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Performance of B-mode ratio and 2D shear wave elastography for the detection and quantification of hepatic steatosis and fibrosis after liver transplantation. Eur J Gastroenterol Hepatol 2020; 32:222-230. [PMID: 31464783 DOI: 10.1097/meg.0000000000001500] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate the diagnostic performance of B-mode ratio and shear wave elastography (SWE) for the assessment of steatosis and liver fibrosis after liver transplantation. MATERIALS AND METHODS Patients hospitalized for a systematic check-up after liver transplantation underwent the same day hepatic ultrasound with B-mode ratio and SWE, followed by liver biopsy and biological examinations. Steatosis was measured using hepatorenal sonographic index of B-mode ratio and liver stiffness using SWE. Liver biopsy, used as gold standard, graded steatosis S0(<5%), S1(5-<33%), S2(33-<66%), or S3(≥66%) and liver fibrosis according to the Metavir score. The results were tested against two external validation cohorts. RESULTS Fifty-eight patients were included. Mean B-ratio value was significantly higher in patients with steatosis (0.95 ± 0.13 versus 1.39 ± 0.41, P < 0.001). A B-mode ratio cutoff values at least 0.985 was found optimal for steatosis' detection [area under the receiver operating characteristic curve (AUROC) 0.902 ± 0.05, sensitivity 95%, specificity 79%]. A B-mode ratio value below 0.9 ruled out steatosis and above 1.12 ruled in steatosis. Mean SWE value for patients without significant fibrosis (≤F1) was 15.90 ± 9.2 versus 19.27 ± 7.7 kPa for patients with fibrosis (P = 0.185). A 2D-SWE value below 7.85 kPa ruled out significant fibrosis and above 26.35 kPa ruled it in. CONCLUSION The B-mode ratio is an efficient and accurate tool for the noninvasive diagnostic of steatosis in postliver transplantation patients. Yet, because liver stiffness is higher in postliver transplantation patients, 2D-SWE is not reliable in the diagnosis of significant fibrosis after liver transplantation.
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2
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Hu B, Yang XB, Sang XT. Liver graft rejection following immune checkpoint inhibitors treatment: a review. Med Oncol 2019; 36:94. [DOI: 10.1007/s12032-019-1316-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/09/2019] [Indexed: 02/07/2023]
Abstract
Abstract
Immune checkpoint inhibitors (ICIs) have demonstrated remarkable efficacy in a variety of solid tumors; nonetheless, they have not been well investigated and are still recognized as a relative contraindication for patients with a liver transplantation (LT) history, since ICIs treatment might potentially lead to graft rejection. The program death-1 (PD-1) and the cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) pathways are implicated in the tolerance of transplanted organ, as well as blockade of the pathways, which contribute to eliminating tumors and may inadvertently lead to peripheral transplant rejection. Currently, no guidelines are available regarding the treatment for ICIs patients with a prior LT history. Therefore, this study was carried out to review the recent studies, attempting to introduce the ICIs-related graft rejection after LT from various aspects. We believed that ICIs could be given for the well-informed patients receiving LT and developed recurrence in a controlled setting. Typically, these patients should be treated according to a clinical care path or a prospective clinical trial, so as obtain a persistent anti-tumor immune response in the meantime of avoiding graft rejection, adjust the immunosuppression, reduce the possibility of graft loss following rejection, and have the opportunity to develop biomarkers for tumor response and transplant rejection.
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Dhanasekaran R, Sanchez W, Mounajjed T, Wiesner RH, Watt KD, Charlton MR. Impact of fibrosis progression on clinical outcome in patients treated for post-transplant hepatitis C recurrence. Liver Int 2015; 35:2433-41. [PMID: 26058570 DOI: 10.1111/liv.12890] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 06/03/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS Patients who achieve sustained virological response (SVR) following the treatment of post-liver transplant (LT) recurrence of hepatitis C virus (HCV) infection have improved outcomes. The full impact of eradication of HCV on allograft histology is, however, not clearly known. METHODS We studied allograft histology in protocol-based paired liver biopsies in consecutive LT recipients who underwent post-LT treatment of recurrence of HCV. RESULTS A total of 116 patients were treated with interferon-based therapy for recurrent HCV. Paired pre-treatment baseline biopsies and post-treatment biopsies were available in 83.2% of patients. SVR was achieved in 37.9% of patients. Among the patients who achieved SVR, 20.5% had progression of fibrosis on post-treatment biopsies vs. 65.5% of patients with non-response/relapse (P < 0.001). The impact of virological response on fibrosis progression was sustained and a similar outcome was observed in the subset of patients who had 4-5 year post-treatment biopsies available. In the SVR group, 12.8% progressed to fibrosis stage ≥3 on post-treatment biopsies vs. 37.9% in the non-response/relapse group (P = 0.001). The 5-year survival in patients with progression of fibrosis 86% vs. 98% among patients who had improvement/stable fibrosis [P = 0.003; HR 3.8 (1.2-11.8)]. A small subset of patients who achieve SVR unfortunately still experience progression of fibrosis, most commonly associated with plasma cell hepatitis. CONCLUSIONS In post-transplant patients treated for HCV, SVR is associated with improved graft survival and also with sustained and significant improvement in histological outcome. Importantly, progression of fibrosis still occurred in a small subset of patients who achieved SVR.
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Affiliation(s)
| | - William Sanchez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Taofic Mounajjed
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Russell H Wiesner
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Michael R Charlton
- Intermountain Transplant Center, Intermountain Medical Center, Murray, UT, USA
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4
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Pretransplant model for end-stage liver disease score as a predictor of postoperative complications after liver transplantation. Transplant Proc 2015; 41:1240-2. [PMID: 19460528 DOI: 10.1016/j.transproceed.2009.02.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The model for end-stage liver disease (MELD) is used to determine organ allocation priorities for orthotopic liver transplantation (OLT), although its value to predict posttransplantation mortality and morbility is controversial. The aim of this study was to analyze postoperative courses and (to evaluate the relationships between MELD score and postoperative) complications. We retrospectively examined the courses of 242 patients including 186 males and 56 females of overall mean age of 53 +/- 10 years who underwent primary liver transplantation. The classification of Dindo-characterized 5 grades of severity to evaluate postoperative events. The data showed that 171 patients (70.7%) experienced complications, while 71 (29.3%) had none. We observed that MELD score and complications were related (P < .05). Patients with complicated courses post-OLT displayed a 22.80 mean value of the MELD score, while those without complications showed a 17.64 mean value. The MELD score was also significantly associated with the time of intensive care unit stay and in hospital. Finally, we noted that MELD score and mortality were significantly correlated (P < .05). In conclusion, MELD score can be considered to be an objective system to predict the prevalence and severity of postoperative complications after liver transplantation.
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5
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Dumortier J, Boillot O, Scoazec JY. Natural history, treatment and prevention of hepatitis C recurrence after liver transplantation: Past, present and future. World J Gastroenterol 2014; 20:11069-11079. [PMID: 25170196 PMCID: PMC4145750 DOI: 10.3748/wjg.v20.i32.11069] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 03/07/2014] [Accepted: 06/23/2014] [Indexed: 02/06/2023] Open
Abstract
Hepatitis C virus (HCV)-related liver disease, including cirrhosis and hepatocellular carcinoma is the main indication for liver transplantation (LT) worldwide. Post-transplant HCV re-infection is almost universal and results in accelerated progression from acute hepatitis to chronic hepatitis, and liver cirrhosis. Comprehension and treatment of recurrent HCV infection after LT have been major issues for all transplant hepatologists and transplant surgeons for the last decades. The aim of this paper is to review the evolution of our knowledge on the natural history of HCV recurrence after LT, including risk factors for disease progression, and antiviral therapy. We will focus our attention on possible ways (present and future) to improve the final long-term results of LT for HCV-related liver disease.
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6
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Dumortier J, Salamé E, Roche B, Hurtova M, Conti F, Radenne S, Vanlemmens C, Pageaux GP, Saliba F, Samuel D, Compagnon P, Neau-Cransac M, Calmus Y, Guillaud O, Gugenheim J, Altieri M, Durand F, Hardwigsen J, Lorho R, Dharancy S, Leroy V, Di Giambattista F, Duvoux C. Severe fibrosis in patients with recurrent hepatitis C after liver transplantation: a French experience on 250 patients over 15 years (the Orfèvre study). Clin Res Hepatol Gastroenterol 2014; 38:292-9. [PMID: 24685602 DOI: 10.1016/j.clinre.2014.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 01/27/2014] [Accepted: 02/18/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Recurrent hepatitis C after liver transplantation (LT) is associated with rapid fibrosis progression. The aim of this study was to evaluate the cumulative risk for severe fibrosis and the factors influencing it. PATIENTS AND METHODS Two hundred and fifty LT patients were included 1 to 15years after LT. Recurrence of chronic hepatitis C on liver graft was classified according to Metavir score. RESULTS Kaplan-Meyer estimates for actuarial progression to severe fibrosis (Metavir>F3) showed a probability of 15.2% and 44.5% at 5 and 10years, respectively. Predictive factors for progression to severe fibrosis were: use of tacrolimus as main CNI, recipient age at time of biopsy<55, donor age ≥45, graft HCV re-infection<3months, biologically suspected graft re-infection and lack of response to antiviral treatment after LT. Multivariate analysis disclosed that only donor age ≥45 (hazard ratio 2.243, 95%CI 1.264-3.983, P=0.0058) and lack of response to antiviral treatment (hazard ratio 2.816, 95%CI 1.227-6.464, P=0.0146) were associated to severe fibrosis. CONCLUSIONS Our study confirms that donor age ≥45 and lack of response to antiviral treatment after LT are major predictive factors of progression of HCV recurrence on liver graft.
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Affiliation(s)
- Jérôme Dumortier
- Unité de transplantation hépatique-fédération des spécialités digestives, HCL, pavillon D, hôpital Edouard-Herriot, 69437 Lyon cedex 03, France.
| | - Ephrem Salamé
- Service de chirurgie digestive et transplantation hépatique, hôpital Trousseau, 37170 Chambray-lès-Tours, France
| | - Bruno Roche
- Centre hépato-biliaire, hôpital Paul-Brousse, AP-HP, 94804 Villejuif, France
| | - Monika Hurtova
- Service d'hépatologie, hôpital Henri-Mondor, AP-HP, 94000 Créteil, France
| | - Filomena Conti
- Service de chirurgie, hôpital Cochin, AP-HP, 75014 Paris, France
| | - Sylvie Radenne
- Service d'hépatologie, HCL, hôpital de la Croix-Rousse, 69205 Lyon, France
| | - Claire Vanlemmens
- Service d'hépatologie, hôpital Jean-Minjoz, CHU de Besançon, 25030 Besançon, France
| | - Georges-Philippe Pageaux
- Fédération médico-chirurgicale des maladies de l'appareil digestif, hôpital Saint-Eloi, 34295 Montpellier, France
| | - Faouzi Saliba
- Centre hépato-biliaire, hôpital Paul-Brousse, AP-HP, 94804 Villejuif, France
| | - Didier Samuel
- Centre hépato-biliaire, hôpital Paul-Brousse, AP-HP, 94804 Villejuif, France
| | - Philippe Compagnon
- Service de chirurgie digestive et hépato-biliaire - transplantation hépatique, hôpital Henri-Mondor, AP-HP, 94000 Créteil, France
| | | | - Yvon Calmus
- Service de chirurgie, hôpital Cochin, AP-HP, 75014 Paris, France
| | - Olivier Guillaud
- Unité de transplantation hépatique-fédération des spécialités digestives, HCL, pavillon D, hôpital Edouard-Herriot, 69437 Lyon cedex 03, France
| | - Jean Gugenheim
- Service de chirurgie digestive, hôpital L'Archet 2, CHU de Nice, 06202 Nice, France
| | - Mario Altieri
- Service de chirurgie digestive, CHU de Côte de Nacre, 14033 Caen, France
| | - François Durand
- Service d'hépatologie, hôpital Beaujon, AP-HP, 92118 Clichy, France
| | - Jean Hardwigsen
- Service de chirurgie digestive, hôpital la Conception, 13385 Marseille, France
| | - Richard Lorho
- Service de chirurgie hépato-biliaire et digestive, hôpital de Pontchaillou, 35033 Rennes, France
| | | | - Vincent Leroy
- Service d'hépato-gastro-entérologie, hôpital A.-Michallon, 38700 La Tronche, France
| | | | - Christophe Duvoux
- Service d'hépatologie, hôpital Henri-Mondor, AP-HP, 94000 Créteil, France
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Layden JE, Tayo BO, Cotler SJ, Clark NM, Baraoidan K, Friedman SL, Cooper RS. Association of genetic variants with rapid fibrosis: progression after liver transplantation for hepatitis C. Transplantation 2014; 97:1072-8. [PMID: 24770613 PMCID: PMC4524502 DOI: 10.1097/01.tp.0000440953.06886.a3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Recurrence of hepatitis C, the main indication for liver transplantation in the United States, leads to rapid fibrosis progression and worse outcomes compared to other indications. While clinical variables play a role, they are insufficient to explain all inter-patient variability in posttransplant fibrosis progression. Genetic factors associated with hepatitis C virus (HCV) outcomes have been identified, but limited studies have been conducted in the context of HCV-related liver transplantation. Therefore, the purpose of this study was to examine candidate genes related to the immune response and rate of fibrosis in subjects undergoing liver transplantation for HCV. METHODS One hundred twelve recipients with detailed posttransplant fibrosis and clinical information were genotyped using 25 single nucleotide variants (SNVs), including five SNVs within the IL28B gene region. Associations between SNVs and rapid fibrosis progression were performed controlling for pertinent clinical variables and haplotype analyses for the IL28B gene were completed. RESULTS Significant multivariable associations were found for rs8099917 (IL28B), rs1991401 (DDX5), rs4969168 (SOC3), and rs7976497 (MLEC). The minor allele was protective against rapid fibrosis progression for the IL28B SNV (G allele), MLEC SNV (T allele), and DDX5 SNV (G allele). For the SOC3 SNV, the minor allele (A) increased the risk for rapid fibrosis progression. Additionally, two recipient haplotype structures for IL28B were significantly associated with rapid fibrosis progression. CONCLUSIONS These findings indicate that recipient genetic factors play a role in posttransplant HCV-related fibrosis progression. Molecular studies of these pathways may elucidate the pathogenesis of posttransplant fibrosis progression and provide risk prediction markers.
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Affiliation(s)
- Jennifer E. Layden
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Medical School, Maywood, IL
- Department of Medicine, Loyola Stritch School of Medicine, Loyola University Medical School, Maywood, IL
| | - Bamidele O. Tayo
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Medical School, Maywood, IL
| | - Scott J. Cotler
- Department of Medicine, Loyola Stritch School of Medicine, Loyola University Medical School, Maywood, IL
| | - Nina M. Clark
- Department of Medicine, Loyola Stritch School of Medicine, Loyola University Medical School, Maywood, IL
| | | | - Scott L. Friedman
- Division of Liver Diseases, Icahn School of Medicine at Mt Sinai, New York, NY
| | - Richard S. Cooper
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Medical School, Maywood, IL
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Howell J, Angus P, Gow P. Hepatitis C recurrence: the Achilles heel of liver transplantation. Transpl Infect Dis 2013; 16:1-16. [PMID: 24372756 DOI: 10.1111/tid.12173] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 06/12/2013] [Accepted: 08/03/2013] [Indexed: 12/18/2022]
Abstract
Hepatitis C virus (HCV) infection is the most common indication for liver transplantation worldwide; however, recurrence post transplant is almost universal and follows an accelerated course. Around 30% of patients develop aggressive HCV recurrence, leading to rapid fibrosis progression (RFP) and culminating in liver failure and either death or retransplantation. Despite many advances in our knowledge of clinical risks for HCV RFP, we are still unable to accurately predict those most at risk of adverse outcomes, and no clear consensus exists on the best approach to management. This review presents a critical overview of clinical factors shown to influence the course of HCV recurrence post transplant, with particular focus on recent data identifying the important role of metabolic factors, such as insulin resistance, in HCV recurrence. Emerging data for genetic markers of HCV recurrence and their usefulness for predicting adverse outcomes will also be explored.
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Affiliation(s)
- J Howell
- Liver Transplant Unit, Austin Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
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9
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Russo MW, Narang T, Eskind L, Hayes D, Casingal V, Purdum PP, Hanson JS, Ahrens W, Norton J, Bonkovsky H. Intravenous interferon administered during liver transplantation is not effective in preventing hepatitis C reinfection. Dig Dis Sci 2013; 58:3010-6. [PMID: 23812862 DOI: 10.1007/s10620-013-2749-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 06/05/2013] [Indexed: 12/09/2022]
Abstract
BACKGROUND Post-transplant hepatitis C is a major challenge after liver transplantation (LT). Antiviral therapy is associated with lower efficacy in the post-transplant setting. AIMS The purpose of this study was to determine the safety and effect of intravenous interferon (IFN) during the anhepatic phase of LT on hepatitis C viral load. METHODS Fifteen consecutive subjects undergoing liver transplant for hepatitis C cirrhosis were enrolled in the study, ten of which received study drug and five subjects served as controls. Cases received weight-based ribavirin and subcutaneous IFN at time of incision followed by intravenous IFN at the start of the anhepatic phase. Adverse events and viral levels were recorded. Repeated measures ANOVA was employed to test for differences over time, between the groups, and time by group interaction. RESULTS All subjects had genotype 1 virus. Hepatitis C viral load was lower at week 4 in cases compared to controls (769,004 ± 924,082 IU/ml and 2,329,896 ± 3,731,749 IU/ml, respectively), but did not reach statistical significance (p = 0.50). Three subjects developed adverse events related to IFN including pulmonary edema, rejection, and neutropenia. CONCLUSIONS Intravenous IFN administered during the anhepatic phase of liver transplant did not prevent graft reinfection and was associated with manageable adverse events. This regimen could be further studied if direct acting antiviral agents alone are insufficient for treating post-transplant hepatitis C.
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Affiliation(s)
- Mark W Russo
- Transplant Center, Department of Medicine, Carolinas Medical Center, 1000 Blythe Blvd, 3rd Floor Annex Building, Charlotte, NC, 28203, USA,
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10
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Satapathy SK, Fiel MI, Vanatta JM, Del Rio Martin J, Schiano TD. Recurrent hepatitis C virus infection and outcome after living-donor liver transplant. EXP CLIN TRANSPLANT 2013; 11:522-9. [PMID: 23901801 DOI: 10.6002/ect.2013.0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES In living-donor liver transplant recipients with hepatitis C virus infection, outcomes of recurrent hepatitis C virus infection and fibrosis progression are not well documented. We evaluated fibrosis progression, response to pegylated interferon treatment, and long-term graft survival in living-donor liver transplant recipients who had hepatitis C virus infection. MATERIALS AND METHODS In 48 transplant recipients, including 29 recipients who had follow-up liver biopsy ≥ 6 months after transplant, histology and clinical courses were reviewed. Outcomes were evaluated for patients grouped into slow and rapid fibrosis groups. Treatment with pegylated interferon and ribavirin was assessed in 18 patients. RESULTS Clinical features were similar between recipients with slow or rapid fibrosis. The time interval from transplant to recurrence of hepatitis C virus infection was significantly shorter in the recipients with rapid fibrosis. Recipients with rapid fibrosis had significantly greater confluent necrosis, acidophil bodies, and fibrosis score than recipients with slow fibrosis. Graft survival rates were similar between patients with slow or rapid fibrosis. Cumulative proportion of long-term graft survival was 60% at 7 years after transplant. Sustained virologic response was noted in 5 of 18 patients (28%) who received pegylated interferon and ribavirin. CONCLUSIONS In recipients of living-donor liver transplant with early recurrence of hepatitis C have worse fibrosis progression but graft survival was not affected. Therapy with pegylated interferon and ribavirin achieved sustained virologic response only in a small proportion of the patients.
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Affiliation(s)
- Sanjaya K Satapathy
- Division of Liver Diseases, Department of Medicine, Mount Sinai Medical Center, New York, NY and the Division of Surgery, Methodist University Hospital Transplant Institute, University of Tennessee Health Sciences Center, Memphis, TN, USA
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11
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Duvoux C, Firpi R, Grazi GL, Levy G, Renner E, Villamil F. Recurrent hepatitis C virus infection post liver transplantation: impact of choice of calcineurin inhibitor. Transpl Int 2013; 26:358-72. [PMID: 23413991 DOI: 10.1111/tri.12065] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 03/23/2012] [Accepted: 12/23/2012] [Indexed: 02/06/2023]
Abstract
Recurrence of hepatitis C virus infection following liver transplantation (LT) for hepatitis C is universal. After LT, hepatitis C is associated with accelerated fibrosis progression and reduced graft and patient survival. Furthermore, responses to antiviral therapy in patients with recurrent hepatitis C virus post-transplant are consistently sub-optimal. Calcineurin inhibitors (CNIs) like cyclosporine A (CsA) and tacrolimus continue to dominate immunosuppressive regimens in this population; however, there is still uncertainty as to whether either offers an advantage in terms of patient outcomes. Although tacrolimus demonstrates improved efficacy in the general LT population, differences have begun to emerge between these agents regarding diabetogenic potential, antiviral activity, and fibrosis progression in patients with hepatitis C. This review critically evaluates the existing literature, providing an overview of the reported differences, concluding that despite conflicting evidence, a potential benefit of CsA in patients with hepatitis C is supported by the data and warrants further investigation. Future studies examining the role of CNIs in hepatitis C virus-positive LT recipients are required to accurately examine the effects of CNIs on outcomes such as fibrosis progression, survival, and effects on response to antiviral therapy, to provide robust information that allows clinicians to make an informed choice concerning which CNI is best for their patients.
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12
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Shear wave elastography in the evaluation of rejection or recurrent hepatitis after liver transplantation. Eur Radiol 2013; 23:1729-37. [PMID: 23300037 DOI: 10.1007/s00330-012-2748-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 11/04/2012] [Accepted: 11/15/2012] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To determine whether shear wave elastography (SWE) would be useful in evaluating the presence of rejection or recurrent hepatitis for post-liver transplantation (LT) follow-up. METHODS This retrospective study was approved by our Institutional Review Board and informed consent was waived. Two hundred sixteen liver recipients and 37 liver donors received SWE and concurrent liver biopsy. Of the liver recipients, 142 patients underwent SWE > 4 weeks after the LT (group 1) and 74 patients underwent SWE ≤ 4 weeks after the LT (group 2). Liver stiffness (LS) was compared among groups of donor, no rejection, acute rejection and recurrent hepatitis. RESULTS In group 1, LS was higher in patients with rejection or hepatitis than in patients without rejection or indefinite rejection (12.29 ± 8.13 kPa vs. 6.33 ± 2.10 kPa, respectively, P < 0.001). In group 2, there was no difference in LS between patients with rejection (n = 8) and those without rejection (n = 61; P > 0.05). The liver recipients without rejection or hepatitis in both groups showed significantly higher LS than the liver donors (P < 0.001). CONCLUSIONS SWE may be used as a non-invasive complementary tool to detect rejection or recurrent hepatitis at follow-up > 4 weeks after the LT. KEY POINTS • Shear wave ultrasound elastography may be useful at follow-up after liver transplantation • Rejection or hepatitis can be predicted >4 weeks after liver transplantation • Normal liver grafts are stiffer than normal liver.
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14
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Carbone M, Lenci I, Baiocchi L. Prevention of hepatitis C recurrence after liver transplantation: An update. World J Gastrointest Pharmacol Ther 2012; 3:36-48. [PMID: 22966482 PMCID: PMC3437445 DOI: 10.4292/wjgpt.v3.i4.36] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 06/20/2012] [Accepted: 06/28/2012] [Indexed: 02/06/2023] Open
Abstract
Hepatitis C related liver failure and hepatocarcinoma are the most common indications for liver transplantation in Western countries. Recurrent hepatitis C infection of the allograft is universal and immediate following liver transplantation, being associated with accelerated progression to cirrhosis, graft loss and death. Graft and patient survival is reduced in liver transplant recipients with recurrent Hepatitis C virus (HCV) infection compared to HCV-negative recipients. Many variables may impact on recurrent HCV liver disease. Overall, excess immunosuppression is believed to be a key factor; however, no immunosuppressive regimen has been identified to be more beneficial or less harmful. Donor age limitations, exclusion of moderately to severely steatotic livers and minimization of ischemic times could be a potential strategy to minimize the severity of HCV disease in transplanted subjects. After transplantation, antiviral therapy based on pegylated IFN alpha with or without ribavirin is associated with far less results than that reported for immunocompetent HCV-infected patients. New findings in the field of immunotherapy and genomic medicine applied to this context are promising.
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Affiliation(s)
- Marco Carbone
- Marco Carbone, Liver Unit, Queen Elizabeth Hospital, Birmingham, B15 2TH, United Kingdom
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15
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Berenguer M, Charco R, Manuel Pascasio J, Ignacio Herrero J. Spanish society of liver transplantation (SETH) consensus recommendations on hepatitis C virus and liver transplantation. Liver Int 2012; 32:712-31. [PMID: 22221843 DOI: 10.1111/j.1478-3231.2011.02731.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 11/23/2011] [Indexed: 02/06/2023]
Abstract
In November 2010, the Spanish Society of Liver Transplantation (Sociedad Española de Trasplante Hepático, SETH) held a consensus conference. One of the topics of debate was liver transplantation in patients with hepatitis C. This document reviews (i) the natural history of post-transplant hepatitis C, (ii) factors associated with post-transplant prognosis in patients with hepatitis C, (iii) the role of immunosuppression in the evolution of recurrent hepatitis C and response to antiviral therapy, (iv) antiviral therapy, both before and after transplantation, (v) follow-up of patients with recurrent hepatitis C and (vi) the role of retransplantation.
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Affiliation(s)
- Marina Berenguer
- Spanish Society of Liver Transplantation (Sociedad Española de Trasplante Hepático, SETH)
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Abstract
Hepatitis-C-virus- (HCV-) related end-stage cirrhosis is the primary indication for liver transplantation in many countries. Unfortunately, however, HCV is not eliminated by transplantation and graft reinfection is universal, resulting in fibrosis, cirrhosis, and finally graft decompensation. The use of poor quality organs, particularly from older donors, has a highly negative impact on the severity of recurrence and patient/graft survival. Although immunosuppressive regimens have a considerable impact on the outcome, the optimal regimen after liver transplantation for HCV-infected patients remains unclear. Disease progression monitoring with protocol biopsy and new noninvasive methods is essential for predicting patient/graft outcome and starting antiviral treatment with the appropriate timing. Antiviral treatment with pegylated interferon and ribavirin is currently considered the most promising regimen with a sustained viral response rate of around 30% to 35%, although the survival benefit of this regimen remains to be investigated. Living-donor liver transplantation is now widely accepted as an established treatment for HCV cirrhosis and the results are equivalent to those of deceased donor liver transplantation.
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17
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Venturi C, Bueno J, Castells L, Quintero J, Casas I, Allende H, Martinez-Ibañez V, Charco R. Long-term outcome of hepatitis C virus infections acquired after pediatric liver transplantation. Liver Transpl 2011; 17:1474-80. [PMID: 21932378 DOI: 10.1002/lt.22439] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The outcomes and characterization of hepatitis C virus (HCV) infections after pediatric liver transplantation (LT) have rarely been reported. We describe our experience with HCV infections after pediatric LT. Ten of 207 children (4.8%) who underwent LT at our institution (1985-2010) developed previously undiagnosed HCV disease. Eight received a liver graft before blood product and donor screening for HCV became available. The mean age at transplantation was 8.9 ± 4.3 years, and the median time from transplantation to the diagnosis of HCV was 15.1 years (range = 0.2-19.7 years). The genotypes were 1 (n = 8), 3 (n = 1), and undetermined (n = 1). At the time of this writing, all the patients were still alive with a mean follow-up of 7.3 ± 5.5 years after the diagnosis of HCV. Five patients did not receive treatment; 2 of these patients achieved spontaneous viral clearance (SVC). Four of the 5 treated patients achieved a sustained virological response, and 3 had an early virological response (EVR). Two of these 4 patients developed chronic rejection while they were on treatment, but this was resolved with a conversion from cyclosporine A to tacrolimus. The remaining patient was continuing treatment and had achieved EVR. In conclusion, despite the limitations of our series, de novo HCV infections after pediatric LT seem to have a slow histological progression. Even with genotype 1, the patients have a good long-term prognosis and respond well to treatment. Nevertheless, chronic rejection during antiviral therapy may develop. In addition, SVC may occur in this population.
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Affiliation(s)
- Carla Venturi
- Pediatric Surgery and Transplant Unit, Saint Luc University Clinics, Brussels, Belgium
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18
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Klintmalm GB, Davis GL, Teperman L, Netto GJ, Washburn K, Rudich SM, Pomfret EA, Vargas HE, Brown R, Eckhoff D, Pruett TL, Roberts J, Mulligan DC, Charlton MR, Heffron TG, Ham JM, Douglas DD, Sher L, Baliga PK, Kinkhabwala M, Koneru B, Abecassis M, Millis M, Jennings LW, Fasola CG. A randomized, multicenter study comparing steroid-free immunosuppression and standard immunosuppression for liver transplant recipients with chronic hepatitis C. Liver Transpl 2011; 17:1394-403. [PMID: 21850690 DOI: 10.1002/lt.22417] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This randomized, prospective, multicenter trial compared the safety and efficacy of steroid-free immunosuppression (IS) to the safety and efficacy of 2 standard IS regimens in patients undergoing transplantation for hepatitis C virus (HCV) infection. The outcome measures were acute cellular rejection (ACR), severe HCV recurrence, and survival. The patients were randomized (1:1:2) to tacrolimus (TAC) and corticosteroids (arm 1; n = 77), mycophenolate mofetil (MMF), TAC, and corticosteroids (arm 2; n = 72), or MMF, TAC, and daclizumab induction with no corticosteroids (arm 3; n = 146). In all, 295 HCV RNA-positive subjects were enrolled. At 2 years, there were no differences in ACR, HCV recurrence (biochemical evidence), patient survival, or graft survival rates. The side effects of IS did not differ, although there was a trend toward less diabetes in the steroid-free group. Liver biopsy samples revealed no significant differences in the proportions of patients in arms 1, 2, and 3 with advanced HCV recurrence (ie, an inflammation grade ≥ 3 and/or a fibrosis stage ≥ 2) in years 1 (48.2%, 50.4%, and 43.0%, respectively) and 2 (69.5%, 75.9%, and 68.1%, respectively). Although we have found that steroid-free IS is safe and effective for liver transplant recipients with chronic HCV, steroid sparing has no clear advantage in comparison with traditional IS.
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19
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Magnetic Resonance Elastography and Biomarkers to Assess Fibrosis From Recurrent Hepatitis C in Liver Transplant Recipients. Transplantation 2011; 92:581-6. [DOI: 10.1097/tp.0b013e31822805fa] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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20
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Liver transplant outcomes in HIV-infected patients: a systematic review and meta-analysis with synthetic cohort. AIDS 2011; 25:777-86. [PMID: 21412058 DOI: 10.1097/qad.0b013e328344febb] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES The relative success of liver transplantation in those with HIV compared to HIV-uninfected individuals remains a point of intense debate. We aimed to evaluate the effectiveness of liver transplantation in HIV-hepatitis co-infected patients using a meta-analysis and individual patient data meta-analysis as a synthetic cohort. METHODS We searched MEDLINE via PubMed, EMBASE, Cochrane CENTRAL, AIDSLINE (inception to 2010), AMED, CINAHL, TOXNET, Development and Reproductive Toxicology, Hazardous Substances Databank, Psych-info and relevant conferences. We included cohort studies and individual case-reports evaluating survival of co-infected transplant patients. We abstracted data on cohort and case demographics and outcomes. We pooled cohorts using a random-effects analysis and created a synthetic cohort of cases using individual patient data. We confirmed this with the pooled cohort analysis. RESULTS We included 15 cohort studies and 49 case series with individual patient data. At 12 months, 84.4% [95% confidence interval (CI) 81.1-87.8%] of patients had survived. Within the HIV-infected population evaluated, HIV-hepatitis B virus (HBV) co-infection was associated with optimal survival. In an adjusted model, individuals positive for HBV were 8.28 (95% CI 2.26-30.33) times more likely to survive when compared to those without HBV. Further, individuals with an undetectable HIV viral load at the time of transplantation were 2.89 (95% CI 1.41-5.91) times more likely to survive when compared to those with detectable HIV viremia. Hepatitis C virus was not a predictor of patient survival when adjusted for by other key predictors [0.54 (95% CI 0.17-1.80)].
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21
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The clinical consequences of utilizing donation after cardiac death liver grafts into hepatitis C recipients. Hepatol Int 2011; 5:830-3. [DOI: 10.1007/s12072-010-9242-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2010] [Accepted: 12/19/2010] [Indexed: 11/27/2022]
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Narang TK, Ahrens W, Russo MW. Post-liver transplant cholestatic hepatitis C: a systematic review of clinical and pathological findings and application of consensus criteria. Liver Transpl 2010; 16:1228-35. [PMID: 21031537 DOI: 10.1002/lt.22175] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Liver transplantation is currently the only definitive modality for the treatment of end-stage liver disease due to chronic hepatitis C. However, recurrent hepatitis C after liver transplantation is nearly universal. Cirrhosis may develop in 20% of recipients within 5 years, and recurrent hepatitis C may lead to graft failure, retransplantation, and even death. A subset of recipients may develop post-liver transplant cholestatic hepatitis C (PLTCHC), which is characterized by cholestasis, hepatocyte ballooning, and rapid progression to graft failure. We present a systematic review of PLTCHC that is focused on hepatitis C-infected liver transplant recipients. We compare the pathological definitions of PLTCHC, clinical factors, management strategies, and outcomes reported in studies. We found differences among studies in the types of histological criteria used to diagnose PLTCHC during liver biopsy and in the types of clinical information provided. Three of the 12 studies published after 2003 used the definition of PLTCHC published by the first International Liver Transplantation Society expert panel consensus conference on liver transplantation and hepatitis C. We propose that studies on PLTCHC use the consensus criteria for diagnosis and suggest clinical information that should be provided in future studies with the goal of improving our understanding and management of this deadly disease.
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Affiliation(s)
- Tarun K Narang
- Department of Medicine, Carolinas Medical Center, Charlotte, NC 28203, USA
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Dhillon N, Walsh L, Krüger B, Ward SC, Godbold JH, Radwan M, Schiano T, Murphy BT, Schröppel B. A single nucleotide polymorphism of Toll-like receptor 4 identifies the risk of developing graft failure after liver transplantation. J Hepatol 2010; 53:67-72. [PMID: 20400193 DOI: 10.1016/j.jhep.2009.12.044] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 12/05/2009] [Accepted: 12/29/2009] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS While studies in animal models have linked Toll-like receptor (TLR) 4 signaling to the pathophysiology of ischemia/reperfusion (IR) injury and liver fibrosis, the relevance of TLR4 activation after human liver transplantation is unknown. The TLR4 single nucleotide polymorphism (SNP) D299G is situated within the extracellular domain and diminishes receptor binding to danger-associated molecular patterns. METHODS We studied the influence of TLR4 D299G on IR injury and graft survival in 430 deceased donor LT recipients. Compared with livers expressing wild-type (WT) alleles, livers with a TLR4 loss-of-function allele were significantly more likely to have initial good graft function (IGGF) (OR 2.20, p=0.01). In contrast, there was no effect of recipient TLR4 genotype on the rate of IGGF. RESULTS The effect of TLR4 D299G on long-term graft survival was analyzed based on hepatitis C virus (HCV) serostatus. In HCV infected recipients, multivariate Cox regression analysis demonstrated a significant association between the presence of recipient, but not donor TLR4 D299G and long-term graft failure (HR 2.48, CI 1.28-4.81; p=0.007). There was no difference in graft survival between TLR4 mutant and WT recipients among non-HCV infected recipients. CONCLUSIONS Collectively, these results demonstrate the differential effects of donor and recipient TLR4 signaling in human liver transplantation. Donor TLR4 contributed to sterile injury following cold preservation and the recipient TLR4 genotype was linked with poor allograft survival among HCV infected recipients.
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Affiliation(s)
- Navdeep Dhillon
- Division of Nephrology, Mount Sinai School of Medicine, New York, NY 10029, USA
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24
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Dhillon N, Walsh L, Krüger B, Mehrotra A, Ward SC, Godbold J, Radwan M, Schiano T, Murphy B, Schröppel B. Complement component C3 allotypes and outcomes in liver transplantation. Liver Transpl 2010; 16:198-203. [PMID: 20104494 DOI: 10.1002/lt.21972] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The complement system has been implicated in the pathogenesis of liver diseases. Human complement component C3 (C3) exists as 2 allotypes, fast (F) and slow (S). We conducted a study to address the influence of these alleles on ischemia-reperfusion (IR) injury and graft survival in liver transplant recipients. Four hundred thirty patients receiving liver transplants from 2000 to 2004 were included. C3 allotypes of 296 donor-recipient pairs were determined and correlated with clinical outcomes. Four groups were analyzed according to the C3 genotype: C3 SS donor and recipient, C3 FS or C3 FF donor and C3 SS recipient, C3 SS donor and C3 FS or C3 FF recipient, and C3 FS or C3 FF donor and recipient. Baseline characteristics of the 4 groups were similar. The mean follow-up time was 4.3 +/- 2.2 years. The 4 groups had similar rates of IR injury (P = 0.16). The hazard ratios for liver allograft survival in the C3 SS donor and recipient group in comparison with the other 3 groups (C3 FS or C3 FF donor and C3 SS recipient, C3 SS donor and C3 FS or C3 FF recipient, and C3 FS or C3 FF donor and recipient) were not significantly different: 1.13 (P = 0.60), 0.99 (P = 0.97), and 1.02 (P = 0.95), respectively. In conclusion, donor and recipient C3 genotypes are not associated with liver transplantation outcomes.
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Affiliation(s)
- Navdeep Dhillon
- Division of Nephrology, Mount Sinai School of Medicine, New York, NY 10029, USA
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25
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Gallegos-Orozco JF, Yosephy A, Noble B, Aqel BA, Byrne TJ, Carey EJ, Douglas DD, Mulligan D, Moss A, de Petris G, Williams JW, Rakela J, Vargas HE. Natural history of post-liver transplantation hepatitis C: A review of factors that may influence its course. Liver Transpl 2009; 15:1872-81. [PMID: 19938138 DOI: 10.1002/lt.21954] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Our aim was to assess long-term survival in patients transplanted for HCV-related end-stage liver disease (ESLD) and evaluate potentially modifiable predictors of survival. We performed a retrospective analysis of adult liver transplants (LT) at our institution for HCV-related ESLD since the program's inception. Pertinent demographic, clinical, and biochemical information was retrieved from electronic medical records and histological data from 990 per-protocol liver biopsies were collected. Three hundred eighty LT were performed at our institution during the study period, 206 patients were transplanted for HCV-related ESLD; 6 died within 30 days of transplantation and were not included. The remaining 200 recipients (DDLT 168 LDLT 32) constituted the evaluable population. The demographics were as follows: 150 males, median age 53 years; median donor age 39 years; hepatocellular carcinoma (HCC) in 26%. Overall 1-, 5-, and 7-year survival: 95%, 81%, and 79%; median survival 43 months, mortality 15%. Significant HCV recurrence (HAI >or=6 and/or fibrosis >or=2) was present in 49%, "early recurrence" (within 1 year of LT) in 30.5% and biopsy-proven acute rejection was present in 27%. Factors with a significant negative impact on patient survival included: fibrosis stage >or=2 at 12-month biopsy, advanced donor age, history of HCC and early acute rejection. Survival was similar regardless of the donor type (DDLT vs. LDLT). Early and aggressive HCV recurrence has a very heavy toll on patient survival. Prompt recognition and treatment of "rapid fibrosers" may impart benefit. As has been described before, avoidance of rejection and selection of young donors for HCV-positive recipients will also improve survival in this population. On the basis of our findings, LDLT is a good option for HCV-positive recipients.
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26
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Firpi RJ, Clark V, Soldevila-Pico C, Morelli G, Cabrera R, Levy C, Machicao VI, Chaoru C, Nelson DR. The natural history of hepatitis C cirrhosis after liver transplantation. Liver Transpl 2009; 15:1063-71. [PMID: 19718647 DOI: 10.1002/lt.21784] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Hepatitis C after liver transplantation leads to graft cirrhosis in up to 30% of patients within 5 years, but limited data exist regarding the clinical course of cirrhosis after transplantation. The aims of this study were to report the natural history of hepatitis C cirrhosis after liver transplantation and to identify risk factors for decompensation and survival. Hepatitis C patients underwent protocol liver biopsies yearly after liver transplantation. After cirrhosis was identified by biopsy, the outcomes of interest were the development of decompensation, death, or retransplantation for hepatitis C. Kaplan-Meier and Cox regression analysis was used to determine survival and risk factors for decompensation and mortality. Out of 502 liver transplants performed for hepatitis C, 88 patients (18%) had cirrhosis within 3.7 years. Seventy-one patients were compensated at diagnosis. The cumulative probability of decompensation 1 year after cirrhosis was 30%. A Model for End-Stage Liver disease score >or= 16 was predictive of decompensation and poor survival, whereas successful interferon treatment was found to reduce this risk (relative risk = 0.05). Once decompensation occurred, 1-year survival was 46%. In conclusion, the results confirm an accelerated natural history of hepatitis C cirrhosis after liver transplantation and demonstrate poor survival after decompensation. The Model for End-Stage Liver Disease can stratify risk for decompensation and survival, whereas successful antiviral therapy may be protective.
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Affiliation(s)
- Roberto J Firpi
- Section of Hepatobiliary Diseases, Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL 32610-0214, USA.
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27
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Karnsakul W, Alford MK, Schwarz KB. Managing pediatric hepatitis C: current and emerging treatment options. Ther Clin Risk Manag 2009; 5:651-60. [PMID: 19707281 PMCID: PMC2731021 DOI: 10.2147/tcrm.s5078] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Indexed: 12/18/2022] Open
Abstract
Since 1992, the maternal–fetal route of transmission has become the dominant route for acquisition of hepatitis C (HCV) infection by children. With increasing knowledge of antiviral treatment for HCV infection, the main goal of therapy is to achieve a sustained virological response (SVR) as defined by undetectable serum HCV RNA by polymerase chain reaction assay six months after cessation of therapy. In young children, interferon therapy is more effective than in adults with chronic HCV infection (CHC). Although children clearly have a milder degree of liver pathology, data have indicated that hepatic inflammation from HCV infection can progress to fibrosis or cirrhosis in children. Hepatocellular carcinoma has been reported in adolescents with CHC. In this article, recent improvements in therapy of children with CHC and in the clinical development of new emerging drugs with potential use in children will be reviewed.
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Affiliation(s)
- Wikrom Karnsakul
- Pediatric Liver Center, Division of Pediatric Gastroenterology and Nutrition, Johns Hopkins School of Medicine, Baltimore, MD, USA
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28
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Sadamori H, Yagi T, Iwagaki H, Matsuda H, Shinoura S, Umeda Y, Ohara N, Yanai H, Ogino T, Tanaka N. Immunohistochemical staining of liver grafts with a monoclonal antibody against HCV-Envelope 2 for recurrent hepatitis C after living donor liver transplantation. J Gastroenterol Hepatol 2009; 24:574-80. [PMID: 19368635 DOI: 10.1111/j.1440-1746.2008.05638.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIM We evaluated the expression of hepatitis C virus (HCV) antigen on liver grafts by immunohistochemical staining (IHS) using IG222 monoclonal antibody (mAb) against HCV-envelope 2 (E2). METHODS The study material was 84 liver biopsy specimens obtained from 28 patients who underwent living donor liver transplantation (LDLT) for HCV infection. The biopsy samples were examined histopathologically, and by IHS using IG222 mAb against HCV-E2. Serum HCV-RNA level was measured in all patients. The IHS grades were compared among the three groups classified according to the time elapsed from LDLT (at 1-30, 31-179 and > or =180 days post-LDLT) and among four post-transplant conditions, including acute cellular rejection (ACR). RESULTS Immunoreactivity to IG222 was detected in 78.6% of the specimens obtained during the first month after LDLT, and there were no significant differences on the IHS grades between the three groups classified according to the time elapsed from LDLT. The IHS grades were significantly stronger in definite recurrent HCV (n = 12) and probable recurrent HCV (n = 7) than in definite ACR (n = 7) and other complications (n = 8). There were no significant differences in serum HCV-RNA levels among the four post-transplant conditions. There was no significant correlation between the IHS grades using IG222 mAb and serum HCV-RNA levels when data of 84 liver biopsy specimens were analyzed. CONCLUSIONS Constant HCV-E2 expression was observed in liver biopsy specimens obtained 1 month or longer. The strong HCV-E2 expression on liver grafts were associated with recurrent hepatitis C after LDLT, but the serum HCV-RNA levels were not.
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Affiliation(s)
- Hiroshi Sadamori
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine and Dentistry, 2-5-1 Shikata, Okayama 700-8558, Japan.
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Abstract
1. Liver failure and liver cancer from chronic hepatitis C are the most common indications for liver transplantation and numbers of both are projected to double over the next 20 years. 2. Recurrent hepatitis C infection of the allograft is universal and immediate following liver transplantation and associated with accelerated progression to cirrhosis, graft loss and death. 3. Graft and patient survival is reduced in liver transplant recipients with recurrent HCV infection compared to HCV-negative recipients. 4. The natural history of chronic hepatitis C is accelerated following liver transplantation compared C, with 20% progressing to cirrhosis by 5 years. However, the rate of fibrosis progression is not uniform and may increase over time. 5. The rates of progression from cirrhosis to decompensation and from decompensation to death are also accelerated following liver transplantation. 6. Multiple host, donor and viral factors are associated with rapid fibrosis progression and HCV-related graft failure. 7. Over the last decade, graft and patient survival rates have improved following liver transplantation for non-HCV disease but not for HCV-cirrhosis. This may reflect worsening donor quality and changes in immunosuppression strategies over recent years. 8. Viral eradication by antiviral therapy prevents disease progression and improves survival. 9. The severity of recurrent hepatitis C at one year post-transplant predicts subsequent progression to cirrhosis. Annual protocol biopsies are recommended to help determine need for antiviral therapy. 10. The projected impact of recurrent hepatitis C on graft and patient survival can only be avoided by the development of safe and effective antiviral strategies which can both prevent initial graft infection and eradicate established hepatitis C recurrence.
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Affiliation(s)
- Edward J Gane
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand.
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30
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Nudo CG, Cortes RA, Weppler D, Schiff ER, Tzakis AG, Regev A. Effect of pretransplant hepatitis C virus RNA status on posttransplant outcome. Transplant Proc 2008; 40:1449-55. [PMID: 18589127 DOI: 10.1016/j.transproceed.2008.03.158] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Accepted: 03/11/2008] [Indexed: 12/30/2022]
Abstract
Undetectable hepatitis C virus (HCV) RNA [RNA(-)] before liver transplantation (OLT) has been shown to decrease the rates of disease recurrence. We sought to determine whether RNA(-) subjects differ in post-OLT recurrence (virological/VR, histological/HR), graft failure (GF), or patient survival from RNA(+) patients using a retrospective review. From 1995 to 2004, a total of 49 patients were RNA(-) at OLT as a result of interferon-based therapy: 22 SVR and 27 with end-of-treatment response (ETR) transplanted when RNA(-) within 6 months of ET. Forty-eight RNA(+) patients were analyzed as controls. Virological recurrence (VR) was seen in 55% of RNA(-) subjects with no difference in HR between RNA(-) vs (+) groups, namely 36.7% versus 56.3% (P = .068), respectively. The RNA(+) subjects showed a lower time to HR (5.6 vs 11 months; P = .027). The SVR subjects displayed lower VR (36.4%) and histological recurrence (HR) (13.6%) compared to ETR (VR 70.4%, P = .023; HR 55.6%, P = .003) or RNA(+) (HR 56%, P = .0008). The SVR subjects, who were identified with a sensitive assay (SVR(S), lower limit <600 IU/mL) showed no VR, HR, or GF. The 1- and 5-year survivals were 87.8%/75.6% and 89.6%/77.8% for RNA(-) and (+) groups, respectively (P = .77). In conclusion, RNA(-)-transplanted patients displayed lower VR and longer time to HR. The SVR patients showed lower VR and HR compared to ETR and RNA(+) patients.
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Affiliation(s)
- C G Nudo
- Center for Liver Diseases, Division of Hepatology, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida 33136, USA.
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31
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Balan V, Ruppert K, Demetris AJ, Ledneva T, Duquesnoy RJ, Detre KM, Wei YL, Rakela J, Schafer DF, Roberts JP, Everhart JE, Wiesner RH. Long-term outcome of human leukocyte antigen mismatching in liver transplantation: results of the National Institute of Diabetes and Digestive and Kidney Diseases Liver Transplantation Database. Hepatology 2008; 48:878-88. [PMID: 18752327 DOI: 10.1002/hep.22435] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
UNLABELLED A perfect or nearly perfect human leukocyte antigen (HLA) match has been associated with better immediate and long-term survival of diseased donor kidney transplants. However, the effect of HLA matching for hepatic allografts remains poorly defined. Using data from the National Institutes of Diabetes and Digestive and Kidney Diseases Liver Transplantation Database, we investigated the association between HLA mismatches and hepatic allograft survival, disease recurrence, and immunosuppression interactions. A, B, and DR loci were used to calculate total mismatch scores of 0 (no mismatches in any loci) to 6 (mismatches in all loci). Seven hundred ninety-nine adults (male, 55%; female, 45%) underwent 883 liver transplants. The 10-year graft survival according to total mismatch score was as follows: 0-2, 60%; 3-4, 54%; and 5-6, 57%. There was a negative effect of mismatching at the A locus on patient survival, with shorter survival for patients with 1 or 2 mismatches compared with 0 mismatches [P = 0.05, hazard ratio (HR) = 1.6]. Patients on tacrolimus with 1 or 2 mismatches at B or DR loci appeared to have increased rates of patient and graft survival compared to patients with 0 mismatches, with the appearance of a protective effect of tacrolimus (HR = 0.67). The effect of HLA mismatching was more pronounced on certain disease recurrences. DR-locus mismatch increased recurrence of autoimmune hepatitis (P = 0.01, HR = 4.2) and primary biliary cirrhosis (P = 0.04, HR = 2). Mismatch in the A locus was associated with more recurrence of hepatitis C virus (P = 0.01, HR = 1.6) and primary sclerosing cholangitis (P = 0.03, HR = 2.9). CONCLUSION Mismatching at the A locus decreases patient survival in liver transplant recipients, and mismatching at the DR and A loci affects recurrence of autoimmune liver diseases and hepatitis C, respectively.
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Affiliation(s)
- Vijayan Balan
- Department of Transplantation Medicine, Mayo Clinic, Phoenix, AZ, USA
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33
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O'Leary JG, Lepe R, Davis GL. Indications for liver transplantation. Gastroenterology 2008; 134:1764-76. [PMID: 18471553 DOI: 10.1053/j.gastro.2008.02.028] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2007] [Revised: 01/22/2008] [Accepted: 02/12/2008] [Indexed: 12/11/2022]
Abstract
Patients should be considered for liver transplantation if they have evidence of fulminant hepatic failure, a life-threatening systemic complication of liver disease, or a liver-based metabolic defect or, more commonly, cirrhosis with complications such as hepatic encephalopathy, ascites, hepatocellular carcinoma, hepatorenal syndrome, or bleeding caused by portal hypertension. While the complications of cirrhosis can often be managed relatively effectively, they indicate a change in the natural history of the disease that should lead to consideration of liver transplantation. Referral to a liver transplant center is followed by a detailed medical evaluation to ensure that transplantation is technically feasible, medically appropriate, and in the best interest of both the patient and society. Patients approved for transplantation are placed on a national transplant list, although donor organs are allocated locally and regionally. Since 2002, priority for transplantation has been determined by the Model of End-Stage Liver Disease (MELD) score, which provides donor organs to listed patients with the highest estimated short-term mortality.
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Affiliation(s)
- Jacqueline G O'Leary
- Hepatology, Department of Medicine, Baylor University Medical Center, Dallas, Texas 75246, USA
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34
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Baiocchi L, Angelico M, Petrolati A, Perrone L, Palmieri G, Battista S, Carbone M, Tariciotti L, Longhi C, Orlando G, Tisone G. Correlation between liver fibrosis and inflammation in patients transplanted for HCV liver disease. Am J Transplant 2008; 8:673-8. [PMID: 18294164 DOI: 10.1111/j.1600-6143.2007.02107.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Hepatitis C virus (HCV) re-infection after liver transplantation (LT) is characterized by an accelerated disease progression in recent years with unclear mechanisms. We evaluate the relationship between progression of liver fibrosis and histological necro-inflammation in HCV recipients, according to age of transplant. Fifty-five patients transplanted (1993-2002) for HCV liver disease, were included in the study. Recipients were retrospectively stratified in three different age of transplant, of 40 months each: group 1) from January 1993 to May 1996; group 2) from June 1996 to august 1999; group 3) from September 1999 to December 2002. Grading (necro-inflammation) and staging (fibrosis) scores were evaluated in liver biopsies at 1, 2 and 3 years from LT (Ishak classification). For all age of transplant the main factor associated with fibrosis progression, was grading score (p < 0.05). However mean staging score for each point of grading increased from 0.3 +/- 0.2 in older LT to 0.7 +/- 0.5 in newer ones (p = 0.01). In conclusion in HCV-LT patients (1) liver fibrosis is strictly associated to histological necro-inflammation; (2) the proportion of this relationship has been changing in recent years since newer LT patients, show an increased amount of fibrosis in comparison with the older ones, for similar grading score.
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Affiliation(s)
- L Baiocchi
- Hepatology Unit, Department of Internal Medicine, University of Rome Tor Vergata, Rome, Italy.
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Lawal A, Ghobrial R, Te H, Artinian L, Eastwood D, Schiano TD. Comparison of hepatitis C histological recurrence rates and patient survival between split and deceased donor liver transplantation. Transplant Proc 2008; 39:3261-5. [PMID: 18089367 DOI: 10.1016/j.transproceed.2007.08.106] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Accepted: 08/08/2007] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Controversy exists as to whether there is an increased severity or frequency of recurrent hepatitis C viral (HCV) infection in recipients of adult living donor liver transplantation (LDLT) grafts. We sought to examine the time to histological recurrence and survival in HCV (+) patients who underwent split liver transplantation (SLT), which is technically similar to what occurs in the LDLT procedure. METHODS Twenty four HCV (+) adult recipients were identified through the UNOS database as having had SLT procedures at three centers: Mount Sinai Medical Center, University of Chicago, and University of California at Los Angeles. Of these, 17 patients with comprehensive data were matched to 32 HCV (+) patients who underwent whole deceased donor liver transplantation (DDLT) during the same time period. Outcome and time to initial HCV recurrence as documented by liver biopsy were assessed. Liver biopsy was performed when clinically indicated. RESULTS Patients who had SLT were significantly older (P=.01). There was no difference in number of rejection episodes (P=.40). Fifteen of 17 SLT (88%) versus 24/32 DDLT (75%) patients had documented HCV recurrence by biopsy (P=.46). The time to median cumulative incidence of recurrence of HCV post-liver transplantation was 12.6 months (SLT) versus 39.8 months (DDLT) patients. There was no difference in survival between SLT and DDLT patients (47 vs 70 months, P=.62) nor in cumulative incidence of histological HCV recurrence at 1, 2, and 3 years (P=.198, .919, and .806, respectively). CONCLUSION There is no difference in the cumulative incidence of histological recurrence of HCV post-liver transplant or in survival between recipients of deceased donor and split liver transplants.
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Affiliation(s)
- A Lawal
- Department of Liver Diseases and Transplantation, Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, New York, NY 10029, USA
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Toniutto P, Fabris C, Bitetto D, Falleti E, Avellini C, Rossi E, Smirne C, Minisini R, Pirisi M. Role of AST to platelet ratio index in the detection of liver fibrosis in patients with recurrent hepatitis C after liver transplantation. J Gastroenterol Hepatol 2007; 22:1904-8. [PMID: 17914968 DOI: 10.1111/j.1440-1746.2006.04628.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIM Per protocol annual liver biopsy represents the gold standard in the assessment of graft fibrosis progression due to recurrent hepatitis C after liver transplantation. Non-invasive liver fibrosis tests have been proposed as surrogate markers of liver fibrosis in hepatitis C virus (HCV)-positive immune-competent patients. No data are available in the literature on the usefulness of non-invasive liver fibrosis tests in liver transplanted patients with recurrent HCV infection. METHODS A total of 102 annual per protocol liver biopsies performed in 51 consecutive HCV-positive recipients (31 men), with a follow-up period lasting up to 5 years, were included and evaluated in this study. At each time point, the following non-invasive liver fibrosis tests were calculated: aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio, age-platelet index, AST to platelet ratio index (APRI), Forns' fibrosis index and Bonacini's discriminant score. RESULTS In discriminating patients with histological fibrosis score >2, APRI provided the best area under the receiver operating characteristic curves (AUROC) (0.801), in comparison to the other four non-invasive liver fibrosis tests. The AUROC of APRI was better in female (0.871) than in male (0.753) recipients. Among female recipients, an APRI value >1.4 was 91% sensitive and 75% specific in detecting a staging score >2. The corresponding values among male recipients were 60% and 77%, respectively. CONCLUSIONS Among non-invasive liver fibrosis tests, APRI has the highest diagnostic value in discriminating liver transplanted patients with progression to significant liver fibrosis, although its accuracy is influenced by recipient sex.
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Affiliation(s)
- Pierluigi Toniutto
- DPMSC, Medical Liver Transplant Unit, University of Udine, Udine, Italy.
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Abstract
Hepatitis C virus (HCV)-related end-stage liver disease is the main indication for liver transplantation performed in Europe and the United States. Recurrence of hepatitis C in the graft is universal and may lead to chronic hepatitis in most patients and to cirrhosis in 20-30% of patients within 5-10 years of transplantation. The natural history of HCV recurrence is highly variable but leads to a lower survival rate than other recurrent liver diseases. The immunosuppressed status and several other factors have been linked with the pattern and severity of recurrence. What remains controversial are those factors associated with fibrosis progression and how these could be modified to improve outcome of recurrent hepatitis C. No single factor but a combination of several factors is associated with fibrosis progression on the graft. The major factors associated with accelerated disease recurrence include: high viral load pre- (>10(6) IU / mL) and / or early post-transplantation (>10(7) IU / mL at 4 months), donor older than 40-50 years, prolonged ischaemic time, cytomegalovirus coinfection, over immunosuppression and / or abrupt changes in immunosuppression, HIV coinfection, infection by genotype 1b. Cautious follow-up of the pathology of the graft is mandatory including routine biopsies and / or noninvasive monitoring of fibrosis.
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Affiliation(s)
- B Roche
- Assistance Publique-Hopitaux de Paris, Hôpital Paul Brousse, Centre Hépato-Biliaire; and INSERM, Unité 785; and Université Paris-Sud, UMR-S 785, Villejuif, France
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Lengyel G, Tulassay Z. [Treatment of recurrent hepatitis C virus infection after liver transplantation]. Orv Hetil 2007; 148:1875-81. [PMID: 17905682 DOI: 10.1556/oh.2007.28217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The main indication of liver transplantation is the final stage of liver cirrhosis developed in hepatitis C virus (HCV) infection. The recurrence of HCV infection after transplantation is a common situation. The recurrent hepatitis C is a progressive disease, in 20 percent of patients it produces liver cirrhosis without treatment beside immunosuppression within 5 years. The treatment of recurrent HCV infection is the most important factor of the survival in patients with transplantation. The authors review the factors influencing the progression of recurrent HCV infection on the basis of literary data and also on their observation. They discuss in details the effect of immunosuppressive treatment, the importance in the selection of corresponding immunosuppressive drugs. They review the main keypoints in the diagnosis of recurrent hepatitis C, underline the important role of liver biopsy carried out according to the protocol in the diagnosis, furthermore the hard consultation among pathologist, hepatologist and surgeon. They demonstrate the observations with the treatment of patients on the waiting list, the results in the early, preemptive treatment of recurrent chronic hepatitis, furthermore the treatment modalities and the results in patients with chronic hepatitis C histologically proved. The drug of choice of chronic hepatitis C after transplantation is the combined therapy with pegylated interferon and ribavirin. This therapy is able to assure virus-free stage in 20-50 percent of patients. In the virus-free patients the inflammatory activity in the liver significantly decreases, the histologic activity index improves. There are data showing the effect of treatment for inhibiting the fibrosis, but multicenter studies are necessary for the confirmation of these data. The advantage of early antiviral therapy without histologic alteration has not been confirmed by most of the trials. The anaemia and the neutropenia are frequent side effects in this patient group, that is why the applications of erythropoietin and granulocyte stimulating factor are recommended. Further trials and clinical studies are necessary for the optimal treatment of patients with recurrent hepatitis C, and to determine the dosage of pegylated interferon and ribavirin, to decrease the duration of therapy and the side effects, finally to achieve a healing phase of higher degree.
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Affiliation(s)
- Gabriella Lengyel
- Semmelweis Egyetem, Altalános Orvostudományi Kar II. Belgyógyászati Klinika Budapest.
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Nemes B, Sárváry E, Gerlei Z, Fazakas J, Doros A, Németh A, Görög D, Fehérvári I, Máthé Z, Gálffy Z, Pár A, Schuller J, Telegdy L, Fehér J, Lotz G, Schaff Z, Nagy P, Járay J, Lengyel G. The recurrence of hepatitis C virus after liver transplantation. Orv Hetil 2007; 148:1971-9. [DOI: 10.1556/oh.2007.28176] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A hazai májátültetési programban magas a hepatitis C-vírus (HCV) okozta végstádiumú májbetegség miatt végzett májátültetések aránya.
Célkitűzés:
A szerzők dolgozatukban elemzik a C-hepatitis miatt májátültetésen átesett betegek adatait.
Módszer:
Az 1995 óta végzett 295 primer májátültetés adatainak retrospektív elemzése: donor- és recipiens-, valamint perioperatív és túlélési adatok, szérumvírus-RNS-titer, percutan májbiopsziák szövettani eredményei.
Eredmények:
A műtét 111 betegnél történt HCV-fertőzés miatt, ez az elvégzett májátültetések 37,6%-a. A vizsgált 111 beteg közül 22 beteg (20%) a posztoperatív időszakban, a vírus kiújulásának észlelése előtt, egyéb okból meghalt. A 89 beteg közül 16 esetben (18%) a vírus visszatérését még nem észlelték, 73 betegnél (82%) azonban a vírus kiújulása szövettanilag igazolható volt. Negyven betegnél (56%) a C-vírus okozta hepatitis kiújulását egy éven belül észlelték, közülük 28 esetben (39%) 6 hónapon belül, 12 esetben hat hónapon túl, de 1 éven belül (17%), és 32 betegnél (44%) egy éven túl. A végstádiumú C-cirrhosis miatt májátültetett betegek kumulatív 1, 3, 5 és 10 éves túlélése 73%, 67%, 56% és 49% volt. A HCV-negatív, májátültetett betegeknél ezek az értékek 80%, 74%, 70% és 70%, a különbség szignifikáns. A májgraft kumulatív túlélése HCV-pozitív betegeknél 72%, 66%, 56% és 49% volt, míg HCV-negatív betegeknél 76%, 72%, 68% és 68%, itt nem szignifikáns a különbség. Korai kiújulás esetén szignifikánsan magasabb szérumvírus-RNS-titert mértek az első 6 hónapban májátültetés után. A májátültetés után 6 hónappal vett protokollbiopszia korai kiújulás esetén magasabb Knodell-pontszámot eredményezett, mint késői kiújuláskor. A fibrosisindex esetében ez fordítva volt. A májátültetéstől az első antivirális kezelésig eltelt idő 1995–2002 között átlagosan 20 hónap volt, 2003 óta 8 hónap.
Következtetések:
Az idősebb donorokból származó, marginális májgraftok magasabb vértranszfúzió-igény mellett történő beültetése előrevetíti a hamarabb bekövetkező vírusrekurrenciát. Ezt a tendenciát erősíti a posztoperatív akut rejectio és az emiatt adott szteroid boluskezelés. A kombinált antivirális kezelés protokollja különbözik az általánosan alkalmazottól: az ún. „stopszabály” nem érvényes. Vírusnegatívvá a betegek csak kevesebb mint 10%-a válik, melynek a fenntartott immunszuppresszió az oka. A májátültetés után korán, akár fél éven belül elkezdett antivirális kezelés a beteg- és grafttúlélést pozitívan befolyásolja, és feltehetően csökkenti a HCV-reinfekció miatti retranszplantációk számát. A második májátültetésnél akkor várhatók jó eredmények, ha időben történik, a recipiens még megfelelő fizikai állapota mellett. Ennek megítélésében a MELD-score segít.
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Affiliation(s)
- Balázs Nemes
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23–25. 1082
| | - Enikő Sárváry
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23–25. 1082
| | - Zsuzsa Gerlei
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23–25. 1082
| | - János Fazakas
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23–25. 1082
| | - Attila Doros
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23–25. 1082
| | - Andrea Németh
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23–25. 1082
| | - Dénes Görög
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23–25. 1082
| | - Imre Fehérvári
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23–25. 1082
| | - Zoltán Máthé
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23–25. 1082
| | - Zsuzsa Gálffy
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23–25. 1082
| | - Alajos Pár
- 2 Pécsi Tudományegyetem, Általános Orvostudományi Kar I. Belgyógyászati Klinika Pécs
| | - János Schuller
- 3 Szent László Kórház III. Belgyógyászati Osztály Budapest
| | - László Telegdy
- 3 Szent László Kórház III. Belgyógyászati Osztály Budapest
| | - János Fehér
- 4 Semmelweis Egyetem, Általános Orvostudományi Kar II. Belgyógyászati Klinika Budapest
| | - Gábor Lotz
- 5 Semmelweis Egyetem, Általános Orvostudományi Kar II. Patológiai Intézet Budapest
| | - Zsuzsa Schaff
- 5 Semmelweis Egyetem, Általános Orvostudományi Kar II. Patológiai Intézet Budapest
| | - Péter Nagy
- 6 Semmelweis Egyetem, Általános Orvostudományi Kar I. Patológiai és Kísérletes Rákkutató Intézet Budapest
| | - Jenő Járay
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23–25. 1082
| | - Gabriella Lengyel
- 4 Semmelweis Egyetem, Általános Orvostudományi Kar II. Belgyógyászati Klinika Budapest
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Rayhill SC, Wu YM, Katz DA, Voigt MD, Labrecque DR, Kirby PA, Mitros FA, Kalil RS, Miller RA, Stolpen AH, Schmidt WN. Older donor livers show early severe histological activity, fibrosis, and graft failure after liver transplantation for hepatitis C. Transplantation 2007; 84:331-9. [PMID: 17700157 DOI: 10.1097/01.tp.0000270313.31328.63] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND In hepatitis C virus (HCV)-positive liver transplant recipients, infection of the allograft and recurrent liver disease are important problems. Increased donor age has emerged as an important variable affecting patient and graft survival; however, specific age cutoffs and risk ratios for poor histologic outcomes and graft survival are not clear. METHODS A longitudinal database of all HCV-positive patients transplanted at our center during an 11-year period was used to identify 111 patients who received 124 liver transplants. Graft survival and histological endpoints (severe activity and fibrosis) of HCV infection in the allografts were compared as a function of donor age at transplantation. RESULTS By Kaplan-Meier analyses, older allografts showed earlier failure and decreased time to severe histological activity and fibrosis as compared with allografts from younger donors. By Cox proportional hazards analysis, older allografts were at greater risk for all severe histologic features and decreased graft survival as compared with younger allografts (P< or =0.02 for all outcomes). Analysis of donor age as a dichotomous variable showed that donors greater than 60 yr were at high risk for deleterious histologic outcomes and graft failure. An age cutoff of 60 yr showed a sensitivity of 94% and specificity of 67% for worse graft survival by receiver operating characteristics curve. CONCLUSIONS Advanced donor age is associated with more aggressive recurrent HCV and early allograft failure in HCV-positive liver transplant recipients. Consideration of donor age is important for decisions regarding patient selection, antiviral therapy, and organ allocation.
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Affiliation(s)
- Stephen C Rayhill
- Department of Surgery, Roy J. and Lucille A. Carver College of Medicine, University of Iowa and Veterans Administration Medical Center, Iowa City, IA, USA.
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McCashland T, Watt K, Lyden E, Adams L, Charlton M, Smith AD, McGuire BM, Biggins SW, Neff G, Burton JR, Vargas H, Donovan J, Trotter J, Faust T. Retransplantation for hepatitis C: results of a U.S. multicenter retransplant study. Liver Transpl 2007; 13:1246-53. [PMID: 17763405 DOI: 10.1002/lt.21322] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
It is widely perceived that outcomes are relatively poor following retransplantation (reTX) for recurrent of hepatitis C virus (HCV) infection. Transplant centers debate the utility of offering another liver to these patients. A U.S. study group was formed to retrospectively compare survival after reTX in patients with recurrent HCV (histologically proven) and those transplanted for other indications greater than 90 days after first transplantation, from 1996 to 2004. Patients were divided into 3 groups; group 1: HCV reTX (n = 43), group 2: non-HCV reTX (n = 73), and group 3: recurrent HCV but no reTX (n = 156). They were predominantly male, Caucasian, with mean age of 47.2 yr. The commonest indications for non-HCV reTX were chronic rejection (36%), hepatic artery thrombosis (31%) and recurrent primary sclerosing cholangitis (17%). Duration of hospitalization, number of intensive care unit (ICU) days, and time interval from listing to transplantation or reTX were similar between reTX groups. The 1-yr and 3-yr survival rates after reTX were also similar for HCV reTX and non-HCV reTX groups (1 yr, 69% vs. 73%; 3 yr, 49% vs. 55%). Model for End-Stage Liver Disease (MELD) scores were not predictive of survival from reTX. However, with a MELD score of >30 in the non HCV group, survival was <50%. In the recurrent HCV not undergoing reTX group, 30% were reevaluated for reTX but only 15% were listed for reTX and the 3-yr survival was 47%. The most common reasons for not listing for reTX were recurrent HCV within 6 months (22%), fibrosing cholestatic hepatitis (19%), and renal dysfunction (9%). In conclusion, patients retransplanted for recurrent HCV had similar 1-yr and 3-yr survival when compared to patients undergoing reTX for other indications. MELD scores were not predictive of post-reTX survival. Survival was <50% in the non-HCV reTx group with MELD score of >30. Many patients with recurrent HCV are not considered for reTX and die from recurrent disease.
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Affiliation(s)
- Timothy McCashland
- Department of Hepatology, University of Nebraska Medical Center, Omaha, NE 68198-3285, USA.
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Arjal RR, Burton JR, Villamil F, Rosen HR. Review article: the treatment of hepatitis C virus recurrence after liver transplantation. Aliment Pharmacol Ther 2007; 26:127-40. [PMID: 17593060 DOI: 10.1111/j.1365-2036.2007.03364.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Recurrent hepatitis C represents a major challenge for the liver transplant community. Given the potentially significant impact that hepatitis C recurrence has on graft and patient survival, several treatment strategies have been utilized to prevent/slow the progression to hepatitis C-related graft failure. AIM To review the efficacy and applicability of treatment strategies for managing recurrent hepatitis C. METHODS Search of MEDLINE (1990 to December 2006) and national meeting abstracts. Search terms included hepatitis C, liver transplantation, treatment, sustained virological response (SVR), and end of treatment virological response. An emphasis was placed on randomized trials. RESULTS The largest study of treatment prior to liver transplantation (n = 124) achieved SVR in 24%. Eight randomized trials (n = 383) examined the efficacy of preemptive therapy with SVR ranging from 0-33%. Eligibility for treatment was low and dose reduction common. Four randomized trials (n = 245; all abstracts) have reported SVR from 33-42% for treating those with histological evidence of recurrent disease. CONCLUSIONS Therapies for treating hepatitis C recurrence have limited applicability and tolerability, and they have a low SVR. Based on available results, preemptive therapy is not recommended. Pegylated interferon and ribavirin is currently the preferred choice for treating established recurrence. There is an urgent need for safer and more effective anti-viral therapy in this situation.
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Affiliation(s)
- R R Arjal
- Division of Gastroenterology and Hepatology, University of Colorado at Denver and Health Sciences Center, Denver, CO 80262, USA
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Abstract
Recurrent hepatitis C virus (HCV) infection after orthotopic liver transplantation (OLT) has been associated with progression to cirrhosis in approximately 20% of patients, 5 years postoperatively. Accelerated decompensation has also been noted when compared with cirrhosis in non-transplant patients. Different treatment strategies are available for recurrent HCV infection post-OLT, but efforts are hindered by the modest response rates, poor tolerability and the risk of rejection as well as graft loss. Anti-HCV immunoglobulin therapy to prevent graft infection with HCV has no established role at present but studies are ongoing. Treatment prior to transplantation in patients with decompensated cirrhosis has been evaluated but the results are too preliminary to make firm recommendations. Prophylactic interferon-based antiviral therapy in the early postoperative period to prevent graft infection was shown to have low response rates and high rates of adverse effects. Treatment of established recurrent HCV infection with combination peginterferon (pegylated interferon) and ribavirin is associated with 10-59% sustained virological response and the predictive value of a positive early virological response has been validated in the post-transplant setting. Improvement in inflammatory activity after viral eradication is well established, but fibrosis regression or stabilisation is less predictable and factors such as rejection and biliary complications may still contribute to graft loss. Most studies have initiated therapy at least 6 months postoperatively in order to optimise patient tolerance and enable the addition of ribavirin. The use of adjuvant agents to treat drug-induced neutropenia and anaemia in this population is evolving and becoming a crucial part of therapy. Determination of optimal doses of both pegylated interferon and ribavirin, and guidance on when to stop treatment, as well as improving tolerability are important steps in achieving higher response rates and minimising drug toxicity.
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Affiliation(s)
- Mazen Alsatie
- Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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Cooper CL, DeForest J, Gill J, Lalonde R. Barriers preventing liver transplantation in Canadians with HIV-infection--perceptions of HIV specialists. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2007; 21:179-82. [PMID: 17377647 PMCID: PMC2657686 DOI: 10.1155/2007/769752] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Liver transplantation is a life-saving procedure with demonstrated utility. There are accumulating data indicating that this procedure is helpful in HIV-infected patients as well. Liver transplantation is currently largely unavailable to those living with HIV in Canada. Understanding the obstacles to this procedure is the first step to increasing access. Between August 2005 and November 2005, HIV physicians, one from each Canadian HIV Trials Network site, were asked to complete a quantitative questionnaire on adult liver transplant access and need. Forty-six per cent (16 of 35) of sites responded. A median 20% of the nearly 12,700 HIV patients followed at these sites had concurrent liver disease (20% caused by hepatitis C virus, 5% caused by hepatitis B virus and 5% were alcohol-related). On average, two patients per site were thought to be appropriate candidates for liver transplant evaluation. Eighty per cent of respondents anticipated increased need for liver transplantation over the next five years. Organ supply was universally identified as the chief obstacle to transplantation in patients with HIV. Other key issues included risk of hepatitis C virus reinfection and transplant surgical team willingness. Based on these data, it is believed that these issues should be the focus of efforts designed to increase access to transplantation in Canadians with end-stage liver disease and concurrent HIV.
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Angelico M, Petrolati A, Lionetti R, Lenci I, Burra P, Donato MF, Merli M, Strazzabosco M, Tisone G. A randomized study on Peg-interferon alfa-2a with or without ribavirin in liver transplant recipients with recurrent hepatitis C. J Hepatol 2007; 46:1009-17. [PMID: 17328985 DOI: 10.1016/j.jhep.2006.12.017] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2006] [Revised: 12/13/2006] [Accepted: 12/18/2006] [Indexed: 01/01/2023]
Abstract
BACKGROUND/AIMS We performed a randomized trial on pegylated interferon alfa-2a (Peg-IFNalpha) monotherapy vs Peg-IFNalpha and ribavirin in non-cirrhotic liver transplant recipients with recurrent hepatitis C. METHODS Forty-two patients transplanted for HCV-related cirrhosis 12-96 months earlier were randomized to Peg-IFNalpha monotherapy (180 microg weekly) or Peg-IFNalpha and ribavirin, up to the maximum tolerated dose, for 48 weeks. RESULTS Early virological response (EVR, i.e., HCV-RNA2 log drop at week 12) occurred in 76% of the monotherapy and 71% of the combination groups, respectively (intention-to treat). Sustained virological response (SVR) occurred in 8 (38%) and 7 (33%) patients, respectively. EVR had a positive predictive value for SVR of 50% and 47%, respectively, and a 100% negative predictive value in both groups. Six drop-outs occurred in the monotherapy (including 3 rejections) and 7 in the combination groups (including one rejection). Peg-INFalpha dose was reduced in 7 and 8 patients, respectively. The average daily dose of ribavirin was 435 mg/day. CONCLUSIONS Peg-IFNalpha-2a, with or without ribavirin, induces SVR in one-third of transplant recipients with recurrent hepatitis C. Treatment cessation is indicated in patients without EVR. The low SVR rate is mainly due to inability to sustain full doses of antivirals and lack of the booster effect of ribavirin.
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Poghosyan T, Ackerman SJ, Ravenel JG. Infectious complications of solid organ transplantation. Semin Roentgenol 2007; 42:11-22. [PMID: 17174171 DOI: 10.1053/j.ro.2006.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Tereza Poghosyan
- Department of Radiology, Medical University of South Carolina, 169 Ashley Avenue, Charleston, SC 29425, USA
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47
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Picciotto FP, Tritto G, Lanza AG, Addario L, De Luca M, Di Costanzo GG, Lampasi F, Tartaglione MT, Marsilia GM, Calise F, Cuomo O, Ascione A. Sustained virological response to antiviral therapy reduces mortality in HCV reinfection after liver transplantation. J Hepatol 2007; 46:459-65. [PMID: 17196700 DOI: 10.1016/j.jhep.2006.10.017] [Citation(s) in RCA: 148] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Revised: 08/28/2006] [Accepted: 10/31/2006] [Indexed: 02/07/2023]
Abstract
BACKGROUND/AIMS HCV infection recurs almost in all HCV-positive patients receiving liver transplantation and carries a poor prognosis. Aim of this study was to analyze efficacy and effect on survival of antiviral therapy in this clinical setting. METHODS Pegylated-interferon alpha-2b and ribavirin were administered at a dose of 1 microg/kg of bwt weekly and 600-800 mg/day. Planned duration of treatment was 24 or 48 weeks according to HCV genotype. Patients who failed to respond at week 24 were considered as non-responders. RESULTS 61 patients were enrolled. According to intention-to-treat analysis, 44 (72%) patients were considered as treatment failure (31 non-responders, 4 relapsers, 9 dropout). Sustained virological response was achieved in 17 cases (28%). Genotype 2, higher doses of antivirals and absence of histological cirrhosis were predictors of sustained virological response. In the follow up, patients with sustained virological response had a significantly lower mortality compared to patients with treatment failure (chi2=6.9; P<0.01). CONCLUSIONS Response rate to antiviral therapy in HCV reinfection after liver transplantation is higher if a full dose of antiviral drugs is administered and if treatment starts before histological cirrhosis has developed. Sustained virological response improves patient survival.
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Affiliation(s)
- Francesco Paolo Picciotto
- Unità Operativa Complessa di Epatologia, Azienda Ospedaliera di Rilievo Nazionale A. Cardarelli, Napoli, Italy
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48
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Watt KDS, Burak K, Deschênes M, Lilly L, Marleau D, Marotta P, Mason A, Peltekian KM, Renner EL, Yoshida EM. Recurrent hepatitis C post-transplantation: where are we now and where do we go from here? A report from the Canadian transplant hepatology workshop. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2007; 20:725-34. [PMID: 17111055 PMCID: PMC2660828 DOI: 10.1155/2006/238218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Approximately 400 liver transplants are performed in Canada every year and close to 6000 per year in the United States. Forty per cent to 45% of all liver transplants are performed for patients with underlying hepatitis C virus (HCV)-related liver disease. These patients have a different natural history, new complication risks and different treatment efficacy than nontransplant HCV patients. Every effort must be made to identify those patients at highest risk for progressive liver disease post-transplant. Recurrent HCV is an Achilles' heel to transplant hepatology. The true natural history of this disease is only starting to unravel and many questions remain unanswered on the optimal management of these patients after liver transplantation. The present report summarizes the literature and ongoing research needs that are specific to HCV-related liver transplantation.
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Shah SA, Cattral MS, McGilvray ID, Adcock LD, Gallagher G, Smith R, Lilly LB, Girgrah N, Greig PD, Levy GA, Grant DR. Selective use of older adults in right lobe living donor liver transplantation. Am J Transplant 2007; 7:142-50. [PMID: 17227563 DOI: 10.1111/j.1600-6143.2006.01596.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Many centers are reluctant to use older donors (>44 years) for adult right-lobe living donor liver transplantation (RLDLT) due to concerns about possible increased morbidity in donors and poorer outcomes in recipients. Since 2000, 130 adult RLDLTs have been performed at our institution. Recipients were divided into those who received a right lobe graft from a donor </=age 44 (n = 89, 68%; median age 30) and those who received a liver graft from a donor age >44 (n = 41, 32%; mean age 52). The two donor and recipient populations had similar demographic and operative profiles. With a median follow-up of 29 months, the severity and number of complications in older donors were similar to those in younger donors. No living donor died. Older donor allografts had initial allograft dysfunction compared to younger donors. Complication rates were similar among recipients in both groups but there was a higher bile duct stricture rate with older donor grafts (27% vs. 12%; p = 0.04). One-year recipient graft survival was 86% for older donors and 85% for younger donors (p = 0.95). Early experience with the use of selected older adults (>44 years) for RLDLT is encouraging, but may be associated with a higher rate of biliary complications in the recipient.
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Affiliation(s)
- S A Shah
- Multi-Organ Transplant Unit, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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50
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Shah SA, Grant DR, McGilvray ID, Greig PD, Selzner M, Lilly LB, Girgrah N, Levy GA, Cattral MS. Biliary strictures in 130 consecutive right lobe living donor liver transplant recipients: results of a Western center. Am J Transplant 2007; 7:161-7. [PMID: 17227565 DOI: 10.1111/j.1600-6143.2006.01601.x] [Citation(s) in RCA: 159] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Biliary strictures remain the most challenging aspect of adult right lobe living donor liver transplantation (RLDLT). Between 04/2000 and 10/2005, 130 consecutive RLDLTs were performed in our center and followed prospectively. Median follow-up was 23 months (range 3-67) and 1-year graft and patient survival was 85% and 87%, respectively. Overall incidence of biliary leaks (n = 19) or strictures (n = 22) was 32% (41/128) in 33 patients (26%). A duct-to-duct (D-D) or Roux-en-Y (R-Y) anastomosis were performed equally (n = 64 each) with no difference in stricture rate (p = 0.31). The use of ductoplasty increased the number of grafts with a single duct for anastomosis and reduced the biliary complication rate compared to grafts >/=2 ducts (17% vs. 46%; p = 0.02). Independent risk factors for strictures included older donor age and previous history of a bile leak. All strictures were managed nonsurgically initially but four patients ultimately required conversion from D-D to R-Y. Ninety-six percent (123/128) of patients are currently free of any biliary complications. D-D anastomosis is safe after RLDLT and provides access for future endoscopic therapy in cases of leak or stricture. When presented with multiple bile ducts, ductoplasty should be considered to reduce the potential chance of stricture.
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Affiliation(s)
- S A Shah
- Department of Surgery, Multi-Organ Transplatation Unit, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
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