Comparison of liver stiffness, fibrotest and liver biopsy for assessment of liver fibrosis in kidney-transplant patients with chronic viral hepatitis

Non-Invasive Assessment of Liver Fibrosis and Steatosis in End-Stage Renal Disease Patients Undergoing Renal Transplant Evaluation

Background

Non-alcoholic fatty liver disease (NAFLD) has an increased prevalence in end-stage renal disease (ESRD) due to similar risk factors. The aim of this study was to assess non-invasive testing including transient elastography (TE) for liver stiffness (LS), controlled attenuated parameter (CAP) for steatosis, Fibrosis-4 (FIB-4) score, aspartate aminotransferase (AST) to platelet ratio index (APRI) and NAFLD fibrosis score (NFS), for evaluation of NAFLD along with advanced fibrosis (AF) in patients with ESRD undergoing renal transplant evaluation.

Methods

Data were retrospectively collected within 12 weeks of TE. Primary outcomes were AF, defined by LS ≥ 9 kPa compared to APRI > 1.5, FIB-4 > 2.67, and NFS of 0.675, and ≥ 5% steatosis by CAP ≥ 263 dB/m compared to liver histology when available.

Results

A total of 171 patients were evaluated: mean age 56, 65% male, 36% obese, 47% had diabetes, 96% hypertension, and 56% dyslipidemia. Mean LS was 6.5 kPa with 21% having AF. Mean CAP was 232 dB/m, with 25% having steatosis. Those with AF were older with higher NFS. Those with steatosis were obese and had diabetes without higher LS or fibrosis scores. Only NFS was associated with LS ≥ 9 kPa. In those with liver histology, AF was associated with LS ≥ 9 kPa but not with APRI, FIB-4, or NFS.

Conclusions

Despite normal liver enzymes, non-invasive assessment via TE in ESRD patients exhibited high prevalence of AF and steatosis not detected by APRI or FIB-4 scores. This high prevalence was secondary to the common risk factors such as obesity and diabetes, among patients with NAFLD and ESRD.

Efficacy and safety of glecaprevir/pibrentasvir in renally impaired patients with chronic HCV infection

BACKGROUND AND AIMS

Chronic hepatitis C virus (HCV) infection increases the risk of incident chronic kidney disease (CKD) and progression to end-stage renal disease (ESRD). Previously available direct-acting antiviral regimens are not approved for patients with advanced CKD across all HCV genotypes.

METHODS

EXPEDITION-5 is a phase 3 study to evaluate efficacy and safety of the fixed-dose combination of glecaprevir and pibrentasvir (G/P) for chronic HCV infection (genotype 1 through 6) in adults without cirrhosis or with compensated cirrhosis and with stage 3b, 4 or 5 CKD. Patients received approved duration of G/P according to HCV genotype, cirrhosis status and prior HCV treatment experience. The primary efficacy endpoint was percentage of patients with sustained virologic response at 12 weeks post-treatment (SVR12).

RESULTS

Among the 101 patients enrolled in the study, 24% had predialysis CKD and 76% were on dialysis. Eighty-four patients were treated with G/P for 8 weeks, 13 patients for 12 weeks and four patients for 16 weeks. Fifty-five per cent of patients had genotype 1, 27% had genotype 2, 15% had genotype 3 and 4% had genotype 4, and none had genotype 5 or 6 infection. The SVR12 rate was 97% (98/101, 95% confidence interval, 91.6-99.0). No patients experienced virologic failure. Adverse events (AEs) reported in at least 5% of the patients were pruritus, bronchitis, hypertension and generalized pruritus. Serious AEs were reported in 12% of patients; none related to study drug.

CONCLUSIONS

G/P treatment yielded high SVR12 rates irrespective of the presence of stage 3b, 4 or 5 CKD. No safety signals were detected. CLINICALTRIALS.

GOV IDENTIFIER

This Phase 3 clinical trial was funded by AbbVie and registered with clinicaltrials.gov as NCT03069365 (EXPEDITION-5).

The Reliability of Fibro-test in Staging Orthotopic Liver Transplant Recipients with Recurrent Hepatitis C

Background and Aims: Liver biopsy remains the gold standard for staging of chronic liver disease following orthotopic liver transplantation. Noninvasive assessment of fibrosis with Fibro-test (FT) is well-studied in immunocompetent populations with chronic hepatitis C virus infection. The aim of this study is to investigate the diagnostic value of FT in the assessment of hepatic fibrosis in the allografts of liver transplant recipients with evidence of recurrent hepatitis C. Methods: We retrospectively compared liver biopsies and FT performed within a median of 1 month of each other in orthotopic liver transplantation recipients with recurrent hepatitis C. Results: The study population comprised 22 patients, most of them male (19/22), and with median age of 62 years. For all patients, there was at least a one-stage difference in fibrosis as assessed by liver biopsy compared to FT, while for the majority (16/22) there was at least a two-stage difference. The absence of correlation between the two modalities was statistically demonstrated (Mann-Whitney U test, p = 0.01). In detecting significant fibrosis (a METAVIR stage of F2 and above), an FT cut-off of 0.5 showed moderate sensitivity (77%) and negative predictive value (80%), but suboptimal specificity (61%) and positive predictive value (58%). Conclusions: In post-transplant patients with recurrent hepatitis C, FT appears to be inaccurately assessing the degree of allograft fibrosis, therefore limiting its reliability as a staging tool.

Usefulness of serum Mac-2 binding protein glycosylation isomer in patients undergoing hepatectomy: A case controlled study

Background

To evaluate the clinical significance of Mac-2 binding protein glycosylation isomer (M2BPGi), we investigated the relationship between M2BPGi and clinicopathological and surgical parameters and posthepatectomy complications.

Materials and methods

We examined M2BPGi in 115 patients with hepatic malignancies undergoing hepatectomy. Significance as an independent prognostic marker was determined with multivariate logistic regression analysis.

Results

The mean serum M2BPGi level was 1.14 ± 1.03 C.O.I. (range 0.2–5.79). M2BPGi in the chronic viral hepatitis group (1.42 ± 1.25) was significantly higher than that in the other disease groups (p < 0.05). The M2BPGi level correlated negatively with platelet count, LHL15 and GSA-Rmax (r = −0.36, −0.69 and −0.56, respectively; p < 0.01) but correlated positively with serum hyaluronate level (fibrotic marker), ICGR15 and HH15 (r = 0.52, 0.63 and 0.57, respectively; p < 0.01). In 53 patients examined for histological hepatic fibrosis, the M2BPGi level was highest for hepatic fibrosis stage 4, indicating cirrhosis (2.15 ± 1.56), and was significantly higher than that for stages 0–2 (p < 0.05). M2BPGi level did not correlate significantly with any surgical parameters. The preoperative level correlated significantly only with increased alanine aminotransferase level (r = −0.21, p < 0.05) and was significantly higher in patients with (1.35 ± 0.78) than without (1.11 ± 1.07) hepatectomy-related complications (p < 0.05). Area under the ROC curve analysis for prediction of hepatic fibrosis score 4 showed a cut-off value of 0.78 for M2BPGi to have high sensitivity (90%) and specificity (58%). For postoperative hepatectomy-related complications, only the M2BPGi level (at a cut-off value 0.90) tended to show significance (p = 0.06).

Conclusions

The non-invasively measured serum level of M2BPGi reflected impaired liver function or cirrhosis and hepatectomy-related complications after surgery, making it potentially useful as a complementary parameter accompanying other liver function parameters.

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The M2BPGi level was higher in patients with posthepatectomy complications.

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The M2BPGi level correlated negatively with the platelet count, LHL 15 and GSA-Rmax by liver scintigraphy.

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The M2BPGi level was highest in the patients with hepatic fibrosis.

Utility of magnetic resonance elastography for predicting ascites in patients with chronic liver disease

OBJECTIVE

This study aimed to evaluate the utility of magnetic resonance elastography (MRE) as a non-invasive method for predicting ascites in patients with chronic liver disease (CLD).

METHODS

A total of 208 CLD patients underwent MRE to measure liver stiffness (LS) at our institution from March 2013 to June 2015. We evaluated the diagnostic performance of MRE for predicting the presence of ascites using receiver-operating characteristic (ROC) curve analysis and compared the performance with that of serum fibrosis markers. Multivariate logistic regression analysis was performed to identify factors associated with the presence of ascites. The cumulative incidence of ascites was examined in patients without ascites at baseline. The pathological stage of liver fibrosis was evaluated in 81 CLD patients using histopathologic diagnosis.

RESULTS

Of the 208 patients, 41 had ascites. The optimal cut-off LS value for the presence of ascites was 6.0 kPa (area under the ROC curve = 0.87). The area under the ROC curve for the presence of ascites was significantly higher for MRE than that for fibrosis markers. Multivariate analysis revealed that LS >6.0 kPa is an independent risk factor for the presence of ascites. The cumulative incidence of ascites was significantly higher among those with LS values >6.0 kPa. There was significantly greater diagnostic accuracy for liver fibrosis stage ≥4 with MRE than that with fibrosis markers.

CONCLUSIONS

Compared with serum fibrosis markers, MRE has higher diagnostic performance in predicting the presence of ascites. MRE-based LS has the potential to predict the presence of ascites in CLD patients.

Hepatitis C virus infection and chronic kidney disease: Time for reappraisal

Hepatitis C virus (HCV) infection is associated with tremendous morbidity and mortality due to liver complications. HCV infection is also associated with many extrahepatic manifestations including cardiovascular diseases, glucose metabolism impairment, cryoglobulinemia vasculitis, B cell non-Hodgkin lymphoma and chronic kidney disease (CKD). Many studies have shown a strong association between HCV and CKD, by reporting (i) an increased prevalence of HCV infection in patients on haemodialysis, (ii) an increased incidence of CKD and proteinuria in HCV-infected patients, and (iii) the development of membranoproliferative glomerulonephritis secondary to HCV-induced cryoglobulinemia vasculitis. HCV seropositivity is found to be associated with an increased relative risk for all-cause and cardiovascular mortality in the dialysis population. HCV seropositivity is linked to lower patient and graft survival after kidney transplantation. Such poor HCV-associated prognosis should have encouraged clinicians to treat HCV in CKD patients. However, due to frequent side effects and the poor efficacy of interferon-based treatments, very few HCV dialysis patients have received HCV medications until now. The emergence of new direct acting, interferon-free antiviral treatment, leading to HCV cure in most cases with a satisfactory safety profile, will shortly modify the management of HCV infection in CKD patients. In patients with a glomerular filtration rate (GFR) >30ml/min, the choice of DAA is not restricted. In those with a GFR <30 and >15ml/min, only paritaprevir/ritonavir/ombitasvir/dasabuvir or a grazoprevir plus elbasvir regimen are approved. In patients with end stage renal disease (GFR <15ml/min or dialysis), current data only allows for the use of a grazoprevir plus elbasvir combination. No doubt these data will be modified in the future with the advent of new studies including larger cohorts of HCV patients with renal impairment.

HCV and the kidney

Chronic hepatitis C (CHC) is significantly associated with a risk of renal deterioration over time. Renal impairment, especially stage 4-5 chronic kidney disease, increases the risk of: (i) the prevalence and incidence (in dialysis/transplantation) of hepatitis C virus (HCV) infection; (ii) liver deterioration during kidney transplantation and (iii) allograft failure and patient mortality. HCV-infected dialysis patients have a higher mortality than non-infected dialysis patients and than HCV-infected kidney recipients. The harmful impact of HCV emphasizes the need for oral antiviral therapies in patients with chronic kidney disease. Symptomatic cryoglobulinemic vasculitis and extensive liver fibrosis are already approved indications for early access to oral antiviral treatment. Patients with stage 4-5 chronic kidney disease should also be given priority: dialysis patients (whatever the stage of fibrosis and whether or not they are candidates for kidney transplantation) as well as all kidney recipients. The results of treatment of HCV with direct-acting antiviral (DAAs) drugs in patients with late chronic kidney disease are excellent, similar to those in the general population, although additional clinical trials are definitely needed, particularly to optimize adjustment of treatment to kidney function and determine the risk of drug-drug interactions.

[Management of hepatitis B virus and hepatitis C virus infection in chronic kidney failure]

Chronic infections by hepatitis B (HBV) and C virus (HCV) result in diagnosis and therapeutic issues in dialysis and kidney recipients patients. The exposure to nosocomial, including blood transfusion, risk explains the high prevalence of HBV and HCV infection in this setting. Chronic infection reduces the survival of both patients and allografts, including a specific risk of de novo glomerulonephritis. Cirrhosis was considered as a contra-indication to renal transplantation given the high risk of decompensation and death, questionning the indication of a combined liver and kidney transplantation. Thus, it is mandatory to screen HBV and HCV markers in all dialysis patients, whether or not they are candidates to transplantation. Liver biopsy allows evaluating the severity of the liver disease since the noninvasive markers of fibrosis appear to be less accurate in "renal" patients than in the general population and to better define antiviral therapeutic indications. HCV treatment was mainly based on pegylated interferon α (and low doses of ribavirin), which is contra-indicated in kidney recipients given the risk of graft rejection; HCV treatment is now based on the use of oral direct acting antivirals, which are very potent and well tolerated. HBV replication is now easily suppressed by second-generation nucleos(t)tidic analogues (entecavir and tenofovir), which will be indicated in all the dialysis patients with significant fibrosis (F2,3 or 4 according to the Metavir scoring system) and in any candidate to renal transplantation and to any HBsAg-positive kidney recipients. The best treatment remains preventive by anti-HBV vaccination for HBV and by the respect of universal hygiene rules for HCV.

Antiviral treatment for chronic hepatitis B in renal transplant patients

Chronic hepatitis B infection is frequent in renal transplant patients. It negatively impacts long term outcomes reducing graft and patient survival. Current guidelines clearly define who needs treatment, when to start, what is the first line therapy, how to monitor treatment response, when to stop, and how patients must be controlled for its safety. There is some data showing a favorable safety and efficacy profile of nucleos(t)ide analogue (NUC) treatment in the renal transplant setting. Entecavir, a drug without major signs of nephrotoxicity, appears to be the first option for NUC naïve patients and tenofovir remains the preferred choice for patients with previous resistance to lamivudine or any other NUC. Renal transplant recipients under antiHBV therapy should be monitored for its efficacy against HBV but also for its safety with a close renal monitoring. Studies including a large number of patients with long term treatment and follow up are still needed to better demonstrate the safety and efficacy of newer NUCs in this population.

Management of hepatitis C in patients with chronic kidney disease

Hepatitis C virus (HCV) infection is highly prevalent among chronic kidney disease (CKD) subjects under hemodialysis and in kidney transplantation (KT) recipients, being an important cause of morbidity and mortality in these patients. The vast majority of HCV chronic infections in the hemodialysis setting are currently attributable to nosocomial transmission. Acute and chronic hepatitis C exhibits distinct clinical and laboratorial features, which can impact on management and treatment decisions. In hemodialysis subjects, acute infections are usually asymptomatic and anicteric; since spontaneous viral clearance is very uncommon in this context, acute infections should be treated as soon as possible. In KT recipients, the occurrence of acute hepatitis C can have a more severe course, with a rapid progression of liver fibrosis. In these patients, it is recommended to use pegylated interferon (PEG-IFN) in combination with ribavirin, with doses adjusted according to estimated glomerular filtration rate. There is no evidence suggesting that chronic hepatitis C exhibits a more aggressive course in CKD subjects under conservative management. In these subjects, indication of treatment with PEG-IFN plus ribavirin relies on the CKD stage, rate of progression of renal dysfunction and the possibility of a preemptive transplant. HCV infection has been associated with both liver disease-related deaths and cardiovascular mortality in hemodialysis patients. Among those individuals, low HCV viral loads and the phenomenon of intermittent HCV viremia are often observed, and sequential HCV RNA monitoring is needed. Despite the poor tolerability and suboptimal efficacy of antiviral therapy in CKD patients, many patients can achieve sustained virological response, which improve patient and graft outcomes. Hepatitis C eradication before KT theoretically improves survival and reduces the occurrence of chronic graft nephropathy, de novo glomerulonephritis and post-transplant diabetes mellitus.

A health technology assessment of transient elastography in adult liver disease

BACKGROUND

An estimated one in 10 Canadians have some form of liver disease. The reference standard for staging and monitoring liver fibrosis is percutaneous liver biopsy--an invasive procedure associated with risks and complications. Transient elastography (TE) represents a noninvasive, ultrasound-based alternative.

OBJECTIVE

To assess the efficacy of TE compared with liver biopsy for fibrosis staging in adults with five common types of liver disease: hepatitis B, hepatitis C, nonalcoholic fatty liver disease, cholestatic liver disease and complications post-liver transplantation.

METHODS

A systematic review of published and grey literature from 2001 to June 2011 was conducted. Included were observational studies evaluating the accuracy of TE using liver biopsy as the comparator. An economic model was developed to estimate the cost per correct diagnosis gained with liver biopsy compared with TE. Identification of moderate fibrosis (stages 2 to 4) and cirrhosis (stage 4) were considered.

RESULTS

Fifty-seven studies were included in the review. The diagnostic accuracy of TE for the five clinical subgroups had sensitivities ranging from 0.67 to 0.92 and specificities ranging from 0.72 to 0.95. Liver biopsy was associated with an additional $1,427 to $7,030 per correct diagnosis gained compared with TE. The model was sensitive to the sensitivity and specificity of TE and the prevalence of fibrosis.

CONCLUSIONS

TE is an accurate diagnostic method in patients with moderate fibrosis or cirrhosis. TE is less effective but less expensive than liver biopsy. Systemic implementation of TE should be considered for the noninvasive assessment of liver fibrosis.

Usefulness of evaluating hepatic elasticity using artificial acoustic radiation force ultrasonography before hepatectomy

AIM

To evaluate hepatic fibrosis and tumor diagnosis preoperatively, we investigated the elasticity calculated by the new parameter of ultrasonography, acoustic radiation force impulse (ARFI).

METHODS

We examined ARFI of the non-tumorous right and left lateral liver and in the tumor by push pulse of probe in 95 patients with hepatic malignancies undergoing hepatectomy. Measurement of ARFI as hepatic stiffness was indicated as the Vs (m/s).

RESULTS

Measuring the Vs in the non-tumor region was achieved in the right liver in 99% and at the left lateral liver in 94%. The Vs in the right liver was significantly lower than in the left lateral liver, and the Vs of the liver tumor was significantly higher than in the non-tumorous liver. The Vs in the right and left lateral liver was correlated with the platelet count, aspartate aminotransferase, fibrotic indices and indocyanine green test. The Vs in the right liver was significantly correlated with the fibrotic marker or index. The Vs of liver cirrhosis and histological stage 4 in the right and left liver was significantly the highest compared to the others. The Vs in the right liver showed a high area under the receiver-operator curve value predicting histological fibrosis. The Vs in the right was significantly correlated with blood loss and postoperative complications, particularly uncontrolled ascites.

CONCLUSION

Non-invasive ARFI imaging elastography is useful in evaluating impaired liver function or in the differential diagnosis of liver malignancies, highly hepatic fibrosis and in predicting posthepatectomy morbidity.

Hepatitis C virus infection and kidney transplantation in 2014: what's new?

Chronic hepatitis C virus (HCV) infection remains an important health problem, which is associated with deleterious consequences in kidney transplant recipients. Besides hepatic complications, several extrahepatic complications contribute to reduced patient and allograft survival in HCV-infected kidney recipients. However, HCV infection should not be considered as a contraindication for kidney transplantation because patient survival is better with transplantation than on dialysis. Treatment of HCV infection is currently interferon-alpha (IFN-α) based, which has been associated with higher renal allograft rejection rates. Therefore, antiviral treatment before transplantation is preferable. As in the nontransplant setting, IFN-free treatment regimens, because of their greater efficacy and reduced toxicity, currently represent promising and attractive therapeutic options after kidney transplantation as well. However, clinical trials will be required to closely evaluate these regimens in kidney recipients. There is also a need for prospective controlled studies to determine the optimal immunosuppressive regimens after transplantation in HCV-infected recipients. Combined kidney and liver transplantation is required in patients with advanced liver cirrhosis. However, in patients with cleared HCV infection and early cirrhosis without portal hypertension, kidney transplantation alone may be considered. There is some agreement about the use of HCV-positive donors in HCV-infected recipients, although data regarding posttransplant survival rates are controversial.

Kidney transplantation from donors with hepatitis C infection

The increasing demand for organ donors to supply the increasing number of patients on kidney waiting lists has led to most transplant centers developing protocols that allow safe utilization from donors with special clinical situations which previously were regarded as contraindications. Deceased donors with previous hepatitis C infection may represent a safe resource to expand the donor pool. When allocated to serology-matched recipients, kidney transplantation from donors with hepatitis C may result in an excellent short-term outcome and a significant reduction of time on the waiting list. Special care must be dedicated to the pre-transplant evaluation of potential candidates, particularly with regard to liver functionality and evidence of liver histological damage, such as cirrhosis, that could be a contraindication to transplantation. Pre-transplant antiviral therapy could be useful to reduce the viral load and to improve the long-term results, which may be affected by the progression of liver disease in the recipients. An accurate selection of both donor and recipient is mandatory to achieve a satisfactory long-term outcome.

Hepatitis C virus infection in hemodialysis patients

Hepatitis C virus (HCV) infection is observed in around 20% of dialysis patients and in allograft recipients and results in a significant morbidity and mortality, especially after transplantation. Its prevalence has markedly decreased in patients who are candidates for transplantation since the introduction of screening, hygiene and prevention measures, including systematic screening of blood and organ donations, use of erythropoietin, and compliance with universal hygiene rules. A liver biopsy is preferable to non-invasive biochemical and/or morphological tests of fibrosis to evaluate liver fibrosis before and even after transplantation. In HCV-infected dialyzed patients who are not candidates for renal transplantation, the indication for antiviral therapy is limited to significant fibrosis (fibrosis ≥ 2 on the METAVIR scale). Antiviral treatment should be proposed to any HCV-infected candidate for renal transplantation, whatever the baseline histopathology. The recommendation is to use standard interferon-α as monotherapy, but pegylated interferon can be used, resulting in sustained virological response, while low doses of combined ribavirin may enhance the antiviral efficacy. After transplantation, interferon-α is contra-indicated but may be used in patients for whom the benefits of antiviral treatment clearly outweigh the risks, especially that of allograft rejection. All cirrhotic patients should be screened for hepatocellular carcinoma, whose risk is enhanced by immunosuppressive regimens. Sustained suppression of necro-inflammation may result in the reversal of cirrhosis, which reduces liver-related morbidity and improves patient and allograft survival. Finally, due to the high mortality after renal transplantation, active cirrhosis must be considered to be a contraindication to kidney transplantation, but an indication to combined liver-kidney transplantation; on the contrary, inactive compensated cirrhosis may permit renal transplantation alone.

Hepatitis C virus and kidney disease

Hepatitis C virus (HCV) is the most frequently observed viral infection in patients with kidney disease. HCV can cause glomerular disease, which can lead to end-stage renal disease that requires dialysis and/or kidney transplantation. It is recommended to test HCV patients once a year for proteinuria, microscopic hematuria and estimated glomerular filtration rate. Membranoproliferative glomerulonephritis is the most common glomerular disease induced by HCV. Over the past few decades, the prevalence of HCV infection has decreased among dialysis and kidney transplant patients. However, survival is significantly lower in HCV-positive than in HCV-negative dialysis patients whereas survival is significantly better in HCV-positive kidney transplant patients compared with HCV-positive dialysis patients. Thus, dialysis patients without a sustained virological response after anti-HCV therapy should be proposed for kidney transplantation. Recurrence or de novo occurrence of glomerular disease is responsible for the lower kidney allograft survival in HCV-positive compared with HCV-negative kidney transplant patients. Dialysis and kidney transplantation do not appear to negatively affect progression of liver fibrosis in the majority of patients. The available data also suggest that occult HCV infection does not exist in dialysis and kidney transplant patients.

Hepatitis C virus and nonliver solid organ transplantation

: Hepatitis C virus (HCV) infection is common in solid organ allograft recipients and is a significant cause of morbidity and mortality after transplantation, so effective management will improve outcomes. In this review, we discuss the extent of the problem associated with HCV infection in donors and kidney, heart, and lung transplant candidates and recipients and recommend follow-up and treatment.Patients with end-stage kidney disease without cirrhosis and selected patients with early-stage cirrhosis can be considered for kidney transplant alone. In HCV-infected kidney allograft recipients, the progression of fibrosis should be evaluated serially by Fibroscan or serologic measures of fibrosis. Transplantation of kidneys from HCV-positive donors should be restricted to HCV-positive recipients as it is associated with a reduced time waiting for a graft and does not affect posttransplant outcomes. Hepatitis C virus antiviral therapy should be considered for all HCV-RNA-positive kidney transplant candidates, irrespective of the baseline liver histopathology. Protease inhibitors have yet to be fully evaluated in patients with renal dysfunction and in the transplant population. As these agents may cause anemia in patients with normal renal function, tolerability may be a problem in patients with end-stage kidney disease.The impact of HCV infection on survival in heart and lung transplantation is unclear. Because of the shortage of organs, few HCV-infected patients are accepted for transplantation.Universal use of nucleic acid amplification testing (NAT) for the screening of potential organ donors should be reserved to high-risk donors. Assays that quantify HCV core antigen may become more cost-effective than NAT for the screening of potential organ donors.

Viral hepatitis in solid organ transplantation other than liver

Transplantation is the best treatment for end-stage organ failure. Hepatitis virus infections, mainly hepatitis B virus (HBV) and hepatitis C virus (HCV) infections still constitute a major problem because they are common in allograft recipients and are a significant cause of morbidity and mortality after transplantation. Recently, hepatitis E virus infection has been added as an emergent cause of chronic hepatitis in organ transplantation. The prevalence of HBV and HCV infections has markedly decreased in patients who are candidates for transplantation since the introduction of screening, hygiene and prevention measures, including systematic screening of blood and organ donations, use of erythropoietin, compliance with universal hygiene rules, segregation of HBV-infected patients from non-infected patients and systematic vaccination against HBV. A liver biopsy is preferable to non-invasive biochemical and/or morphological tests of fibrosis to evaluate liver fibrosis before and even after transplantation. Treatment with entecavir or tenofovir is indicated in HBV-infected dialyzed patients who have moderate or severe disease (≥A2 or F2 on the Metavir scale) in preparation for renal transplantation. Due to the risks of severe reactivation, fibrosing cholestatic hepatitis or histological deterioration after transplantation, systematic use of nucleoside or nucleotide analogues shortly before or at the time of transplantation is recommended (tenofovir or entecavir are preferable to lamivudine) in all patients, whatever the baseline histological evaluation. In HCV-infected dialyzed patients who are not candidates for renal transplantation, the indication for antiviral therapy is limited to significant fibrosis (fibrosis ≥2 on the Metavir scale). Treatment must be proposed to all candidates for renal transplantation, whatever their baseline histopathology, and interferon-α should be used as monotherapy. After transplantation, interferon-α is contraindicated but may be used in patients for whom the benefits of antiviral treatment clearly outweigh the risks, especially that of allograft rejection. All cirrhotic patients, notably after solid organ transplantation, should be screened for hepatocellular carcinoma. Sustained suppression of necro-inflammation may result in regression of cirrhosis, which in turn may lead to decreased disease-related morbidity and improved survival. Finally, due to the high mortality after renal transplantation, active (namely without sustained viral suppression) cirrhosis should be considered a contraindication to kidney transplantation, but an indication to combined liver-kidney transplantation; on the contrary, inactive (namely with sustained viral suppression) compensated cirrhosis may permit renal transplantation alone. Organ transplantations other than kidney (cardiac or pulmonary transplantations) involve the same diagnosis and therapeutic issues.

Elastography for the diagnosis of severity of fibrosis in chronic liver disease: a meta-analysis of diagnostic accuracy

BACKGROUND & AIMS

Transient elastography is a non-invasive method, for the assessment of hepatic fibrosis, developed as an alternative to liver biopsy. We studied the performance of elastography for diagnosis of fibrosis using meta-analysis.

METHODS

MEDLINE, EMBASE, SCI, Cochrane Library, conference abstracts books, and article references were searched. We included studies using biopsy as a reference standard, with the data necessary to calculate the true and false positive, true and false negative diagnostic results of elastography for a fibrosis stage, and with a 3-month maximum interval between tests. The quality of the studies was rated with the QUADAS tool.

RESULTS

We identified 40 eligible studies. Summary sensitivity and specificity was 0.79 (95% CI 0.74-0.82) and 0.78 (95% CI 0.72-0.83) for F2 stage and 0.83 (95% CI 0.79-0.86) and 0.89 (95% CI 0.87-0.91) for cirrhosis. After an elastography result at/over the threshold value for F2 or cirrhosis ("positive" result), the corresponding post-test probability for their presence (if pre-test probability was 50%) was 78%, and 88% respectively, while, if values were below these thresholds ("negative" result), the post-test probability was 21% and 16%, respectively. No optimal stiffness cut-offs for individual fibrosis stages were validated in independent cohorts and cut-offs had a wide range and overlap within and between stages.

CONCLUSIONS

Elastography theoretically has good sensitivity and specificity for cirrhosis (and less for lesser degrees of fibrosis); however, it should be cautiously applied to everyday clinical practice because there is no validation of the stiffness cut-offs for the various stages. Such validation is required before elastography is considered sufficiently accurate for non-invasive staging of fibrosis.

No evidence of occult hepatitis C virus (HCV) infection in serum of HCV antibody-positive HCV RNA-negative kidney-transplant patients

Persistence of hepatitis C virus (HCV) in patients who cleared HCV is still debated. Occult HCV infection is described as the presence of detectable HCV RNA in liver or peripheral blood mononuclear cells (PBMCs) of patients with undetectable plasma HCV-RNA by conventional PCR assays. We have assessed the persistence of HCV in 26 kidney-transplant patients, followed up for 10.5 years (range 2-16), after HCV elimination while on hemodialysis. If HCV really did persist, arising out of the loss of immune control caused by institution of the regimen of immunosuppressive drugs after kidney transplantation, HCV reactivation would have taken place. Their immunosuppression relied on calcineurin inhibitors (100%), and/or steroids (62%), and/or antimetabolites (94%). An induction therapy, given to 22 patients, relied on rabbit antithymocyte globulin (59%) or anti-IL2-receptor blockers (32%). All patients had undetectable HCV RNA as ascertained by several conventional tests. At the last follow-up, no residual HCV RNA was detected in the five liver biopsies, the 26 plasma, and in the 37 nonstimulated and 24 stimulated PBMCs tested with an ultrasensitive RT-PCR assay (detection limit, 2 IU/ml). No biochemical or virologic relapse was seen during follow-up. The absence of HCV relapse in formerly HCV-infected immunocompromised patients suggests the complete eradication of HCV after its elimination while on dialysis.

Transplantation in the patient with hepatitis C

Hepatitis C virus (HCV) infection is the most frequent cause of liver disease after renal transplantation. Its clinical course is irrelevant in the short term, except for rare cases of fibrosing cholestatic hepatitis. However, in the long run, HCV infection can lead to major liver complications. Because interferon (IFN) is generally contraindicated in renal transplant patients, the best approach is to treat patients on dialysis. Until more information with pegylated-IFN is available, the use of alpha-IFN monotherapy is recommended. Most of the patients with sustained virological response remain HCV RNA negative after transplantation. HCV-positive renal transplant patients have a higher risk for proteinuria, chronic rejection, infections and post-transplant diabetes (PTDM). Long-term patient- and graft-survival rates are lower in HCV-positive patients. Mortality is higher, mainly as a result of liver disease and infections. HCV can contribute to the development of certain neoplasias such as post-transplant lymphoproliferative disease (PTLD). HCV infection is also an independent risk factor for graft loss. PTDM, transplant glomerulopathy and HCV-related glomerulonephritis can contribute to graft failure. Despite this, transplantation is the best option for end-stage renal disease in HCV-positive patients. Several measures to minimize the consequences of HCV infection have been recommended. Adjustment of immunosuppression and careful follow up in the outpatient clinic for early detection of HCV-related complications are mandatory.