Increased risk of hepatic complications in kidney transplantation with chronic virus hepatitis infection: A nationwide population-based cohort study

Outcomes after kidney transplant alone in patients with cirrhosis-A case-control study

BACKGROUND

Guidelines recommend kidney transplant alone (KTA) in compensated cirrhosis based on a few small studies, but this is not widely performed despite its potential benefit to patients and the organ supply. Our aim was to determine the outcomes of KTA in patients with compensated cirrhosis.

STUDY DESIGN

From 1/2012 to 12/2021, outcomes in KTA recipients with compensated cirrhosis were retrospectively compared to patients with chronic liver disease (CLD) but no cirrhosis. Patients with compensated cirrhosis were also compared to a matched cohort (based on age, time on hemodialysis, sex, and ethnicity) of KTA recipients without CLD. The outcomes included patient survival, allograft failure, allograft rejection, serious infection, liver decompensation, and length of stay (LOS).

RESULTS

Over 9 years, 1562 KTAs were performed, with 150 (9.6%) patients having CLD mostly due to chronic hepatitis C, and a median follow-up of 3.5 years. 32/150 (21%) had compensated cirrhosis at the time of KTA with a mean MELD-Na of 22 (1.5). Matched controls (n = 189) were identified. We found no differences in patient survival (p = .07), allograft failure (p = .6), allograft rejection (p = .43), rates of serious infection (p = .31), as well as LOS (p = .61) among patients with compensated cirrhosis compared to patients with CLD but no cirrhosis, but with higher rates of liver decompensation (p = .004). Similarly, compared to patients without CLD, patients with cirrhosis had similar rates of patient survival (p = .20), allograft failure (p = .27), allograft rejection (p = .62) and LOS (p = .19) but with higher rates of serious infections (p = .001).

CONCLUSIONS

Our study supports the safety and efficacy of KTA in patients with compensated cirrhosis.

Risk Stratification for Hepatitis B Virus Reactivation in Kidney Transplant Recipients With Resolved HBV Infection

The prophylaxis strategy for hepatitis B virus (HBV) reactivation in kidney transplant recipients (KTRs) with resolved HBV infection remains unclear. In this hospital-based retrospective cohort study, consecutive KTRs with resolved HBV infection were screened from the years 2000 through 2020. After excluding confounding conditions, 212 and 45 patients were respectively recruited into Anti-HBs positive and Anti-HBs negative groups. Cumulative incidences of, and subdistribution hazard ratios (SHRs) for HBV reactivation were analyzed after adjusting the competing risk. During a median 8.3 (mean 8.4 ± 4.9) years of follow-up, the 10-year cumulative incidence of HBV reactivation was significantly higher in Anti-HBs negative group when compared to that in Anti-HBs positive group (15.2%, 95% CI: 3.6-26.7 vs. 1.3%, 95% CI: 0.0-3.0; p < 0.001). In multivariable regression analysis, absence of anti-HBs (SHR 14.2, 95% CI: 3.09-65.2; p < 0.001) and use of high-dose steroids, i.e., steroid dose ≥20 mg/day of prednisolone equivalent over 4 weeks (SHR 8.96, 95% CI: 1.05-76.2; p = 0.045) were independent risk factors related to HBV reactivation. Accordingly, the 10-year cumulative incidence of HBV reactivation occurring in patients with two, one and zero risk factors was 42.7% (95% CI: 0.0-87.1), 7.9% (95% CI: 1.2-14.7) and 0%, respectively (p < 0.001). In conclusion, the strategy of HBV antiviral prophylaxis may be defined according to the risk stratification.

The Impact of Antiviral Treatment of Hepatitis B Virus after Kidney Transplant and the Latest Insights

BACKGROUND

The current frequency of hepatitis B virus infection in patients with advanced chronic kidney disease (CKD) (including patients on maintenance dialysis and kidney transplant recipients) is low but not negligible worldwide. HBV has a deleterious effect on survival after a kidney transplant; antiviral treatments improved the short-term outcomes of kidney transplant recipients, but their long-term impact remains uncertain.

AIM

The aim of this review is to assess the role of antiviral therapy for HBV in improving survival after a kidney transplant. The recent publication of large surveys has prompted us to update the available evidence on the impact of HBV on patient and graft survival after a kidney transplant.

METHODS

We have conducted an extensive review of the medical literature, and various research engines have been used.

RESULTS

We retrieved several studies (n = 11; n = 121,436 unique patients) and found an association between positive serologic HBsAg status and diminished patient and graft survival after a kidney transplant; the adjusted relative risk (aRR) of all-cause mortality and graft loss was 2.85 (95% CI, 2.36; 3.33, p < 0.0001) and 1.26 (95% CI, 1.02; 1.51, p < 0.0001), respectively. To our knowledge, at least six studies reported improved patient and graft survival after the adoption of antiviral therapies for HBV (this result was reported with both survival curves and multivariable regression). According to novel clinical guidelines, entecavir has been suggested as a 'first line' antiviral agent for the treatment of HBV after a kidney transplant.

CONCLUSIONS

The recent availability of safe and effective antiviral drugs for the treatment of HBV has meant that the survival curves of HBsAg-positive patients on antiviral therapy and HBsAg-negative patients after a kidney transplant can be comparable. Antiviral therapy should be systematically proposed to HBV-positive kidney transplant recipients and candidates to avoid the deleterious hepatic and extra-hepatic effects of chronic HBV replication.

Hepatic Angiosarcoma Post-Renal Transplantation: A Case Report

BACKGROUND

DNA damage and oncogenic viruses increase the risk of cancer post-kidney transplantation, including skin cancer, Kaposi's sarcoma, oral cancer, and non-Hodgkin lymphoma. Here we report an uncommon case of liver angiosarcoma that occurred 8 years after kidney transplantation. This study strictly complied with the Helsinki Congress and the Istanbul Declaration regarding donor source.

CASE REPORT

A 57-year-old female patient received a cadaver kidney transplantation 8 years ago. She followed a long-term regimen of tacrolimus, mycophenolate sodium, and everolimus, with good renal function. She received annual regular abdominal ultrasound examinations after kidney transplantation, which showed no findings. The patient suffered from several symptoms for approximately 2 weeks before a scheduled abdominal ultrasound: diarrhea, epigastric pain, abdominal fullness, tea-colored urine, and little stool passage. The abdominal computerized tomography showed multiple hepatic tumors in both the hepatic lobes with engorged vasculatures and mild hemoperitoneum. A liver biopsy revealed the histopathology of angiosarcoma. The patient suffered multiple organ failure within one month of treatment.

CONCLUSIONS

Various post-transplant malignancies are not uncommon after transplantation, warranting periodic screenings for any symptoms in these patients.

An Update on Hepatocellular Carcinoma in Chronic Kidney Disease

Simple Summary

Chronic kidney disease is a major public health issue globally and the risk of hepatocellular cancer appears greater in patients with chronic kidney disease compared with the general population. Non-alcoholic fatty liver disease is a liver disorder ranging from simple fatty infiltration to advanced fibrosis plus inflammation; it plays a role in developing liver-related and extra liver-related diseases including HCC and CKD, respectively. Approximately 90% of HCCs are associated with a known underlying etiology; viral hepatitis is a well-known cause of HCC, particularly in CKD population. Antiviral therapy of HBV and HCV is important in the management of HCC in CKD patients. Therapy of HCC in CKD patients includes liver transplant (in selected patients), local approach (surgery or interventional radiology), and tyrosine kinase inhibitors (advanced HCC).

Abstract

Chronic kidney disease is a major public health issue globally and the risk of cancer (including HCC) is greater in patients on long-term dialysis and kidney transplant compared with the general population. According to an international study on 831,804 patients on long-term dialysis, the standardized incidence ratio for liver cancer was 1.2 (95% CI, 1.0–1.4) and 1.5 (95% CI, 1.3–1.7) in European and USA cohorts, respectively. It appears that important predictors of HCC in dialysis population are hepatotropic viruses (HBV and HCV) and cirrhosis. 1-, 3-, and 5-year survival rates are lower in HCC patients on long-term dialysis than those with HCC and intact kidneys. NAFLD is a metabolic disease with increasing prevalence worldwide and recent evidence shows that it is an important cause of liver-related and extra liver-related diseases (including HCC and CKD, respectively). Some longitudinal studies have shown that patients with chronic hepatitis B are aging and the frequency of comorbidities (such as HCC and CKD) is increasing over time in these patients; it has been suggested to connect these patients to an appropriate care earlier. Antiviral therapy of HBV and HCV plays a pivotal role in the management of HCC in CKD and some combinations of DAAs (elbasvir/grazoprevir, glecaprevir/pibrentasvir, sofosbuvir-based regimens) are now available for HCV positive patients and advanced chronic kidney disease. The interventional management of HCC includes liver resection. Some ablative techniques have been suggested for HCC in CKD patients who are not appropriate candidates to surgery. Transcatheter arterial chemoembolization has been proposed for HCC in patients who are not candidates to liver surgery due to comorbidities. The gold standard for early-stage HCC in patients with chronic liver disease and/or cirrhosis is still liver transplant.

Hepatitis C virus and hepatitis B virus in patients with schizophrenia

This study evaluated the severe hepatic outcome (SHO) in patients with schizophrenia and viral hepatitis who received antipsychotics.Using the nationwide Taiwan National Health Insurance Research Database, patients first diagnosed with schizophrenia between 2002 and 2013 were identified. Patients diagnosed with schizophrenia who had viral hepatitis, including hepatitis B virus (HBV) or hepatitis C virus (HCV), were designated as the viral hepatitis group. A control group without viral hepatitis was matched for age, sex, and index year in a 2:1 ratio. Patients with severe hepatic outcomes before enrollment were excluded. The 2 cohorts were observed until December 31, 2013. The primary endpoint was occurrence of a SHO, including liver cancer, liver failure, liver decompensation, or transplantation.Among the 16,365 patients newly diagnosed with schizophrenia between January 2002 and December 2013, we identified 614 patients with viral hepatitis and 1228 matched patients without viral hepatitis. Of these 1842 patients, 41 (2.22%) developed SHOs, including 26 (4.23%) in the viral hepatitis group and 15 (1.22%) in the control group, during the mean follow-up period of 3.71 ± 2.49 years. Cox proportional hazard analysis indicated that the SHO risk increased by 3.58 (95% confidence interval [CI]: 1.859-6.754; P < .001) in patients with schizophrenia and viral hepatitis. Moreover, patients with schizophrenia having HCV had a higher SHO risk than those without viral hepatitis (hazard ratio: 5.07, 95% CI: 1.612-15.956; P < .0001). Patients having both schizophrenia and viral hepatitis, especially HCV, had a higher risk of SHOs.

Correlation of serum CA199 levels with glycemic control and microvascular complications in patients with type 2 diabetes mellitus

OBJECTIVE

This study aimed to explore the correlation between glycemic control, microvascular complications and serum glycogen antigen (CA199) in patients with type 2 diabetes mellitus (T2DM).

METHODS

519 patients with T2DM admitted to our hospital were included. All patients had CA199 levels measured. Patients were divided into low glycation (LH) group (HbA1C <7.5%), Hyperglycemia (HH) group (HbA1C ≥7.5%), fasting glucose compliance (SF) group (FBG <7.0 mmol/L), high fasting glucose (HF) group (FBG ≥7.0 mmol/L), postprandial glucose compliance (SP) group (PBG <10.0 mmol/L) and high postprandial glucose (HP) group (PBG ≥10.0 mmol/L) and with microvascular complications group, and no microvascular complications group. Division was according to levels of glycated hemoglobin (HbA1C), fasting blood glucose (FBG), 2-hour postprandial blood glucose (2hPBG), and diabetic microvascular complications.

RESULTS

CA199 levels were significantly higher in the HH and HF groups than in the LH and SF groups (P<0.05); HbA1C and FBG were positively correlated with CA199; CA199 levels were not significantly different between SP and HP groups (P>0.05), and PBG was not significantly correlated with CA199 levels. CA199 levels were significantly higher in the group with microvascular complications than in the group without microvascular complications (P<0.05); HbA1C was an independent risk factor for elevated CA199.

CONCLUSION

Patients with T2DM and higher CA199 levels need to be evaluated for glycemic status and the presence of microvascular complications. HbA1C is a major risk factor for elevated CA199 levels.

Telbivudine for renal transplant recipients with chronic hepatitis B infection: a randomized controlled trial with early termination

BACKGROUND

The aim of this study was to analyze changes in renal function in HBsAg-positive renal transplant recipients receiving lamivudine who did or did not switch to telbivudine.

METHODS

In this prospective randomized clinical trial (RCT), HBsAg-positive renal transplant recipients who had received lamivudine prophylaxis for at least 6 months were 1:2 randomized to receive either lamivudine or telbivudine for another 24 months. Renal function was evaluated by creatinine level and estimated glomerular filtration rate (eGFR) at the time of randomization (baseline), 6, 12, 18, and 24 months respectively.

RESULTS

This RCT was prematurely terminated after recruiting only 17 patients due to a high incidence (61.5%; 8/13) of clinical myalgia in the telbivudine group. Cox's proportional hazards model revealed that there was no independent predictor of myalgia. Based on intention-to-treat and per protocol analyses using generalized estimating equations, the patients in the randomized telbivudine group had a significantly increased eGFR and the patients in the lamivudine group had a significantly decreased eGFR at the end of follow-up compared to the values at study enrollment. However, there was no significant difference between the lamivudine and telbivudine groups.

CONCLUSIONS

The renal protective effect of telbivudine for HBsAg positive renal transplant recipients was uncertain for high incidence of myalgia and only patients who were on telbivudine for 24 months had renal function maintenance.

Paliperidone is associated with reduced risk of severe hepatic outcome in patients with schizophrenia and viral hepatitis: A nationwide population-based cohort study

OBJECTIVE

Paliperidone, a second-generation antipsychotic, has been found to have minimal hepatotoxicity in patients with schizophrenia. However, long-term hepatic outcome in patients with schizophrenia and viral hepatitis remains unclear.

METHODS

Data obtained from the Taiwan National Health Insurance Research Database was used to enroll newly diagnosed schizophrenic patients between January 2007 and December 2013. Patients with schizophrenia and viral hepatitis who were receiving paliperidone were allocated to the paliperidone group while those who were not receiving paliperidone were allocated to the control group. Using a 1:2 ratio, we matched the age, sex, and index year to select the control participants. Patients with severe hepatic outcomes (SHOs) before enrollment were excluded. The two groups were studied until December 31, 2013. The primary endpoint was the occurrence of SHOs including liver failure, liver decompensation, liver transplantation, or liver cancer.

RESULTS

We identified 134 patients with schizophrenia and viral hepatitis who received paliperidone and 268 matched patients who did not receive paliperidone. Of the 402 patients, 22 (5.47%) developed SHOs during a mean follow-up period of 3.57 ± 1.62 years, including 2 (1.49%) from the paliperidone cohort and 20 (7.46%) from the control group. Furthermore, the Cox multivariate proportional hazards analysis revealed that the risk decreased with paliperidone use (adjusted hazard ratio [HR]: 0.155, 95% confidence interval [CI]: 0.032-0.737, p = 0.019) after adjusted for confounding factors.

CONCLUSION

Paliperidone treatment was associated with a reduced risk of SHOs in patients with schizophrenia and viral hepatitis.

Successful Treatment of Chronic Hepatitis C Virus Infection With Sofosbuvir and Ledipasvir in Renal Transplant Recipients

BACKGROUND

Treatment of chronic hepatitis C virus (HCV) infection after renal allograft transplantation has been an obstacle because of contraindications associated with IFN-based therapies. Direct-acting antiviral agents are highly efficient treatment options that do not require IFN and may not require ribavirin. Therefore, we assessed the efficacy and safety of sofosbuvir and ledipasvir in renal transplant patients with chronic HCV infection.

METHODS

Fifteen renal allograft recipients with therapy-naive HCV genotype (GT) 1a, 1b, or 4 were treated with the combination of sofosbuvir and ledipasvir without ribavirin for 8 or 12 weeks. Clinical data were retrospectively analyzed for viral kinetics and for renal and liver function parameters. Patients were closely monitored for trough levels of immunosuppressive agents, laboratory values, and potential adverse effects.

RESULTS

Ten patients (66%) exhibited a rapid virologic response within 4 weeks (HCV GT1a, n = 4; HCV GT1b, n = 6). The other 5 patients exhibited a virologic response within 8 (HCV GT 1b, n = 4) or 12 weeks (HCV GT4, n = 1). One hundred percent of patients exhibited sustained virologic response at week 12 after the end of treatment. Clinical measures of liver function improved substantially for all patients. Adverse events were scarce; renal transplant function and proteinuria remained stable. Importantly, dose adjustments for tacrolimus were necessary for maintaining sufficient trough levels.

CONCLUSIONS

The described regimen appears to be safe and effective for patients after renal transplant and is a promising treatment regimen for eradicating HCV in this patient population.