Liver transplantation for chronic hepatitis C: long-term results, role of antiviral therapy, and outcome of retransplantation:

Cost and outcome analysis and cost determinants of liver transplantation in a European National Health Service hospital

BACKGROUND

Liver transplantation has become established therapy for end-stage liver disease. Survival rates are satisfactory and the current challenge is the implementation of cost-optimization policies.

METHODS

This study was a cost-outcome and cost-determinant analyses in an Italian National Health Services liver transplantation unit. Collection of data related to survival and costs in 235 adult transplant recipients from 1997 to 2000. Costs included consumption-related costs (e.g., diagnostics, medication) and structure-related costs (e.g., staff, general costs, and overhead) allocated individually according to hospital patient days. The main variables were average cost per patient alive at the end of each year, average cost per month of patient alive, and average cost per transplantation.

RESULTS

Two hundred fifty-two transplantations were performed in 235 adults (mean follow-up, 16.5 months). Average cost per patient alive was constant (e107,014-e117,782), whereas average cost per month of patient alive progressively diminished to e7,098. Costs differed according to reason for transplantation, being lower in nonviral (mainly alcoholic) hepatitis and higher in fulminant hepatic failure and in rare liver diseases. Higher costs were also observed in patients with portal thrombosis and high pretransplant serum creatinine. The average cost per transplantation was fairly constant (e75,747-e83,846) and plateaued after 120 to 140 transplantations.

CONCLUSIONS

The optimization of the cost-to-outcome ratio is linked to a reasonably high number of transplants per year, which allows early achievement of a cost-per-transplant plateau associated with a better survival rate, in addition to careful consideration of risk factors and diagnoses.

A longitudinal analysis of T-cell epitope-coding regions of hepatitis C virus after liver transplantation

BACKGROUND

Hepatitis C virus (HCV)-related liver failure is the single leading indication for orthotopic liver transplantation (OLT) worldwide. The mechanisms that underlie the observed differences in natural history of HCV recurrence remain poorly understood. We have previously demonstrated that differential T-cell responses correlate with histologic severity after OLT. We hypothesized that amino acid substitutions within critical T-cell epitopes could lead to increased severity of HCV disease.

METHODS

We determined the peptide sequences from sequential serum-derived viral RNA by reverse transcription and direct polymerase chain reaction sequence analysis from 32 HCV genotype 1-infected patients with well-characterized outcomes after liver transplantation. Serum samples were analyzed for HCV sequence the day of OLT and at least one time point post-OLT. To construct evolutionary relationships among the different patient samples, phylogenetic analyses of core and NS3 sequences were performed using a matrix fed into a neighbor-joining tree algorithm.

RESULTS

The phylogenetic analyses revealed remarkable conservation within a given individual and no significant differences when comparing patients with severe versus mild recurrence. Accordingly, the synonymous mutation rate was consistently greater than the nonsynonymous substitution rate. The nine epitopic regions analyzed were also preserved so that, with the exception of one patient with mild recurrence, none of the patients demonstrated a shift in viral peptide sequence.

CONCLUSIONS

HCV core and NS3 viral peptide sequences are identical before and after OLT in most patients, suggesting that the prevalent sequence is preserved in most cases, and viral variants are competent to establish infection after OLT. Although these results do not support viral mutation as a dominant pathogenic mechanism after OLT, other viral regions need to be analyzed.

Update on the Management of Hepatitis C in Liver Transplant Recipients

Hepatic failure due to hepatitis C is the leading indicator for orthotopic liver transplantation (OLT) in the United States. Unfortunately, recurrent hepatitis C virus infection is essentially universal following orthotopic liver transplantation. Although significant advances have been made in the past decade for the treatment of hepatitis C, a similar level of success has not yet been achieved for most hepatitis C virus-infected liver transplant recipients. In addition, deleterious side effects of the currently available antiviral agents continue to significantly hamper their use. Several recent reports, however, indicate that newer immunosuppressive regimens combined with novel modifications of existing treatment paradigms will likely lead to improved clinical outcomes for the hepatitis C virus-infected liver transplant recipient.