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Kashibadze K, Nakashidze M, Beridze S, Shanava K, Bolkvadze R, Beridze D, Gudadze S, Mikeladze L. Is Liver Retransplant Possible After Oropharyngeal Squamous Cell Carcinoma Development? EXP CLIN TRANSPLANT 2023; 21:626-629. [PMID: 37341457 DOI: 10.6002/ect.2023.0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Affiliation(s)
- Kakhaber Kashibadze
- From the Batumi State University, Department of Surgery and Transplantation, Batumi Referral Hospital, Batumi, Georgia
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Stefanowicz M, Kaliciński P, Kowalewski G, Kowalski A, Ciopiński M, Szymczak M, Kwiecińska A, Patkowski W, Zieniewicz K, Grzelak I, Kamińska D, Ismail H. The Impact of Hepatic Artery Thrombosis on the Outcome of Pediatric Living Donor Liver Transplantations. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020340. [PMID: 36832468 PMCID: PMC9955988 DOI: 10.3390/children10020340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/25/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023]
Abstract
The aim of our study was to assess risk factors for hepatic artery thrombosis (HAT) and to evaluate the impact of HAT management on long-term outcomes after pediatric living donor liver transplantation (LDLT). We retrospectively analyzed 400 patients who underwent primary LDLT between 1999 and 2020. We compared preoperative data, surgical factors, complications, and patient and graft survivals in patients with HAT (HAT Group) and without HAT (non-HAT Group). A total of 27 patients (6.75%) developed HAT. Acute liver failure, a hepatic artery (HA) anastomosis diameter below 2 mm, and intraoperative HA flow dysfunction were significantly more common in the HAT Group (p < 0.05, p = 0.02026, and p = 0.0019, respectively). In the HAT Group, 21 patients (77.8%) underwent urgent surgical revision. The incidence of biliary stenosis and retransplantation was significantly higher in the HAT Group (p = 0.00002 and p < 0.0001, respectively). Patient and graft survivals were significantly worse in the HAT Group (p < 0.05). The close monitoring of HA flow with Doppler ultrasound during the critical period of 2 to 3 weeks after LDLT and the immediate attempt of surgical revascularization may attenuate the elevated risk of biliary stenosis, graft loss, and the need for retransplantation due to HAT.
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Affiliation(s)
- Marek Stefanowicz
- Department of Pediatric Surgery and Organ Transplantation, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland
| | - Piotr Kaliciński
- Department of Pediatric Surgery and Organ Transplantation, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland
- Correspondence:
| | - Grzegorz Kowalewski
- Department of Pediatric Surgery and Organ Transplantation, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland
| | - Adam Kowalski
- Department of Pediatric Surgery and Organ Transplantation, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland
| | - Mateusz Ciopiński
- Department of Pediatric Surgery and Organ Transplantation, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland
| | - Marek Szymczak
- Department of Pediatric Surgery and Organ Transplantation, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland
| | - Agnieszka Kwiecińska
- Department of Pediatric Surgery and Organ Transplantation, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland
| | - Waldemar Patkowski
- Department of General Surgery, Transplantation and Liver Surgery, Warsaw Medical University, 02-091 Warsaw, Poland
| | - Krzysztof Zieniewicz
- Department of General Surgery, Transplantation and Liver Surgery, Warsaw Medical University, 02-091 Warsaw, Poland
| | - Ireneusz Grzelak
- Department of General Surgery, Transplantation and Liver Surgery, Warsaw Medical University, 02-091 Warsaw, Poland
| | - Diana Kamińska
- Department of Gastroenterology, Hepatology, Nutritional Disorders and Pediatrics, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland
| | - Hor Ismail
- Department of Pediatric Surgery and Organ Transplantation, The Children’s Memorial Health Institute, 04-730 Warsaw, Poland
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Outcomes of Adult Liver Retransplantation: A Canadian National Database Analysis. Can J Gastroenterol Hepatol 2022; 2022:9932631. [PMID: 35360444 PMCID: PMC8964213 DOI: 10.1155/2022/9932631] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 02/12/2022] [Accepted: 02/16/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Liver retransplantation remains as the only treatment for graft failure. This investigation aims to assess the incidence, post-transplant outcomes, and risk factors in liver retransplantation recipients in Canada. MATERIALS AND METHODS The Canadian Organ Replacement Register was used to obtain and analyse data on all adult liver retransplant recipients, matched donors, transplant-specific variables, and post-transplant outcomes from January 2000 to December 2018. RESULTS 377 (6.5%) patients underwent liver retransplantation. Autoimmune liver disease and hepatitis C virus (HCV) were the most common underlying diagnoses. Graft failure was 7.9% and 12.5%, and overall survival was 77.1% and 65.6% at 1 year and 5 years, respectively. In contrast to recipients receiving their first graft transplant, the retransplantation group had a significantly higher incidence of graft failure (p < 0.001) and lower overall survival (p < 0.001). The graft failure and patient survival rates were comparable between second transplant and repeat retransplant recipients. Furthermore, there were no differences in graft failure and patient survival when stratified according to time to retransplantation. Recipient and donor age (HR = 1.12, p=0.011; HR = 1.09, p=0.008), recipient HCV status (HR = 1.81, p=0.014), and donor cytomegalovirus status (HR = 4.10, p=0.006) were predictors of patient mortality. CONCLUSION This analysis of liver retransplantation demonstrates that this is a safe treatment for early and late graft failure. Furthermore, even in patients requiring more than two grafts, similar outcomes to initial retransplantation can be achieved with careful selection.
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Nakamura T, Shirouzu T. Antibody-Mediated Rejection and Recurrent Primary Disease: Two Main Obstacles in Abdominal Kidney, Liver, and Pancreas Transplants. J Clin Med 2021; 10:5417. [PMID: 34830699 PMCID: PMC8619797 DOI: 10.3390/jcm10225417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 02/08/2023] Open
Abstract
The advances in acute phase care have firmly established the practice of organ transplantation in the last several decades. Then, the next issues that loom large in the field of transplantation include antibody-mediated rejection (ABMR) and recurrent primary disease. Acute ABMR is a daunting hurdle in the performance of organ transplantation. The recent progress in desensitization and preoperative monitoring of donor-specific antibodies enables us to increase positive outcomes. However, chronic active ABMR is one of the most significant problems we currently face. On the other hand, recurrent primary disease is problematic for many recipients. Notably, some recipients, unfortunately, lost their vital organs due to this recurrence. Although some progress has been achieved in these two areas, many other factors remain largely obscure. In this review, these two topics will be discussed in light of recent discoveries.
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Affiliation(s)
- Tsukasa Nakamura
- Department of Organ Transplantation and General Surgery, Kyoto Prefectural University of Medicine, Kajii-cho 465, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Takayuki Shirouzu
- Molecular Diagnositcs Division, Wakunaga Pharmaceutical Co., Ltd., 13-4 Arakicho, shinjyuku-ku, Tokyo 160-0007, Japan;
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Safe use of livers from deceased donors older than 70 years in recipients with HCV cirrhosis treated with direct-action antivirals. Retrospective cohort study. Int J Surg 2021; 91:105981. [PMID: 34098075 DOI: 10.1016/j.ijsu.2021.105981] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/28/2021] [Accepted: 05/25/2021] [Indexed: 01/05/2023]
Abstract
INTRODUCTION There is controversy regarding the use of older grafts for liver transplantation (LT) in HCV-infected patients, but the introduction of direct-acting antivirals (DAA) can radically change that debate. METHODS The aim of this retrospective cohort study was to evaluate outcomes of the use of liver grafts from donors older than 70 years in recipients with HCV infection who underwent pre- or post-LT treatment with DAA. We compared two groups of patients who underwent LT using livers >70 years; the groups were defined according to antiviral therapy: non-DAA therapy group (n = 62; LT between May 1996 and December 2013), and DAA therapy group (n = 31; LT between January 2014 and December 2019). RESULTS Thirty (96.8%) patients of DAA therapy and nine (14.5%) of non-DAA therapy (21 patients underwent complete therapy with interferon-ribavirin) achieved sustained viral response (SVR). One, 3-, and 5-year patient survival were 83.9%, 67.7%, and 56.5% in the non-DAA group vs 93.5%, 88.4%, and 88.4% in the DAA group (P = 0.04); the 1-, 3-, and 5-year graft survival were 77.4%, 62.9%, and 51.6% in the non-DAA group vs. 88.6%, 83.7%, and 83.7% in the DAA group (P = 0.03). Multivariate analysis demonstrated donor female sex and DAA therapy as protective factors of graft survival. CONCLUSIONS Pre- or post-LT therapy with DAA in HCV-infected patients has achieved an almost overall SVR. The use of liver grafts >70 years in these patients treated with DAA was associated with significantly higher 5-year patient and graft survival in DAA group compared to non-DAA group. Thus, the introduction of DAA therapy has allowed the safe use of livers >70 years in HCV-positive recipients.
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Wairimu F, Ward NC, Liu Y, Dwivedi G. Cardiac Transplantation in HIV-Positive Patients: A Narrative Review. J Acquir Immune Defic Syndr 2021; 87:763-768. [PMID: 33534274 DOI: 10.1097/qai.0000000000002647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/18/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Before the introduction of highly active antiretroviral therapy, patients infected with HIV experienced poor prognosis including high rates of opportunistic infections, rapid progression to AIDS, and significant mortality. Increased life expectancy after therapeutic improvements has led to an increase in other chronic diseases for these patients, including cardiovascular disease and, in particular, end-stage heart failure. Historically, HIV infection was deemed an absolute contraindication for transplantation. Since the development of highly active antiretroviral therapy, however, life expectancy for HIV-positive patients has significantly improved. In addition, there is a low incidence of opportunistic infections and the current antiretrovirals have an improved toxicity profile. Despite this, the current status of cardiac transplants in HIV-positive patients remains unclear. With this in mind, we conducted a narrative review on cardiac transplantation in patients with HIV.
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Affiliation(s)
- Faith Wairimu
- Harry Perkins Institute for Medical Research, Fiona Stanley Hospital, Perth Australia
| | - Natalie C Ward
- School of Medicine, University of Western Australia, Perth Australia ; and
- The Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Canada
| | - Yingwei Liu
- The Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Canada
| | - Girish Dwivedi
- Harry Perkins Institute for Medical Research, Fiona Stanley Hospital, Perth Australia
- School of Medicine, University of Western Australia, Perth Australia ; and
- The Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Canada
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Jain A, Miller D, Schreibman I, Riley TR, Krok KL, Dohi T, Sharma R, Kadry Z. Is there increased risk of hepatocellular carcinoma recurrence in liver transplant patients with direct-acting antiviral therapy? Hepatol Int 2019; 13:190-198. [PMID: 30680672 DOI: 10.1007/s12072-019-09930-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 01/10/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recently, a controversy has emerged: is the rate of recurrence of hepatocellular carcinoma (HCC) higher following treatment of hepatitis C virus (HCV) with direct-acting antiviral (DAA) therapy? However, the risk of HCC recurrence has not been studied in liver transplant (LTx) recipients who received DAA therapy. The aim of the present study is to compare the rate of HCC recurrence in LTx recipients who did or did not receive DAA therapy. PATIENTS AND METHODS Sixty-three patients received LTx with HCC. Twenty-seven (42.9%) with HCV received DAA therapy (Group A), 20 (31.7%) with HCV did not receive DAA therapy (Group B), and 16 (25.4%) did not have HCV (Group C). RESULTS In group A, three (11%), in group B, one (5%), and in group C, none had recurrence of HCC. Actuarial 4-year recurrence-free survival was 88.9, 95, and 100% in group A, B, and C, respectively (p = 0.37). Group A was subdivided into two groups for comparison with Group B: A1 included five patients who had end of treatment response (ETR) without sustained virological response (SVR), and A2 included 20 patients who achieved SVR. Three patients from A1 had HCC recurrence and no patients from A2 had HCC recurrence. (p = 0.0038; group A1, A2, and B). CONCLUSIONS The rate of HCC recurrence in LTx patients with DAA therapy was significantly higher with ETR, without SVR, after DAA therapy compared to patients with SVR or patients who did not receive DAA therapy. LTx recipients with HCC receiving DAA therapy requires further studies.
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Affiliation(s)
- Ashokkumar Jain
- Division of Transplantation, Department of Surgery, College of Medicine, Pennsylvania State University, Mail Code H062, 500 University Drive, PO Box 850, Hershey, PA, 17033-0850, USA.
| | - Danielle Miller
- Division of Transplantation, Department of Surgery, College of Medicine, Pennsylvania State University, Mail Code H062, 500 University Drive, PO Box 850, Hershey, PA, 17033-0850, USA
| | - Ian Schreibman
- Division of Gastroenterology, Department of Medicine, College of Medicine, Pennsylvania State University, Hershey, PA, USA
| | - Thomas R Riley
- Division of Gastroenterology, Department of Medicine, College of Medicine, Pennsylvania State University, Hershey, PA, USA
| | - Karen L Krok
- Division of Gastroenterology, Department of Medicine, College of Medicine, Pennsylvania State University, Hershey, PA, USA
| | - Takehiko Dohi
- Division of Transplantation, Department of Surgery, College of Medicine, Pennsylvania State University, Mail Code H062, 500 University Drive, PO Box 850, Hershey, PA, 17033-0850, USA
| | - Rajeev Sharma
- CSL Behring, 1020 First Ave, King of Prussia, PA, USA
| | - Zakiyah Kadry
- Division of Transplantation, Department of Surgery, College of Medicine, Pennsylvania State University, Mail Code H062, 500 University Drive, PO Box 850, Hershey, PA, 17033-0850, USA
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Jain A, Riley TR, Krok KL, Schreibman I, Karamchandani DM, Liao X, Tian Y, Dohi T, Kadry Z. Incidence of Post-Liver Transplant Hepatic Dysfunction After Sustained Virologic Response Following Direct-Acting Anti-Hepatitis C Therapy. EXP CLIN TRANSPLANT 2018; 18:345-352. [PMID: 30295586 DOI: 10.6002/ect.2018.0127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Newly developed, direct-acting antiviral therapy is effective in over 90% of cases to eradicate hepatitis C virus infection. Direct-acting antiviral therapy is also effective in liver transplant recipients with recurrent hepatitis C virus infection. However, hepatic function after sustained virologic response in transplant recipients is unknown. Here, we aimed to uncover the incidence of hepatic dysfunction in this patient group at our center. MATERIALS AND METHODS Our study included 40 consecutive (January 2014 to February 2016) and compliant posttransplant recipients who achieved sustained viral response from direct-acting antiviral therapy. Patients were investigated for incidence and causes of hepatic dysfunction. RESULTS In our patient group, 4 (10%) experienced hepatic dysfunction with stable baseline immunosuppression, with 2 having drastic increases in alanine aminotransferase at 15 and 32 weeks after direct-acting antiviral therapy. Biopsies showed hepatitis, and both patients were treated with hydrocortisone, which increased their baseline immunosuppression. The 3rd patient had an increase in bilirubin at 21 weeks posttherapy, with biopsy showing macrovascular steatosis. The 4th patient had a rapid increase in bilirubin at 7 weeks after direct-acting antiviral therapy, with biopsy showing significant duct loss. CONCLUSIONS During the study period, 10% of patients experienced hepatic dysfunction after sustained viral response. Presumed causative factors included partial immune reconstitution and nonalcoholic fatty liver disease.
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Affiliation(s)
- Ashokkumar Jain
- From the Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
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Assessing the Non-tumorous Liver: Implications for Patient Management and Surgical Therapy. J Gastrointest Surg 2018; 22:344-360. [PMID: 28924922 DOI: 10.1007/s11605-017-3562-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 08/24/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Hepatic resection is performed for various benign and malignant liver tumors. Over the last several decades, there have been improvements in the surgical technique and postoperative care of patients undergoing liver surgery. Despite this, liver failure following an extended hepatic resection remains a critical potential postoperative complication. Patients with underlying parenchymal liver diseases are at particular risk of liver failure due to impaired liver regeneration with an associated mortality risk as high as 60 to 90%. In addition, live donor liver transplantation requires a thorough presurgical assessment of the donor liver to minimize the risk of postoperative complications. RESULTS AND CONCLUSION Recently, cross-sectional imaging assessment of diffuse liver diseases has gained momentum due to its ability to provide both anatomical and functional assessments of normal and abnormal tissues. Various imaging techniques are being employed to assess diffuse liver diseases including magnetic resonance imaging (MRI), computed tomography (CT), and ultrasound (US). MRI has the ability to detect abnormal intracellular and molecular processes and tissue architecture. CT has a high spatial resolution, while US provides real-time imaging, is inexpensive, and readily available. We herein review current state-of-the-art techniques to assess the underlying non-tumorous liver. Specifically, we summarize current approaches to evaluating diffuse liver diseases including fatty liver alcoholic or non-alcoholic (NAFLD, AFLD), hepatic fibrosis (HF), and iron deposition (ID) with a focus on advanced imaging techniques for non-invasive assessment along with their implications for patient management. In addition, the role of and techniques to assess hepatic volume in hepatic surgery are discussed.
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10
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Chan KC, Yeh JR, Sun WZ. The role of autonomic dysfunction in predicting 1-year mortality after liver transplantation. Liver Int 2017; 37:1239-1248. [PMID: 28107591 DOI: 10.1111/liv.13364] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 01/08/2017] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Model for end-stage liver disease (MELD) score has been extensively used to prioritize patients for liver transplantation and determine their prognosis, but with limited predictive value. Autonomic dysfunction may correlate with increased mortality after liver transplant. In this study, two autonomic biomarkers, complexity and deceleration capacity, were added to the predicting model for 1-year mortality after liver transplantation. METHODS In all, 30 patients with end-stage liver diseases awaiting liver transplantation were included. Complexity and deceleration capacity were calculated by multi-scale entropy and phase-rectified signal averaging, respectively. Different combinations of autonomic factors and MELD score were used to predict mortality rate of liver transplant after 1-year follow-up. Receiver-operating characteristics curve analysis was performed to determine clinical predictability. Area under the receiver-operating characteristics curve represents the overall accuracy. RESULTS The 1-year mortality rate was 16.7% (5/30). The overall accuracy of MELD score used for predicting mortality after liver transplantation was 0.752. By adding complexity and deceleration capacity into the predicting model, the accuracy increased to 0.912. Notably, the accuracy of the prediction using complexity and deceleration capacity alone was 0.912. CONCLUSION Complexity and deceleration capacity, which represent different dynamical properties of a human autonomic system, are critical factors for predicting mortality rate of liver transplantation. We recommend that these pre-operative autonomic factors may be helpful as critical adjuncts to predicting model of mortality rate in prioritizing organ allocation.
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Affiliation(s)
- Kuang-Cheng Chan
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jia-Rong Yeh
- Research Center for Adaptive Data Analysis and Center for Dynamical Biomarkers and Translational Medicine, National Central University, Taoyuan, Taiwan
| | - Wei-Zen Sun
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
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Abstract
Diagnosis and treatment of hepatitis C virus (HCV) -related autoimmune features has become a clinical challenge in HCV-infected patients, in whom chronic liver disease associated with severe autoimmune features may contribute to a very poor prognosis. Both antiviral and immunosuppressive therapies, either alone or in combination, seem likely to have a key role. Based on the experience of mycophenolate mofetil (MMF) use in HCV patients receiving organ transplantation, this new immunosuppressive agent might represent a safe and effective therapeutic option to treat HCV-related extrahepatic features. Recent data are available for the use of MMF in HCV patients with autoimmune manifestations, mainly for autoimmune cytopenias and vasculitic features. MMF may be used as monotherapy or in association with other drugs for cases of HCV-related autoimmune diseases refractory or intolerant to common immunosuppressive treatments, allowing the reduction of the drug dosage and avoiding serious side effects.
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Affiliation(s)
- M Ramos-Casals
- Department of Autoimmune Diseases, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), School of Medicine, University of Barcelona, Hospital Clinic, Barcelona, Spain
| | - J Font
- Department of Autoimmune Diseases, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), School of Medicine, University of Barcelona, Hospital Clinic, Barcelona, Spain
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12
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Abstract
Diagnosis and treatment of hepatitis C virus (HCV) -related autoimmune features has become a clinical challenge in HCV-infected patients, in whom chronic liver disease associated with severe autoimmune features may contribute to a very poor prognosis. Both antiviral and immunosuppressive therapies, either alone or in combination, seem likely to have a key role. Based on the experience of mycophenolate mofetil (MMF) use in HCV patients receiving organ transplantation, this new immunosuppressive agent might represent a safe and effective therapeutic option to treat HCV-related extrahepatic features. Recent data are available for the use of MMF in HCV patients with autoimmune manifestations, mainly for autoimmune cytopenias and vasculitic features. MMF may be used as monotherapy or in association with other drugs for cases of HCV-related autoimmune diseases refractory or intolerant to common immunosuppressive treatments, allowing the reduction of the drug dosage and avoiding serious side effects.
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Affiliation(s)
- M Ramos-Casals
- Department of Autoimmune Diseases, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), School of Medicine, University of Barcelona, Hospital Clínic, Barcelona, Spain.
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Management of post liver transplantation recurrent hepatitis C infection with directly acting antiviral drugs: a review. Hepatol Int 2016; 10:749-61. [PMID: 27337961 DOI: 10.1007/s12072-016-9744-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 05/17/2016] [Indexed: 12/20/2022]
Abstract
Recurrent HCV infection (rHCV) of the liver allograft following transplantation is universal and is associated with poor graft and patient survival in comparison with other indications. Treatment of rHCV infection in the previous era with pegylated interferon and ribavirin was associated with low sustained virological response (SVR) due to poor tolerability, adverse events and graft rejection. Recently, directly acting antiviral drugs (DAA) have been approved for the treatment of hepatitis C infection and a number of clinical trials have been conducted across various centers in the management of rHCV infection of the graft. In this review we discuss about recent studies that have emerged on the use of NS5b polymerase inhibitor, sofosbuvir in combination with second generation protease inhibitor, simeprevir, fixed dose ledipasvir or daclatasvir with or without ribavirin in the treatment of post transplant rHCV infection.
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Izzy M, Jibara G, Aljanabi A, Alani M, Giannattasio E, Zaidi H, Said Z, Gaglio P, Wolkoff A, Reinus JF. Limited Fibrosis Progression but Significant Mortality in Patients Ineligible for Interferon-Based Hepatitis C Therapy. J Clin Exp Hepatol 2016; 6:100-8. [PMID: 27493457 PMCID: PMC4963315 DOI: 10.1016/j.jceh.2016.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 02/25/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Individuals ineligible for interferon-based hepatitis C therapy may have a worse prognosis than patients who have failed or not received treatment. AIMS To provide information about the limitations of medical treatment of hepatitis C in real-world patients. METHODS We studied 969 treatment-ineligible patients and 403 treated patients enrolled between 1/1/01 and 6/30/06; data were collected until 3/31/13. Treatment barriers were grouped into five categories and classified as health-related or health-unrelated. Fibrosis stage was assessed initially and at the end of follow-up. Mortality was determined by search of the Social Security database. Death certificates of treatment-ineligible patients were reviewed. RESULTS Initially, 288 individuals had advanced fibrosis and compensated disease; 87 untreated patients developed advanced fibrosis during follow-up. Health-related treatment barriers were more commonly associated with fibrosis progression and worse survival. During follow-up, 247 untreated patients died: 47% of liver-related and 53% of liver-unrelated causes. Patients with significant comorbid illness had the worst five- (70%) and ten-year (50.5%) survival. Despite high mortality (47%) in persons with decompensated liver disease, no treatment barrier was associated with a greater incidence of liver-related death. Only significant comorbid medical illness was an independent predictor of disease progression; however, it was not associated with a greater incidence of liver-related death. Furthermore, treated patients had better 10-year survival than untreated patients on Kaplan-Meier analysis (80.3% vs. 74.5%, P = 0.005). CONCLUSION Many patients with hepatitis C will die of non-liver-related causes and may not be helped by anti-viral treatment.
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Affiliation(s)
- Manhal Izzy
- Department of Medicine, Division of Gastroenterology and Liver Diseases, Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, NY, United States,Address for correspondence: Manhal Izzy, Montefiore Medical Center/Albert Einstein College Of Medicine, Division of Gastroenterology, 111 East 210th Street, Bronx, NY 10467, United States.
| | - Ghalib Jibara
- Department of Urology, The Brookdale University Hospital and Medical Center, Brooklyn, NY, United States
| | - Aws Aljanabi
- Department of Medicine, Division of Gastroenterology and Liver Diseases, Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, NY, United States
| | - Mustafa Alani
- Department of Medicine, Division of Gastroenterology and Liver Diseases, Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, NY, United States
| | - Emily Giannattasio
- Department of Medicine, Division of Gastroenterology and Liver Diseases, Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, NY, United States
| | - Hina Zaidi
- Department of Medicine, Division of Gastroenterology and Liver Diseases, Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, NY, United States
| | - Zaid Said
- Department of Medicine, Division of Gastroenterology and Liver Diseases, Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, NY, United States
| | - Paul Gaglio
- Department of Medicine, Division of Gastroenterology and Liver Diseases, Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, NY, United States
| | - Allan Wolkoff
- Department of Medicine, Division of Gastroenterology and Liver Diseases, Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, NY, United States
| | - John F. Reinus
- Department of Medicine, Division of Gastroenterology and Liver Diseases, Montefiore Medical Center, The Albert Einstein College of Medicine, Bronx, NY, United States
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Yu C, Gifford AL, Christiansen CL, Drainoni ML. Hepatitis C Is Poorly Associated With Drug Use in Cambodian Americans in Lowell, Massachusetts. Open Forum Infect Dis 2016; 3:ofw099. [PMID: 27419171 PMCID: PMC4943542 DOI: 10.1093/ofid/ofw099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 05/06/2016] [Indexed: 12/29/2022] Open
Abstract
Background. Hepatitis C (HCV) is the most common chronic blood-borne infection in the United States and affects Asian and non-Asian Americans comparably. Injection drug use, the most common national transmission risk, is not as prevalent in Asian-Americans, but prior studies do not include many Cambodian Americans. Lowell, Massachusetts has the second largest population of Cambodian Americans, allowing a direct comparison of HCV-infected Cambodian and non-Cambodian Americans not previously done. Improving our understanding of HCV risks in this unique community may improve their linkage to care. Methods. In this cross-sectional study, medical data were collected regarding HCV risk factors for HCV-infected Cambodian and non-Cambodian Americans seen at Lowell Community Health Center from 2009 to 2012. Results. Cambodian Americans (n = 128) were older (mean age 53 vs 43 years old) and less likely to be male (41% vs 67%, P < .001) compared with non-Cambodians (n = 541). Cambodians had lower rates of injection drug use (1.6% vs 33.6%, P < .001) and any drug use (2.3% vs 82.1%, P < .001). More Cambodians were born between 1945 and 1965 (66.4% vs 44.5%). Within this birth cohort, more Cambodians had no other risk factor (82% vs 69%, P = .02). Fewer Cambodians had chronic HCV (53% vs 74%, P < .001). Conclusions. Birth between 1945 and 1965 was the major HCV risk factor for Cambodian Americans. Cambodians had lower rates of injection drug use or any drug use history. Risk behavior screening fails to describe HCV transmission for Cambodian Americans and creates a barrier to their linkage to care.
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Affiliation(s)
| | - Allen L Gifford
- Boston University School of Public Health; Boston University School of Medicine, Massachusetts; Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
| | | | - Mari-Lynn Drainoni
- Boston University School of Public Health; Boston University School of Medicine, Massachusetts; Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
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16
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Garcia JHP, Araújo Filho AHD, Braga LLBC, Viana CFG, Rocha TDS, Pereira KB. PEGYLATED INTERFERON AND RIBAVIRIN FOR TREATMENT OF RECURRENT HEPATITIS C AFTER LIVER TRANSPLANTATION: a single-liver transplant center experience in Brazil. ARQUIVOS DE GASTROENTEROLOGIA 2016; 52:216-21. [PMID: 26486290 DOI: 10.1590/s0004-28032015000300012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 04/27/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Treatment of hepatitis C virus infection in post-transplantation patients is a challenge due to poor tolerance and low success rates. OBJECTIVE To determine the response rate to pegylated interferon and ribavirin in post-liver transplant patients with hepatitis C recurrence. METHODS Between 18 May 2002 and 18 December 2011, 601 patients underwent liver transplantation at our service (Hospital Universitário Walter Cantídio, University of Ceará), 176 (29.2%) of whom were hepatitis C virus positive. Forty received antiviral therapy and were included in this cohort study. Twenty-eight (70%) completed the treatment protocol, which consisted of pegylated interferon and ribavirin for 48 weeks. RESULTS The sustained virological response rate was 55% according to intention-to-treat analysis. Recipient age and exposure to antiviral drugs prior to liver transplantation were associated with sustained virological response in the multivariate analysis. Patients were followed for 57 months on the average. Survival at 1 and 5 years was 100% in responders, versus 100% and 78%, respectively, in non-responders. CONCLUSION Sustained virological response rates were satisfactory in our series of liver transplantation patients, and decreased with increasing recipient age. Non-exposure to antiviral drugs prior to liver transplantation was positively associated with sustained virological response. The overall survival of responders and non-responders was similar.
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17
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Perumpail RB, Hahambis TA, Aggarwal A, Younossi ZM, Ahmed A. Treatment strategies for chronic hepatitis C prior to and following liver transplantation. World J Hepatol 2016; 8:69-73. [PMID: 26783422 PMCID: PMC4705454 DOI: 10.4254/wjh.v8.i1.69] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 10/30/2015] [Accepted: 12/18/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatitis C virus (HCV)-related liver disease is the leading indication for liver transplantation (LT) worldwide. However, HCV is an independent predictor of lower survival following LT, and recurrence of HCV post-LT is virtually universal. The historic standard of care during the interferon era of HCV therapy was expectant management-initiation of antiviral therapy in the setting of documented disease progression following LT. With the advent of new direct acting antiviral (DAA) therapies for HCV, the paradigm of expectant treatment for recurrent HCV infection post-LT is shifting. The safety, tolerability, and efficacy of DAAs, even among the sickest patients with advanced liver disease, enables treatment of HCV in the pre-transplant setting among LT waitlist registrants. Finally, emerging data are supportive of preemptive therapy with DAAs in liver transplant recipients as the preferred approach. Expectant management of HCV following LT can rarely be justified in the modern era of HCV therapy.
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18
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Punzalan CS, Barry C, Zacharias I, Rodrigues J, Mehta S, Bozorgzadeh A, Barnard GF. Sofosbuvir plus simeprevir treatment of recurrent genotype 1 hepatitis C after liver transplant. Clin Transplant 2015; 29:1105-11. [PMID: 26358816 DOI: 10.1111/ctr.12634] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Patients with recurrent hepatitis C (HCV) infection post-liver transplant can be difficult to treat safely and effectively. A prior (COSMOS) study in patients with non-transplant HCV, using sofosbuvir plus simeprevir, had high efficacy and tolerability in treating patients with HCV genotype 1, even prior non-responders to interferon therapy and those with cirrhosis. Our aim was to evaluate the efficacy of sofosbuvir and simeprevir in patients with genotype 1 HCV post-liver transplant. METHODS In this prospective, observational study, patients received sofosbuvir 400 mg plus simeprevir 150 mg daily for 12 wk without ribavirin. The primary end point was a sustained virologic response 12 wk after the end of therapy. RESULTS Forty-two patients completed the treatment. Twenty-six percent started the treatment ≤ 6 months post-liver transplant. Nineteen percent of the included patients had cirrhosis, 14% with decompensation. At week 4 on the treatment, 21% of patients had detectable virus but at the end of the treatment, 100% were undetectable. Twelve weeks after the end of the treatment, 95% of the patients had undetectable hepatitis C. The regimen was generally well tolerated. CONCLUSION The oral regimen of sofosbuvir plus simeprevir without ribavirin is efficacious and well tolerated in the treatment of patients with genotype 1 hepatitis C post-liver transplant.
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Affiliation(s)
- Carmi Santos Punzalan
- Division of Gastroenterology, Department of Medicine, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Curtis Barry
- Division of Gastroenterology, Department of Medicine, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Isabel Zacharias
- Division of Gastroenterology, Department of Medicine, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Julie Rodrigues
- Division of Gastroenterology, Department of Medicine, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Savant Mehta
- Division of Gastroenterology, Department of Medicine, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Adel Bozorgzadeh
- Division of Transplant Surgery, Department of Surgery, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Graham F Barnard
- Division of Gastroenterology, Department of Medicine, University of Massachusetts Medical Center, Worcester, MA, USA
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Sun N, Zhang J, Li X, Zhang C, Zhou X, Zhang C. Biliary tract reconstruction with or without T-tube in orthotopic liver transplantation: a systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2015; 9:529-38. [PMID: 25583036 DOI: 10.1586/17474124.2015.1002084] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION At present whether to use T-tube or not during orthotopic liver transplantation (OLT) in biliary tract reconstruction still remains controversial. Most transplant centers choose not to use T-tube because the T-tube can increase the incidence of cholangitis, but some centers still use T-tube because the T-tube can decrease the incidence of anastomotic strictures. AIM The purpose of this study is to compare biliary complications after biliary tract reconstruction with or without T-tube in OLT. METHODS systematic review and meta-analysis of a collection of 15 studies (six randomized control trails (RCTs) and nine comparative studies) to compare biliary complications after biliary tract reconstruction with or without T-tube in OLT. RESULTS The data showed that the biliary tract reconstruction with T-tube and without T-tube had equivalent outcomes for overall biliary complications (six RCTs p = 0.76; odd ratio [OR] = 1.19; 95% CI: 0.40, 3.58; all studies p = 0.14; OR = 1.50; 95% CI: 0.88, 2.57), bile leaks (six RCTs p = 0.61; OR = 0.86; 95% CI: 0.49, 1.52; all studies p = 0.09; OR = 1.39; 95% CI: 0.95, 2.02), cholangitis (six RCTs p = 0.13; OR = 5.54; 95% CI: 0.62, 49.79; all studies p = 0.08; OR = 4.27; 95% CI: 0.86, 21.16), hepatic artery thrombosis (two RCTs p = 1.00; OR = 1.00; 95% CI: 0.22, 4.49; all studies p = 0.75; OR = 1.19; 95% CI: 0.41, 3.44). However, in the group with T-tube there were better outcomes for biliary strictures (six RCTs p = 0.0003; OR = 0.34; 95% CI: 0.19, 0.61; all studies p < 0.0001; OR = 0.49; 95% CI: 0.34, 0.69). DISCUSSION Although most organizations choose not to use T-tube in OLT, we suggest that use of T-tube in biliary tract reconstruction during OLT for the recipients who possibly have high risks of biliary stricture is useful and necessary.
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Affiliation(s)
- Ning Sun
- Department of Hepatobiliary and Transplantation Surgery, the First Affiliated Hospital of China Medical University, Shenyang, P.R. China
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20
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Dai WC, Chan SC, Chok KSH, Cheung TT, Sharr WW, Chan ACY, Fung JYY, Wong TCL, Lo CM. Retransplantation using living-donor right-liver grafts. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:579-84. [PMID: 24550160 DOI: 10.1002/jhbp.100] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND This study reviews the outcomes of retransplantation using living-donor right-liver grafts. METHODS A retrospective study of liver retransplants performed between 1996 and 2013 was conducted. The retransplants were divided into the DD group (with deceased donors) and the LD group (with living donors). Survival outcomes were analyzed. RESULTS The DD group contained 23 patients and 27 retransplants using whole-liver grafts and the LD group contained 11 patients and 11 retransplants using right-liver grafts. Vascular and biliary complications were the main indications for retransplantation in both groups. The LD group had significantly younger donors, lighter grafts, shorter cold ischemia and longer operations. The two groups were comparable in age, preoperative liver function, warm ischemia, blood loss, transfusion, intensive care unit stay, hospital stay, hospital mortality, complication and graft loss. The 1-year, 3-year and 5-year patient survival rates were 78.3%, 73.7% and 63.8%, respectively, in the DD group. The LD group had the corresponding rates all at 90.9% (P = 0.246). The 1-year, 3-year and 5-year graft survival rates were 74.1%, 65.8% and 61.5%, respectively, in the DD group. The LD group had the corresponding rates all at 90.9% (P = 0.132). CONCLUSION Excellent long-term survival after retransplantation using living-donor right-liver grafts can be achieved.
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Affiliation(s)
- Wing Chiu Dai
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China.
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21
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Joshi SN. Hepatitis C screening. Ochsner J 2014; 14:664-8. [PMID: 25598732 PMCID: PMC4295744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Hepatitis C screening is now recommended for all individuals born between the years 1945-1965 in addition to individuals who have high-risk factors. Although most clinicians have extensive experience with the diagnosis and treatment of the disease, they have limited experience screening for it. METHODS We report current screening guidelines and methods. RESULTS By identifying the disease as early as possible, screening and treatment can reduce morbidity and mortality. CONCLUSION Screening for hepatitis C leads to the appropriate evaluation and treatment of individuals chronically infected with the hepatitis C virus and prevents the progression of liver disease to cirrhosis, hepatocellular carcinoma, and the associated morbidity and mortality. Screening for hepatitis C is also cost effective.
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Affiliation(s)
- Shobha N. Joshi
- Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA and Tulane University School of Medicine, New Orleans, LA
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22
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Gurusamy KS, Tsochatzis E, Toon CD, Xirouchakis E, Burroughs AK, Davidson BR. Antiviral interventions for liver transplant patients with recurrent graft infection due to hepatitis C virus. Cochrane Database Syst Rev 2013; 2013:CD006803. [PMID: 24307460 PMCID: PMC8930021 DOI: 10.1002/14651858.cd006803.pub4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Antiviral therapy for recurrent hepatitis C infection after liver transplantation is controversial due to unresolved balance between benefits and harms. OBJECTIVES To compare the therapeutic benefits and harms of different antiviral regimens in patients with hepatitis C re-infected grafts after liver transplantation. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1, 2013), MEDLINE, EMBASE, and Science Citation Index Expanded to February 2013. SELECTION CRITERIA We considered only randomised clinical trials (irrespective of language, blinding, or publication status) comparing various antiviral therapies (alone or in combination) in the treatment of hepatitis C virus recurrence in liver transplantation for the review. DATA COLLECTION AND ANALYSIS Two authors collected the data independently. We calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) using the fixed-effect and the random-effects models based on available case-analysis. In the presence of only trials for a dichotomous outcome, we performed the Fisher's exact test. MAIN RESULTS Overall, 17 trials with 736 patients met the inclusion criteria for this review. All trials had high risk of bias. Five hundred and one patients randomised in 11 trials provided information for various comparisons in this systematic review after excluding post-randomisation drop-outs and patients from trials that did not report any of the outcomes of interest for this review. The comparisons for which outcomes were available included pegylated (peg) interferon versus control; peg interferon plus ribavirin versus control; ribavirin plus peg interferon versus peg interferon; peg interferon (1.5 μg/kg/week) plus ribavirin versus peg interferon (0.5 μg/kg/week) plus ribavirin; amantadine plus peg interferon plus ribavirin versus peg interferon plus ribavirin; interferon versus control; interferon plus ribavirin versus control; ribavirin versus interferon; and ribavirin versus placebo. Long-term follow-up was not available in these trials. There were no significant differences in mortality, retransplantation, graft rejections requiring retransplantation or medical treatment, or fibrosis worsening between the groups in any of the comparisons in which these outcomes were reported. Quality of life and liver decompensation were not reported in any of the trials. There was a significantly higher proportion of participants who developed serious adverse events in the ribavirin plus peg interferon combination therapy group than in the peg interferon monotherapy group (1 trial; 56 participants; 17/28 (60.7%) in the intervention group versus 5/28 (17.9%) in the control group; RR 3.40; 95% CI 1.46 to 7.94). There was no significant difference in proportion of participants who developed serious adverse events or in the number of serious adverse events between the intervention and control groups in the other comparisons that reported serious adverse events. AUTHORS' CONCLUSIONS Considering the lack of clinical benefit, there is currently no evidence to recommend or refute antiviral treatment for recurrent liver graft infection with hepatitis C virus. Further randomised clinical trials with low risk of bias and low risk of random errors with adequate duration of follow-up are necessary.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Emmanuel Tsochatzis
- Royal Free Hampstead NHS Foundation Trust and UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentrePond StreetHampsteadLondonUKNW3 2QG
| | - Clare D Toon
- University College LondonDivision of Surgery & Interventional Science9th Floor, Royal Free HospitalRowland Hill StreetLondonLondonUKNW3 2PF
| | - Elias Xirouchakis
- Athens Medical Group, Hospital P. FaliroGI and Hepatology36 Areos str.AthensGreece17562
| | - Andrew K Burroughs
- Royal Free Hampstead NHS Foundation TrustSheila Sherlock Liver CentrePond StreetHampsteadLondonUKNW3 2QG
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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23
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Gurusamy KS, Tsochatzis E, Toon CD, Davidson BR, Burroughs AK. Antiviral prophylaxis for the prevention of chronic hepatitis C virus in patients undergoing liver transplantation. Cochrane Database Syst Rev 2013; 2013:CD006573. [PMID: 24297303 PMCID: PMC6599865 DOI: 10.1002/14651858.cd006573.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND It is not clear whether prophylactic antiviral therapy is indicated to improve patient and graft survival in patients undergoing liver transplantation for chronic decompensated hepatitis C virus (HCV) infection. OBJECTIVES To compare the benefits and harms of different prophylactic antiviral therapies for patients undergoing liver transplantation for chronic HCV infection. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1, 2013), MEDLINE, EMBASE, and Science Citation Index Expanded to February 2013. SELECTION CRITERIA Only randomised clinical trials irrespective of language, blinding, or publication status and comparing various prophylactic antiviral therapies (alone or in combination) in the prophylactic treatment of patients undergoing liver transplantation for chronic HCV infection. DATA COLLECTION AND ANALYSIS Two authors collected the data independently. We calculated the risk ratio (RR) or mean difference (MD) or hazard ratio (HR) with 95% confidence intervals (CI) using the fixed-effect and the random-effects models based on available case analysis. MAIN RESULTS A total of 501 liver transplant recipients undergoing liver transplantation for chronic HCV infection were randomised in 12 trials to various experimental interventions and control interventions. The proportion of genotype I varied between 49% and 100% in the seven trials that reported the genotype. Only one or two trials were included under each comparison. All the trials were of high risk of bias. Ten trials including 441 liver transplant recipients provided data for this review.There were no significant differences in the 90-day mortality (1 trial; 81 participants; 5/35 (adjusted proportion: 14.2%) in interferon group versus 5/46 (10.9%) in control group; RR 1.31; 95% CI 0.41 to 4.19); mortality at maximal follow-up (2 trials; 105 participants; 7/47 (adjusted proportion: 14.8%) in interferon group versus 10/58 (17.2%) in control group; RR 0.86; 95% CI 0.36 to 2.08); long-term mortality (1 trial; 81 participants; HR 0.45; 95% CI 0.13 to 1.56); mortality at maximal follow-up (1 trial; 54 participants; 1/26 (3.9%) in pegylated interferon group versus 2/28 (7.1%) in control group; RR 0.54; 95% CI 0.05 to 5.59); 90-day mortality (1 trial; 115 participants; 5/55 (9.1%) in pegylated interferon plus ribavirin group versus 3/60 (5.0%) in control group; RR 1.82; 95% 0.46 to 7.25); 90-day mortality (3 trials; 53 participants; 3/37 (adjusted proportion: 4.3%) in HCV antibody group versus 1/16 (6.3%) in placebo group; RR 0.69; 95% CI 0.15 to 3.11); or 90-day mortality (2 trials; 31 participants; 2/14 (adjusted proportion: 16.2%) in HCV antibody high-dose group versus 1/17 (5.9%) in HCV antibody low-dose group; RR 2.75; 95% CI; 0.30 to 25.35). There were no significant differences in the retransplantation at maximal follow-up (2 trials; 105 participants; 2/47 (adjusted proportion: 4.0%) in interferon group versus 2/58 (3.4%) in control group; RR 1.17; 95% CI 0.22 to 6.2); 90-day retransplantation (1 trial; 18 participants; 1/12 (8.3%) in HCV antibody group versus 0/6 (0%) in control group; RR 1.71; 95% CI 0.09 to 32.93); or 90-day retransplantation (1 trial; 12 participants; 1/6 (17.7%) in HCV antibody high-dose group versus 0/6 (0%) in HCV antibody low-dose group; RR 3.00; 95% CI 0.15 to 61.74). There were no significant differences in serious adverse events, graft rejection, worsening of fibrosis, or HCV recurrence between intervention and control groups in any of the comparisons that reported these outcomes. None of the trials reported quality of life, liver decompensation, intensive therapy unit stay, or hospital stay. Life-threatening adverse events were not reported in either group in any of the comparisons. AUTHORS' CONCLUSIONS There is currently no evidence to recommend prophylactic antiviral treatment to prevent recurrence of HCV infection either in primary liver transplantation or retransplantation. Further randomised clinical trials with adequate trial methodology and adequate duration of follow-up are necessary.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
| | - Emmanuel Tsochatzis
- Royal Free Hampstead NHS Foundation Trust and UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentrePond StreetHampsteadLondonUKNW3 2QG
| | - Clare D Toon
- West Sussex County CouncilPublic Health1st Floor, The GrangeTower StreetChichesterUKPO19 1QT
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
| | - Andrew K Burroughs
- Royal Free Hampstead NHS Foundation TrustSheila Sherlock Liver CentrePond StreetHampsteadLondonUKNW3 2QG
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24
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Waghray A, O'Shea R, Pai R, Menon KVN. Hepatocellular carcinoma complicating recurrent hepatitis C after liver transplantation. Hepatology 2013; 58:1854-5. [PMID: 23744815 DOI: 10.1002/hep.26548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Accepted: 05/02/2013] [Indexed: 12/07/2022]
Affiliation(s)
- Abhijeet Waghray
- Department of Gastroenterology and Hepatology, Digestive Disease Institute (DDI), and Pathology, Cleveland Clinic, Cleveland, OH
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25
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Yoo PS, Umman V, Rodriguez-Davalos MI, Emre SH. Retransplantation of the liver: review of current literature for decision making and technical considerations. Transplant Proc 2013; 45:854-9. [PMID: 23622570 DOI: 10.1016/j.transproceed.2013.02.063] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Liver transplantation (LTx) is an established treatment modality for patients with end-stage liver disease, metabolic disorders, and patients with acute liver failure. When a graft fails after primary LTx, retransplantation of the liver (reLTx) is the only potential cure. ReLTx accounts for 7%-10% of all LTx in the United States. Early causes of graft failure for which reLTx may be indicated include primary graft nonfunction and vascular inflow thrombosis. ReLTx in such cases in the early postoperative period is usually straightforward as long as an appropriate secondary allograft is secured in a timely fashion. Late indications may include ischemic cholangiopathy, chronic rejection, and recurrence of the primary liver disease. ReLTx performed in the late period is often more complex and selection criteria are more stringent due to the persistent shortage of organs. The question of whether to retransplant patients with recurrent hepatitis C remains controversial, but these practices are likely to change as the epidemic progresses and new treatments evolve. We also present recent results with reLTx from Yale-New Haven Transplant Center and early results with the use of living donors for reLTx.
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Affiliation(s)
- P S Yoo
- Department of Surgery, Section of Transplantation and Immunology, Yale School of Medicine, New Haven, Connecticut 06520, USA
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26
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Germani G, Tsochatzis E, Papastergiou V, Burroughs AK. HCV in liver transplantation. Semin Immunopathol 2012; 35:101-10. [PMID: 22829333 DOI: 10.1007/s00281-012-0329-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 07/01/2012] [Indexed: 12/23/2022]
Abstract
HCV-related cirrhosis represents the leading indication for liver transplantation in the Western countries. HCV reinfection after liver transplantation occurs in virtually all patients transplanted for HCV-related liver disease Histological evidence of chronic HCV infection develops in 50 to 90 % of patients by 12 months after liver transplantation, and cirrhosis occurs in about 20 % of patients within 5 years after transplant. Several studies have evaluated host, viral, and transplant-related factors that might be associated with the severity of HCV recurrence. Among host factors, immunosuppression is one of the major factors that accounts for accelerated HCV recurrence and it has been an area of extensive research and controversy. Donor age, steatosis, and immunogenetic factors are also relevant in determining the outcome in patients transplanted for HCV-related cirrhosis. A major step to prevent complications of HCV recurrence related to the rapid fibrosis is the posttransplant antiviral treatment. Two strategies have been tried: pre-emptive or other strategies as soon as possible after liver transplantation or elective therapy once there is histological evidence of recurrent hepatitis C. Retransplantation due to graft failure from recurrent hepatitis C is rarely an option in the era of organ shortage as it is associated with poor outcome, but many case needs to be considered early in the evolution of disease. New antivirals may change the outcome dramatically of patients transplanted for HCV cirrhosis.
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Affiliation(s)
- Giacomo Germani
- The Royal Free Sheila Sherlock Liver Centre and University Department of Surgery, Royal Free Hospital and UCL, London, UK
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27
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Crivellin C, De Martin E, Germani G, Gambato M, Senzolo M, Russo FP, Vitale A, Zanus G, Cillo U, Burra P. Risk factors in liver retransplantation: a single-center experience. Transplant Proc 2011; 43:1110-3. [PMID: 21620065 DOI: 10.1016/j.transproceed.2011.01.141] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Liver retransplantation (Re-OLT) is one of the most debated issues in medicine over the past decade. Re-OLT, currently is accepted for patients with irreversible failure of a hepatic graft caused by primary nonfunction (PNF), hyperacute/chronic rejection, or hepatic artery thrombosis (HAT); whereas it is still controversial for patients with recurrent viral disease, in particular hepatitis C virus (HCV) cirrhosis. Patient and graft survival rates are lower than those observed after primary liver transplantation (OLT). The aim of the present study was to analyze the risk factors that adversely affect survival after Re-OLT in a single center. Medical data were collected for 23 patients who underwent Re-OLT from November 2002 to December 2008 including six men and seven women of mean age of 51.3 years. The most frequent indications for Re-OLT were: PNF (69.5%; 16/23), HCV recurrence (8.6%; 2/23), or HAT (8.6%; 2/23). Mean Model for End-Stage Liver Disease (MELD) at Re-OLT was 27.7 (range = 9-40). After a mean follow-up of 37.4 ± 30 (standard deviation) months, 43% (10/23) of patients had died, including 70% within the first 2 months after Re-OLT. Sepsis represented the commonest cause of death (40%). Re-OLT was performed for PNF among 90% of succumbing patients. As regards dead patients, 4/10 were HCV(+) whose causes of death were sepsis (n=2), alcoholic cirrhosis (n=2), and undetermined (n=1). Comparing patients who died after liver Re-OLT versus alive patients, we did not find any significant difference in terms of mean MELD (28.6 vs 27; P=NS), MELD > 25 (60% vs 61.5%, P=NS), donor age > 60 years (30% vs 15.3%, P=NS), HCV(+) (40% vs 62%, P = NS), or time interval from OLT to Re-OLT (12.2 vs 777.7 days, P=NS). Patient survivals after Re-OLT were 67% at 3 years and 50% at 5 years, which were lower than those of first transplantations, as reported by other European and International Centers. Forty percent of deaths after Re-OLT occurred among HCV(+) recipients, but for reasons unrelated to HCV infection.
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Affiliation(s)
- C Crivellin
- Multivisceral Transplant Unit, Department of Surgical and Gastroenterological Sciences, University Hospital of Padua, Padua, Italy
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Azarbal B, Poommipanit P, Arbit B, Hage A, Patel J, Kittleson M, Kar S, Kaldas FM, Busuttil RW. Feasibility and safety of percutaneous coronary intervention in patients with end-stage liver disease referred for liver transplantation. Liver Transpl 2011; 17:809-13. [PMID: 21425429 DOI: 10.1002/lt.22301] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Percutaneous coronary intervention (PCI) has traditionally not been an option for patients with end-stage liver disease (ESLD) and coronary artery disease (CAD). This retrospective study was designed to demonstrate the feasibility and safety of PCI in liver transplant candidates. Patients with ESLD and hemodynamically significant CAD who were otherwise deemed to be acceptable candidates for liver transplantation underwent PCI. The procedural success rates, mortality and myocardial infarction rates, and bleeding outcomes were examined. Sixteen patients with ESLD underwent PCI: 15 with bare-metal stents (1.3 stents per patient on average) and 1 with balloon angioplasty alone. The median diameter stenosis per lesion was 80%, the median platelet count was 68 × 10(9) /L, the median international normalized ratio was 1.3, and the median Model for End-Stage Liver Disease score was 13. PCI was successful in 94% of the patients. One patient had a suboptimal residual stenosis of 50% after stenting. There were no in-hospital or 30-day deaths or myocardial infarctions, and no patients developed hematomas. One patient required a 1-U platelet transfusion, and another required 1 U of packed red blood cells. All patients remained clinically stable 1 month after PCI. Nine of the 16 patients were listed for liver transplantation, and 3 patients underwent liver transplantation. In conclusion, we have demonstrated the safety and feasibility of PCI in a small cohort of patients with ESLD and hemodynamically significant CAD, the majority of whom had significant thrombocytopenia. Larger studies are required to determine whether PCI is an effective treatment strategy for patients with ESLD and hemodynamically significant CAD who otherwise would not be candidates for liver transplantation.
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Affiliation(s)
- Babak Azarbal
- Cedars-Sinai Heart Institute/California Heart Center, Cedars-Sinai Medical Center, Los Angeles, CA 90211, USA.
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Tsoulfas G, Agorastou P. Role of living donor liver transplantation in the treatment of hepatitis C virus infection. HEPATITIS MONTHLY 2011; 11:427-33. [PMID: 22087173 PMCID: PMC3212794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Revised: 03/17/2011] [Accepted: 04/17/2011] [Indexed: 11/26/2022]
Abstract
Hepatitis C virus (HCV) infection is one of the most common indications for liver transplantation worldwide. Because of the existing organ shortage, adult-to-adult living donor liver transplantation (LDLT) has become an important method of expanding the donor pool to meet the ever-increasing need. However, despite advantages such as the quality of the hepatic graft and the timing of the transplant, the exact role of LDLT in the treatment of HCV is still unclear. In this review, we aim to address some of these issues in an effort to highlight both the advantages and disadvantages, as well as to identify the main challenges, of using LDLT for treating patients with HCV infection.
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Affiliation(s)
- Georgios Tsoulfas
- Department of Surgery, Aristoteleion University of Thessaloniki, Thessaloniki, Greece,Corresponding author at: Georgios Tsoulfas, Department of Surgery, Aristoteleion University of Thessaloniki, 66 Tsimiski Street, 54622, Thessaloniki, Greece. Tel.: +30-6971895190, E-mail:
| | - Polyxeni Agorastou
- Department of Gastroenterology, Aristoteleion University of Thessaloniki, Thessaloniki, Greece
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Gurusamy KS, Tsochatzis E, Davidson BR, Burroughs AK. Antiviral prophylactic intervention for chronic hepatitis C virus in patients undergoing liver transplantation. Cochrane Database Syst Rev 2010:CD006573. [PMID: 21154370 DOI: 10.1002/14651858.cd006573.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND It is not clear whether prophylactic antiviral therapy is indicated in patients undergoing liver transplantation for chronic decompensated hepatitis C virus (HCV) infection. OBJECTIVES To compare the benefits and harms of different prophylactic anti-viral therapies for patients undergoing liver transplantation for chronic HCV infection. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until August 2010. SELECTION CRITERIA Only randomised clinical trials irrespective of language, blinding, or publication status and comparing various prophylactic antiviral therapies (alone or in combination) in the prophylactic treatment of patients undergoing liver transplantation for chronic HCV infection. DATA COLLECTION AND ANALYSIS Two authors collected the data independently. We calculated the risk ratio (RR) or mean difference (MD) or hazard ratio (HR) with 95% confidence intervals (CI) using the fixed-effect and the random-effects models based on available case analysis. MAIN RESULTS A total of 477 liver transplant recipients undergoing liver transplantation for chronic HCV infection were randomised in eleven trials to various interventions and controls. The proportion of genotype I varied between 49% to 88% in the five trials that reported the genotype. Only one or two trials were included under each comparison. All the trials were of high risk of bias. There was no significant differences in the patient survival, graft rejection, re-transplantation, or HCV recurrence between intervention and control groups in any of the comparisons that reported these outcomes. None of the trials reported liver decompensation, primary graft non-function, intensive therapy unit stay, hospital stay, or quality of life. Life-threatening adverse events were not reported in either group in any of the comparisons. Up to 91% of patients required reduction in dose and up to 36% of patients required cessation of treatment in the various comparisons because of adverse events or because of patient's choice to stop treatment. AUTHORS' CONCLUSIONS There is currently no evidence to recommend prophylactic antiviral treatment to prevent recurrence of HCV infection either in primary liver transplantation or re-transplantation. Further randomised clinical trials with adequate trial methodology and adequate duration of follow-up are necessary.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Department of Surgery, Royal Free Campus, UCL Medical School, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG
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Jiao M, Greanya ED, Haque M, Yoshida EM, Soos JG. Methadone maintenance therapy in liver transplantation. Prog Transplant 2010. [PMID: 20929104 DOI: 10.7182/prtr.20.3.r8n4k17212158k62] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Cirrhosis due to chronic infection with hepatitis C virus remains by far the most common reason for liver transplantation in North America. Currently, parenteral use of street drugs is the most common means of acquiring hepatitis C. Methadone maintenance therapy is an accepted form of treatment for chronic opiate (eg, heroin) addiction and, not surprisingly, a significant proportion of methadone-treated patients have chronic hepatitis C. The feasibility of liver transplant candidacy in hepatitis patients who require methadone maintenance therapy is controversial, and some transplant centers require patients to withdraw from such therapy in order for the transplant process to move forward. Thus stable patients with end-stage cirrhosis who are receiving methadone maintenance are left in a most difficult situation: discontinue methadone and accept the side effects of withdrawal with the risk of recidivism to use of street opiates, an absolute contraindication for transplantation, or continue methadone therapy and risk exclusion from the transplant process. The issue of methadone replacement therapy in end-stage cirrhosis and the posttransplant literature on the subject are explored in this paper.
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Affiliation(s)
- Modi Jiao
- University of Toronto Scarborough, Toronto, Ontario
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Jiao M, Greanya ED, Haque M, Yoshida EM, Soos JG. Methadone Maintenance Therapy in Liver Transplantation. Prog Transplant 2010; 20:209-14; quiz 215. [DOI: 10.1177/152692481002000303] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cirrhosis due to chronic infection with hepatitis C virus remains by far the most common reason for liver transplantation in North America. Currently, parenteral use of street drugs is the most common means of acquiring hepatitis C. Methadone maintenance therapy is an accepted form of treatment for chronic opiate (eg, heroin) addiction and, not surprisingly, a significant proportion of methadone-treated patients have chronic hepatitis C. The feasibility of liver transplant candidacy in hepatitis patients who require methadone maintenance therapy is controversial, and some transplant centers require patients to withdraw from such therapy in order for the transplant process to move forward. Thus stable patients with end-stage cirrhosis who are receiving methadone maintenance are left in a most difficult situation: discontinue methadone and accept the side effects of withdrawal with the risk of recidivism to use of street opiates, an absolute contraindication for transplantation, or continue methadone therapy and risk exclusion from the transplant process. The issue of methadone replacement therapy in end-stage cirrhosis and the posttransplant literature on the subject are explored in this paper.
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Affiliation(s)
- Modi Jiao
- University of Toronto Scarborough, Toronto, Ontario (MJ), Vancouver General Hospital (EDG, JGS), University of British Columbia (MH, EMY), British Columbia Transplant (MJ, EDG, MH, EMY, JGS), Vancouver, BC
| | - Erica D. Greanya
- University of Toronto Scarborough, Toronto, Ontario (MJ), Vancouver General Hospital (EDG, JGS), University of British Columbia (MH, EMY), British Columbia Transplant (MJ, EDG, MH, EMY, JGS), Vancouver, BC
| | - Mazhar Haque
- University of Toronto Scarborough, Toronto, Ontario (MJ), Vancouver General Hospital (EDG, JGS), University of British Columbia (MH, EMY), British Columbia Transplant (MJ, EDG, MH, EMY, JGS), Vancouver, BC
| | - Eric M. Yoshida
- University of Toronto Scarborough, Toronto, Ontario (MJ), Vancouver General Hospital (EDG, JGS), University of British Columbia (MH, EMY), British Columbia Transplant (MJ, EDG, MH, EMY, JGS), Vancouver, BC
| | - John G. Soos
- University of Toronto Scarborough, Toronto, Ontario (MJ), Vancouver General Hospital (EDG, JGS), University of British Columbia (MH, EMY), British Columbia Transplant (MJ, EDG, MH, EMY, JGS), Vancouver, BC
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Schmidt SC, Bahra M, Bayraktar S, Berg T, Schmeding M, Pratschke J, Neuhaus P, Neumann U. Antiviral treatment of patients with recurrent hepatitis C after liver transplantation with pegylated interferon. Dig Dis Sci 2010; 55:2063-9. [PMID: 19798575 DOI: 10.1007/s10620-009-0982-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2009] [Accepted: 09/09/2009] [Indexed: 12/14/2022]
Abstract
BACKGROUND The recurrence of hepatitis C virus (HCV) after liver transplantation (OLT) leads to recurrent cirrhosis in up to 40% of patients. AIMS To identify patients who profit the most from antiviral therapy and to delineate whether early treatment after OLT is effective to reach sustained virological response (SVR), we analyzed factors associated to SVR during pegylated interferon/ribavirin (PegIFN/RBV) therapy. METHODS A retrospective analysis of efficiency and viral decline kinetics in 83 HCV-infected liver transplant recipients who received therapy with PegIFN/RBV was carried out. RESULTS Forty-one of 83 (49.4%) patients became HCV RNA-negative. SVR was achieved in 26/83 (31.3%) patients. Viral decline of at least 2 log 10 (n = 47) at week 12 was significantly associated with an end-of-treatment (EOT) response. Eleven early viral response patients were not able to clear HCV RNA, whereas five patients without a 2 log decline achieved SVR. The highest predictive value for SVR was an undetectable viremia at week 24 (92%). CONCLUSIONS The outcome of antiviral combination therapy for HCV reinfection after OLT can be best predicted by week-24 virologic response. The high SVR rates in patients with detectable HCV RNA at week 12 might suggest a prolonged treatment protocol in liver transplant recipients.
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Affiliation(s)
- Sven C Schmidt
- Klinik für Allgemein-, Viszeral-, und Transplantationschirurgie, Charité Campus Virchow-Klinikum, Universitätsmedizin Berlin, Berlin, Germany.
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Gurusamy KS, Tsochatzis E, Xirouchakis E, Burroughs AK, Davidson BR. Antiviral therapy for recurrent liver graft infection with hepatitis C virus. Cochrane Database Syst Rev 2010:CD006803. [PMID: 20091608 DOI: 10.1002/14651858.cd006803.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Antiviral therapy to treat recurrent hepatitis C infection after liver transplantation is controversial due to unresolved balance between benefits and harms. OBJECTIVES To compare the therapeutic benefits and harms of different antiviral regimens in patients with hepatitis C re-infected grafts after liver transplantation. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until March 2009. SELECTION CRITERIA Only randomised clinical trials (irrespective of language, blinding, or publication status) comparing various antiviral therapies (alone or in combination) in the treatment of hepatitis C virus recurrence in liver transplantation were considered for the review. DATA COLLECTION AND ANALYSIS Two authors collected the data independently. We calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) using the fixed-effect and the random-effects models based on available case-analysis. In the presence of only trial for a dichotomous outcome, we performed the Fisher's exact test. MAIN RESULTS A total of 425 liver transplant recipients with proven hepatitis C recurrence were randomised in twelve trials to various interventions and controls. The mean proportion of genotype I was 79.9% in the nine trials that reported the genotype. All the trials were of high risk of bias. One to two trials were included under each comparison including single drug or multidrug regimens of interferon, ribavirin, and amantadine. There was no significant difference in the mortality, graft rejection, or in re-transplantation between intervention and control in any of the comparisons that reported these outcomes. None of the trials reported liver decompensation or quality of life. Life-threatening adverse effects were not reported in either group in any of the comparisons. Up to 87.5% of patients required reduction in dose and up to 42.9% of patients required cessation of treatment in the various comparisons because of adverse effects or because of patient's choice to stop treatment. AUTHORS' CONCLUSIONS Considering the lack of clinical benefit and the frequent adverse effects, there is currently no evidence to recommend antiviral treatment for recurrent liver graft infection with HCV. Further randomised clinical trials with adequate trial methodology and adequate duration of follow-up are necessary.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG
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35
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Jain A, Sharma R, Ryan C, Safadjou S, Kashyap R, Mantry P, Maliakkal B, Orloff M. Response to antiviral therapy in liver transplant recipients with recurrent hepatitis C viral infection: a single center experience. Clin Transplant 2010; 24:104-11. [DOI: 10.1111/j.1399-0012.2009.00961.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Sung RS, Pomfret EA, Andreoni KA, Baker TB, Peters TG. The high-risk recipient: the Eighth Annual American Society of Transplant Surgeons' State-of-the-Art Winter Symposium. Clin Transplant 2009; 24:23-8. [PMID: 19919609 DOI: 10.1111/j.1399-0012.2009.01156.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The evolution of organ transplantation has produced results so successful that many transplant programs commonly see recipients with medical risks, which in the past, would have prohibited transplantation. The Eighth Annual American Society of Transplant Surgeons State-of-the-Art Winter Symposium focused on the high-risk recipient. The assessment of risk has evolved over time, as transplantation has matured. The acceptance of risk associated with a given candidate today is often made in consideration of the relative value of the organ to other candidates, the regulatory environment, and philosophical notions of utility, equity, and fairness. In addition, transplant programs must balance outcomes, transplant volume, and the costs of organ transplantation, which are impacted by high-risk recipients. Discussion focused on various types of high-risk recipients, such as those with coronary artery disease, morbid obesity, and hepatitis C; strategies to reduce risk, such as down-staging of hepatocellular carcinoma and treatment of pulmonary hypertension; the development of alternatives to transplantation; and the degree to which risk can or should be used to define candidate selection. These approaches can modify the impact of recipient risk on transplant outcomes and permit transplantation to be applied successfully to a greater variety of patients.
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Affiliation(s)
- Randall S Sung
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
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37
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Tsoulfas G, Goulis I, Giakoustidis D, Akriviadis E, Agorastou P, Imvrios G, Papanikolaou V. Hepatitis C and liver transplantation. Hippokratia 2009; 13:211-5. [PMID: 20011084 PMCID: PMC2776333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Cirrhosis due to chronic hepatitis C is the leading indication for liver transplantation in Europe, United States and Japan. Reinfection after liver transplantation is universal and chronic liver disease develops in at least 70% of patients at 3 years, with an accelerated course compared to the nontransplant setting. These facts underscore the need for a better understanding of hepatitis C infection and the various treatment modalities. This paper attempts a brief review of the scope of the disease, as well as the different treatment modalities, with special emphasis given to orthotopic liver transplantation.
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Affiliation(s)
- G Tsoulfas
- Surgical Department of Transplantation, Aristotle University, Hippokratio General Hospital, Thessaloniki, Greece.
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Orthotopic liver transplantation: T-tube or not T-tube? Systematic review and meta-analysis of results. Transplantation 2009; 87:1672-80. [PMID: 19502959 DOI: 10.1097/tp.0b013e3181a5cf3f] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The purpose of this study was to compare outcomes after duct-to-duct anastomoses with or without biliary T-tube in orthotopic liver transplantation. METHODS We pooled the outcomes of 1027 patients undergoing choledocho-choledochostomy with or without T-tube in 9 of 46 screened trials by means of fixed or random effects models. RESULTS The "without T-tube" and "with T-tube" groups had equivalent outcomes for: anastomotic bile leaks or fistulas, choledocho-jejunostomy revisions, dilatation and stenting, hepatic artery thromboses, retransplantation, and mortality due to biliary complications. The "without T-tube" group had better outcomes when considering "fewer episodes of cholangitis," "fewer episodes of peritonitis," and showed a favorable trend for "overall biliary complications." Although the "with T-tube" group showed superior result for "anastomotic and nonanastomotic strictures," the incidence of interventions was not diminished. CONCLUSIONS Our systematic review and meta analysis favor the abandonment of T-tubes in orthotopic liver transplantation.
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Lang H, Sotiropoulos GC, Beckebaum S, Fouzas I, Molmenti EP, Omar OS, Sgourakis G, Radtke A, Nadalin S, Saner FH, Malagó M, Gerken G, Paul A, Broelsch CE. Incidence of liver retransplantation and its effect on patient survival. Transplant Proc 2009; 40:3201-3. [PMID: 19010234 DOI: 10.1016/j.transproceed.2008.09.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE The purpose of this study was to review our institutional experience with re-liver transplantation (OLT) after split and full-size OLT. PATIENTS AND METHODS We evaluated data corresponding to retransplanted patients over an 8-year period who underwent deceased donor OLT at our institution. Variables analyzed included indications for primary OLT, and re-OLT, the type of graft used during the initial versus re-OLT, the time from initial to re-OLT, and patient survival after re-OLT. RESULTS Sixty-four of 697 first OLT (9.2%) required re-OLT. Forty-nine cases were among 637 (7.6%) full-size OLT, while 15 were among 60 (25%) split OLT (P < .001). Median time to re-OLT was 8 days (range = 1-1885 days). Main indications for re-OLT were primary nonfunction/initial poor function (44%), hepatic artery thrombosis (26%), biliary complications (11%), and hepatitis C recurrence (6%). Forty-eight percent of the re-OLTs were performed within the first posttransplant week. The overall survival for these 64 patients was 55% and 48% at 1 and 3 years after the primary OLT, and 44% at both 1 and 3 years after the re-OLT, respectively. CONCLUSIONS The overall incidence of re-OLT remains 9%. Approximately half of all re-OLT occured within the first posttransplant week. Early retransplantation was associated with the best patient survival. Overall survival after re-OLT was about 10% to 20% lower than that after primary OLT.
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Affiliation(s)
- H Lang
- Department of General and Abdominal Surgery, Johannes Gutenberg University Hospital, Mainz, Germany; Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, Essen, Germany.
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40
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Bekker J, Ploem S, de Jong KP. Early hepatic artery thrombosis after liver transplantation: a systematic review of the incidence, outcome and risk factors. Am J Transplant 2009; 9:746-57. [PMID: 19298450 DOI: 10.1111/j.1600-6143.2008.02541.x] [Citation(s) in RCA: 342] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To clarify inconsistencies in the literature we performed a systematic review to identify the incidence, risk factors and outcome of early hepatic artery thrombosis (eHAT) after liver transplantation. We searched studies identified from databases (MEDLINE, EMBASE, Science Citation Index) and references of identified studies. Seventy-one studies out of 999 screened abstracts were eligible for this systematic review. The incidence of eHAT was 4.4% (843/21, 822); in children 8.3% and 2.9% in adults (p < 0.001). Doppler ultrasound screening (DUS) protocols varied from 'no routine' to 'three times a day.' The median time to detection was at day seven. The overall retransplantation rate was 53.1% and was higher in children (61.9%) than in adults (50%, p < 0.03). The overall mortality rate of patients with eHAT was 33.3% (range: 0-80%). Mortality in adults (34.3%) was higher than in children (25%, p < 0.03). The reported risk factors for eHAT were, cytomegalovirus mismatch (seropositive donor liver in seronegative recipient), retransplantation, arterial conduits, prolonged operation time, low recipient weight, variant arterial anatomy, and low volume transplantation centers. eHAT is associated with significant graft loss and mortality. Uniform definitions of eHAT and uniform treatment modalities are obligatory to confirm these results and to obtain a better understanding of this disastrous complication.
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Affiliation(s)
- J Bekker
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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de Arias AE, Haworth SE, Belli LS, Burra P, Pinzello G, Vangeli M, Minola E, Guido M, Boccagni P, De Feo TM, Torelli R, Cardillo M, Scalamogna M, Poli F. Killer cell immunoglobulin-like receptor genotype and killer cell immunoglobulin-like receptor-human leukocyte antigen C ligand compatibility affect the severity of hepatitis C virus recurrence after liver transplantation. Liver Transpl 2009; 15:390-9. [PMID: 19326408 DOI: 10.1002/lt.21673] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
In 20% to 30% of infected individuals, hepatitis C virus (HCV) can cause cirrhosis and hepatocellular carcinoma, for which liver transplantation is the best treatment available. HCV re-infection is universal, and hepatitis disease recurrence occurs in most cases with a 30% probability of progression to graft cirrhosis at 5 years post-transplant. The immunological response to HCV involves natural killer (NK) cells and killer cell immunoglobulin-like receptors (KIRs), which specifically recognize human leukocyte antigen (HLA) class I antigens present on target cells. The effector functions of NK cells are influenced by inhibitory KIR interaction with self-HLA class I ligands, with HLA-C being the most predominant. This study examines the roles of KIR genotypes and their HLA ligands in both HCV disease recurrence and its progression. A total of 151 patients were included in the cohort, and their clinical details were recorded. Liver biopsies were used to define the absence/presence of recurrent hepatitis, the degree of fibrosis, and the progression to cirrhosis over a 10-year period. Mismatching of KIR-HLA-C ligands between donor-recipient pairs was associated with the recurrence of hepatitis (P = 0.008). The presence of KIR2DL3 in the recipient correlated with progression to liver fibrosis (P = 0.04). The mismatching of HLA-KIR ligands favored the progression of the recurrent hepatitis to fibrosis only in the presence of KIR2DL3 (P = 0.04). These preliminary results indicate that the KIR genotype and KIR-HLA-C ligand compatibility play roles in the recurrence and progression of hepatitis C disease in liver transplant recipients.
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Affiliation(s)
- Alejandro Espadas de Arias
- Department of Regenerative Medicine, Organ and Tissue Transplantation Immunology, Ospedale Maggiore Policlinico, Mangiagalli, Regina Elena, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
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Gurusamy KS, Osmani B, Xirouchakis E, Burroughs AK, Davidson BR. Antiviral therapy for recurrent liver graft infection with hepatitis C virus. Cochrane Database Syst Rev 2009:CD006803. [PMID: 19160303 DOI: 10.1002/14651858.cd006803.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Antiviral therapy to treat recurrent hepatitis C infection after liver transplantation is controversial. OBJECTIVES To compare the therapeutic efficacy and side effects of different antiviral regimens in patients with hepatitis C re-infected grafts after liver transplantation. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until September 2007. SELECTION CRITERIA Only randomised clinical trials (irrespective of language, blinding, or publication status) comparing various antiviral therapies (alone or in combination) in the treatment of hepatitis C virus recurrence in liver transplantation were considered for the review. DATA COLLECTION AND ANALYSIS Two authors collected the data independently. We calculated the relative risk (RR) or weighted mean difference (WMD) with 95% confidence intervals (CI) using the fixed-effect and the random-effects models based on available case-analysis. MAIN RESULTS A total of 389 liver transplant recipients with proven hepatitis C recurrence were randomised in eleven trials to various interventions and controls. The mean proportion of genotype I was 77.8% in the seven trials that reported the genotype. Only one or two trials were included under each comparison. All the trials were of high risk of bias. There was no difference in the mortality, graft rejection, or in re-transplantation between intervention and control in any of the comparisons that reported these outcomes. None of the trials reported liver decompensation or quality of life. Life-threatening adverse effects were not reported in either group in any of the comparisons. Up to 87.5% of patients required reduction in dose and up to 42.9% of patients required cessation of treatment in the various comparisons because of adverse effects or because of patient's choice to stop treatment. AUTHORS' CONCLUSIONS 1. Considering the lack of clinical benefit and the frequent adverse effects, there is currently no evidence to recommend antiviral treatment for recurrent liver graft infection with HCV. 2. Further randomised clinical trials with adequate trial methodology and adequate duration of follow-up are necessary.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG.
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Briceño J, Ciria R, Pleguezuelo M, de la Mata M, Muntané J, Naranjo A, Sánchez-Hidalgo J, Marchal T, Rufián S, López-Cillero P. Impact of donor graft steatosis on overall outcome and viral recurrence after liver transplantation for hepatitis C virus cirrhosis. Liver Transpl 2009; 15:37-48. [PMID: 19109846 DOI: 10.1002/lt.21566] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The aim of this study was to determine the influence of donor graft steatosis on overall outcome, viral recurrence, and fibrosis progression in orthotopic liver transplantation (OLT) for hepatitis C virus (HCV) cirrhosis. One hundred twenty patients who underwent OLT for HCV cirrhosis between 1995 and 2005 were included in the study. Donor steatosis was categorized as absent (0%-10%; n = 40), mild (10%-30%; n = 32), moderate (30%-60%; n = 29), or severe (>60%; n = 19). A Cox multivariate analysis for marginal donor variables and a Model for End-Stage Liver Disease index were performed. Fibrosis evolution was analyzed in liver biopsies (fibrosis < 2 or > or =2) 3, 6, and 12 months post-OLT and in the late post-OLT period. Fifty-six grafts were lost (46%). The survival of the grafts was inversely proportional to donor liver steatosis: 82%, 72%, and 72% at 1, 2, and 3 years post-OLT in the absence of steatosis; 73%, 63%, and 58% with mild steatosis; 74%, 62%, and 43% with moderate steatosis; and 62%, 49%, and 42% with severe steatosis (P = 0.012). HCV recurrence was earlier and more frequent in recipients with steatosis > 30% (46% versus 32% at 3 months, P = 0.017; 58% versus 43% at 6 months, P = 0.020; 70% versus 56% at 12 months, P = 0.058; and 95% versus 69% at 3 years post-OLT, P = 0.0001). Graft survival was lower in alcoholic liver disease recipients versus HCV recipients when steatosis was >30% at 3, 6, and 12 months post-OLT (P = 0.042) but not when steatosis was <30% (P = 0.53). A higher fibrosis score was obtained 3 months post-OLT (P = 0.033), 6 months post-OLT (P = 0.306), 12 months post-OLT (P = 0.035), and in the late post-OLT period (P = 0.009). In conclusion, donor graft steatosis influences the outcome of OLT for HCV cirrhosis. HCV recurrence is more frequent and earlier in recipients of moderately and severely steatotic livers. Fibrosis evolution is higher when graft steatosis is >30%. OLT with >30% steatotic donor livers should be precluded in HCV recipients.
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Affiliation(s)
- Javier Briceño
- Unit of Hepatobiliary Surgery and Liver Transplantation, Reina Sofía University Hospital, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas CiberEHD, Córdoba, Spain
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Qasim A, Zaman BM, Geoghegan J, Maguire D, Traynor O, Hegarty J, McCormick PA. Significant influence of the primary liver disease on the outcomes of hepatic retransplantation. Ir J Med Sci 2008; 178:47-51. [PMID: 18982406 DOI: 10.1007/s11845-008-0234-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Accepted: 09/25/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND There are many indications for hepatic retransplantation. AIM To identify factors influencing retransplantation needs and outcomes. PATIENTS AND METHODS Retransplantation records from January 1993 to March 2005 were analysed. Patient and disease characteristics and survival outcomes for retransplantation were compared between various groups. RESULTS Totally, 286 primary and 42 hepatic retransplantations were performed. Retransplantation indications included primary sclerosing cholangitis (PSC), primary biliary cirrhosis, chronic hepatitis C (HCV), chronic active hepatitis (CAH), and alcohol-related disease. Mean follow-up post-retransplantation was 31 +/- 9 months. Actuarial patient survival at 3 months, 1 year, 3 years, 5 years, and at the end of study was 71.4, 69, 59.5, 54.7, and 50%, respectively. Early and late retransplantation had 1-year survival of 73 and 68.5%, respectively. Retransplantation need was significantly higher for PSC, HCV, and CAH. CONCLUSIONS Hepatic retransplantation remains a successful salvage option for transplant complications; however, its need is significantly influenced by the primary liver disease.
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Affiliation(s)
- A Qasim
- Liver Transplant Unit, St Vincent's University Hospital, Dublin, Ireland.
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45
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Briceño J, Ruiz J, Ciria R, Naranjo A, Sánchez-Hidalgo J, Luque A, Rufián S, de la Mata M, López-Cillero P. Factors Affecting Survival and Tumor Recurrence in Patients Transplanted for Hepatocellular Carcinoma and Coexistent Hepatitis C Virus. Transplant Proc 2008; 40:2990-3. [DOI: 10.1016/j.transproceed.2008.09.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Treatment strategy for hepatitis C after liver transplantation. ACTA ACUST UNITED AC 2008; 15:111-23. [DOI: 10.1007/s00534-007-1295-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Accepted: 12/10/2007] [Indexed: 12/22/2022]
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Briceño J, Ciria R, Pleguezuelo M, Naranjo A, Sánchez-Hidalgo J, Ruiz-Rabelo J, López-Cillero P, Luque A, de la Mata M, Rufián S. Contribution of marginal donors to liver transplantation for hepatitis C virus infection. Transplant Proc 2007; 39:2297-9. [PMID: 17889169 DOI: 10.1016/j.transproceed.2007.07.069] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The use of marginal liver donors can affect the outcomes of liver transplantation in patients with hepatitis C virus (HCV) infection. There are no firm conclusions about which donor criteria are important for allocation of high-risk grafts to recipients with HCV cirrhosis. We performed 120 consecutive liver transplantations for HCV infection between 1995 and 2005. Marginal donor criteria were considered to be: age >70 years, macrovesicular steatosis >30%, moderate-to-severe liver preservation injury, high inotropic drug dose (dopamine >15 microg/kg/min; epinephrine, norepinephrine, or dobutamine at any doses), peak serum sodium >155 mEq/L, any hypotensive episode <60 mm Hg and >1 hour, cold ischemia time >12 hours, ICU hospitalization >4 days, bilirubin >2 mg/dL, AST and/or ALT >200 UI/dL. Graft survival with donors showing these marginal criteria was compared with optimal donors using Kaplan-Meier analysis and the log-rank test. Independent predictors of survival were computed with the Cox proportional hazards model. Fifty-six grafts (46%) were lost during follow-up irrespective of the Model for End-Stage Liver Disease (MELD) scores of the recipients in each category. Upon univariate analysis, grafts with moderate-to-severe steatosis (P = .012), those with severe liver preservation injury (P = .007) and prolonged cold ischemia time (P = .0001) showed a dismal prognosis at 1, 3, and 5 years. Upon multivariate analysis, fat content (P = .0076; OR = 4.2) and cold ischemia time >12 hours (P = .034; OR = 7.001) were independent predictors of graft survival. Among HCV recipients, marginal liver donors worked similar to those from "good" donors, except for those with fatty livers >30%, especially when combined with a prolonged cold ischemia time.
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Affiliation(s)
- J Briceño
- Liver Transplantation Unit, Hospital Reina Sofia, Córdoba, Spain.
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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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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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