Sterneck
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,German Center for Infection Research (DZIF), Hamburg-Lübeck-Borstel site, Hamburg, Germany
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17
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Saxena V, Terrault NA. Treatment of Hepatitis C Infection in Renal Transplant Recipients: The Long Wait Is Over. Am J Transplant 2016; 16:1345-7. [PMID: 26718478 PMCID: PMC5899894 DOI: 10.1111/ajt.13697] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 12/07/2015] [Accepted: 12/23/2015] [Indexed: 01/25/2023]
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18
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Carrion AF, Khaderi SA, Sussman NL. Model for end-stage liver disease limbo, model for end-stage liver disease purgatory, and the dilemma of treating hepatitis C in patients awaiting liver transplantation. Liver Transpl 2016; 22:279-80. [PMID: 26663608 DOI: 10.1002/lt.24383] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 12/10/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Andres F Carrion
- Division of Gastroenterology and Hepatology, Texas Tech University Health Sciences Center, El Paso, TX
| | - Saira A Khaderi
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Norman L Sussman
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
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