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Lim N, Singh D, Jackson S, Lake JR. Recurrence of Hepatocellular Carcinoma in Hepatitis C Virus (HCV) Liver Transplant Recipients Treated with Pretransplant Direct-Acting Antiviral (DAA) Therapy. Gastrointest Tumors 2020; 7:134-143. [PMID: 33173777 DOI: 10.1159/000510341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 07/17/2020] [Indexed: 12/27/2022] Open
Abstract
Background Direct-acting antivirals (DAAs) have revolutionized the treatment of hepatitis C virus (HCV). The impact of DAAs on recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) remains uncertain. Objective We aimed to evaluate the risk of HCC recurrence in LT recipients cleared of HCV with DAAs at the time of LT compared to a control group of LT recipients who were viremic at the time of LT. Methods The study was a single-center, retrospective cohort study of patients undergoing LT for HCV-related HCC from 2002 to 2017. We compared time to post-LT HCC recurrence in patients with a sustained virological response (SVR) from DAAs prior to LT (DAA group) to patients who were viremic at LT (HCV+ group) using Kaplan-Meier analysis. We performed a secondary analysis comparing post-LT HCC recurrence in the DAA group to LT recipients with SVR from interferon-based treatment prior to LT (IFN group). Results One hundred fifty-one patients underwent LT for HCC related to HCV: 34 patients in DAA group, 95 patients in HCV+ group, and 22 in IFN group. Kaplan-Meier estimates of being HCC free were 96.2, 96.2, and 78.8% at 6, 12, and 24 months in DAA group, respectively, and 100, 98.6, and 95.8% at 6, 12, and 24 months in the HCV+ group, respectively; p = 0.08. There was no difference observed for HCC recurrence between the DAA and IFN groups. In a multivariate Cox proportional hazards model, DAA use increased the risk of post-LT HCC recurrence (HR 5.2, 95% CI 0.9-29.81, p = 0.07). Conclusions A strong trend was observed on both Kaplan-Meier and multivariate analyses toward increased post-LT HCC recurrence in patients who achieved SVR prior to LT with DAAs compared to patients who were viremic at LT. Caution is required when considering pre-LT treatment of HCV with DAAs in patients with HCC.
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Affiliation(s)
- Nicholas Lim
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Dupinder Singh
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Scott Jackson
- Fairview Health Services, Minneapolis, Minnesota, USA
| | - John R Lake
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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2
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Awad SM, Taha M, Omar M, Khalil A. The implication of genetic variation in the complement C3 allotypes on the first-year allograft outcome after live donor liver transplantation. Transpl Immunol 2020; 60:101294. [PMID: 32305505 DOI: 10.1016/j.trim.2020.101294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 04/11/2020] [Accepted: 04/13/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The component (C3) of the complement system constitutes a central element in liver transplantation. C3 is produced mainly by the liver and comprises both slow (C3-S), and fast (C3-F) components. METHODS The effect of a single nucleotide variation in the C3 gene on the first-year outcome examined by ARMS PCR in 30 recipients of living donor allograft. RESULTS Frequencies of C3-S and C3-F in the Egyptian recipients' population were 67% and 33%. C3-F allele frequency was prevalent than the C3-S allele in recipients who developed acute rejection. The C3-SF and C3-FF genotypes significantly associated with acute rejection with 6.25 times increase in the risk of rejection than C3-SS (OR: 6.25; CI:1.05-37.07, p < .05). C3-SS increases the survival 2.5 times more than C3-SF or C3-FF but without significant association (OR: 0.40, CI: 0.07-2.44, p = .3). C3 genotypes or allotypes had no significant association with the recipient's survival, death, graft loss, infection, or serum levels of tacrolimus (all p > .05). C3-FF and C3-SF genotypes had the highest HCV recurrence rate but without significant association (p > .05). CONCLUSION In liver allograft recipients, C3-SF and C3-FF genotypes significantly associated with acute rejection with the C3-F allele more prevalent than the C3-S. C3-SS genotype increases survival without significant association.
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Affiliation(s)
- Samah Mohamed Awad
- Department of Clinical Microbiology and Immunology, National Liver Institute, Menoufia University, Egypt
| | - Mohammed Taha
- Department of Hepatobiliary and Pancreatic Surgery and Gastroenterology, National Liver Institute, Menoufia University, Egypt
| | - Mahmoud Omar
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Egypt
| | - Ashraf Khalil
- Department of Clinical Biochemistry and Molecular Diagnostics, National Liver Institute, Menoufia University, Egypt.
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3
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Cieciura T, Hryniewiecka E, Foroncewicz B, Strzelczyk Z, Ciszek M, Paczek L. Long-Term Follow-up of Liver Transplant Recipients Treated With Direct-Acting Antiviral Agents for Hepatitis C Recurrence After Transplantation. Transplant Proc 2020; 52:2468-2471. [PMID: 32241638 DOI: 10.1016/j.transproceed.2020.01.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/26/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Treatment of hepatitis C virus (HCV) recurrence after liver transplantation (LTX) with direct-acting antiviral agents (DAA) is effective and leads to sustained viral response (SVR) in most cases. Long-term effect of HCV elimination on LTX function is not clear. The aim of the study was to evaluate the long-term influence of DAA with HCV on the liver function in LTX recipients. METHODS The study included 120 LTX patients with HCV recurrence. Before starting DAA therapy, all patients underwent liver biopsy and elastography. Biochemical tests and HCV viremia were assessed at baseline, 4, 12, and 24 weeks and 24 months after the end of treatment (EOT). The study protocol conformed with the Declaration of Helsinki. RESULTS In the HCV genotype 1 (G1) group, 106 patients were treated with ledipasvir/sofosbuvir with ribavirin (RBV), and 3 patients received paritaprevir/ritonavir/ombitasvir/dasabuvir/RBV. All HCV genotype 3 (G3) patients were treated with sofosbuvir/RBV; all HCV genotype 4 (G4) patients were treated with paritaprevir/ombitasvir/RBV. The efficacy of the treatment defined as SVR at week 12 after EOT (SVR12) was 97.3% in G1 group, 75% in G3, and 100% in G4 group. Median alanine (ALT) and aspartate (AST) transaminase before therapy were 44.0 IU/mL and 42.5 IU/mL, respectively. Median ALT and AST at 24 months after EOT were 17 IU/mL and 22 IU/mL, respectively. The lack of transaminases normalization was observed in 10 patients 24 months after EOT. CONCLUSION The efficacy of DAA therapy of HCV recurrence after LTX is as high as that reported in randomized clinical trials. It is also associated with the improvement of liver function tests during long-term follow-up.
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Affiliation(s)
- Tomasz Cieciura
- Department of Immunology, Transplant Medicine, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Ewa Hryniewiecka
- Department of Immunology, Transplant Medicine, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Bartosz Foroncewicz
- Department of Immunology, Transplant Medicine, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Ziemowit Strzelczyk
- Department of Immunology, Transplant Medicine, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Michal Ciszek
- Department of Immunology, Transplant Medicine, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland.
| | - Leszek Paczek
- Department of Immunology, Transplant Medicine, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
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4
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Sedki M, Cortesi C, O'Brien C, Levy C, Martin P, Roth D, Bhamidimarri KR. Outcomes After Direct-Acting Antiviral Therapy Based on Donor Hepatitis C Serostatus Among Hepatitis C Virus-Infected Kidney Transplant Recipients. EXP CLIN TRANSPLANT 2020. [PMID: 32133941 DOI: 10.6002/ect.2019.0185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Renal grafts from hepatitis C virus-positive deceased donors, which were once discarded, can now be transplanted into recipients and treated posttransplant due to the emergence of direct-acting antivirals, significantly improving wait list time and organ shortages. Here, we compared outcomes in hepatitis C virus-positive patients who received kidneys from hepatitis C virus-positive versus -negative donors. MATERIALS AND METHODS In this single-center retrospective study, we divided 52 kidney transplant recipients who were viremic for hepatitis C virus pretransplant into 2 groups based on donors' hepatitis C virus serostatus (positive/negative). Demographics, time to transplant, efficacy of direct-acting antivirals, rejection episodes, immunosuppression adjustments, and renal function were assessed in both groups. RESULTS Our cohort included 50 patients receiving kidneys from deceased donors and 2 from living donors (1 related, 1 unrelated). Recipients of hepatitis C virus-positive kidneys had significantly less wait list time (36 days) than recipients of hepatitis C virus-negative kidneys (806 days; P < .001). All recipients responded well to direct-acting antivirals, with both groups showing similar sustained virologic response rates that were comparable to the general population. Intention-to-treat analyses showed rates of 91% and 100% in donor seropositive and donor seronegative groups, respectively (P = .273). Four antibody-mediated rejection episodes occurred in the donor seropositive and one mixed rejection in the donor seronegative group. Tacrolimus dose adjustments were required in 54% and 59% of recipients in the donor seropositive and seronegative groups, respectively. Recipients in the donor seropositive group had lower rates of worsening renal function than recipients in the donor seronegative group (11% vs 17.5%; P = .519). CONCLUSIONS In hepatitis C-positive recipients with donor negative or donor positive hepatitis C virus serostatus, response of direct-acting antiviral response was not significantly different and renal allograft function was maintained without any evidence of long-term adverse consequences to the graft.
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Affiliation(s)
- Mai Sedki
- From the Department of Internal Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
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Skoglund C, Lagging M, Castedal M. No need to discontinue hepatitis C virus therapy at the time of liver transplantation. PLoS One 2019; 14:e0211437. [PMID: 30794555 PMCID: PMC6386281 DOI: 10.1371/journal.pone.0211437] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 12/29/2018] [Indexed: 02/06/2023] Open
Abstract
Objectives Direct antiviral agents (DAA) has dramatically improved the therapy outcome of hepatitis C-virus (HCV) infection, both on the waiting-list and post liver transplantation (LT). DAA are generally well-tolerated in patients with mild to moderate liver and kidney failure, but some DAAs are contraindicated in patients with severe dysfunction of these organs. Today there are few studies of peri-LT DAA use and treatment is commonly discontinued at the time of LT. We report here our experience of DAA therapy given continuously in the perioperative LT period in a real-life setting in Sweden. Material In total 10 patients with HCV-cirrhosis, with or without hepatocellular carcinoma, and a median age of 60.5 years (range, 52–65) were treated with DAAs on the waiting list for LT, and continued in the early postoperative period without any interruption, on the basis of not having reached a full treatment course at the time of LT. Sofosbuvir and a NS5A inhibitor with or without ribavirin, or sofosbuvir and ribavirin only, were given. The distribution of genotypes was genotype 1 and 3, in 4 and 6 patients, respectively. Six of the 10 patients had previously been treated with IFN-based therapy. Results There were no adverse events leading to premature DAA discontinuation. All recipients achieved a sustained viral response 12 weeks after end-of-treatment (SVR12). At the time of LT the median MELD-score was 16.5 (range 7–21), CTP-score 9.0 (range 5–10), creatinine 82.5 μmol/L (range 56–135, reference 60–105), bilirubin 33 μmol/L (range 16–79, reference 5–25) and PK-INR 1.5 (range 1.1–1.8). The median duration of DAA therapy was 60 days (range 18–132) pre-LT, 54 days post-LT (range 8–111 days) and in total 15.5 weeks (range 12–30 weeks). Conclusion Interferon-free DAA therapy of HCV-infection given in the immediate pre- and post-operative LT period is safe, well-tolerated and yields high SVR rates.
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Affiliation(s)
- Catarina Skoglund
- The Transplant Institute, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Martin Lagging
- Department of Infectious Diseases/Virology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Maria Castedal
- The Transplant Institute, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- * E-mail:
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Ayloo S, Pentakota SR, Molinari M. Trends of characteristics and outcomes of donors and recipients of deceased donor liver transplantation in the United States: 1990 to 2013. World J Transplant 2018; 8:167-177. [PMID: 30211025 PMCID: PMC6134273 DOI: 10.5500/wjt.v8.i5.167] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/23/2018] [Accepted: 08/03/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To compare trends in donor/recipient characteristics and outcomes using four period cohorts of liver transplant recipients from 1990 to 2009. METHODS Seventy thousand three hundred and seventy-seven adult first-time recipients of whole-organ deceased-donor liver grafts from 1990 to 2009 were followed up until September 2013. Four periods based on transplantation dates were considered to account for developments in transplantation. Descriptive statistics were used to describe donor/recipient characteristics and transplant outcomes. Statistical comparisons between periods were performed using χ2/Fischer's exact test (categorical variables) and t-tests/Mann-Whitney U test (continuous variables). Univariate descriptive statistics/survival data were generated using Kaplan-Meier curves. Cox Proportional Hazards models were used for regression analyses of patient and graft survival. RESULTS Mean age (years), body mass index (kg/m2), and the proportion of males were, respectively, 39.1 (± 17.4), 25.9 (± 5.7) and 60.3 for donors, and 51.3 (± 10.5), 27.7 (± 5.6), and 64.4 for recipients. Donor and transplantation rates differed between racial/ethnic groups. Median (Q1-Q3) cold and warm ischemia, waitlist, and hospital stay times were 8 (6.0-10.0) h and 45 (35-59) min, 93 (21-278) d, and 12 (8-20) d. Total functional assistance was required by 8% of recipients at wait-listing and 13.4% at transplantation. Overall survival at 1, 3, 5, 10, 15, and 20 years was 87.3%, 79.4%, 73.6%, 59.8%, 46.7%, and 35.9%, respectively. The 2005-2009 cohort had better patient and graft survival than the 1990-1994 cohort overall [HR 0.67 (0.62-0.72) and 0.66 (0.62-0.71)] and at five years [HR 0.73 (0.66-0.80) and 0.71 (0.65-0.77)]. CONCLUSION Despite changes in donor quality, recipient characteristics, and declining functional status among transplant recipients, overall patient survival is superior and post-transplant outcomes continue to improve.
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Affiliation(s)
- Subhashini Ayloo
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
| | - Sri Ram Pentakota
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
| | - Michele Molinari
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
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7
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Kim JM, Lee KW, Sinn DH, Choi GS, Yi NJ, Kwon CHD, Suh KS, Joh JW. Use of direct antiviral agents in liver transplant recipients with hepatitis C virus in Korea: 2-center experience. Ann Surg Treat Res 2018; 95:147-151. [PMID: 30182021 PMCID: PMC6121168 DOI: 10.4174/astr.2018.95.3.147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 01/14/2018] [Accepted: 01/30/2018] [Indexed: 12/19/2022] Open
Abstract
Purpose The proportion of liver recipients with HCV is gradually increasing in Korea. Limited data are available regarding the efficacy of direct antiviral agents (DAAs) in liver transplant recipients in Asia. We aimed to assess the efficacy and safety of DAAs in HCV-infected liver recipients in Korea. Methods Forty HCV-infected patients from 2 centers received DAAs in the pretransplant or posttransplant period between May 2015 and November 2016. Results DAA was administered in the pretransplant period in 6 patients and the posttransplant period in 34 patients. Dalastavir and asunaprevir (n = 2) and sofosbuvir/ledipasvir and ribvarin (n = 4) were used in the pretransplant period. HCV RNA was not detected before liver transplantation in all patients. Sustained virological response (SVR) at 12 and 24 weeks after liver transplantation was 100%. In the posttransplant period, 33 of 34 patients received sofosfovir-based therapy. SVR at 12 weeks in those patients was 94%. Recurrent virologic relapse developed in 2 patients because of HCC recurrence or treatment failure. Adverse events included anemia (n = 2) and abdominal discomfort (n = 1). Conclusion DAAs are an effective and well-tolerated treatment for HCV-infected recipients in Korea.
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Affiliation(s)
- Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Hyun Sinn
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Choon Hyuck David Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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8
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Campos-Varela I, Agudelo EZ, Terrault NA. Outcomes of antiviral treatment in hepatitis C virus liver transplant patients off immunosuppression in the direct acting antivirals era: A case series. Clin Transplant 2018; 32:e13303. [PMID: 29851150 DOI: 10.1111/ctr.13303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clearance of hepatitis C virus (HCV) under antiviral therapy, including direct-acting antivirals (DAAs), has been associated with higher risk of rejection. Whether patients who are not on immunosuppression (IS) during DAA therapy are at higher risk of rejection is unknown. METHODS Four transplant recipients who were off IS and treated with DAA therapy were identified. RESULTS All patients were genotype 1 infection and treated for 12 weeks with sofosbuvir/ledipasvir/ribavirin. At the time of DAA therapy, patients were off IS for a median of 9.5 years. Time from liver transplant (LT) to treatment was 12.9 years. Median baseline ALT was 70 IU/L, at follow-up week 12 was 18 IU/L. No signs of rejection were observed during DAA therapy or follow-up after the end of therapy. All 4 patients obtained sustained virological response. CONCLUSION Direct-acting antivirals therapy in HCV patients off IS post-LT can be successfully undertaken without the need to restart IS.
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Affiliation(s)
- Isabel Campos-Varela
- Universidade de Santiago de Compostela (CLINURSID), Santiago de Compostela, Spain.,Department of Internal Medicine, Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Eliana Z Agudelo
- Department of Medicine, University of California, San Francisco, CA, USA.,Department of Surgery, University of California, San Francisco, CA, USA
| | - Norah A Terrault
- Department of Medicine, University of California, San Francisco, CA, USA.,Department of Surgery, University of California, San Francisco, CA, USA
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Daniel KE, Said A. Considerations When Treating Hepatitis C in a Cirrhotic Transplant Candidate. Curr Gastroenterol Rep 2018; 20:20. [PMID: 29623506 DOI: 10.1007/s11894-018-0626-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW This review examines the issues in determining the decision to treat a HCV-positive patient who is a liver transplant (LT) candidate with highly effective and well-tolerated direct-acting antiviral (DAA) therapies. RECENT FINDINGS Cure of HCV with DAA can improve liver function and allow delisting in some patients. Beyond a threshold of hepatic impairment (likely MELD score > 16 to 20), patients may experience a decline in MELD score with HCV cure without improvement in liver-related complications resulting in decreased opportunity to receive a LT. Eradicating HCV from patients who need LT regardless also deprives them of the option of receiving HCV-positive donor organs. Patients with MELD > 16 or Child-Pugh B/C may also have reduced cure rates of HCV, increased risk of hepatic decompensation, and adverse events with DAA pre-LT compared to post-LT DAA therapy. Preliminary data demonstrates increase risk of hepatocellular carcinoma (HCC) recurrence after treatment with DAA with subsequent studies raising doubts about this association. Patients with HCV cirrhosis on the LT waiting list with MELD score > 16, CTP-B/C, and HCC are best treated after LT with better response, tolerability, and the ability to receive organs from a larger donor pool that includes HCV-positive donors. Larger, prospective studies are needed to assess whether increased HCC recurrence after DAA is a true effect.
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Affiliation(s)
- Kimberly E Daniel
- Gastroenterology and Hepatology Fellow, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Adnan Said
- Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health and Madison VAMC, Madison, WI, USA.
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Pascasio JM, Vinaixa C, Ferrer MT, Colmenero J, Rubin A, Castells L, Manzano ML, Lorente S, Testillano M, Xiol X, Molina E, González-Diéguez L, Otón E, Pascual S, Santos B, Herrero JI, Salcedo M, Montero JL, Sánchez-Antolín G, Narváez I, Nogueras F, Giráldez Á, Prieto M, Forns X, Londoño MC. Clinical outcomes of patients undergoing antiviral therapy while awaiting liver transplantation. J Hepatol 2017; 67:1168-1176. [PMID: 28842296 DOI: 10.1016/j.jhep.2017.08.008] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 08/09/2017] [Accepted: 08/09/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Antiviral therapy for the treatment of hepatitis C (HCV) infection has proved to be safe and efficacious in patients with cirrhosis awaiting liver transplantation (LT). However, the information regarding the clinical impact of viral eradication in patients on the waiting list is still limited. The aim of the study was to investigate the probability of delisting in patients who underwent antiviral therapy, and the clinical outcomes of these delisted patients. METHODS Observational, multicenter and retrospective analysis was carried out on prospectively collected data from patients positive for HCV, treated with an interferon-free regimen, while awaiting LT in 18 hospitals in Spain. RESULTS In total, 238 patients were enrolled in the study. The indication for LT was decompensated cirrhosis (with or without hepatocellular carcinoma [HCC]) in 171 (72%) patients, and HCC in 67 (28%) patients. Sustained virologic response (SVR) rate was significantly higher in patients with compensated cirrhosis and HCC (92% vs. 83% in patients with decompensated cirrhosis with or without HCC, p=0.042). Among 122 patients with decompensated cirrhosis without HCC, 29 (24%) were delisted due to improvement. No patient with baseline MELD score >20 was delisted. After delisting (median follow-up of 88weeks), three patients had clinical decompensations and three had de novo HCC. Only two of the patients with HCC had to be re-admitted onto the waiting list. The remaining 23 patients remained stable, with no indication for LT. CONCLUSIONS Antiviral therapy is safe and efficacious in patients awaiting LT. A quarter of patients with decompensated cirrhosis can be delisted asa result of clinical improvement, which appears to be remain stable in most patients. Thus, delisting is a safe strategy that could spare organs and benefit other patients with a more urgent need. LAY SUMMARY Antiviral therapy in patients awaiting liver transplantation is safe and efficacious. Viral eradication allows removal from the waiting list of a quarter of treated patients. Delisting because of clinical improvement is a safe strategy that can spare organs for patients in urgent need.
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Affiliation(s)
- Juan Manuel Pascasio
- UGC Digestive Diseases, Hospital Universitario Virgen del Rocío, IBIS, CIBERehd, Sevilla, Spain
| | - Carmen Vinaixa
- Liver Unit, Digestive Medicine Service, Hospital Universitario La Fé, CIBERehd, Valencia, Spain
| | - María Teresa Ferrer
- UGC Digestive Diseases, Hospital Universitario Virgen del Rocío, IBIS, CIBERehd, Sevilla, Spain
| | - Jordi Colmenero
- Liver Unit, Hospital Clinic, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Angel Rubin
- Liver Unit, Digestive Medicine Service, Hospital Universitario La Fé, CIBERehd, Valencia, Spain
| | - Lluis Castells
- Internal Medicine Service, Hospital Universitari Vall d'Hebron, CIBERehd, Barcelona, Spain
| | - María Luisa Manzano
- Digestive Diseases Service, Hospital Universitario 12 Octubre, Madrid, Spain
| | - Sara Lorente
- Liver Transplant Unit, Digestive Diseases Service, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Milagros Testillano
- Liver Unit, Digestive Diseases Service, Hospital Universitario Cruces, Vizcaya, Spain
| | - Xavier Xiol
- Digestive Diseases Service, Hospital Universitari Bellvitge, Barcelona, Spain
| | - Esther Molina
- Abdominal Transplant Unit, CHU Santiago de Compostela, IDIS, Santiago, Spain
| | | | - Elena Otón
- Digestive Diseases Service, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | - Sonia Pascual
- Liver Unit, Hospital General Universitario, CIBERehd, Alicante, Spain
| | - Begoña Santos
- Internal Medicine Service, Hospital Universitari Vall d'Hebron, CIBERehd, Barcelona, Spain
| | | | - Magdalena Salcedo
- Liver Transplant Unit, Hospital General Universitario Gregorio Marañón, CIBERehd, Madrid, Spain
| | - José Luis Montero
- UGC Aparato Digestivo, Hospital Universitario Reina Sofía, Córdoba, Spain
| | | | - Isidoro Narváez
- Digestive Diseases Service, Hospital Universitario Infanta Cristina, Badajoz, Spain
| | - Flor Nogueras
- Digestive Diseases Service, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Álvaro Giráldez
- UGC Digestive Diseases, Hospital Universitario Virgen del Rocío, IBIS, CIBERehd, Sevilla, Spain
| | - Martín Prieto
- Liver Unit, Digestive Medicine Service, Hospital Universitario La Fé, CIBERehd, Valencia, Spain
| | - Xavier Forns
- Liver Unit, Hospital Clinic, IDIBAPS, CIBERehd, Barcelona, Spain
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Sofosbuvir/Ledipasvir Without Ribavirin Achieved High Sustained Virologic Response for Hepatitis C Recurrence After Liver Transplantation: Two-Center Experience. Transplantation 2017; 101:996-1000. [PMID: 27631598 DOI: 10.1097/tp.0000000000001467] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current recommended regimens to treat patients with hepatitis C virus (HCV) infection after liver transplantation include the use of ribavirin (RBV). Limited data are available on the efficacy of RBV-free regimens posttransplant, particularly the use of sofosbuvir (SOF)/ledipasvir (LDV) without RBV in this patient population. We aimed to assess the efficacy and safety of SOF/LDV fixed-dose combination without RBV in patients with HCV recurrence posttransplant. METHODS This is a retrospective study of 46 patients with HCV recurrence posttransplant. SOF/LDV without RBV was used for 12 weeks in patients with early-stage fibrosis (F0-F2) or for 24 weeks in those with advanced fibrosis (F3-F4) and/or cholestatic hepatitis. The primary endpoint was sustained virologic response at 12 weeks after the end of treatment. Secondary outcomes included relapse after treatment and adverse events. RESULTS Forty-six patients, with a mean age of 62 ± 8 years, a median duration since time of transplant of 904 days (range, 78-3525 days), an HCV genotype 1, and a mean baseline viral load of 7.79 million IU/mL, were treated. Of these, 32 patients were treated for 12 weeks, and 14 patients were treated for 24 weeks. Twenty-five patients (54%) were treatment experienced (21 with interferon and 4 with SOF). All 46 patients (100%) achieved sustained virological response (SVR) 12. Neither virologic relapses nor serious adverse events were noted. CONCLUSIONS The combination of SOF/LDV without RBV for 12 or 24 weeks produced 100% SVR 12 in patients with HCV recurrence after liver transplantation. The use of RBV may not be necessary to achieve SVR in this patient population.
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Bhamidimarri KR, Ladino M, Pedraza F, Guerra G, Mattiazzi A, Chen L, Ciancio G, Kupin W, Martin P, Burke G, Roth D. Transplantation of kidneys from hepatitis C-positive donors into hepatitis C virus-infected recipients followed by early initiation of direct acting antiviral therapy: a single-center retrospective study. Transpl Int 2017; 30:865-873. [PMID: 28332729 DOI: 10.1111/tri.12954] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 01/24/2017] [Accepted: 03/12/2017] [Indexed: 12/28/2022]
Abstract
The availability of direct acting antiviral agents (DAA) has transformed the treatment of hepatitis C virus (HCV) infection. The current study is a case series that reports the outcomes from a cohort of twenty-five HCV-infected ESRD patients who received a kidney from an anti-HCV-positive deceased organ donor followed by treatment with DAAs in the early post-transplant period. Time to transplantation and the efficacy of DAA therapy as measured by sustained viral response at 12 weeks were assessed. The median waiting time from original date of activation on the United Network Organ Sharing (UNOS) waiting list until transplantation was 427 days; however, the median time from entering the patient into UNetsm for a HCV-positive offer until transplantation was only 58 days. The 25 patients were started on antiviral treatment early post-transplant (median 125 days) and 24 of 25 (96%) achieved a sustained virologic response at 12 weeks. Tacrolimus dose adjustments were required during antiviral treatment in 13 patients to maintain therapeutic levels. Accepting a kidney from an anti-HCV-positive deceased donor shortened the waiting time for HCV-infected kidney transplant candidates. We recommend that kidneys from anti-HCV-positive donors should be considered for transplant into HCV-infected recipients followed by early post-transplant treatment with DAA agents.
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Affiliation(s)
- Kalyan R Bhamidimarri
- Department of Medicine, University of Miami Miller School of Medicine and the Miami Veterans Administration Hospital, Miami, FL, USA
| | - Marco Ladino
- Department of Medicine, University of Miami Miller School of Medicine and the Miami Veterans Administration Hospital, Miami, FL, USA
| | - Fernando Pedraza
- Department of Medicine, University of Miami Miller School of Medicine and the Miami Veterans Administration Hospital, Miami, FL, USA
| | - Giselle Guerra
- Department of Medicine, University of Miami Miller School of Medicine and the Miami Veterans Administration Hospital, Miami, FL, USA
| | - Adela Mattiazzi
- Department of Medicine, University of Miami Miller School of Medicine and the Miami Veterans Administration Hospital, Miami, FL, USA
| | - Linda Chen
- Department of Surgery, University of Miami Miller School of Medicine and the Miami Veterans Administration Hospital, Miami, FL, USA
| | - Gaetano Ciancio
- Department of Surgery, University of Miami Miller School of Medicine and the Miami Veterans Administration Hospital, Miami, FL, USA
| | - Warren Kupin
- Department of Medicine, University of Miami Miller School of Medicine and the Miami Veterans Administration Hospital, Miami, FL, USA
| | - Paul Martin
- Department of Medicine, University of Miami Miller School of Medicine and the Miami Veterans Administration Hospital, Miami, FL, USA
| | - George Burke
- Department of Surgery, University of Miami Miller School of Medicine and the Miami Veterans Administration Hospital, Miami, FL, USA
| | - David Roth
- Department of Medicine, University of Miami Miller School of Medicine and the Miami Veterans Administration Hospital, Miami, FL, USA
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Liver transplantation for hepatocellular carcinoma: outcomes and novel surgical approaches. Nat Rev Gastroenterol Hepatol 2017; 14:203-217. [PMID: 28053342 DOI: 10.1038/nrgastro.2016.193] [Citation(s) in RCA: 289] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Liver transplantation for hepatocellular carcinoma (HCC) is the best treatment option for patients with early-stage tumours and accounts for ∼20-40% of all liver transplantations performed at most centres worldwide. The Milan criteria are the most common criteria to select patients with HCC for transplantation but they can be seen as too restrictive. Several proposals have been made for a moderate expansion of the criteria, which result in good outcomes but with an increase in the risk of tumour recurrence. In this Review, we provide a comprehensive overview of the outcomes after liver transplantation for HCC, focusing on tumour recurrence in terms of surveillance, prevention and treatment. Additionally, novel surgical techniques have been developed to increase the available pool of organs for liver transplantation (such as living donor liver transplantation, donation after circulatory death and split livers), but the effect of these techniques on patients with HCC is still under debate. Thus, we will describe these techniques and expose the benefits and disadvantages of each surgical approach. Finally, we will comment on the limitations of the current priority policies for liver transplantation and the need to further refine them to better serve the population.
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Ponziani FR, Mangiola F, Binda C, Zocco MA, Siciliano M, Grieco A, Rapaccini GL, Pompili M, Gasbarrini A. Future of liver disease in the era of direct acting antivirals for the treatment of hepatitis C. World J Hepatol 2017; 9:352-367. [PMID: 28321272 PMCID: PMC5340991 DOI: 10.4254/wjh.v9.i7.352] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/26/2016] [Accepted: 12/01/2016] [Indexed: 02/06/2023] Open
Abstract
Hepatitis C virus (HCV) infection has been a global health problem for decades, due to the high number of infected people and to the lack of effective and well-tolerated therapies. In the last 3 years, the approval of new direct acting antivirals characterized by high rates of virological clearance and excellent tolerability has dramatically improved HCV infection curability, especially for patients with advanced liver disease and for liver transplant recipients. Long-term data about the impact of the new direct acting antivirals on liver fibrosis and liver disease-related outcomes are not yet available, due to their recent introduction. However, previously published data deriving from the use of pegylated-interferon and ribavirin lead to hypothesizing that we are going to observe, in the future, a reduction in mortality and in the incidence of hepatocellular carcinoma, as well as a regression of fibrosis for people previously affected by hepatitis C. In the liver transplant setting, clinical improvement has already been described after treatment with the new direct acting antivirals, which has often led to patients delisting. In the future, this may hopefully reduce the gap between liver organ request and availability, probably expanding liver transplant indications to other clinical conditions. Therefore, these new drugs are going to change the natural history of HCV-related liver disease and the epidemiology of HCV infection worldwide. However, the global consequences will depend on treatment accessibility and on the number of countries that could afford the use of the new direct acting antivirals.
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Affiliation(s)
- Francesca Romana Ponziani
- Francesca Romana Ponziani, Francesca Mangiola, Cecilia Binda, Maria Assunta Zocco, Massimo Siciliano, Antonio Grieco, Maurizio Pompili, Antonio Gasbarrini, Internal Medicine, Gastroenterology and Hepatology, Catholic University Sacred Heart of Rome, Agostino Gemelli Hospital, 00168 Rome, Italy
| | - Francesca Mangiola
- Francesca Romana Ponziani, Francesca Mangiola, Cecilia Binda, Maria Assunta Zocco, Massimo Siciliano, Antonio Grieco, Maurizio Pompili, Antonio Gasbarrini, Internal Medicine, Gastroenterology and Hepatology, Catholic University Sacred Heart of Rome, Agostino Gemelli Hospital, 00168 Rome, Italy
| | - Cecilia Binda
- Francesca Romana Ponziani, Francesca Mangiola, Cecilia Binda, Maria Assunta Zocco, Massimo Siciliano, Antonio Grieco, Maurizio Pompili, Antonio Gasbarrini, Internal Medicine, Gastroenterology and Hepatology, Catholic University Sacred Heart of Rome, Agostino Gemelli Hospital, 00168 Rome, Italy
| | - Maria Assunta Zocco
- Francesca Romana Ponziani, Francesca Mangiola, Cecilia Binda, Maria Assunta Zocco, Massimo Siciliano, Antonio Grieco, Maurizio Pompili, Antonio Gasbarrini, Internal Medicine, Gastroenterology and Hepatology, Catholic University Sacred Heart of Rome, Agostino Gemelli Hospital, 00168 Rome, Italy
| | - Massimo Siciliano
- Francesca Romana Ponziani, Francesca Mangiola, Cecilia Binda, Maria Assunta Zocco, Massimo Siciliano, Antonio Grieco, Maurizio Pompili, Antonio Gasbarrini, Internal Medicine, Gastroenterology and Hepatology, Catholic University Sacred Heart of Rome, Agostino Gemelli Hospital, 00168 Rome, Italy
| | - Antonio Grieco
- Francesca Romana Ponziani, Francesca Mangiola, Cecilia Binda, Maria Assunta Zocco, Massimo Siciliano, Antonio Grieco, Maurizio Pompili, Antonio Gasbarrini, Internal Medicine, Gastroenterology and Hepatology, Catholic University Sacred Heart of Rome, Agostino Gemelli Hospital, 00168 Rome, Italy
| | - Gian Lodovico Rapaccini
- Francesca Romana Ponziani, Francesca Mangiola, Cecilia Binda, Maria Assunta Zocco, Massimo Siciliano, Antonio Grieco, Maurizio Pompili, Antonio Gasbarrini, Internal Medicine, Gastroenterology and Hepatology, Catholic University Sacred Heart of Rome, Agostino Gemelli Hospital, 00168 Rome, Italy
| | - Maurizio Pompili
- Francesca Romana Ponziani, Francesca Mangiola, Cecilia Binda, Maria Assunta Zocco, Massimo Siciliano, Antonio Grieco, Maurizio Pompili, Antonio Gasbarrini, Internal Medicine, Gastroenterology and Hepatology, Catholic University Sacred Heart of Rome, Agostino Gemelli Hospital, 00168 Rome, Italy
| | - Antonio Gasbarrini
- Francesca Romana Ponziani, Francesca Mangiola, Cecilia Binda, Maria Assunta Zocco, Massimo Siciliano, Antonio Grieco, Maurizio Pompili, Antonio Gasbarrini, Internal Medicine, Gastroenterology and Hepatology, Catholic University Sacred Heart of Rome, Agostino Gemelli Hospital, 00168 Rome, Italy
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Berenguer M. Last gasps of the hepatitis C virus dragon: Direct acting antiviral failures and hepatitis C virus-positive donors. Liver Transpl 2016; 22:47-51. [PMID: 27465590 DOI: 10.1002/lt.24520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 07/19/2016] [Indexed: 12/20/2022]
Affiliation(s)
- Marina Berenguer
- Hepatology and Liver Transplantation Unit, La Fe University, University of Valencia, Valencia, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Valencia, Spain.
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Londoño MC, Manzardo C, Rimola A, Ruiz P, Costa J, Forner A, Ambrosioni J, Agüero F, Laguno M, Lligoña A, Moreno A, Miró JM. IFN-free therapy for HIV/HCV-coinfected patients within the liver transplant setting. J Antimicrob Chemother 2016; 71:3195-3201. [PMID: 27402009 DOI: 10.1093/jac/dkw270] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 05/17/2016] [Accepted: 06/01/2016] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES IFN-based therapy against hepatitis C recurrence after liver transplantation (LT) has poor effectiveness and tolerability. In HIV/HCV-coinfected liver transplant recipients, the results are even poorer. Here, we report our experience using direct antiviral agents (DAAs) in 11 consecutive coinfected patients within the LT setting. METHODS Four patients with compensated cirrhosis and hepatocellular carcinoma were treated while awaiting LT and seven patients received antiviral therapy due to severe hepatitis C recurrence after LT [fibrosing cholestatic hepatitis (n = 1), fibrosis stage ≥F3 (n = 2) and decompensated cirrhosis (n = 4)]. Patients were treated with different sofosbuvir-based regimens with or without ribavirin for 12 or 24 weeks. RESULTS Sustained virological response (SVR) was achieved in all patients. Two of the four patients treated while awaiting LT reached the time of transplant with undetectable HCV-RNA that remained undetectable 12 weeks after LT, one patient had detectable HCV-RNA at the time of transplant but achieved SVR after completing 12 weeks of therapy after LT and the last patient is still on the waiting list. Seven patients with severe post-LT hepatitis C recurrence were treated within 11-120 months after LT. In these patients, viral eradication was associated with an improvement in liver function and clinical decompensation. Tolerance to antiviral therapy was good and only four patients reported mild adverse events. CONCLUSIONS IFN-free regimens are effective and well tolerated in HIV/HCV-coinfected patients within the LT setting, but more data are needed to confirm our promising results and to establish the best treatment option in this population.
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Affiliation(s)
- Maria-Carlota Londoño
- Liver Unit, Hospital Clínic Barcelona, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Christian Manzardo
- Infectious Disease Service, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Antoni Rimola
- Liver Unit, Hospital Clínic Barcelona, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Pablo Ruiz
- Liver Unit, Hospital Clínic Barcelona, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Josep Costa
- Microbiology Service (CDB), Hospital Clínic Barcelona, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Alejandro Forner
- Liver Unit, Hospital Clínic Barcelona, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Juan Ambrosioni
- Infectious Disease Service, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Fernando Agüero
- Infectious Disease Service, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Montserrat Laguno
- Infectious Disease Service, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Anna Lligoña
- Addictive Behavior Unit, Hospital Clínic Barcelona, Barcelona, Spain
| | - Asunción Moreno
- Infectious Disease Service, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jose-Maria Miró
- Infectious Disease Service, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
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The changing ‘face’ of wait-listed patients in the USA. Curr Opin Organ Transplant 2016; 21:89-90. [DOI: 10.1097/mot.0000000000000300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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