The use of partial splenic artery embolization made it possible to administer interferon and ribavirin therapy in a liver transplant patient with fibrosing cholestatic hepatitis C complicated with thrombocytopenia

Large splenic volume may be a useful predictor for partial splenic embolization-induced liver functional improvement in cirrhotic patients

BACKGROUND

Partial splenic embolization (PSE) for cirrhotic patients has been reported not only to achieve an improvement in thrombocytopenia and portal hypertension, but also to induce PSE-associated fringe benefit such as individual liver functional improvement. The purpose of this study was to clarify the predictive marker of liver functional improvement due from PSE in cirrhotic patients.

METHODS

From April 1999 to January 2009, 83 cirrhotic patients with hypersplenism-induced thrombocytopenia (platelet count <10 × 10(4)/μl) underwent PSE. Of them, 71 patients with follow-up for more than one year after PSE were retrospectively investigated.

RESULTS

In liver tissues after PSE, proliferating cell nuclear antigen (PCNA)-positive hepatocytes were remarkably increased, speculating that PSE induced liver regenerative response. Indeed, serum albumin and cholinesterase levels increased to 104 ± 14% and 130 ± 65% each of the pretreatment level at one year after PSE. In a multiple linear regression analysis, preoperative splenic volume was extracted as the predictive factor for the improvement in cholinesterase level after PSE. Cirrhotic patients with preoperative splenic volume >600 ml obtained significantly higher serum albumin and cholinesterase levels at one year after PSE compared to those with less than 600 ml (P-values were 0.029 in both).

CONCLUSION

A large preoperative splenic volume was the useful predictive marker for an effective PSE-induced liver functional improvement.

Urgent splenectomy after partial splenic embolization in liver-transplanted patient: a case report

We describe a 51-year-old-male. Three months after liver transplantation due to hepatitis C virus (HCV) hepatopathy, an HCV relapse was detected, and partial splenic embolization (PSE) was performed prior to antiviral treatment. Eleven days after PSE emergency splenectomy was performed due to the development of a splenic abscess, which is a rare but severe complication of PSE. Between May 2002 and March 2012, 18 PSEs have been performed in transplant patients in our centre. The patient presented here is the only case of splenic abscess and the only one who has needed surgery after complications of PSE.

A retrospective cohort study of partial splenic embolization for antiviral therapy in chronic hepatitis C with thrombocytopenia

BACKGROUND

Although partial splenic embolization (PSE) is reportedly effective prior to interferon (IFN)-based therapy, the number of subjects in these studies is small, and the appropriate candidates and disease prognosis remain unknown.

METHODS

PSE was performed in 30 patients with advanced hepatitis C who could not receive IFN-based therapy because of thrombocytopenia, platelet counts of ≤100,000/mm(3), and hypersplenism. Also, we compared 25 PSE-treated patients with 23 PSE-untreated patients with thrombocytopenia receiving pegylated IFN (PEG-IFN)-alpha 2b plus ribavirin over the same period.

RESULTS

PSE significantly increased platelet and leukocyte counts. PSE was well tolerated with no severe complications. All the patients could receive IFN-based therapy. Discontinuation of therapy in the total cohort of PSE-treated patients was not due to thrombocytopenia. Although PSE did not significantly increase the sustained virological response (SVR) rate, it significantly maintained higher platelet counts throughout the observation period and increased the percentage of patients with 100% adherence to PEG-IFN in the total controlled study population and in subjects with genotype 2. In PSE-treated patients with genotype 2, a trend towards increased SVR was noted. Four patients developed hepatocellular carcinoma (HCC) at a median of 14.5 months after PSE, even though two of these patients had achieved an SVR.

CONCLUSIONS

IFN-based therapy following PSE had an advantage in the maintenance of higher platelet counts, and PSE possibly caused an increase in adherence to PEG-IFN. Although patients with genotype 2 might be better candidates for PSE, further evaluation is needed. Careful follow-up of PSE-treated patients, even though they may have achieved an SVR, is needed to detect HCC.

Post-liver transplant cholestatic hepatitis C: a systematic review of clinical and pathological findings and application of consensus criteria

Liver transplantation is currently the only definitive modality for the treatment of end-stage liver disease due to chronic hepatitis C. However, recurrent hepatitis C after liver transplantation is nearly universal. Cirrhosis may develop in 20% of recipients within 5 years, and recurrent hepatitis C may lead to graft failure, retransplantation, and even death. A subset of recipients may develop post-liver transplant cholestatic hepatitis C (PLTCHC), which is characterized by cholestasis, hepatocyte ballooning, and rapid progression to graft failure. We present a systematic review of PLTCHC that is focused on hepatitis C-infected liver transplant recipients. We compare the pathological definitions of PLTCHC, clinical factors, management strategies, and outcomes reported in studies. We found differences among studies in the types of histological criteria used to diagnose PLTCHC during liver biopsy and in the types of clinical information provided. Three of the 12 studies published after 2003 used the definition of PLTCHC published by the first International Liver Transplantation Society expert panel consensus conference on liver transplantation and hepatitis C. We propose that studies on PLTCHC use the consensus criteria for diagnosis and suggest clinical information that should be provided in future studies with the goal of improving our understanding and management of this deadly disease.

Therapeutic factors considered according to the preoperative splenic volume for a prolonged increase in platelet count after partial splenic embolization for liver cirrhosis

PURPOSE

Infarcted splenic volume has been identified as the predictive factor for a prolonged increase in platelet count after partial splenic embolization (PSE). However, despite enough infarcted splenic volume, some patients show only a slight increase in platelet counts after PSE because of rapid regrowth of the noninfarcted splenic parenchyma within several months post-PSE. The purpose of this study was to determine the therapeutic factors based on the preoperative splenic volume for a prolonged increase in platelet counts after PSE.

METHODS

In 72 cirrhotic patients with follow-ups longer than 1 year post-PSE, depending on the preoperative splenic volume, the splenic factors associated with a prolonged increase in platelet counts at 1 year after PSE were retrospectively examined.

RESULTS

In 57 patients with preoperative splenic volumes <or=700 ml, the preoperative splenic volume (P = 0.001), infarcted splenic volume (P < 0.001), and splenic infarction ratio (P = 0.001) showed positive correlations with increments in platelet counts at 1 year post-PSE. In 15 patients with preoperative splenic volumes >700 ml, noninfarcted splenic volume (P = 0.003) and splenic infarction ratio (P = 0.002) showed negative and positive correlations with the increment in platelet counts at 1 year post-PSE, respectively.

CONCLUSIONS

In patients with splenic volumes <or=700 ml, the infarcted splenic area significantly affects the prolonged increase in platelet counts post-PSE. In patients with splenic volumes >700 ml, the noninfarcted splenic area is significant.

Laparoscopic splenectomy may be a superior supportive intervention for cirrhotic patients with hypersplenism

BACKGROUND AND AIMS

To evaluate and compare laparoscopic splenectomy and partial splenic embolization as supportive intervention for cirrhotic patients with hypersplenism to overcome peripheral cytopenia before the initiation of and during interferon therapy or anticancer therapy for hepatocellular carcinoma.

METHODS

Between December 2000 and April 2008, 43 Japanese cirrhotic patients with hypersplenism underwent either laparoscopic splenectomy or partial splenic embolization as a supportive intervention to facilitate the initiation and completion of either interferon therapy or anticancer therapy for hepatocellular carcinoma. We reviewed the peri- and post-intervention outcomes and details of the subsequent planned main therapies. For interferon therapy, the rate of completion, the rate of treatment cessation and virological responses were evaluated. Anti-cancer therapies for hepatocellular carcinoma included liver resection, ablation therapy, intra-arterial chemotherapy, and transarterial chemoembolization.

RESULTS

All patients tolerated the operations well with no significant complications. The platelet count was significantly higher in the laparoscopic splenectomy group than in the partial splenic embolization group at 1 and 2 weeks after the intervention. Interferon therapy was stopped in two patients in the partial splenic embolization group due to recurrent thrombocytopenia whereas all patients in the laparoscopic splenectomy group completed interferon therapy. The planned anticancer therapies were performed in all patients, and were completed in all patients without any problems or major complications.

CONCLUSION

Laparoscopic splenectomy may be superior to partial splenic embolization as a supportive intervention for cirrhotic patients with hypersplenism. Future prospective, randomized controlled patient studies are required to confirm these findings.

Treatment modalities for hypersplenism in liver transplant recipients with recurrent hepatitis C

Hepatitis C is the most common indication for orthotopic liver transplantation in the United States. Unfortunately, hepatitis C recurs universally in the transplanted liver and is the major cause of decreased graft and patient survival. The combination therapy of interferon and ribavirin has been shown to be the most effective therapy for recurrent hepatitis C. However, pre- and post-transplant hypersplenism often precludes patients from receiving the antiviral therapy. Splenectomy and partial splenic embolization are the two invasive modalities that can correct the cytopenia associated with hypersplenism. In this report we review the two treatment options, their associated outcomes and complications.

Thrombopoietin agonists for the treatment of thrombocytopenia in liver disease and hepatitis C

Thrombocytopenia is a condition of unusually low level of platelets in blood, resulting from an imbalance between the production and destruction of platelets, and is associated with aplastic anemia, myelodysplasia, and idiopathic thrombocytopenic purpura (ITP). Thrombocytopenia can also be associated with severe chronic liver disease as a result of several factors that may act in concert, including reduced production of the endogenous thrombopoietic growth factor, thrombopoietin (TPO). This article examines the nature of thrombocytopenia, ITP, and TPO.

Successful laparoscopic splenectomy after living-donor liver transplantation for thrombocytopenia caused by antiviral therapy

Although interferon (IFN) based therapy for recurrent hepatitis C virus (HCV) infection after liver transplantation has been widely accepted, it induces various adverse effects such as thrombocytopenia, resulting in its interruption. Recently, concomitant splenectomy at the time of living donor liver transplantation (LDLT) has been tried to overcome this problem, but this procedure leads to several complications such as excessive intraoperative bleeding and serious infection. A 60-year-old female received LDLT using a left lobe graft from her second son for liver failure caused by hepatitis C-related cirrhosis. Six months after LDLT, she was diagnosed as recurrent HCV infection by liver biopsy. IFN monotherapy was started from 7 mo after LDLT and her platelet count decreased to less than 50 000/&mgr;L, which thus made it necessary to discontinue the treatment. We decided to attempt laparoscopic splenectomy (LS) under general anesthesia. Since intra-abdominal findings did not show any adhesion formations around the spleen, LS could be successfully performed. After LS, since her platelet count immediately increased to 225 000/&mgr;L 14 d after operation, IFN therapy was restarted and we could convert the combination therapy of IFN and ribavirin, resulting in no detectable viral marker. In conclusion, LS can be performed safely even after LDLT, and LS after LDLT is a feasible and less invasive modality for thrombocytopenia caused by antiviral therapy.

Risk factors for complications after partial splenic embolization for liver cirrhosis

BACKGROUND

Partial splenic embolization (PSE) in patients with cirrhosis can achieve a prolonged increase in blood cell count. However, there is little information on the risk factors for complications after PSE for liver cirrhosis.

METHODS

Seventy patients (41 men and 29 women) with cirrhosis-induced hypersplenism underwent PSE. Based on the Child-Pugh classification, 30, 35 and five patients had class A, B and C disease respectively. Risk factors for complications after PSE were examined retrospectively by logistic regression analysis.

RESULTS

The mean splenic infarction rate was 77.1 per cent. Twelve patients (17 per cent) had complications following PSE. In univariable analysis, Child-Pugh class C, total bilirubin level of 1.4 mg/dl or more, serum albumin level of 2.8 g/dl or less and infarcted splenic volume of 540 ml or more were significantly associated with complications after PSE. In multivariable analysis, Child-Pugh class C (P = 0.012) and infarcted splenic volume of 540 ml or more (P = 0.031) were identified as risk factors, with an odds ratio of 22.92 and 5.01 respectively.

CONCLUSION

Child-Pugh class C and a large splenic infarction volume are risk factors for complications after PSE for liver cirrhosis.