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Mikulska M, Knelange N, Nicolini LA, Tridello G, Santarone S, Di Bartolomeo P, de la Camara R, Cuéllar C, Velardi A, Perruccio K, Ljungman P, Zaucha J, Piekarska A, Basak G, Karakulska-Prystupiuk E, Angelucci E, Ciceri F, Lupo-Stanghellini MT, Fouillard L, García-Cadenas I, Menconi M, Blau IW, Nassi L, Cesaro S, Styczynski J. Efficacy, safety and feasibility of treatment of chronic HCV infection with directly acting agents in hematopoietic stem cell transplant recipients - Study of infectious diseases working party of EBMT. J Infect 2021; 84:71-79. [PMID: 34757138 DOI: 10.1016/j.jinf.2021.10.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 10/11/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Limited data is available on HCV directly acting agents (DAAs) in haematopoietic stem cell transplant (HSCT) recipients. This study aimed at reporting the characteristics, treatment practices and treatment efficacy in HSCT recipients with chronic HCV. METHODS Prospective observational study from EBMT Infectious Diseases Working Party (IDWP). Patients with chronic HCV infection were included. RESULTS Between 12/2015 and 07/2018, 45 patients were included: male in 53%; median age 49 years (range, 8-75); acute leukaemia in 48.9%, lymphoma in 17.7%, non-malignant disorders in 22.3%; allogeneic HSCT in 84%; 77.8% no immunosuppressive treatment. Genotypes 1, 2, 3 and 4 were detected in 54.5%, 20.5%, 13.6% and 11.4%, respectively; advanced fibrosis in 40%, including cirrhosis in 11.4%. Overall, 37 (82.2%) patients received DAAs, at a median of 8.4 years after HSCT (16.2% within 6 months from HSCT). Sofosbuvir-based treatment was given to 62.2%. Thirty-five patients completed planned treatment course, with sustained virological response (SVR) of 89.1%, and 94.3% (33/35) in those who completed the treatment. Side effects possibly related to DAAs were reported in 5 (14%) and did not require treatment discontinuation. CONCLUSIONS DAAs treatment was effective, safe and feasible in this cohort of mainly allogeneic HSCT recipients with mild/moderate liver damage.
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Affiliation(s)
- Malgorzata Mikulska
- Division of Infectious Diseases, University of Genoa (DISSAL) and IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, 10, Genova 16132, Italy.
| | - Nina Knelange
- Department Medical Statistics & Bioinformatics, EBMT Data Office, Leiden, the Netherlands
| | - Laura Ambra Nicolini
- Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Gloria Tridello
- Paediatric Haematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Stella Santarone
- Dipartimento Oncologia Ematologia, Terapia Intensiva Ematologica, Ospedale Civile, Pescara, Italy
| | - Paolo Di Bartolomeo
- Dipartimento Oncologia Ematologia, Terapia Intensiva Ematologica, Ospedale Civile, Pescara, Italy
| | | | - Clara Cuéllar
- Department of Hematology, Hospital 12 de Octubre, Madrid, Spain
| | - Andrea Velardi
- Department of Medicine, Division of Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | - Katia Perruccio
- Pediatric Oncology Hematology, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Per Ljungman
- Department for Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Jan Zaucha
- University Hospital Department of Haematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Agnieszka Piekarska
- University Hospital Department of Haematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Grzegorz Basak
- Department of Hematology, Transplantation and Internal Medicine, University Clinical Center of the Medical University of Warsaw, Warsaw, Poland; Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Ewa Karakulska-Prystupiuk
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Emanuele Angelucci
- Ematologia e Centro Trapianti, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy; School of Medicine, Vita-Salute San Raffaele University, Milano, Italy
| | | | | | - Irene García-Cadenas
- Hematology Department, Hospital de la Santa Creu i Sant Pau, Sant Pau and Jose Carreras Leukemia Research Institutes, Autonomous University of Barcelona, Barcelona, Spain
| | - Mariacristina Menconi
- Unità Operativa Oncoematologia Pediatrica, Azienda Ospedaliera Universitaria Pisa, Pisa, Italy
| | | | - Luca Nassi
- Division of Hematology, Department of Translational Medicine, Universita' del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carita, Novara, Italy
| | - Simone Cesaro
- Paediatric Haematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Jan Styczynski
- Department of Pediatric Hematology and Oncology, University Hospital, Collegium Medicum UMK Torun, Bydgoszcz, Poland
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Onodera K, Onishi Y, Inoue J, Tanaka Y, Yonha L, Ichikawa S, Fukuhara N, Yokoyama H, Murai K, Masamune A, Harigae H. Second direct-acting antiviral therapy for hepatitis C virus infection after umbilical cord blood transplantation: A case report. J Infect Chemother 2021; 27:1230-1233. [PMID: 33589371 DOI: 10.1016/j.jiac.2021.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 01/28/2021] [Accepted: 02/01/2021] [Indexed: 12/27/2022]
Abstract
Hepatitis C virus (HCV) infection has an adverse impact on outcomes after allogeneic hematopoietic stem cell transplantation (HSCT). It is recommended that HSCT candidates infected with HCV receive the treatment prior to transplantation. Although the recent approval of direct-acting antivirals (DAAs) has led to great advances in the treatment of HCV infection, little information is available on the efficacy and safety of DAA therapy in patients receiving allogeneic HSCT. Herein, we report the clinical course of an umbilical cord blood (UCB) recipient treated with DAAs for HCV infection. The patient achieved HCV RNA negativity with glecaprevir and pibrentasvir after consolidation therapy for acute myeloid leukemia (AML), and underwent transplantation before confirming sustained virological response (SVR) at 12 weeks. The HCV viral load became detectable on day +28 after transplantation and second HCV treatment with sofosbuvir, velpatasvir, and ribavirin was required. It is important to confirm SVR prior to transplantation, but it is often difficult. If early transplantation is required, close monitoring of HCV RNA after transplantation is needed. Further investigation is required to clarify the optimal management of HCV infection for allogeneic HSCT recipients in the DAA era.
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Affiliation(s)
- Koichi Onodera
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Yasushi Onishi
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Inoue
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yuya Tanaka
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Lee Yonha
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Satoshi Ichikawa
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Noriko Fukuhara
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hisayuki Yokoyama
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazunori Murai
- Department of Hematology, Iwate Prefectural Central Hospital, Iwate, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hideo Harigae
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
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3
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Grasso AG, Sonzogni A, Zanon D, Maestro A, Loiacono S, Maximova N. Treatment of hepatitis C in two paediatric patients using sofosbuvir during haematopoietic stem cell transplantation. Antivir Ther 2020; 24:603-607. [PMID: 31509110 DOI: 10.3851/imp3332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
Abstract
We report the first two paediatric cases of sofosbuvir treatment during high-intensity myeloablative conditioning and engraftment phases of haematopoietic stem cell transplantation. These reports highlight the safety of sofosbuvir during all phases of transplantation and the lack of interaction between sofosbuvir and alkylating or immunosuppressive agents.
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Affiliation(s)
- Antonio G Grasso
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Aurelio Sonzogni
- Department of Pathology, Ospedale Beato Papa Giovanni XXIII, Bergamo, Italy
| | - Davide Zanon
- Pharmacy and Clinical Pharmacology Unit, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | - Alessandra Maestro
- Pharmacy and Clinical Pharmacology Unit, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | - Stefano Loiacono
- Pharmacy and Clinical Pharmacology Unit, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | - Natalia Maximova
- Bone Marrow Transplant Unit, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
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Ramgopal A, Lauko A, Rotz S, Hanna R. Safety of allogeneic hematopoietic stem cell transplantation in beta-thalassemia patients with chronic hepatitis C infections treated at a pediatric center. Pediatr Transplant 2019; 23:e13520. [PMID: 31209983 DOI: 10.1111/petr.13520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/30/2019] [Accepted: 05/23/2019] [Indexed: 12/11/2022]
Abstract
The outcome of allogeneic HCT in patients previously infected with HCV is a widely debated topic and rarely reported in the pediatric and young adult age group given the small population of affected patients. New medications directly targeting HCV have induced virologic cures for over 90% of patients, and their use in the pretransplant setting may improve outcomes for patients infected with HCV. We describe two patients with transfusion-dependent beta-thalassemia major who underwent matched sibling donor bone marrow transplantation, one with a myeloablative regimen and one with a reduced-intensity conditioning regimen. Allogeneic HCT appears feasible in patients with HCV infection that clear viremia prior to conditioning therapy and with a reduced-intensity conditioning regimen. Further investigation is warranted to better define transplant risks in this population.
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Affiliation(s)
- Archana Ramgopal
- Department of Hematology Oncology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Adam Lauko
- Department of Hematology Oncology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Seth Rotz
- Department of Hematology Oncology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Rabi Hanna
- Department of Hematology Oncology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
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5
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Treatment of hepatitis C in a pediatric patient using simeprevir and sofosbuvir immediately after an umbilical cord blood transplantation. Bone Marrow Transplant 2016; 51:735-7. [DOI: 10.1038/bmt.2015.309] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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6
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Kyvernitakis A, Mahale P, Popat UR, Jiang Y, Hosry J, Champlin RE, Torres HA. Hepatitis C Virus Infection in Patients Undergoing Hematopoietic Cell Transplantation in the Era of Direct-Acting Antiviral Agents. Biol Blood Marrow Transplant 2015; 22:717-722. [PMID: 26712592 DOI: 10.1016/j.bbmt.2015.12.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 12/15/2015] [Indexed: 02/06/2023]
Abstract
There is paucity of literature regarding hepatitis C virus (HCV) infection in hematopoietic cell transplant (HCT) recipients. In the study described herein we evaluated several aspects of HCV infection in HCT recipients, including the impact of this infection on cancer status, liver-related outcomes, mortality, and the role of antiviral treatment (AVT), including direct-acting antivirals (DAAs). The medical records of HCV-infected allogeneic and autologous HCT recipients, seen at The University of Texas MD Anderson Cancer Center from August 2009 to November 2015, were reviewed. Patients seen from August 1, 2009 to October 30, 2012 were reviewed retrospectively, whereas those seen from November 1, 2012 to November 30, 2015 were analyzed prospectively in an observational study. Of 434 HCV-infected cancer patients evaluated, 64 underwent 69 HCTs. Most (78%) underwent autologous transplantation. Thirteen percent of patients became HCV-seronegative post-HCT. Compared with patients who did not receive AVT, treated patients had fewer relapses of HCV-associated non-Hodgkin lymphomas (20% versus 86%; P = .015), higher 5-year survival rates (75% versus 39%; P = .02), and a trend toward lower rate of progression to cirrhosis (5% versus 21%; P = .06). AVT discontinuation rate post-HCT was 71% in those receiving IFN-containing regimens and 0% in those receiving DAAs (P < .01). AVT was effective in 12 of 37 patients (32%) and 11 of 13 patients (85%) receiving IFN-based and DAA regimens, respectively (P = .003). HCV is an important cause of morbidity and mortality in this population. HCV seropositivity can be lost post-HCT, posing a diagnostic challenge. Treatment of HCV infection in HCT recipients improves both oncologic and hepatic outcomes. These patients can be successfully treated with DAAs.
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Affiliation(s)
- Andreas Kyvernitakis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Parag Mahale
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Uday R Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ying Jiang
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeff Hosry
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Harrys A Torres
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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7
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Torres HA, Chong PP, De Lima M, Friedman MS, Giralt S, Hammond SP, Kiel PJ, Masur H, McDonald GB, Wingard JR, Gambarin-Gelwan M. Hepatitis C Virus Infection among Hematopoietic Cell Transplant Donors and Recipients: American Society for Blood and Marrow Transplantation Task Force Recommendations. Biol Blood Marrow Transplant 2015; 21:1870-82. [PMID: 26256943 DOI: 10.1016/j.bbmt.2015.07.033] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 07/31/2015] [Indexed: 02/08/2023]
Affiliation(s)
- Harrys A Torres
- The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Pearlie P Chong
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Marcos De Lima
- University Hospitals Case Medical Center and University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | | | - Sergio Giralt
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sarah P Hammond
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Patrick J Kiel
- Indiana University Simon Cancer Center, Indianapolis, Indiana
| | - Henry Masur
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | - George B McDonald
- University of Washington and Fred Hutchinson Cancer Research Center, Seattle, Washington
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8
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Prophylaxis for Infections Following Allogeneic Hematopoietic Stem Cell Transplantation. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2015. [DOI: 10.1097/ipc.0000000000000190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Hsiao HH, Liu YC, Wang HC, Wu CH, Cho SF, Hsu JF, Tsai HJ, Hsiao S, Chang CS, Lin SF, Liu TC, Chuang WL, Yu ML. Hepatitis C transmission from viremic donors in hematopoietic stem cell transplant. Transpl Infect Dis 2014; 16:1003-6. [PMID: 25367218 DOI: 10.1111/tid.12306] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 06/30/2014] [Accepted: 08/12/2014] [Indexed: 01/04/2023]
Affiliation(s)
- H.-H. Hsiao
- Division of Hematology/Oncology; Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
- Faculty of Internal Medicine; College of Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
| | - Y.-C. Liu
- Division of Hematology/Oncology; Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
- Faculty of Internal Medicine; College of Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
| | - H.-C. Wang
- Division of Hematology/Oncology; Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
| | - C.-H. Wu
- Division of Hematology/Oncology; Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
| | - S.-F. Cho
- Division of Hematology/Oncology; Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
| | - J.-F. Hsu
- Division of Hematology/Oncology; Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
| | - H.-J. Tsai
- Division of Hematology/Oncology; Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
| | - S.Y. Hsiao
- Division of Hematology/Oncology; Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
| | - C.-S. Chang
- Division of Hematology/Oncology; Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
- Faculty of Internal Medicine; College of Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
| | - S.-F. Lin
- Division of Hematology/Oncology; Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
- Faculty of Internal Medicine; College of Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
| | - T.-C. Liu
- Division of Hematology/Oncology; Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
- Faculty of Internal Medicine; College of Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
| | - W.-L. Chuang
- Faculty of Internal Medicine; College of Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
- Hepatobiliary Division; Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
| | - M.-L. Yu
- Faculty of Internal Medicine; College of Medicine; Kaohsiung Medical University; Kaohsiung Taiwan
- Hepatobiliary Division; Department of Internal Medicine; Kaohsiung Medical University Hospital; Kaohsiung Taiwan
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10
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Treatment of Infections After Hematopoietic Stem Cell Transplantation. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2014. [DOI: 10.1097/ipc.0000000000000178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Puri P, Anand AC, Saraswat VA, Acharya SK, Sarin SK, Dhiman RK, Aggarwal R, Singh SP, Amarapurkar D, Arora A, Chhabra M, Chetri K, Choudhuri G, Dixit VK, Duseja A, Jain AK, Kapoor D, Kar P, Koshy A, Kumar A, Madan K, Misra SP, Prasad MV, Nagral A, Puri AS, Jeyamani R, Saigal S, Shah S, Sharma PK, Sood A, Thareja S, Wadhawan M. Consensus Statement of HCV Task Force of the Indian National Association for Study of the Liver (INASL). Part II: INASL Recommendations for Management of HCV in India. J Clin Exp Hepatol 2014; 4:117-40. [PMID: 25755549 PMCID: PMC4116713 DOI: 10.1016/j.jceh.2014.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 06/04/2014] [Indexed: 12/12/2022] Open
Abstract
The estimated prevalence of hepatitis C virus (HCV) infection in India is between 0.5 and 1.5% with hotspots showing much higher prevalence in some areas of northeast India, in some tribal populations and in certain parts of Punjab. Genotype 3 is the most prevalent type of infection. Recent years have seen development of a large number of new molecules that are revolutionizing the treatment of hepatitis C. Some of the new directly acting agents (DAAs) like sofosbuvir have been called game-changers because they offer the prospect of interferon-free regimens for the treatment of HCV infection. These new drugs have not yet been approved in India and their cost and availability is uncertain at present. Till these drugs become available at an affordable cost, the treatment that was standard of care for the whole world before these newer drugs were approved should continue to be recommended. For India, cheaper options, which are as effective as the standard-of-care (SOC) in carefully selected patients, are also explored to bring treatment within reach of poorer patients. It may be prudent to withhold treatment at present for selected patients with genotype 1 or 4 infection and low levels of fibrosis (F1 or F2), and for patients who are non-responders to initial therapy, interferon intolerant, those with decompensated liver disease, and patients in special populations such as stable patients after liver and kidney transplantation, HIV co-infected patients and those with cirrhosis of liver.
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Key Words
- ALT, alanine amintraonsferase
- ANC, absolute neutrophil count
- AST, aspartate aminotransferase
- CH–C, Chronic Hepatitis C
- CKD, chronic kidney disease
- CTP, Child-Turcotte-Pugh
- EIA, enzyme immunoassay
- ETR, end-of-treatment response
- EVR, early virological response
- GRADE, Grading of Recommendations Assessment, Development and Evaluation
- HCV, hepatitis C virus
- HIV, Human immunodeficiency virus
- IFNa, interferon alfa
- INASL, Indian National Association for Study of the Liver
- PCR, polymerase chain reaction
- Peg-IFNa, pegylated interferon alfa
- RBV, Ribavirin
- RVR, rapid virological response
- SOC, standard of care
- SVR, sustained virological response
- ULN, upper limit of normal
- anti-HCV, antibody to HCV
- antiviral therapy
- chronic hepatitis
- hepatitis C virus
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Affiliation(s)
- Pankaj Puri
- Department of Gastroenterology, Army Hospital (R & R), New Delhi 110010, India
| | - Anil C. Anand
- Department of Gastroenterology and Hepatology, Indraprastha Apollo Hospital, New Delhi 110076, India
| | - Vivek A. Saraswat
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical, Sciences, Lucknow, Uttar Pradesh 221016, India
| | - Subrat K. Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Shiv K. Sarin
- Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi 110070, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and, Research, Chandigarh 160012, India
| | - Rakesh Aggarwal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical, Sciences, Lucknow, Uttar Pradesh 221016, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, Odisha 753007, India
| | - Deepak Amarapurkar
- Department of Gastroenterology, Bombay Hospital, Mumbai, Maharashtra 400020, India
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi 110060, India
| | - Mohinish Chhabra
- Department of Gastroenterology, Fortis Hospital, Mohali, Punjab 160047, India
| | - Kamal Chetri
- Department of Gastroenterology, International Hospital, Guwahati, Assam 781005, India
| | - Gourdas Choudhuri
- Department of Gastroenterology, Fortis Hospital, Gurgaon, Haryana 122002, India
| | - Vinod K. Dixit
- Department of Gastroenterology, Banaras Hindu University, Varanasi, Uttar Pradesh 221005, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and, Research, Chandigarh 160012, India
| | - Ajay K. Jain
- Department of Gastroenterology, Choithram Hospital & Research Centre, Indore, Madhya Pradesh 452014, India
| | - Dharmesh Kapoor
- Department of Gastroenterology, Global Hospital, Hyderabad, Andhra Pradesh 500004, India
| | - Premashis Kar
- Department of Gastroenterology, LNJP Hospital, and Maulana Azad Medical College, New Delhi 110002, India
| | - Abraham Koshy
- Department of Hepatology, Lakeshore Hospital, Cochin, Kerala 682304, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital, New Delhi 110060, India
| | - Kaushal Madan
- Department of Gastroenterology, Medanta Medicity, Gurgaon, Haryana 122001, India
| | - Sri P. Misra
- Department of Gastroenterology, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh 211001 India
| | - Mohan V.G. Prasad
- Department of Gastroenterology, VGM Hospital, Coimbatore, Tamil Nadu 641005, India
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital, Mumbai, Maharashtra 400026, India
| | - Amarendra S. Puri
- Department of Gastroenterology, GB Pant Hospital, New Delhi 110002, India
| | - R. Jeyamani
- Department of Gastroenterology, Christian Medical College, Vellore, Tamil Nadu 632004, India
| | - Sanjiv Saigal
- Department of Gastroenterology, Medanta Medicity, Gurgaon, Haryana 122001, India
| | - Samir Shah
- Department of Gastroenterology, Global Hospital, Mumbai, Maharashtra 400078, India
| | - Praveen K. Sharma
- Department of Medicine, Armed Forces Medical College, Pune, Maharashtra 411040, India
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College, Ludhiana, Punjab 141001, India
| | - Sandeep Thareja
- Department of Gastroenterology, Army Hospital (R & R), New Delhi 110010, India
| | - Manav Wadhawan
- Department of Gastroenterology and Hepatology, Indraprastha Apollo Hospital, New Delhi 110076, India
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Nakasone H, Kurosawa S, Yakushijin K, Taniguchi S, Murata M, Ikegame K, Kobayashi T, Eto T, Miyamura K, Sakamaki H, Morishima Y, Nagamura T, Suzuki R, Fukuda T. Impact of hepatitis C virus infection on clinical outcome in recipients after allogeneic hematopoietic cell transplantation. Am J Hematol 2013; 88:477-84. [PMID: 23483626 DOI: 10.1002/ajh.23436] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 03/05/2013] [Indexed: 01/12/2023]
Abstract
The impact of hepatitis C virus (HCV) infection on outcomes following allogeneic hematopoietic cell transplantation (HCT) remains a matter of debate. We have retrospectively examined the significance of HCV infection among recipients who received allogeneic HCT, using a Japan transplant outcome registry database between 2006 and 2009. Among 7,831 recipients, 136 were HCV-positive. The rate of hematopoietic recovery was lower in the HCV-positive group (neutrophil recovery of 500 × 10(6) /L or higher: 79% vs. 87% at Day 30, P = 0.087; platelet recovery of 50 × 10(9) /L or higher: 57% vs. 65% at Day 60, P = 0.012). The HCV-positive group had a significantly higher incidence of nonrelapse mortality 38% vs. 25% at 2 years, P < 0.01) and inferior overall survival (41% vs. 51% at 2 years, P < 0.01). A multivariate analysis revealed that HCV seropositivity was associated with an independent risk for higher nonrelapse mortality (hazard ratio: 1.65, P < 0.01) and inferior overall survival (hazard ratio: 1.39, P < 0.01). The incidences of death due to hepatic problems (8% vs. 2%, P < 0.01), bacterial infection (10% vs. 4%, P < 0.01), or graft failure (5% vs. 2%, P = 0.084) tended to be higher in the HCV-positive group. HCV infection had an adverse impact on the clinical outcome following HCT, especially in the setting of unrelated transplantation. Careful evaluation before embarking on HCT and intensive assessment against complications are warranted in HCV-infected recipients.
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Affiliation(s)
| | | | | | | | - Makoto Murata
- Department of Hematology and Oncology; Nagoya University Graduate School of Medicine; Nagoya; Japan
| | - Kazuhiro Ikegame
- Division of Hematology; Department of Internal Medicine; Hyogo College of Medicine; Nishinomiya; Japan
| | - Takeshi Kobayashi
- Hematology Division; Tokyo Metropolitan Cancer & Infectious Disease Center, Komagome Hospital; Tokyo; Japan
| | - Tetsuya Eto
- Department of Hematology; Hamanomachi Hospital; Fukuoka; Japan
| | - Koichi Miyamura
- Department of Hematology; Japanese Red Cross Nagoya First Hospital; Nagoya; Japan
| | - Hisashi Sakamaki
- Hematology Division; Tokyo Metropolitan Cancer & Infectious Disease Center, Komagome Hospital; Tokyo; Japan
| | - Yasuo Morishima
- Division of Epidemiology and Prevention; Aichi Cancer Center Research Institute; Nagoya; Japan
| | - Tokiko Nagamura
- Department of Cell Processing and Transfusion; Institute of Medical Science; University of Tokyo; Tokyo; Japan
| | - Ritsuro Suzuki
- Department of HSCT Data Management and Biostatistics; Nagoya University; Nagoya; Japan
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13
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Abstract
Reactivation of hepatitis B virus (HBV) or hepatitis C virus (HCV) infection following anticancer chemotherapy and immunosuppressive therapy is a well-known complication. HBV reactivation has been reported to be associated with anti-CD20 monoclonal antibody rituximab-containing chemotherapy and tumor necrosis factor-α inhibitor-containing immunosuppressive therapy in HBV resolved patients (hepatitis B surface antigen negative and antibodies against hepatitis B core antigen positive and/or antibodies against surface antigen positive). On the other hand, HCV reactivation has been reported to be associated with liver damage or hepatic dysfunction, but fulminant hepatitis due to HCV reactivation is a rare complication. In this review, we describe the pathophysiology of the reactivation of HBV and HCV infection, as well as the clinical evidence and management of HCV reactivation.
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Affiliation(s)
- Tsunamasa Watanabe
- Department of Virology and Liver Unit, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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14
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Tomblyn M, Chen M, Kukreja M, Aljurf MD, Al Mohareb F, Bolwell BJ, Cahn JY, Carabasi MH, Gale RP, Gress RE, Gupta V, Hale GA, Ljungman P, Maziarz RT, Storek J, Wingard JR, Young JAH, Horowitz MM, Ballen KK. No increased mortality from donor or recipient hepatitis B- and/or hepatitis C-positive serostatus after related-donor allogeneic hematopoietic cell transplantation. Transpl Infect Dis 2012; 14:468-78. [PMID: 22548788 DOI: 10.1111/j.1399-3062.2012.00732.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 09/14/2011] [Accepted: 12/21/2011] [Indexed: 01/17/2023]
Abstract
Limited data exist on allogeneic transplant outcomes in recipients receiving hematopoietic cells from donors with prior or current hepatitis B (HBV) or C virus (HCV) infection (seropositive donors), or for recipients with prior or current HBV or HCV infection (seropositive recipients). Transplant outcomes are reported for 416 recipients from 121 centers, who received a human leukocyte antigen-identical related-donor allogeneic transplant for hematologic malignancies between 1995 and 2003. Of these, 33 seronegative recipients received grafts from seropositive donors and 128 recipients were seropositive. The remaining 256 patients served as controls. With comparable median follow-up (cases, 5.9 years; controls, 6.7 years), the incidence of treatment-related mortality, survival, graft-versus-host disease, and hepatic toxicity, appears similar in all cohorts. The frequencies of hepatic toxicities as well as causes of death between cases and controls were similar. Prior exposure to HBV or HCV in either the donor or the recipient should not be considered an absolute contraindication to transplant.
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Affiliation(s)
- M Tomblyn
- Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA.
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15
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Long-term follow-up of HCV-infected hematopoietic SCT patients and effects of antiviral therapy. Bone Marrow Transplant 2011; 47:1217-21. [PMID: 22158388 DOI: 10.1038/bmt.2011.238] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This prospective study was initiated in 1993 with the aim to study late effects and responses to antiviral therapy in a cohort of hepatitis C virus (HCV)-infected patients. A total of 195 patients were included from 12 centers. In all, 134 patients had undergone allogeneic and 61 autologous hematopoietic SCT (HSCT). The median follow-up from HSCT is currently 16.8 years and the maximum 27.2 years. Overall 33 of 195 patients have died of which 6 died from liver complications. The survival probability was 81.6% and the cumulative incidence for death in liver complications was 6.1% at 20 years after HSCT. The cumulative incidence of severe liver complications (death from liver failure, cirrhosis and liver transplantation) was 11.7% at 20 years after HSCT. In all, 85 patients have been treated with IFN; 42 in combination with ribavirin. The sustained response rate was 40%. The rates of severe side effects were comparable to other patient populations and no patient developed significant exacerbations of GVHD. Patients receiving antiviral therapy had a trend toward a decreased risk of severe liver complications (odds ratio=0.33; P=0.058). HCV infection is associated with morbidity and mortality in long-term survivors after HSCT. Antiviral therapy can be given safely and might reduce the risk for severe complications.
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16
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Hepatitis C in haematological patients. HEPATITIS RESEARCH AND TREATMENT 2010; 2010:961359. [PMID: 21188204 PMCID: PMC3004006 DOI: 10.1155/2010/961359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 07/08/2010] [Accepted: 08/06/2010] [Indexed: 02/08/2023]
Abstract
There is no consensus guideline concerning the management of chronic hepatitis C patients during chemotherapy, and immunosuppression. However, there are some suggestions in literature that hepatitis C viral load increases during chemotherapy and there is a risk of rebound immunity against hepatitis C after discontinuation of immunosuppression with a consequent liver injury. A close monitoring of liver function of these patients is prudent during treatment of haematological malignancy. Antiviral treatment is deferred after the completion of chemotherapy and recovery of patients' immunity to minimize the toxicity of treatment. A combination of pegylated interferon and ribavirin is the standard therapy in hepatitis C infected haematological patients.
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17
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Lazarus HM, Laughlin MJ. Viral Infections in Hematopoietic Stem Cell Transplant Recipients. ALLOGENEIC STEM CELL TRANSPLANTATION 2010. [PMCID: PMC7120500 DOI: 10.1007/978-1-59745-478-0_29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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18
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Prevention and treatment of hepatitis virus infections in hematopoietic stem cell transplant recipients. Mediterr J Hematol Infect Dis 2009; 1:e2009017. [PMID: 21415956 PMCID: PMC3033126 DOI: 10.4084/mjhid.2009.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 12/08/2009] [Indexed: 02/08/2023] Open
Abstract
Infections with Hepatitis viruses B and C pose major problems both short and long term respectively after HSCT. The key to prevention for Hepatitis B disease remains vaccination for HBV-naïve patients and judicial use of anti-viral therapy in both pre- and post-transplant settings for HBV-infected patients. HBsAg positive grafts to HBV-naïve recipients result in transmission of the virus in about 50%. The newer anti-viral agents have enabled effective treatment of post-transplant patients who might be lamivudine-resistant or might develop so. Selecting a previously infected donor who has high titres of surface antibody for HBsAg positive patients gives the best chance for immunological clearance. The most challenging aspect of preventing HBV reactivation remains the duration of anti-viral therapy and timing of its withdrawal as most reactivations and often fatal ones occur after this period. Hepatitis C, on the other hand affects long-term survival with early onset of fibrosis and cirrhosis. Early effect of Hepatitis C virus on the immune system remains conjectural. The standard combination therapy seems to be effective, but data on this front remains sparse, as in the case of the use of newer antiviral agents. HSCT from HCV infected grafts result in more consistent transmission of the virus and pre-donation treatment of donors should be undertaken to render them non-viremic, if possible. The current understanding and recommendations regarding prevention and management of these infections in HSCT recipients are discussed.
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Tomblyn M, Chiller T, Einsele H, Gress R, Sepkowitz K, Storek J, Wingard JR, Young JAH, Boeckh MJ, Boeckh MA. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant 2009; 15:1143-238. [PMID: 19747629 PMCID: PMC3103296 DOI: 10.1016/j.bbmt.2009.06.019] [Citation(s) in RCA: 1155] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Accepted: 06/23/2009] [Indexed: 02/07/2023]
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20
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21
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Socié G, de Latour RP, McDonald GB. Hepatitis C virus and allogeneic stem cell transplantation still matters! Haematologica 2009; 94:170-2. [PMID: 19181791 DOI: 10.3324/haematol.2008.002048] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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22
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Sequential antiviral and iron chelation treatment in a teenage boy with congenital anemia, chronic hepatitis C, and secondary hemosiderosis. J Pediatr Gastroenterol Nutr 2009; 48:382-5. [PMID: 19274798 DOI: 10.1097/mpg.0b013e3181602190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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23
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Field KM, Dow C, Michael M. Part I: Liver function in oncology: biochemistry and beyond. Lancet Oncol 2008; 9:1092-101. [DOI: 10.1016/s1470-2045(08)70279-1] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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24
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Peffault de Latour R, Ribaud P, Robin M, Valla D, Marcellin P, Socié G, Asselah T. Allogeneic hematopoietic cell transplant in HCV-infected patients. J Hepatol 2008; 48:1008-17. [PMID: 18433917 DOI: 10.1016/j.jhep.2008.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hepatitis C virus (HCV) is a major cause of liver disease worldwide. After allogeneic Hematopoietic Cell Transplant (HCT), HCV is known to be associated with transient hepatitis in the immediate post-transplant period, and a potential risk factor of veno-occlusive disease (SOS). Very recently, HCV-infected HCT recipients have been shown to be at higher risk of earlier cirrhosis, leading to greater morbidity and mortality. Long-term survivors after HCT are thus at a high risk for HCV-related complications and, as a consequence, the treatment of HCV infection becomes critical. We describe here the potential clinical complications in HCV-infected recipients, in the short, but also the long-term follow-up after HCT. The pathophysiology of liver fibrosis is discussed as well as the present recommended therapy in this particular population.
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25
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Abstract
Viral hepatitis is the third major cause of liver dysfunction in allogeneic transplant recipients and has become a significant concern in patients with hematological malignancies receiving chemotherapy. Thus, identification of patients at risk for viral hepatitis is very important when evaluating and treating hematological malignancies. Serologic screening for all patients should include anti-HCV, hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and hepatitis B core antibody (anti-HBc) testing. Current therapies for hepatitis B (HBV) virus infection are aimed at viral suppression, while treatment for hepatitis C (HCV) virus can eradicate infection in many treated patients. To prevent HBV viral reactivation, prophylaxis with nucleoside analogues should be initiated for all HBsAg-positive patients. HCV infection appears to have little impact on short-term survival after bone marrow transplantation (BMT), but eventually can impact long-term survival due to progression of liver disease. In this review we will highlight the mechanisms of virus reactivation, clinical manifestations, and management strategies to minimize acute and chronic morbidity in this population.
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Affiliation(s)
- Roberto J Firpi
- Division of Gastroenterology, Hepatology and Nutrition Section of Hepatobiliary Diseases and Liver Transplantation, University of Florida Gainesville, FL 32610-0214, USA.
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26
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Carreras E. Risk assessment in haematopoietic stem cell transplantation: The liver as a risk factor. Best Pract Res Clin Haematol 2007; 20:231-46. [PMID: 17448959 DOI: 10.1016/j.beha.2006.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patients with liver dysfunction have an increased risk of developing early and late complications after haematopoietic stem-cell transplantation (HSCT). That's why it is mandatory to evaluate liver status before transplantation in all cases. This evaluation should allow us to decide whether HSCT can be performed or whether we should adopt measures focused on preventing these complications. The evaluation of the liver in an HSCT candidate requires the collection of information by history-taking, physical examination, liver-function tests and, occasionally, imaging tests and liver biopsy. Additionally, as infection by hepatitis B or C viruses represents the most relevant cause of hepatic dysfunction after HSCT, the serological status of the patient should be carefully evaluated. This chapter tries to analyse and systematise the most important aspects in the patient's evaluation. Finally, as some liver dysfunctions in the stem-cell donor can have a negative impact for the donor during the harvest and/or for the recipient during HSCT, the methodology to evaluate the donors will also be analysed.
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27
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Abstract
Hepatic diseases are common complications of haematopoietic cell transplant. The causes are multiple: myeloablative conditioning regimens may cause sinusoidal injury; acute and chronic graft-versus-host disease lead to damaged hepatocytes and small bile ducts; microcrystalline deposits in the gall bladder can cause biliary symptoms; drug-induced liver injury is common; and the liver may be infected by viruses and fungi during the period of severe immune suppression that follows transplant. Pre-transplant evaluation and prevention of liver injury are often more useful than treatment of deeply jaundiced patients in improving transplant outcomes. This review covers pre-transplant evaluation, common hepatobiliary problems in the six months following transplant, and hepatic problems in long-term survivors.
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Affiliation(s)
- G B McDonald
- Gastroenterology/Hepatology Section, Fred Hutchinson Cancer Research Center, University of Washington School of Medicine, Seattle, WA 98109-1024, USA
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28
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Abstract
AbstractViral hepatitis is the third most common cause of liver disease in allogeneic transplant recipients and causes significant morbidity and mortality. When treating patients with hematological malignancies, an emphasis should be placed on identification of patients at risk for viral hepatitis with appropriate screening. Initial screening serology should include anti-HCV, HBsAg, anti-HBs, and anti-HBc testing. When hepatitis B exposure has been documented, prophylaxis of viral reactivation for all HBsAg-positive patients with a nucleoside analogue should be implemented. HCV infection appears to have little short-term impact on survival after bone marrow transplantation, but is a risk factor for veno-occlusive disease (VOD) and graft-versus-host disease (GVHD). In the long-term survivor, HCV infection can lead to significant morbidity and mortality due to the development of cirrhosis, decompensation, and liver cancer. Since effective antiviral therapies are available for both hepatitis B and C, routine screening and selected intervention is recommended once reactivation and disease recurrence is documented. In this chapter we will highlight the mechanisms of virus reactivation, clinical manifestations, and management strategies to minimize acute and chronic morbidity in this population.
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Affiliation(s)
- Roberto J Firpi
- Division of Gastroenterology, Hepatology and Nutrition, Section of Hepatobiliary Diseases and Liver Transplantation, University of Florida, Gainesville, FL 32610, USA
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