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Clark PJ, Valery PC, Strasser SI, Weltman M, Thompson A, Levy MT, Leggett B, Zekry A, Rong J, Sinclair M, George J, Bollipo S, McGarity B, Sievert W, MacQuillan G, Tse E, Nicoll A, Wade A, Cheng W, Roberts SK. Broadening and strengthening the health providers caring for patients with chronic hepatitis C may improve continuity of care. J Gastroenterol Hepatol 2024; 39:568-575. [PMID: 38114452 DOI: 10.1111/jgh.16440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/14/2023] [Accepted: 11/19/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Direct-acting antiviral (DAA) therapies for hepatitis C virus infection (HCV) lead to excellent rates of sustained virological response (SVR). However, loss to follow-up (LTFU) for SVR testing remains a challenge. We examine factors associated with LTFU in a real-world setting. METHODS Adults who received DAA therapy for HCV in one of 26 centers across Australia during 2016-2021 were followed up for 2 years. Data sources included the patient medical records and the national Pharmaceutical and Medicare Benefits Schemes. Linkage to Medicare provided utilization data of other health-care providers and re-treatment with DAAs. LTFU was defined as no clinic attendance for SVR testing by at least 52 weeks after DAA treatment commencement. Multivariable logistic regression assessed factors associated with LTFU. RESULTS In 3619 patients included in the study (mean age 52.0 years; SD = 10.5), 33.6% had cirrhosis (69.4% Child-Pugh class B/C), and 19.3% had HCV treatment prior to the DAA era. Five hundred and fifteen patients (14.2%) were LTFU. HCV treatment initiation in 2017 or later (adj-OR = 2.82, 95% confidence interval [CI] 2.25-3.54), younger age (adj-OR = 2.63, 95% CI 1.80-3.84), Indigenous identification (adj-OR = 1.99, 95% CI 1.23-3.21), current injection drug use or opioid replacement therapy (adj-OR = 1.66, 95% CI 1.25-2.20), depression treatment (adj-OR = 1.49, 95% CI 1.17-1.90), and male gender (adj-OR = 1.31, 95% CI 1.04-1.66) were associated with LTFU. CONCLUSIONS These findings stress the importance of strengthening the network of providers caring for patients with HCV. In particular, services targeting vulnerable groups of patients such as First Nations Peoples, youth health, and those with addiction and mental health disorders should be equipped to treat HCV.
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Affiliation(s)
- Paul J Clark
- Department of Gastroenterology, Princess Alexandra and Mater Hospitals, and Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Patricia C Valery
- QIMR Berghofer Medical Research Institute, and Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Simone I Strasser
- AW Morrow Gastroenterology and Liver Centre Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Martin Weltman
- Hepatology Services, Nepean Hospital, Penrith, New South Wales, Australia
| | - Alex Thompson
- Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Miriam T Levy
- USYD, Department of Gastroenterology and Liver, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Barbara Leggett
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital and Faculty of Medicine, Brisbane, Queensland, Australia
| | - Amany Zekry
- Department of Gastroenterology and Hepatology, St George Hospital, Sydney, New South Wales, Australia
| | - Julian Rong
- Gippsland Gastroenterology, Latrobe Regional Hospital, Traralgon, Victoria, 3844, Australia
| | - Marie Sinclair
- Department of Gastroenterology and Hepatology, Austin Hospital, Melbourne, Victoria, Australia
| | - Jacob George
- Faculty of Medicine, The University of Sydney, Sydney, New South Wales, Australia
- Storr Liver Unit, Westmead Hospital, Westmead, New South Wales, Australia
| | - Steven Bollipo
- Gastroenterology Department, John Hunter Hospital, New Lambton, New South Wales, Australia
- Gastroenterology Department, John Hunter Hospital, Newcastle and School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Bruce McGarity
- Bathurst Liver Clinic Bathurst Hospital, Bathurst, New South Wales, Australia
| | - William Sievert
- Gastrointestinal and Liver Unit, Monash Health and Monash University, Melbourne, Victoria, Australia
| | - Gerry MacQuillan
- Department of Hepatology and Liver Transplant Unit, Sir Charles Gairdner Hospital, Nedlands, West Australia, Australia
| | - Edmund Tse
- Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | - Amanda Wade
- Burnet Institute, Melbourne, Victoria, Australia
- Barwon Health Liver Clinic University Hospital, Geelong, Victoria, Australia
| | - Wendy Cheng
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, West Australia, Australia
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Jayawardena T, Attree C, Cole S, Hui S, Jaques B, MacQuillan G, Smith B, Wallace M, Garas G, Adams L, Jeffrey G. Successful Liver Retransplantation in a Patient With Disseminated Aspergillosis and Nocardiosis: A Case Report. Transplant Proc 2024; 56:244-248. [PMID: 38218696 DOI: 10.1016/j.transproceed.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/10/2023] [Accepted: 11/13/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Clinical guidelines list active fungal infection and sepsis as contraindications to liver transplantation due to the risk of worsening infection with immunosuppression postoperatively. Mortality from systemic opportunistic infections in transplant recipients is high, approaching 100% for disseminated aspergillosis. However, the optimal duration of treatment required before transplant is unclear. Additionally, delaying surgery while the infection is treated risks death from hepatic decompensation and physical deconditioning, preventing progression to transplantation. CASE REPORT Here, we present a patient who underwent successful repeat liver transplantation for recurrent autoimmune hepatitis and graft rejection while undergoing treatment for disseminated aspergillosis and nocardiosis. He had pulmonary, hepatic, and central nervous system involvement. He had received 2 months of antimicrobials but had ongoing radiologic evidence of infection when listed for retransplantation. He remains well and infection-free 1 year postoperatively. CONCLUSION Few cases of successful liver transplantation in the setting of disseminated aspergillosis have been reported previously. To our knowledge, this is the first successful liver transplant in a patient with disseminated nocardial infection.
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Affiliation(s)
- Thisuri Jayawardena
- Hepatology Department and Liver Transplantation Service, Sir Charles Gairdner Hospital, Perth, Australia.
| | - Chloe Attree
- Hepatology Department and Liver Transplantation Service, Sir Charles Gairdner Hospital, Perth, Australia
| | - Sarah Cole
- Infectious Diseases Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Siong Hui
- Infectious Diseases Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Bryon Jaques
- General Surgery Department, Hepatobiliary/Transplant unit, Sir Charles Gairdner Hospital, Perth, Australia
| | - Gerry MacQuillan
- Hepatology Department and Liver Transplantation Service, Sir Charles Gairdner Hospital, Perth, Australia
| | - Briohny Smith
- Hepatology Department and Liver Transplantation Service, Sir Charles Gairdner Hospital, Perth, Australia
| | - Michael Wallace
- Hepatology Department and Liver Transplantation Service, Sir Charles Gairdner Hospital, Perth, Australia
| | - George Garas
- Hepatology Department and Liver Transplantation Service, Sir Charles Gairdner Hospital, Perth, Australia
| | - Leon Adams
- Hepatology Department and Liver Transplantation Service, Sir Charles Gairdner Hospital, Perth, Australia; School of Medicine, the University of Western Australia, Perth, Australia
| | - Gary Jeffrey
- Hepatology Department and Liver Transplantation Service, Sir Charles Gairdner Hospital, Perth, Australia; School of Medicine, the University of Western Australia, Perth, Australia
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3
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Bertot LC, Jeffrey GP, de Boer B, Wang Z, Huang Y, Garas G, MacQuillan G, Wallace M, Smith BW, Adams LA. Comparative Accuracy of Clinical Fibrosis Markers, Hepascore and Fibroscan® to Detect Advanced Fibrosis in Patients with Nonalcoholic Fatty Liver Disease. Dig Dis Sci 2023; 68:2757-2767. [PMID: 36947289 DOI: 10.1007/s10620-023-07896-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 02/21/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Non-invasive tests are widely used to diagnose fibrosis in patients with non-alcoholic fatty liver disease (NAFLD), however, the optimal method remains unclear. We compared the accuracy of simple serum models, a serum model incorporating direct measures of fibrogenesis (Hepascore), and Fibroscan®, for detecting fibrosis in NAFLD. METHODS NAFLD patients undergoing liver biopsy were evaluated with Hepascore, NAFLD Fibrosis Score (NFS), FIB-4 and AST-platelet ratio index (APRI), with a subset (n = 131) undergoing Fibroscan®. Fibrosis on liver biopsy was categorized as advanced (F3-4) or cirrhosis (F4). Accuracy was determined by area under receiving operating characteristic curves (AUC). Indeterminate ranges were calculated using published cut-offs. RESULTS In 271 NAFLD patients, 83 (31%) had F3-4 and 47 (17%) cirrhosis. 6/131 (4%) had an unreliable Fibroscan®. For the detection of advanced fibrosis, the accuracy of Hepascore (AUC 0.88) was higher than FIB-4 (0.73), NFS (0.72) and APRI (0.69) (p < 0.001 for all). Hepascore had similar accuracy to Fibroscan® (0.80) overall, but higher accuracy in obese individuals (0.91 vs 0.80, p = 0.001). Hepascore more accurately identified patients with cirrhosis than APRI (AUC 0.85 vs 0.71, p = 0.01) and NFS (AUC 0.73, p = 0.01) but performed similar to FIB-4 and Fibroscan®. For the determination of F3-4, the proportion of patients in indeterminate area was lower for Hepascore (4.8%), compared to FIB-4 (42%), NFS (36%) and APRI (44%) (p < 0.001 for all). CONCLUSIONS Hepascore has greater accuracy and a lower indeterminate range than simple serum fibrosis tests for advanced fibrosis in NAFLD, and greater accuracy than Fibroscan® in obese individuals.
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Affiliation(s)
- Luis C Bertot
- Medical School, University of Western Australia, QEII Medical Campus, Verdun St, Nedlands, WA, 6009, Australia
| | - Gary P Jeffrey
- Medical School, University of Western Australia, QEII Medical Campus, Verdun St, Nedlands, WA, 6009, Australia
- Department of Hepatology, Sir Charles Gairdner Hospital, QEII Medical Campus, Verdun St, Nedlands, WA, 6009, Australia
| | - Bastiaan de Boer
- Department of Anatomical Pathology, Pathwest, QEII Medical Campus, Verdun St, Nedlands, WA, 6009, Australia
| | - Zhengyi Wang
- Medical School, University of Western Australia, QEII Medical Campus, Verdun St, Nedlands, WA, 6009, Australia
| | - Yi Huang
- Medical School, University of Western Australia, QEII Medical Campus, Verdun St, Nedlands, WA, 6009, Australia
| | - George Garas
- Department of Hepatology, Sir Charles Gairdner Hospital, QEII Medical Campus, Verdun St, Nedlands, WA, 6009, Australia
| | - Gerry MacQuillan
- Department of Hepatology, Sir Charles Gairdner Hospital, QEII Medical Campus, Verdun St, Nedlands, WA, 6009, Australia
| | - Michael Wallace
- Medical School, University of Western Australia, QEII Medical Campus, Verdun St, Nedlands, WA, 6009, Australia
- Department of Hepatology, Sir Charles Gairdner Hospital, QEII Medical Campus, Verdun St, Nedlands, WA, 6009, Australia
| | - Briohny W Smith
- Department of Hepatology, Sir Charles Gairdner Hospital, QEII Medical Campus, Verdun St, Nedlands, WA, 6009, Australia
| | - Leon A Adams
- Medical School, University of Western Australia, QEII Medical Campus, Verdun St, Nedlands, WA, 6009, Australia.
- Department of Hepatology, Sir Charles Gairdner Hospital, QEII Medical Campus, Verdun St, Nedlands, WA, 6009, Australia.
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Boan P, Pang S, Mowlaboccus S, Wrobel JP, Musk M, Lavender M, Yaw MC, Hernest A, MacQuillan G, Dembo LG, Coombs GW, Gardam DJ, Pereira LA, Robinson JO. Apophysomyces Variabilis Infection in Transplant Recipients due to Unrecognized Infection in an Intravenous Drug-Using Donor. Transplantation 2022; 106:e169-e171. [PMID: 35100230 DOI: 10.1097/tp.0000000000003921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Peter Boan
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, WA, Australia.,Department of Microbiology, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Perth, WA, Australia
| | - Stanley Pang
- Department of Microbiology, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Perth, WA, Australia.,College of Science, Health, Engineering and Education, Murdoch University, Perth, WA, Australia
| | - Shakeel Mowlaboccus
- Department of Microbiology, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Perth, WA, Australia.,College of Science, Health, Engineering and Education, Murdoch University, Perth, WA, Australia
| | - Jeremy P Wrobel
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Perth, WA, Australia.,Department of Medicine, University of Notre Dame Australia, Perth, WA, Australia
| | - Michael Musk
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Perth, WA, Australia
| | - Melanie Lavender
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Perth, WA, Australia
| | - Meow Cheong Yaw
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Perth, WA, Australia
| | - Adrian Hernest
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Perth, WA, Australia
| | - Gerry MacQuillan
- Western Australian Liver Transplantation Service, Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - Lawrence G Dembo
- Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Perth, WA, Australia
| | - Geoffrey W Coombs
- Department of Microbiology, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Perth, WA, Australia.,College of Science, Health, Engineering and Education, Murdoch University, Perth, WA, Australia
| | - Dianne J Gardam
- Department of Microbiology, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Perth, WA, Australia
| | - Lynette A Pereira
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, WA, Australia.,Department of Microbiology, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Perth, WA, Australia
| | - J Owen Robinson
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, WA, Australia.,Department of Microbiology, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Perth, WA, Australia.,College of Science, Health, Engineering and Education, Murdoch University, Perth, WA, Australia.,Department of Infectious Diseases, Royal Perth Hospital, Perth, WA, Australia
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5
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Kemp W, Majeed A, Mitchell J, Majumdar A, Tse E, Skoien R, Croagh D, Dev A, Gao H, Weltman M, Craig P, Stuart K, Cheng W, Edmunds S, Lee E, Sood S, Metz A, Thompson A, Sinclair M, Beswick L, Nicoll A, Riordan S, Braund A, Muller K, MacQuillan G, Sandanayake N, Shackel N, Roberts SK. Management, outcomes and survival of an Australian IgG4-SC cohort: The MOSAIC study. Liver Int 2021; 41:2934-2943. [PMID: 34392596 DOI: 10.1111/liv.15036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/21/2021] [Accepted: 08/06/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS IgG4 sclerosing cholangitis (IgG4-SC) is the biliary component of the multisystem IgG4-related disease. We aimed to investigate the clinical features, demographics, treatment response and outcomes of IgG4-SC in a large Australian cohort. METHODS We conducted nationwide retrospective cohort via the Australian Liver Association Clinical Trials Network (ALA-CRN). 39 sites were invited to participate. IgG4-SC was defined by the clinical diagnostic criteria established by the Japanese Biliary Association in 2012. Data were collected on patient demographic, clinical and laboratory information, presenting features, response to therapy and clinical outcomes. RESULTS 67 patients meet inclusion criteria from 22 sites. 76% were male with mean age of 63.3 ± 14.5 years and a median IgG4 level of 3.6 g/L [0.09-67.1]. The most frequent presenting symptom was jaundice (62%) and abdominal pain (42%) and Type 1 biliary stricturing (52%) at the distal common bile duct was the most frequent biliary tract finding. Prednisolone was used as a primary treatment in 61 (91%) and partial or complete response occurred in 95% of subjects. Relapse was common (42%) in those who ceased medical therapy. After a median follow up of 3.9 years there was one hepatocellular carcinoma and no cholangiocarcinomas. CONCLUSIONS Our study confirms the preponderance of IgG4-SC in males and highlights the steroid response nature of this condition although relapse is common after steroid cessation. Progression to malignancy was uncommon.
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Affiliation(s)
- William Kemp
- Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | - Ammar Majeed
- Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | | | - Avik Majumdar
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Edmund Tse
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Richard Skoien
- Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | | | - Anouk Dev
- Monash Medical Centre, Melbourne, VIC, Australia
| | - Hugh Gao
- Monash Medical Centre, Melbourne, VIC, Australia
| | | | | | | | | | | | - Eric Lee
- Westmead Hospital, Sydney, NSW, Australia
| | | | - Andrew Metz
- Royal Melbourne Hospital, Melbourne, VIC, Australia
| | | | | | | | | | | | - Alicia Braund
- Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Kate Muller
- Flinders Medical Centre, Adelaide, SA, Australia
| | | | | | | | - Stuart Keith Roberts
- Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
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6
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Roberts SK, Strasser SI, Nicoll AJ, Kemp W, Majeed A, Mitchell J, Stuart K, Gow P, Sood S, MacQuillan G, George J, Mitchell J, McCaughan GW. Efficacy and safety profile of calcineurin inhibitor salvage therapy in autoimmune hepatitis. Scand J Gastroenterol 2020; 55:1309-1317. [PMID: 33070650 DOI: 10.1080/00365521.2020.1821764] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND As data is limited on the outcomes of calcineurin inhibitors (CNI) in autoimmune hepatitis (AIH), we evaluated the efficacy and safety of CNI in AIH patients who failed prior treatment(s). METHODS A retrospective study was performed of AIH patients who received cyclosporine A (CsA) and/or tacrolimus (TAC) after prior treatment(s) failure. Records were reviewed for baseline demographic and clinical characteristics, and treatment outcomes. The primary outcome was biochemical remission. UNLABELLED Results: Thirty-three AIH patients received CNI across seven liver centers:17 received CsA, 21 TAC and 5 TAC after CsA failure/intolerance. 82% received CNI for an insufficient response to treatment(s). Overall, 48% of CNI treated patients achieved biochemical remission including 41% in prior non-responders and 83% in treatment intolerant patients. Remission rates with CNI as second-line and third-line therapy were 63% and 29% respectively. There were no baseline predictors of response to CNI on multivariate analysis. Eighteen (55%) patients developed significant side effects and 8 (24%) discontinued due to intolerance. Three patients required liver transplantation for decompensated cirrhosis and 6 patients died including one from malignancy possibly related to CNI. CONCLUSION CNI salvage therapy is well tolerated and moderately effective achieving remission in around 50% of AIH who failed standard therapy.
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Affiliation(s)
- Stuart K Roberts
- The Alfred Hospital, Melbourne, Australia.,Monash University, Melbourne, Australia
| | - Simone I Strasser
- Royal Prince Alfred Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia
| | - Amanda J Nicoll
- Monash University, Melbourne, Australia.,Eastern Health, Melbourne, Australia
| | - William Kemp
- The Alfred Hospital, Melbourne, Australia.,Monash University, Melbourne, Australia
| | - Ammar Majeed
- The Alfred Hospital, Melbourne, Australia.,Monash University, Melbourne, Australia
| | | | | | - Paul Gow
- Austin Hospital, Melbourne, Australia
| | | | | | - Jacob George
- University of Sydney, Sydney, Australia.,Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital, Sydney, Australia
| | | | - Geoffrey W McCaughan
- Royal Prince Alfred Hospital, Sydney, Australia.,Centenary Research Institute, Sydney, Australia
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7
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Wallace MC, Samuelson S, Khoo T, Ooi J, Tibballs J, Ferguson J, Preen DB, Knuiman M, Garas G, MacQuillan G, Adams LA, Jeffrey GP. The MAAPE score in intermediate and advanced hepatocellular carcinoma treated with Yttrium-90 resin microsphere radioembolization. J Gastroenterol Hepatol 2020; 35:1945-1952. [PMID: 32036614 DOI: 10.1111/jgh.15008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 01/06/2020] [Accepted: 02/03/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIM Yttrium-90 resin microsphere radioembolization (RE) is not recommended for routine use in intermediate or advanced hepatocellular carcinoma (HCC) by recent guidelines. This study aims to establish pre-treatment variables which predict survival in HCC patients treated with RE to identify those who will benefit most from it, and to inform patient selection for future trials. METHODS Single center, retrospective study of consecutive patients with HCC treated with RE from 2007 to 2018. Patients included if undergoing their first RE treatment for intermediate or advanced HCC; a Child-Pugh score of B7 or less; and a performance status of 1 or less. Multivariable Cox regression identified variables that were significantly associated with survival. A predictive score was developed based upon coefficients from the fitted Cox regression model, and cubic spline regression was used to identify prognostic groups. RESULTS One hundred thirteen patients with intermediate (53.1%) and advanced HCC (45.1%) followed for a median of 13.2 months were included. Variables associated with superior survival used to derive the MAAPE score were lower Model for End-Stage Liver Disease score (≤ 7), lower Alpha-fetoprotein (≤ 150 IU/L), higher serum Albumin (> 37 g/L), absence of Portal vein tumor thrombus, and better performance status (Eastern Cooperative Oncology Group = 0). Three survival prognostic groups were identified: good (median overall survival 25.0 months), average (15.3 months), and poor (6.3 months) (overall log-rank test, P < 0.001). CONCLUSION The MAAPE score accurately identifies HCC patients in whom RE is safe and effective. This will allow for optimal patient selection for future trials of RE versus systemic therapy.
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Affiliation(s)
- Michael C Wallace
- Medical School, University of Western Australia, Nedlands, Western Australia, Australia.,Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,School of Population and Global Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - Shaun Samuelson
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Tiffany Khoo
- Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Jacob Ooi
- Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Jonathan Tibballs
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - John Ferguson
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - David B Preen
- School of Population and Global Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - Matthew Knuiman
- School of Population and Global Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - George Garas
- Medical School, University of Western Australia, Nedlands, Western Australia, Australia.,Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Gerry MacQuillan
- Medical School, University of Western Australia, Nedlands, Western Australia, Australia.,Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Leon A Adams
- Medical School, University of Western Australia, Nedlands, Western Australia, Australia.,Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Gary P Jeffrey
- Medical School, University of Western Australia, Nedlands, Western Australia, Australia.,Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
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8
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Wang Z, Huang Y, Nossent H, Chan JJ, Adams LA, Joseph J, Cheng W, Garas G, MacQuillan G, Jeffrey GP. Hepascore predicts liver outcomes and all-cause mortality in long-term methotrexate users: A retrospective cohort study. JGH Open 2020; 4:1211-1216. [PMID: 33319058 PMCID: PMC7731826 DOI: 10.1002/jgh3.12430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/01/2020] [Accepted: 09/09/2020] [Indexed: 12/24/2022]
Abstract
Background and aim Methotrexate (MTX) is routinely used for immunological disorders, and its long‐term use is associated with hepatotoxicity. The aim of this study was to investigate whether a serum liver fibrosis test (Hepascore) predicted the risk of adverse liver‐related outcomes and mortality. Methods A total of 92 patients in Western Australia who had a long‐term MTX intake history,from 2004 to 2016, were recruited and followed up from the first Hepascore to death or end of the study. Clinical data, all deaths, and liver‐related outcomes (liver‐related death and decompensation) were obtained from hospital, PathWest, and WA Data Linkage Unit databases. Results Nine deaths and four adverse liver‐related outcomes occurred during the follow up of 354 person‐years. The 5‐year survival was 86.1%. The liver‐related outcome free survival was 95.6%. Baseline Hepascore ≥0.84 was associated with advanced fibrosis on liver biopsy (P = 0.025). A baseline Hepascore ≥0.84 was significantly associated with higher risks for adverse liver‐related outcomes (P < 0.001) and all‐cause mortality (P = 0.001). Cox regression demonstrated that only baseline Hepascore ≥0.84 was independently associated with the increased risk of all‐cause mortality (7.91 [1.52–41.29], P = 0.014). Moreover, any Hepascore ≥0.84 found during follow up was independently associated with the increased risk of all‐cause mortality (86.18 [4.03–1844.83], P = 0.007). Conclusions This study demonstrated the potential importance of Hepascore monitoring in long‐term MTX users. Patients with a Hepascore higher than 0.84 at any stage had increased mortality, but further studies are required to confirm this finding.
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Affiliation(s)
- Zhengyi Wang
- School of Medicine and PharmacologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Department of HepatologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Yi Huang
- School of Medicine and PharmacologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Department of HepatologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Hans Nossent
- School of Medicine and PharmacologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Department of RheumatologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Jonathan J Chan
- Department of DermatologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Leon A Adams
- School of Medicine and PharmacologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Department of HepatologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - John Joseph
- Department of BiochemistryPathWest Laboratory MedicinePerthWestern AustraliaAustralia
| | - Wendy Cheng
- Department of Gastroenterology and HepatologyRoyal Perth HospitalPerthWestern AustraliaAustralia
| | - George Garas
- Department of HepatologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Gerry MacQuillan
- School of Medicine and PharmacologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Department of HepatologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Gary P Jeffrey
- School of Medicine and PharmacologyThe University of Western AustraliaPerthWestern AustraliaAustralia
- Department of HepatologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
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9
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Papaluca T, Roberts SK, Strasser SI, Stuart KA, Farrell G, MacQuillan G, Dore GJ, Wade AJ, George J, Hazeldine S, O'Beirne J, Wigg A, Fisher L, McGarity B, Sawhney R, Sinclair M, Thomas J, Valiozis I, Weltman M, Wilson M, Woodward A, Ahlenstiel G, Haque M, Levy M, Prewett E, Sievert W, Sood S, Tse E, Valaydon Z, Bowden S, Douglas M, New K, O'Keefe J, Hellard M, Doyle J, Stoove M, Thompson AJ. Efficacy and safety of sofosbuvir/velpatasvir/voxilaprevir for HCV NS5A-inhibitor experienced patients with difficult to cure characteristics. Clin Infect Dis 2020; 73:e3288-e3295. [PMID: 32887983 DOI: 10.1093/cid/ciaa1318] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND In clinical trials, HCV salvage treatment with Sofosbuvir/Velpatasvir/Voxilaprevir (SOF/VEL/VOX) achieved an SVR12 rate of >95% in NS5A-experienced participants. Lower SVR12 rates have been reported in real-world studies, particularly for genotype (GT)3 infection and cirrhosis. We determined the efficacy and safety of SOF/VEL/VOX in a large real-world cohort. METHODS We assessed the efficacy of salvage SOF/VEL/VOX for HCV infection in NS5A-inhibitor experienced participants with cirrhosis and portal hypertension, prior liver transplantation (LT) or severe extra-hepatic manifestations. SOF/VEL/VOX was available via an early access program. The primary outcome was SVR12. Secondary outcome was frequency of adverse events (AE). FINDINGS Ninety-seven participants were included. Median age was 58, 82% were male, 78% had cirrhosis, most with portal hypertension (61%, n=46/76), and 18% had prior-LT. Of the cirrhotic participants, 96% were Child-Turcotte-Pugh class A and 4% were class B. Of the 72% with GT3, 76% were also cirrhotic. By intention-to-treat analysis, SVR12 rate was 85% (n=82/97). Per protocol, the SVR12 rate was 90%, including 91% in GT1 (GT1a n=18/18, GT1b n=2/4), 89% in GT3 (n=59/66) and 100% in GT6 (n=3/3). SVR12 in participants with GT3 and cirrhosis was 90%. No predictors of non-SVR12 were identified. There were four serious AEs including one death and three hepatic decompensation events. NS5A resistance-associated substitutions detected at baseline did not affect SVR12. CONCLUSION This real-world study confirms high efficacy of SOF/VEL/VOX for the treatment of difficult-to-cure NS5A-inhibitor experienced patients, including those with GT3 and cirrhosis. Treatment was well tolerated in most however serious AEs can occur in those with advanced liver disease.
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Affiliation(s)
- Timothy Papaluca
- St Vincent's Hospital Melbourne, Victoria, Australia.,The University of Melbourne, Victoria, Australia
| | - Stuart K Roberts
- The Alfred Hospital Melbourne, Victoria, Australia.,Monash University, Victoria, Australia
| | - Simone I Strasser
- Royal Prince Alfred Hospital, New South Wales, Australia.,The University of Sydney, New South Wales, Australia
| | | | | | - Gerry MacQuillan
- Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,Medical School, University of Western Australia, Nedlands, Western Australia, Australia
| | - Gregory J Dore
- Kirby Institute, UNSW Sydney, New South Wales, Australia.,St Vincent's Hospital Sydney, New South Wales, Australia
| | - Amanda J Wade
- University Hospital Geelong, Victoria, Australia.,Burnet Institute, Victoria, Australia
| | - Jacob George
- Westmead Hospital, New South Wales, Australia.,Westmead Institute for Medical Research, The University of Sydney, New South Wales, Australia
| | | | - James O'Beirne
- Sunshine Coast University Hospital, Queensland, Australia.,University of Sunshine Coast, Queensland, Australia
| | - Alan Wigg
- Flinders Medical Centre, South Australia, Australia
| | - Leslie Fisher
- The University of Melbourne, Victoria, Australia.,Bendigo Health, Victoria, Australia
| | | | - Rohit Sawhney
- Monash University, Victoria, Australia.,Eastern Health, Victoria, Australia
| | - Marie Sinclair
- The University of Melbourne, Victoria, Australia.,Austin Health, Victoria, Australia
| | - James Thomas
- Princess Alexandra Hospital, Queensland, Australia.,Sunshine Coast University Hospital, Queensland, Australia.,The Prince Charles Hospital, Queensland, Australia.,University of Queensland, St Lucia, Queensland, Australia
| | | | | | | | - Aidan Woodward
- University of Queensland, St Lucia, Queensland, Australia.,Mater Hospital Brisbane, Queensland Australia
| | | | - Mazhar Haque
- University of Queensland, St Lucia, Queensland, Australia.,Mater Hospital Brisbane, Queensland Australia
| | - Miriam Levy
- Liverpool Hospital, New South Wales, Australia
| | - Emily Prewett
- University Hospital Geelong, Victoria, Australia.,Deakin University, Victoria, Australia
| | - William Sievert
- Monash University, Victoria, Australia.,Monash Health, Victoria, Australia
| | - Siddharth Sood
- The University of Melbourne, Victoria, Australia.,Royal Melbourne Hospital, Victoria, Australia
| | - Edmund Tse
- Royal Adelaide Hospital, South Australia, Australia
| | - Zina Valaydon
- The University of Melbourne, Victoria, Australia.,Western Health, Victoria, Australia
| | - Scott Bowden
- Victorian Infectious Diseases Reference Laboratory, Victoria, Australia
| | - Mark Douglas
- Westmead Hospital, New South Wales, Australia.,Westmead Institute for Medical Research, The University of Sydney, New South Wales, Australia
| | - Kate New
- St Vincent's Hospital Melbourne, Victoria, Australia
| | - Jacinta O'Keefe
- Victorian Infectious Diseases Reference Laboratory, Victoria, Australia
| | - Margaret Hellard
- The Alfred Hospital Melbourne, Victoria, Australia.,Monash University, Victoria, Australia.,Burnet Institute, Victoria, Australia
| | - Joseph Doyle
- The Alfred Hospital Melbourne, Victoria, Australia.,Monash University, Victoria, Australia.,Burnet Institute, Victoria, Australia
| | - Mark Stoove
- Monash University, Victoria, Australia.,Burnet Institute, Victoria, Australia
| | - Alexander J Thompson
- St Vincent's Hospital Melbourne, Victoria, Australia.,The University of Melbourne, Victoria, Australia
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10
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Wallace MC, Sek K, Francis RJ, Samuelson S, Ferguson J, Tibballs J, Asad A, Preen DB, MacQuillan G, Garas G, Adams LA, Jeffrey GP. Baseline and Post-treatment 18F-Fluorocholine PET/CT Predicts Outcomes in Hepatocellular Carcinoma Following Locoregional Therapy. Dig Dis Sci 2020; 65:647-657. [PMID: 31440998 DOI: 10.1007/s10620-019-05781-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 08/07/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS 18F-fluorocholine positron emission tomography/computed tomography (18F-FCH PET/CT) is an emerging functional imaging technique in the diagnosis and management of hepatocellular carcinoma (HCC). The aim of this study was to assess the ability of a pre- and post-treatment 18F-FCH PET/CT to predict prognosis and treatment response in early-stage HCC. METHODS Patients with early- or intermediate-stage HCC planned for locoregional therapy were prospectively enrolled. Baseline demographic and tumor information was collected and baseline and post-treatment 18F-FCH PET/CT performed. Maximum standardized uptake values (SUVmax) were determined for each HCC lesion, and the difference between baseline and post-treatment SUVmax values were compared with progression-free survival outcomes. RESULTS A total of 29 patients with 39 confirmed HCC lesions were enrolled from a single clinical center. Patients were mostly men (89.7%) with hepatitis C or alcohol-related cirrhosis (65.5%) and early-stage disease (89.7%). Per-patient and per-lesion sensitivity of 18F-FCH PET/CT was 72.4% and 59.0%, respectively. A baseline SUVmax < 13 was associated with a superior median progression-free survival compared with an SUVmax of > 13 (17.7 vs. 5.1 months; p = 0.006). A > 45% decrease in SUVmax between baseline and post-treatment 18F-FCH PET/CT ("responders") was associated with a superior mean progression-free survival than a percentage decrease of < 45% ("non-responders," 36.1 vs. 11.6 months; p = 0.034). CONCLUSIONS Baseline and post-treatment 18F-FCH PET/CT predicts outcomes in early-stage HCC undergoing locoregional therapy. This technique may identify patients with an objective response post-locoregional therapy who would benefit from further therapy.
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Affiliation(s)
- Michael C Wallace
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, 6009, WA, Australia. .,Medical School, University of Western Australia, Nedlands, WA, Australia. .,School of Population and Global Health, University of Western Australia, Nedlands, WA, Australia.
| | - Kenny Sek
- Department of Nuclear Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Roslyn J Francis
- Medical School, University of Western Australia, Nedlands, WA, Australia.,Department of Nuclear Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Shaun Samuelson
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - John Ferguson
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Jonathan Tibballs
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Ali Asad
- Department of Medical Technology and Physics, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - David B Preen
- School of Population and Global Health, University of Western Australia, Nedlands, WA, Australia
| | - Gerry MacQuillan
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, 6009, WA, Australia.,Medical School, University of Western Australia, Nedlands, WA, Australia
| | - George Garas
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, 6009, WA, Australia.,Medical School, University of Western Australia, Nedlands, WA, Australia
| | - Leon A Adams
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, 6009, WA, Australia.,Medical School, University of Western Australia, Nedlands, WA, Australia
| | - Gary P Jeffrey
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, 6009, WA, Australia.,Medical School, University of Western Australia, Nedlands, WA, Australia
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11
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Huang Y, Joseph J, de Boer WB, Cheng W, Adams LA, MacQuillan G, Garas G, Raftopoulos S, Jeffrey GP. Long-term Liver-related Outcomes of Patients With Chronic Liver Diseases in Australia. Clin Gastroenterol Hepatol 2020; 18:496-504.e3. [PMID: 31319186 DOI: 10.1016/j.cgh.2019.07.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 07/04/2019] [Accepted: 07/09/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND & AIMS Chronic liver disease is a major health burden that produces significant liver-related morbidity and mortality. We aimed to evaluate liver-related outcomes of patients with different causes of chronic liver disease in Australia. METHODS We collected data from 10,933 patients with chronic liver disease assessed by Hepascore (a serum fibrosis model) in Western Australia from 2004 through 2015. We obtained records of liver-related death, transplantation, decompensation, and hepatocellular carcinoma from WA Data Linkage Unit databases. Competing risk analysis was used to calculate the cumulative risk of each clinical endpoint, and risks for clinical endpoints were compared among all causes of chronic liver disease. RESULTS In our final cohort for analysis, 5566 patients had hepatitis C virus (HCV) infection, 1989 had HBV infection, 119 were infected with HBV and HCV, 955 had alcohol-associated liver disease, 1597 had non-alcoholic fatty liver disease (NAFLD), 123 had alcohol-associated liver disease and metabolic risk factors, 561 had autoimmune liver disease without overlap syndrome, and 23 autoimmune overlap syndrome. Significant differences among chronic liver diseases were observed in risk of all-cause death (P < .001), liver-related death (P < .001), liver transplantation (P < .001), and decompensation (P < .001) but not hepatocellular carcinoma (P=.095). Patients with alcohol-associated liver disease had the highest 5-year cumulative risk of liver-related death (17.1%) and the second-highest 5-year cumulative risk of decompensation (29.2%). Multivariate analysis found patients with alcohol-associated liver disease had significantly higher risks of liver-related death and decompensation than patients with HCV infection with hazard ratios (HRs) of 2.39 (95% CI, 1.88-3.03) and 3.42 (95% CI, 2.74-4.27), respectively. Patients with NAFLD had a significantly lower risk of liver related death and decompensation than patients with HCV infection, with HRs of 0.67 (95% CI, 0.48-0.95) and 0.70 (95% CI, 0.52-0.94) respectively. CONCLUSIONS In an analysis of patients in Western Australia, we found patients with alcohol-associated liver disease to have significantly higher risk of decompensation and liver-related death than patients with HCV infection, whereas patients with NAFLD have significantly lower risks of either outcome.
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Affiliation(s)
- Yi Huang
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia; Department of Hepatology, Sir Charles Gairdner Hospital, Perth, Australia
| | - John Joseph
- Department of Biochemistry, PathWest Laboratory Medicine, Perth, Australia
| | - W Bastiaan de Boer
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Perth, Australia
| | - Wendy Cheng
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Australia
| | - Leon A Adams
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia; Department of Hepatology, Sir Charles Gairdner Hospital, Perth, Australia
| | - Gerry MacQuillan
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia; Department of Hepatology, Sir Charles Gairdner Hospital, Perth, Australia
| | - George Garas
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia; Department of Hepatology, Sir Charles Gairdner Hospital, Perth, Australia
| | - Spiro Raftopoulos
- Department of Hepatology, Sir Charles Gairdner Hospital, Perth, Australia
| | - Gary P Jeffrey
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia; Department of Hepatology, Sir Charles Gairdner Hospital, Perth, Australia.
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12
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Nicoll AJ, Roberts SK, Lim R, Mitchell J, Weltman M, George J, Wigg A, Stuart K, Gow P, MacQuillan G, Tse E, Levy M, Sood S, Zekry A, Cheng W, Mitchell J, Skoien R, Sievert W, Strasser SI, McCaughan GW. Beneficial response to mycophenolate mofetil by patients with autoimmune hepatitis who have failed standard therapy, is predicted by older age and lower immunoglobulin G and INR levels. Aliment Pharmacol Ther 2019; 49:1314-1322. [PMID: 30972807 DOI: 10.1111/apt.15248] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/15/2018] [Accepted: 03/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Mycophenolate mofetil is a commonly used salvage therapy for patients with autoimmune hepatitis (AIH). AIM To evaluate the predictors of response to mycophenolate rescue therapy to facilitate clinical decision making. METHODS We performed a retrospective observational cohort study of AIH patients managed in 17 major Australian liver centres who received mycophenolate after an inadequate response or intolerance to corticosteroids with/without thiopurine(s). Baseline demographic, clinical and laboratory variables were compared between responders and nonresponders. A multivariable logistic regression model was developed using forward selection to identify independent predictors of treatment response. RESULTS A total of 105 patients received mycophenolate rescue therapy of whom 63 (60%) achieved biochemical remission. On univariable analysis, older age (P = 0.003), INR < 1.1 (P = 0.02), and lower immunoglobulin gamma (IgG; P < 0.002) levels were associated with treatment response, while no association was found with cirrhosis status (P = 0.07) or treatment indication (P = 0.63). On multivariable analysis, lower pre-treatment serum IgG level (P = 0.01), higher age at commencing mycophenolate (P = 0.01) and higher INR (P = 0.03) were the only significant independent predictors. An IgG level <17 g/L had a positive and negative predictive value for response of 71% and 60% respectively, while age ≥54 years when commencing mycophenolate had a positive and negative predictive value for response of 80% and 59% respectively. CONCLUSION Mycophenolate remains an excellent treatment option for patients with AIH refractory to or intolerant of standard therapy with those most likely to benefit being older and/or having lower pre-treatment IgG levels.
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13
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Ramlaul N, Ooi J, Jeffrey GP, MacQuillan G, Garas G, Adams LA, Iqbal M, Nolan N, Houlihan DD, McCormick PA, Mac Nicholas R. Liver Transplantation in Adults With Liver Disease Due to Common Variable Immunodeficiency Leads to Early Recurrent Disease and Poor Outcome. Liver Transpl 2018; 24:1622-1626. [PMID: 30260552 DOI: 10.1002/lt.25343] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 09/05/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Navneet Ramlaul
- National Liver Transplant Unit, St. Vincent's University Hospital, Dublin, Ireland
| | - Jacob Ooi
- Western Australia Liver Transplant Unit, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Gary P Jeffrey
- Western Australia Liver Transplant Unit, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Gerry MacQuillan
- Western Australia Liver Transplant Unit, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - George Garas
- Western Australia Liver Transplant Unit, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Leon A Adams
- Western Australia Liver Transplant Unit, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Masood Iqbal
- National Liver Transplant Unit, St. Vincent's University Hospital, Dublin, Ireland
| | - Niamh Nolan
- National Liver Transplant Unit, St. Vincent's University Hospital, Dublin, Ireland
| | - Diarmaid D Houlihan
- National Liver Transplant Unit, St. Vincent's University Hospital, Dublin, Ireland
| | - P Aiden McCormick
- National Liver Transplant Unit, St. Vincent's University Hospital, Dublin, Ireland
| | - Ross Mac Nicholas
- National Liver Transplant Unit, St. Vincent's University Hospital, Dublin, Ireland
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14
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Bertot LC, Jeffrey GP, de Boer B, MacQuillan G, Garas G, Chin J, Huang Y, Adams LA. Diabetes impacts prediction of cirrhosis and prognosis by non-invasive fibrosis models in non-alcoholic fatty liver disease. Liver Int 2018; 38:1793-1802. [PMID: 29575516 DOI: 10.1111/liv.13739] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 03/07/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Non-alcoholic fatty liver disease (NAFLD) patients with diabetes are at increased risk of cirrhosis and liver-related death, and thus accurate fibrosis assessment in these patients is important. We examined the ability of non-invasive fibrosis models to determine cirrhosis and outcomes in NAFLD patients with and without diabetes. METHODS Non-alcoholic fatty liver disease patients diagnosed between 2006 and 2015 had Hepascore, NAFLD fibrosis score (NFS), APRI and FIB-4 scores calculated at baseline and were followed up for outcomes of overall and liver-related mortality/liver transplantation, hepatic decompensation and hepatocellular carcinoma (HCC). Model accuracy was determined by Harrell's C-index and by Kaplan-Meier analysis. RESULTS A total of 284 patients (53% diabetic, 15% cirrhotic) were followed up for a median of 51.4 months, (range 6.1-146). During follow-up, diabetic patients had a greater risk of liver-related death/transplantation, HR 3.4 (95% CI 1.2-9.1) decompensation, HR 4.7 (95% CI 2.0-11.3) and HCC, HR 2.9 (95% CI 1.2-7.3). Among 241 subjects with a baseline liver biopsy, the accuracy of Hepascore, APRI and FIB-4 for predicting cirrhosis was lower amongst diabetics compared to non-diabetics (P < .005 for all). Model accuracy apart from Hepascore, was also significantly lower for predicting liver death/transplantation in patients with diabetes. No patient with a low fibrosis score and without diabetes developed liver decompensation or HCC, whereas up to 21% of diabetic patients with a low fibrosis score developed liver decompensation and up to 27% developed HCC at 5 years. CONCLUSIONS Non-invasive scoring systems are less accurate at predicting cirrhosis and liver-related outcomes in patients with NAFLD and diabetes.
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Affiliation(s)
- Luis C Bertot
- Medical School, University of Western Australia, Nedlands, WA, Australia
| | - Gary P Jeffrey
- Medical School, University of Western Australia, Nedlands, WA, Australia.,Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Bastiaan de Boer
- Department of Anatomical Pathology, Pathwest, Nedlands, WA, Australia
| | - Gerry MacQuillan
- Medical School, University of Western Australia, Nedlands, WA, Australia.,Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - George Garas
- Medical School, University of Western Australia, Nedlands, WA, Australia.,Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Justin Chin
- Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Yi Huang
- Medical School, University of Western Australia, Nedlands, WA, Australia
| | - Leon A Adams
- Medical School, University of Western Australia, Nedlands, WA, Australia.,Department of Hepatology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
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15
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Ma MX, Huang Y, Adams LA, Gilpin R, Garas G, MacQuillan G, Jeffrey GP, Nicholas RM. Prevalence of restless legs syndrome in a tertiary cohort of ambulant patients with chronic liver disease. Intern Med J 2018; 48:347-350. [DOI: 10.1111/imj.13719] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 09/18/2017] [Accepted: 10/03/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Michael X. Ma
- WA Liver Transplantation Service; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Yi Huang
- WA Liver Transplantation Service; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
| | - Leon A. Adams
- WA Liver Transplantation Service; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
| | - Robert Gilpin
- WA Liver Transplantation Service; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - George Garas
- WA Liver Transplantation Service; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
| | - Gerry MacQuillan
- WA Liver Transplantation Service; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
| | - Gary P. Jeffrey
- WA Liver Transplantation Service; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
| | - Ross Mac Nicholas
- WA Liver Transplantation Service; Sir Charles Gairdner Hospital; Perth Western Australia Australia
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16
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Roberts SK, Lim R, Strasser S, Nicoll A, Gazzola A, Mitchell J, Siow W, Khoo T, Hamarneh Z, Weltman M, Gow P, Janko N, Tse E, Mishra G, Cheng EH, Levy M, Cheng W, Sood S, Skoien R, Mitchell J, Zekry A, George J, MacQuillan G, Wigg A, Stuart K, Sievert W, McCaughan G. Efficacy and Safety of Mycophenolate Mofetil in Patients With Autoimmune Hepatitis and Suboptimal Outcomes After Standard Therapy. Clin Gastroenterol Hepatol 2018; 16:268-277. [PMID: 29050991 DOI: 10.1016/j.cgh.2017.09.063] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 08/18/2017] [Accepted: 09/25/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Little is known about outcomes of patients with autoimmune hepatitis (AIH) who have a suboptimal outcome to standard therapy and are then given mycophenolate mofetil as rescue therapy. We evaluated the efficacy and safety of mycophenolate mofetil in patients failed by or intolerant to corticosteroids, with or without azathioprine. METHODS We performed a retrospective study of 105 patients with AIH who received mycophenolate mofetil therapy after an inadequate response or intolerance to standard therapy (98% received combination therapy with corticosteroids plus thiopurines). Patients were recruited from 17 liver clinics via the Australian Liver Association Clinical Research Network. We reviewed records for baseline demographic features and characteristics of liver disease, initial therapy, mycophenolate mofetil indications, treatment outcome, and side effects. The primary outcome was biochemical remission, defined as levels of alanine and aspartate transferase and IgG level within the normal reference range, with or without normal liver histology within the first 2 years of treatment. RESULTS The indication for mycophenolate mofetil therapy was non-response to treatment for 40% of cases and intolerance to therapy for 60%. Overall, 63 patients (60%) achieved biochemical remission following a median 12 weeks treatment with mycophenolate mofetil. The proportion of patients who achieved biochemical remission was similar between patients receiving mycophenolate mofetil for non-response to standard therapy (57%) and patients with intolerance to standard therapy (62%). However, a lower proportion of patients with cirrhosis achieved biochemical remission (47%) than patients without cirrhosis (6%) (P = .07). Serious adverse events occurred in 3 patients (2.7%) including 1 death, and 10 patients (9.2%) discontinued mycophenolate mofetil because of adverse events. CONCLUSION In this retrospective study of patients with AIH who received mycophenolate mofetil as a rescue therapy, we found the drug to be well tolerated and moderately effective, inducing biochemical remission in 60% of subjects. Rates of response are lower and rates of infection are higher in patients with AIH and cirrhosis. Prospective studies of mycophenolate mofetil are warranted for this population.
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Affiliation(s)
| | - Ricky Lim
- Royal Prince Alfred Hospital, Sydney
| | - Simone Strasser
- Royal Prince Alfred Hospital, Sydney; Centenary Research Institute, Sydney
| | - Amanda Nicoll
- Eastern Health, Box Hill Hospital, and Monash University, Box Hill
| | | | | | - Way Siow
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Sydney
| | | | | | | | | | - Natasha Janko
- The Alfred, Melbourne; Eastern Health, Box Hill Hospital, and Monash University, Box Hill
| | | | - Gauri Mishra
- Monash Medical Centre and Monash University, Melbourne
| | | | | | | | | | | | | | | | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Sydney
| | | | | | | | | | - Geoffrey McCaughan
- Royal Prince Alfred Hospital, Sydney; Centenary Research Institute, Sydney
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17
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Wallace MC, Huang Y, Preen DB, Garas G, Adams LA, MacQuillan G, Tibballs J, Ferguson J, Samuelson S, Jeffrey GP. HKLC Triages More Hepatocellular Carcinoma Patients to Curative Therapies Compared to BCLC and Is Associated with Better Survival. Dig Dis Sci 2017; 62:2182-2192. [PMID: 28547649 DOI: 10.1007/s10620-017-4622-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 05/16/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS The Hong Kong Liver Cancer (HKLC) system proposes to triage hepatocellular carcinoma (HCC) patients to more aggressive treatment and may be associated with superior survival compared with the Barcelona Clinic Liver Cancer (BCLC) system. We aimed to identify the influence of adherence to HKLC or BCLC treatment recommendations on survival and time to progression. METHODS We examined a prospectively enrolled cohort of 292 patients undergoing 532 treatment episodes from a single clinical center. RESULTS The BCLC and HKLC systems accurately predicted overall survival and time to progression after each treatment episode (BCLC: p < 0.001; HKLC: p < 0.001). Adherence to treatment recommendations was higher for HKLC than for BCLC (55.6 vs. 47.9%, p = 0.01). Survival was superior with adherence to HKLC recommendations compared to non-adherence (45.3 vs. 27.1 months, p < 0.001). There was no difference in survival in BCLC with adherence compared to non-adherence (34.6 vs. 32.3 months, p = 0.96). The survival benefit was limited to early- and very early stage disease for both HKLC (p < 0.001) and BCLC (p = 0.007). More patients were triaged to curative therapies by HKLC than BCLC (p = 0.004). The use of transarterial chemoembolization instead of ablation or resection in early- and very early stage disease for technical reasons was the major cause for non-recommended treatment and was associated with worse survival (p < 0.001). CONCLUSIONS These data support the use of HKLC in early- and very early stage HCC. Efforts should be made to overcome technical reasons for not performing ablation in early- and very early stage disease.
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Affiliation(s)
- Michael C Wallace
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, WA, 6009, Australia.
- School of Medicine and Pharmacology, University of Western Australia, Nedlands, WA, Australia.
- School of Population Health, University of Western Australia, Nedlands, WA, Australia.
| | - Yi Huang
- School of Medicine and Pharmacology, University of Western Australia, Nedlands, WA, Australia
| | - David B Preen
- School of Population Health, University of Western Australia, Nedlands, WA, Australia
| | - George Garas
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, WA, 6009, Australia
| | - Leon A Adams
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, WA, 6009, Australia
- School of Medicine and Pharmacology, University of Western Australia, Nedlands, WA, Australia
| | - Gerry MacQuillan
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, WA, 6009, Australia
- School of Medicine and Pharmacology, University of Western Australia, Nedlands, WA, Australia
| | - Jonathan Tibballs
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - John Ferguson
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Shaun Samuelson
- Department of Radiology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Gary P Jeffrey
- Department of Hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Perth, WA, 6009, Australia
- School of Medicine and Pharmacology, University of Western Australia, Nedlands, WA, Australia
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18
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Jeffrey AW, Huang Y, de Boer WB, Adams LA, MacQuillan G, Speers D, Joseph J, Jeffrey GP. Improved Hepascore in hepatitis C predicts reversal in risk of adverse outcome. World J Hepatol 2017; 9:850-856. [PMID: 28740596 PMCID: PMC5504360 DOI: 10.4254/wjh.v9.i19.850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/30/2017] [Accepted: 05/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To establish if serial Hepascore tests (referred to as delta Hepascore) in those with chronic hepatitis C (CHC) correlate with the increase and/or decrease in risk of liver related complications.
METHODS Three hundred and forty-six CHC patients who had two Hepascore tests performed were studied. During 1944 patient years follow-up 28 (8.1%) reached an endpoint. The Hepascore is a serum test that provides clinically useful data regarding the stage of liver fibrosis and subsequent clinical outcomes in chronic liver disease.
RESULTS Patients with a baseline Hepascore > 0.75 had a significantly increased rate of reaching a composite endpoint consisting of hepatocellular carcinoma, liver death, and/or decompensation (P < 0.001). In those with an initial Hepascore > 0.75, a subsequent improved Hepascore showed a significantly decreased risk for the composite endpoint (P = 0.004). There were no negative outcomes in those with a stable or improved delta Hepascore. The minimum time between tests that was found to give a statically significant result was in those greater than one year (P = 0.03).
CONCLUSION In conclusion, Hepascore is an accurate predictor of liver related mortality and liver related morbidity in CHC patients. Of note, we have found that there is a decreased risk of mortality and morbidity in CHC patients when the patient has an improving delta Hepascore. Repeat Hepascore tests, when performed at a minimum one-year interval, may be of value in routine clinical practice to predict liver related clinical outcomes and to guide patient management.
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19
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Mitchell T, Chakera A, Jeffrey GP, Adams LA, Garas G, Jones T, MacQuillan G. Reversal of end-stage renal failure using direct-acting antiviral agents for chronic hepatitis C. Med J Aust 2017; 205:205-6. [PMID: 27581262 DOI: 10.5694/mja16.00207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/09/2016] [Indexed: 11/17/2022]
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20
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Bertot LC, Jeffrey GP, Wallace M, MacQuillan G, Garas G, Ching HL, Adams LA. Nonalcoholic fatty liver disease-related cirrhosis is commonly unrecognized and associated with hepatocellular carcinoma. Hepatol Commun 2017; 1:53-60. [PMID: 29404433 PMCID: PMC5747027 DOI: 10.1002/hep4.1018] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 01/12/2017] [Indexed: 12/11/2022] Open
Abstract
Determination of cirrhosis in nonalcoholic fatty liver disease (NAFLD) is important as it alters prognosis and management. We aimed to examine whether cirrhosis was diagnosed incidentally or intentionally in patients with NAFLD. We reviewed 100 patients with NAFLD cirrhosis to determine mode of cirrhosis diagnosis (incidental or by intent), severity of liver disease at diagnosis, diagnostician, and previous clinical imaging or laboratory evidence of unrecognized cirrhosis. The majority (66/100) of patients with NAFLD cirrhosis were diagnosed incidentally, with the majority of these (74%) diagnosed with NAFLD simultaneously. Those with incidental cirrhosis diagnoses had more deranged platelet and international normalized ratio levels (P < 0.05) and were more likely to have concomitant hepatocellular carcinoma (HCC) (12% versus 0%, P < 0.05). Incidental cirrhosis was diagnosed following imaging (32%) or liver tests (26%) performed for reasons unrelated to liver disease, following unexpected endoscopic finding of varices (21%) or an unexpected surgical finding (14%). Diagnoses by intent were predominantly made by gastroenterologists/hepatologists, whereas general practitioners, surgeons, and physicians tended to diagnose cirrhosis incidentally (P < 0.001). The majority of patients diagnosed incidentally (n = 48/66, 73%) had previous thrombocytopenia, splenomegaly, or high noninvasive fibrosis scores. Following diagnosis, patients diagnosed incidentally were less likely to undergo HCC screening. Conclusion: The majority of patients with NAFLD cirrhosis are diagnosed incidentally. These patients are more likely to have advanced liver disease and HCC. Increased awareness of screening for cirrhosis is needed in patients with NAFLD. (Hepatology Communications 2017;1:53–60)
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Affiliation(s)
- Luis C Bertot
- School of Medicine and Pharmacology University of Western Australia Nedlands Western Australia Australia
| | - Gary P Jeffrey
- School of Medicine and Pharmacology University of Western Australia Nedlands Western Australia Australia.,Department of Hepatology Sir Charles Gairdner Hospital Nedlands Western Australia Australia
| | - Michael Wallace
- School of Medicine and Pharmacology University of Western Australia Nedlands Western Australia Australia.,Department of Hepatology Sir Charles Gairdner Hospital Nedlands Western Australia Australia
| | - Gerry MacQuillan
- School of Medicine and Pharmacology University of Western Australia Nedlands Western Australia Australia.,Department of Hepatology Sir Charles Gairdner Hospital Nedlands Western Australia Australia
| | - George Garas
- School of Medicine and Pharmacology University of Western Australia Nedlands Western Australia Australia.,Department of Hepatology Sir Charles Gairdner Hospital Nedlands Western Australia Australia
| | - Helena L Ching
- School of Medicine and Pharmacology University of Western Australia Nedlands Western Australia Australia
| | - Leon A Adams
- School of Medicine and Pharmacology University of Western Australia Nedlands Western Australia Australia.,Department of Hepatology Sir Charles Gairdner Hospital Nedlands Western Australia Australia
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21
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Mitchell T, Gooding H, Mews C, Adams L, MacQuillan G, Garas G, Ravikumara M, Lopez A, Collins M, Jeffrey G. Transition to adult care for pediatric liver transplant recipients: the Western Australian experience. Pediatr Transplant 2017; 21. [PMID: 27762479 DOI: 10.1111/petr.12820] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2016] [Indexed: 01/25/2023]
Abstract
Transition to adult care is a vulnerable period for pediatric transplant recipients and is associated with reduced medication compliance, graft loss, and increased mortality. Psychosocial outcomes in young adults differ between pediatric transplant recipients and their healthy peers. We conducted a single-center, retrospective cohort study of all pediatric liver transplant recipients who were transitioned through our center. This study aimed to assess the outcomes of transitioned pediatric liver transplant recipients at an Australian center, including mortality, adherence, and psychosocial morbidity. The 1- and 5-year survival rates following transition were 100% and 92%, respectively. There were no episodes of late rejection. In total, 66.7% of patients were compliant with immunosuppression and 61.1% of patients were compliant with clinic attendance. There was a significant relationship between medication compliance and clinic attendance, as well as presence of psychological issues with clinic non-attendance. Psychosocial outcomes were in keeping with age-matched data from the general population. All patients were employed or studying following transition. This is the first study of its kind in the Australian population, and outcomes were superior to published international data. Despite the demonstrated good outcomes, transition programs may improve healthcare engagement in this cohort.
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Affiliation(s)
- Tim Mitchell
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Hannah Gooding
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Cathy Mews
- Department of Gastroenterology, Princess Margaret Hospital for Children, Perth, WA, Australia
| | - Leon Adams
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - Gerry MacQuillan
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - George Garas
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Madhur Ravikumara
- Department of Gastroenterology, Princess Margaret Hospital for Children, Perth, WA, Australia
| | - Ainslie Lopez
- Department of Gastroenterology, Princess Margaret Hospital for Children, Perth, WA, Australia
| | - Megan Collins
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Gary Jeffrey
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
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22
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Pateria P, Jeffrey GP, Garas G, Tibballs J, Ferguson J, Delriviere L, Huang Y, Adams LA, MacQuillan G. Transjugular intrahepatic portosystemic shunt: Indications, complications, survival and its use as a bridging therapy to liver transplant in Western Australia. J Med Imaging Radiat Oncol 2017; 61:441-447. [DOI: 10.1111/1754-9485.12563] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 10/28/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Puraskar Pateria
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - Gary P Jeffrey
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
| | - George Garas
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
| | - Jonathan Tibballs
- Department of Radiology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - John Ferguson
- Department of Radiology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - Luc Delriviere
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
- Department of Surgery; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
| | - Yi Huang
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
| | - Leon A Adams
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
| | - Gerry MacQuillan
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Nedlands Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Nedlands Western Australia Australia
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23
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Lubel J, Strasser S, Stuart KA, Dore G, Thompson A, Pianko S, Bollipo S, Mitchell JL, Fragomeli V, Jones T, Chivers S, Gow P, Iser D, Levy M, Tse E, Gazzola A, Cheng W, Nazareth S, Galhenage S, Wade A, Weltman M, Wigg A, MacQuillan G, Sasadeusz J, George J, Zekry A, Roberts SK. Real-world efficacy and safety of ritonavir-boosted paritaprevir, ombitasvir, dasabuvir ± ribavirin for hepatitis C genotype 1 – final results of the REV1TAL study. Antivir Ther 2017; 22:699-710. [DOI: 10.3851/imp3168] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2017] [Indexed: 10/19/2022]
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24
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Huang Y, MacQuillan G, Adams LA, Garas G, Collins M, Nwaba A, Mou L, Bulsara MK, Delriviere L, Jeffrey GP. Effect of airplane transport of donor livers on post-liver transplantation survival. World J Gastroenterol 2016; 22:9154-9161. [PMID: 27895402 PMCID: PMC5107596 DOI: 10.3748/wjg.v22.i41.9154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 07/26/2016] [Accepted: 08/23/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the effect of long haul airplane transport of donor livers on post-transplant outcomes.
METHODS A retrospective cohort study of patients who received a liver transplantation was performed in Perth, Australia from 1992 to 2012. Donor and recipient characteristics information were extracted from Western Australian liver transplantation service database. Patients were followed up for a mean of six years. Patient and graft survival were evaluated and compared between patients who received a local donor liver and those who received an airplane transported donor liver. Predictors of survival were determined by univariate and multivariate analysis using cox regression.
RESULTS One hundred and ninety-three patients received a local donor liver and 93 patients received an airplane transported donor liver. Airplane transported livers had a significantly lower alanine transaminase (mean: 45 U/L vs 84 U/L, P = 0.035), higher donor risk index (mean: 1.88 vs 1.42, P < 0.001) and longer cold ischemic time (CIT) (mean: 10.1 h vs 6.4 h, P < 0.001). There was a weak correlation between CIT and transport distance (r2 = 0.29, P < 0.001). Mean follow up was six years and 93 patients had graft failure. Multivariate analysis found only airplane transport retained significance for graft loss (HR = 1.92, 95%CI: 1.16-3.17). One year graft survival was 0.88 for those with a local liver and was 0.71 for those with an airplane transported liver. One year graft loss was due to primary graft non-function or associated with preservation injury in 20.8% of recipients of an airplane transported liver compared with 4.6% in those with a local liver (P = 0.027).
CONCLUSION Airplane transport of donor livers was independently associated with reduced graft survival following liver transplantation.
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Pateria P, Jeffrey GP, MacQuillan G, Speers D, Ching H, Chinnaratha MA, Watts GF, Adams LA. The association between chronic hepatitis C infection and cardiovascular risk. Intern Med J 2016; 46:63-70. [PMID: 26477784 DOI: 10.1111/imj.12936] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/29/2015] [Accepted: 10/10/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Vascular disease is a common cause of death in patients with chronic hepatitis C (CHC) infection; however, the association between CHC and atherosclerosis is unclear. AIMS To determine whether patients with CHC have increased subclinical vascular disease and whether genotype or antiviral treatment modifies this risk. METHODS Fifty CHC patients and 22 age-matched and sex-matched healthy controls underwent clinical and biochemical assessment for vascular risk factors. In addition, vascular risk was assessed by measuring arterial stiffness (aortic augmentation index and carotid-femoral pulse wave velocity (PWV)), endothelial dysfunction (brachial artery flow-mediated dilatation (FMD) and dilatation post-glycerol trinitrate administration) and carotid intima-media thickness (CIMT). Assessment was repeated in subset of CHC patients (n = 12) undergoing antiviral treatment 18 months after initiation of treatment. RESULTS Baseline vascular risk factors and measures of arterial stiffness, endothelial dysfunction and CIMT were not different between cases and controls (P > 0.2 for all). Genotype 1 CHC patients had greater endothelial dysfunction with lower FMD (8.2 ± 3.5% vs 10.9 ± 5.2%, P = 0.03) and higher right CIMT (0.6 ± 0.1 mm vs 0.5 ± 0.07 mm, P = 0.04) compared with non-genotype 1. Patients who achieved sustained virological response (7/12) showed significant improvement in insulin resistance (homeostasis model of assessment of insulin resistance 2.3 ± 1.2 vs 1.8 ± 0.8, P = 0.02) and arterial stiffness (PWV 7.4 ± 1.1 m/s vs 6.5 ± 0.6 m/s, P = 0.04). CONCLUSIONS Subclinical vascular disease is not greater in CHC subjects compared with controls. However, among CHC subjects, genotype 1 infection is associated with greater endothelial dysfunction and increased carotid-intima medial thickness compared with non-genotype 1 infection. Successful viral eradication may improve insulin resistance and arterial stiffness.
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Affiliation(s)
- P Pateria
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital
| | - G P Jeffrey
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital.,School of Medicine and Pharmacology, University of Western Australia
| | - G MacQuillan
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital.,School of Medicine and Pharmacology, University of Western Australia
| | - D Speers
- PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre
| | - H Ching
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital.,School of Medicine and Pharmacology, University of Western Australia
| | - M A Chinnaratha
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital
| | - G F Watts
- School of Medicine and Pharmacology, University of Western Australia.,Lipid Disorders Clinic, Cardiovascular Medicine, Royal Perth Hospital, University of Western Australia, Perth, Western Australia, Australia
| | - L A Adams
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital.,School of Medicine and Pharmacology, University of Western Australia
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26
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Huang Y, Adams LA, MacQuillan G, Speers D, Joseph J, Bulsara MK, Jeffrey GP. Serum models accurately predict liver-related clinical outcomes in chronic hepatitis C. J Gastroenterol Hepatol 2016; 31:1736-1741. [PMID: 26945918 DOI: 10.1111/jgh.13333] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 02/16/2016] [Accepted: 03/02/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM This study developed liver outcome scores in chronic hepatitis C (CHC) that directly predict liver-related death, hepatocellular carcinoma (HCC), and liver decompensation. METHODS Six hundred seventeen CHC patients were followed up for a mean of 6 years and randomized into a training set (n = 411) and a validation set (n = 206). Clinical outcomes were determined using a population-based data linkage system. RESULTS In the training set, albumin, gamma-glutamyl transpeptidase, hyaluronic acid, age, and sex were in the final model to predict 5-year liver-related death (area under receiver operating characteristic curve [AUROC] 0.95). Two cut points (4.0 and 5.5) defined three risk groups with an incidence rate for liver-related death of 0.1%, 2%, and 13.2%, respectively (P < 0.001). Albumin, gamma-glutamyl transpeptidase, hyaluronic acid, age, and sex were used to predict 5-year liver decompensation (AUROC 0.90). A cut point of 4.5 gave a sensitivity of 94% and a specificity of 84% to predict 5-year decompensation and defined two groups with an incidence rate for decompensation of 0.2% and 5.8%, respectively (P < 0.001). Alkaline phosphatase, α2-macroglobulin, age, and sex were used to predict 5-year HCC occurrence (AUROC 0.95). A cut-point of eight had a sensitivity of 90% and specificity of 88% to predict 5-year HCC occurrence and defined two groups with an incidence rate for HCC of 0.2% and 5.6%, respectively (P < 0.001). Similar results were obtained using the validation set. CONCLUSIONS All three liver outcome scores had excellent predictive accuracy and were able to stratify risk into clinical meaningful categories for CHC patients.
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Affiliation(s)
- Yi Huang
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia.,Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Leon A Adams
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia.,Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Gerry MacQuillan
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia.,Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - David Speers
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia.,Department of Microbiology, PathWest Laboratory Medicine, QEII Medical Centre, Perth, Western Australia, Australia
| | - John Joseph
- Department of Biochemistry, PathWest Laboratory Medicine, QEII Medical Centre, Perth, Western Australia, Australia
| | - Max K Bulsara
- Institute of Health and Rehabilitation Research, University of Notre Dame, Perth, Western Australia, Australia
| | - Gary P Jeffrey
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia. .,Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
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27
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Pateria P, Jeffrey GP, MacQuillan G, Speers D, Ching H, Chinnaratha MA, Watts GF, Adams LA. Author reply. Intern Med J 2016; 46:863. [DOI: 10.1111/imj.13119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 04/10/2016] [Indexed: 11/30/2022]
Affiliation(s)
- P. Pateria
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - G. P Jeffrey
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
| | - G. MacQuillan
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
| | - D. Speers
- PathWest Laboratory Medicine WA; Queen Elizabeth II Medical Centre; Perth Western Australia Australia
| | - H. Ching
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
| | - M. A. Chinnaratha
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - G. F. Watts
- Lipid Disorders Clinic, Cardiovascular Medicine, Royal Perth Hospital, School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
| | - L. A. Adams
- Department of Gastroenterology and Hepatology; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth Western Australia Australia
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28
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Harding DJ, MacQuillan G, Howman R, de Boer B, Adams L, Mitchell A, Jeffrey G. Successful Use of Dasatinib After Liver Transplantation for Imatinib-Induced Fulminant Liver Failure in Chronic Myeloid Leukemia. J Clin Oncol 2016; 34:e97-8. [DOI: 10.1200/jco.2013.50.1320] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Damian J. Harding
- Western Australian Liver Transplantation Service, Sir Charles Gairdner Hospital, Perth, Australia
| | - Gerry MacQuillan
- Western Australian Liver Transplantation Service, Sir Charles Gairdner Hospital, Perth, Australia
| | | | | | - Leon Adams
- Western Australian Liver Transplantation Service, Sir Charles Gairdner Hospital, Perth, Australia
| | - Andrew Mitchell
- Western Australian Liver Transplantation Service, Sir Charles Gairdner Hospital, Perth, Australia
| | - Gary Jeffrey
- Western Australian Liver Transplantation Service, Sir Charles Gairdner Hospital, Perth, Australia
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29
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Huang Y, de Boer WB, Adams LA, MacQuillan G, Bulsara MK, Jeffrey GP. Clinical outcomes of chronic hepatitis C patients related to baseline liver fibrosis stage: a hospital-based linkage study. Intern Med J 2015; 45:48-54. [PMID: 25371273 DOI: 10.1111/imj.12626] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 10/02/2014] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS Rates of long-term clinical outcomes of chronic hepatitis C in patients with none, mild or severe liver fibrosis are required to determine benefits of anti-viral therapies. This study evaluated long-term outcomes for chronic hepatitis C stratified by all Metavir fibrosis stages. METHODS Clinical outcomes were determined using population-based data linkage methodology for 880 hepatitis C patients who had a liver biopsy performed from 1992 to 2012. RESULTS During 9386 person-years of follow up, 28 patients developed hepatocellular carcinoma, 58 developed liver decompensation and 122 died or underwent liver transplantation. There was no significant difference in liver-related death for those with F0-F2 with an 18-year survival probability >94%. Hazard ratio of liver-related death for F3 compared with F0-F2 was 4.24 (P = 0.003), with no significant difference in the first 13-year follow up. The 15-year decompensation-free survival for F0, F1 and F2 was 100%, 96% and 94% respectively and for hepatocellular carcinoma-free survival was 100%, 99% and 98%. Hazard ratio of liver complication (hepatocellular carcinoma or decompensation)-free survival for F3 compared with F0-F2 was 3.22 (P = 0.001), with no significant difference during the first 7-year follow up. F4 had significantly higher risk of liver-related death, decompensation and hepatocellular carcinoma than F3 (P < 0.001). CONCLUSIONS Chronic hepatitis C patients with F2 or less had few liver complications after 15 years. For F3 patients, the significant increase in liver-related death occurred after 13 years and for liver complications after 7 years.
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Affiliation(s)
- Y Huang
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia; Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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Speers DJ, Ma MX, Faddy HM, Nash M, Bowden S, Boer B, MacNicholas R, MacQuillan G, Adams L. Domestically acquired hepatitis E successfully treated with ribavirin in an Australian liver transplant recipient. Med J Aust 2015; 202:209-11. [DOI: 10.5694/mja14.00453] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 09/18/2014] [Indexed: 12/24/2022]
Affiliation(s)
| | | | | | - Monica Nash
- Australian Red Cross Blood Service, Sydney, NSW
| | - Scott Bowden
- Victorian Infectious Diseases Reference Laboratory, Melbourne, VIC
| | - Bastiaan Boer
- University of Western Australia, Perth, WA
- PathWest Laboratory Medicine WA, Perth WA
| | | | | | - Leon Adams
- Sir Charles Gairdner Hospital, Perth, WA
- University of Western Australia, Perth, WA
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Huang Y, de Boer WB, Adams LA, MacQuillan G, Bulsara MK, Jeffrey GP. Image analysis of liver biopsy samples measures fibrosis and predicts clinical outcome. J Hepatol 2014; 61:22-7. [PMID: 24607623 DOI: 10.1016/j.jhep.2014.02.031] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 01/20/2014] [Accepted: 02/22/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Histopathological scoring of liver fibrosis mainly measures architectural abnormalities and requires a minimum biopsy size (⩾ 10 mm). Liver collagen quantification may allow use of small size biopsies and improve the prediction of clinical outcomes. This study evaluated the ability of the collagen proportional area (CPA) measurement to predict clinical outcomes. METHODS Clinical outcomes were determined using population based data-linkage for chronic hepatitis C (CHC) patients from 1992 to 2012. Quantitative digital image analysis of liver biopsies was used for CPA measurement. RESULTS 533 patients with a biopsy size ⩾ 5 mm were included. Median follow up was 10.5 years. 26 developed hepatocellular carcinoma (HCC), 39 developed liver decompensation and 33 had liver related death. 453 had Metavir F0-F2 and 80 had F3-F4. CPA ranged from 1.3% to 44.6%. CPA and Metavir stage were independently associated with liver related death. Metavir stage, CPA stage and age were independently associated with HCC. CPA stage (C1: 0%-5%, C2: 5%-10%, C3: 10%-20%, C4: >20%) stratified risk and a significant difference in outcomes was present between all CPA stages for HCC and between C2-C3 and C3-C4 for decompensation and liver related death. The 15 year composite endpoint-free survival was 97% for C1, 89% for C2, 60% for C3, 7% for C4. C4 had significantly worse survival than ⩽ C3 (p<0.001) in cirrhotic patients. CONCLUSIONS CPA stage gave additional information regarding risk stratification for adverse clinical outcomes independent of Metavir stage.
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Affiliation(s)
- Yi Huang
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia; Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Australia
| | - W Bastiaan de Boer
- Department of Anatomical Pathology, PathWest, QEII Medical Centre, Perth, Australia
| | - Leon A Adams
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia; Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Australia
| | - Gerry MacQuillan
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia; Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Australia
| | - Max K Bulsara
- Institute of Health and Rehabilitation Research, University of Notre Dame, Perth, Australia
| | - Gary P Jeffrey
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia; Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Australia.
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Chinnaratha MA, Jeffrey GP, MacQuillan G, Rossi E, de Boer BW, Speers DJ, Adams LA. Prediction of morbidity and mortality in patients with chronic hepatitis C by non-invasive liver fibrosis models. Liver Int 2014; 34:720-7. [PMID: 24034439 DOI: 10.1111/liv.12306] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Liver fibrosis is prognostic of outcomes among patients with chronic hepatitis C (CHC). We evaluated the accuracy of non-invasive markers and liver biopsy in predicting morbidity and mortality in CHC patients. METHODS Compensated CHC patients were evaluated over a 10-year period. Non-invasive markers including Hepascore, FIB-4, APRI and liver biopsy results were retrospectively collated. Follow-up morbidity and mortality data were obtained from the Western Australian Data Linkage System. The prognostic significance of baseline non-invasive markers and biopsy were assessed using Kaplan-Meier analysis. RESULTS A total of 406 subjects (64% male, mean age 48 ± 11 years) were followed up for 2385 person-years, during which there were 22 (5.4%) deaths including 14 (3.4%) who died from liver disease or required liver transplantation. Sixteen (3.9%) subjects developed liver decompensation. Hepascore and liver biopsy (P < 0.005) but not APRI or FIB-4 were predictive of overall and liver-related mortality as well as liver decompensation. A Hepascore>0.5 was associated with increased overall mortality [Hazard Ratio (95%CI) 6.7 (2.6-17), P < 0.001], liver-related mortality [32.8 (4.3-250), P = 0.001] and risk of future decompensation [11.8 (3.3-41), P < 0.001], whereas a Hepascore ≤0.5 was associated with a 99% probability of not dying from liver-related causes over 10 years. Hepascore had comparable accuracy with liver biopsy in predicting liver-related mortality with AUROC of 0.86 (95%CI 0.80-0.90) and 0.87 (0.79-0.96), respectively. CONCLUSION Hepascore is predictive of overall and liver-related mortality and morbidity in CHC patients with comparable accuracy to liver biopsy. Hepascore may be a useful prognostic marker in clinical practice.
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Affiliation(s)
- Mohamed A Chinnaratha
- Department of Gastroenterology/Hepatology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
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Nwaba A, MacQuillan G, Adams LA, Garas G, Delriviere L, Augustson B, DeBoer B, Moody H, Jeffrey GP. Tacrolimus-induced thrombotic microangiopathy in orthotopic liver transplant patients: case series of four patients. Intern Med J 2013; 43:328-33. [PMID: 23441660 DOI: 10.1111/imj.12048] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 08/26/2012] [Indexed: 12/23/2022]
Abstract
Thrombotic microangiopathy (TMA) is a potentially fatal complication in solid organ and bone marrow transplant patients, with reported incidence of 0.5-3% and mortality of about 75%. To emphasise the importance of early diagnosis and prompt commencement of therapy results in improved clinical outcomes. A retrospective study of all patients who underwent orthotopic liver transplantation (OLTX) at the Western Australian Liver Transplantation Service from May 1994 to December 2010 was conducted to identify patients who developed tacrolimus-induced TMA. We identified four patients with tacrolimus-induced TMA post-OLTX, derived from a cohort of 104 patients treated with tacrolimus in our institution. The mean age at diagnosis was 40 years, and the mean time of onset was 63 ± 7.5 weeks after OLTX. The indications for OLTX in the four patients were fulminant hepatic failure in three (Wilson disease, paracetamol overdose and post-partum thrombotic thrombocytopenic purpura) and hepatitis C virus-related cirrhosis. All patients had tacrolimus post-OLTX. At diagnosis, tacrolimus was discontinued in all patients, and three of the four patients underwent plasma exchange and all patients improved clinically. Mean duration of follow up was 15 ± 7.5 months. There was no mortality 6 months post-TMA. Early diagnosis with immediate discontinuation or conversion of calcineurin inhibitors and plasma exchange should be offered to OLTX patients with TMA as it results in good outcomes.
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Affiliation(s)
- A Nwaba
- West Australian Liver Transplant Service, University of Western Australia, Perth, Australia.
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Huang Y, de Boer WB, Adams LA, MacQuillan G, Rossi E, Rigby P, Raftopoulos SC, Bulsara M, Jeffrey GP. Image analysis of liver collagen using sirius red is more accurate and correlates better with serum fibrosis markers than trichrome. Liver Int 2013; 33:1249-56. [PMID: 23617278 DOI: 10.1111/liv.12184] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 04/01/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND Collagen proportional area (CPA) determined by quantitative digital image analysis better quantifies liver fibrosis than histological stage; however, its clinical use has been limited by non-standardized methods. AIM This study aimed to compare CPA obtained using different staining methods, magnifications and biopsy sizes. METHODS Two hundred and forty-nine patients with chronic hepatitis C who had a liver biopsy and serum fibrosis markers performed were included. CPA was measured either using a sirius red (CPAs) or a trichrome (CPAt) stain. RESULTS CPAs measured at 20× and 40× magnifications generated similar outcomes with interclass correlation (ICC) coefficient of 0.98. Compared with trichrome, sirius red staining had much less variation with an ICC coefficient of 0.99 for slides stained in the same batch and 0.92 in different batches. Mean CPAs was higher than mean CPAt by 3.53%, P < 0.001. Morphological analysis found that sirius red detected delicate fibrous septa and spurs better than trichrome. Both CPAs and CPAt correlated well with Metavir stage, whereas CPAs had better ability to detect cirrhosis with the area under ROC curve of 0.95. Overall CPA had superior correlation with serum markers of fibrosis in Metavir F2-F4 than that in F0-F1 and CPAs correlated better with serum fibrosis markers than CPAt in Metavir F0-F1. Multivairate analysis found that HA, α2-macroglobulin, platelet count and albumin were independently correlated with CPAs and only HA was independently correlated with CPAt. CONCLUSIONS Sirius red staining for CPA determination was more accurate and reliable for quantifying hepatic collagen compared with trichrome staining.
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Affiliation(s)
- Yi Huang
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia.
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Abstract
Drug and substance abuse remains a major medical problem. Alcohol use, abuse and dependence are highly prevalent conditions. Alcohol related liver disease can present as simple steatosis, steatohepatitis, alcoholic hepatitis or liver cirrhosis. Paracetamol hepatotoxicity secondary to accidental or deliberate overdose is another common problem. While the adverse cardiovascular, neurological, renal and psychiatric consequences of various illicit substance abuses are widely studied and publicized, less attention has been directed towards possible hepatotoxic effects. Illicit drug abuse can cause a range of liver abnormalities ranging from asymptomatic derangement of liver function tests to fulminant hepatic failure. This article reviews the epidemiology, risk factors, clinical manifestations, pathogenesis, investigations, management and prognostic factors of alcohol related liver disease and paracetamol hepatotoxicity as well as the current knowledge pertaining to hepatotoxicity of the more commonly used illicit substances including cannabis, amphetamine type stimulants, cocaine, khat chewing and complementary and alternate medicine.
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Affiliation(s)
- Puraskar Pateria
- Western Australian Liver Transplant Service, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia 6009, Australia.
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Harding DJ, Subramaniam K, MacQuillan G, Davis J, Nolan D. Severe drug-induced hypersensitivity syndrome with a shared HLA-B allele. Med J Aust 2012; 197:411-3. [PMID: 23025739 DOI: 10.5694/mja12.10477] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Talbot-Smith A, Syn WK, MacQuillan G, Neil D, Elias E, Ryan P. Familial idiopathic pulmonary fibrosis in association with bone marrow hypoplasia and hepatic nodular regenerative hyperplasia: a new "trimorphic" syndrome. Thorax 2009; 64:440-3. [PMID: 19401489 DOI: 10.1136/thx.2008.099796] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This is the first report of familial idiopathic pulmonary fibrosis associated with hepatic nodular regenerative hyperplasia and bone marrow hypoplasia. Four members of one family presented with this triad of organ dysfunction. The response to immunosuppressive treatment was poor and all four members succumbed to the disease processes. The current literature is reviewed and mechanisms that could have been involved in the development of this new syndrome are proposed.
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Affiliation(s)
- A Talbot-Smith
- Department of Respiratory Medicine, Hereford County Hospital, UK.
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Tan T, de Boer BW, Mitchell A, Delriviere L, Adams LA, Jeffrey GP, MacQuillan G. LEVETIRACETAM AS A POSSIBLE CAUSE OF FULMINANT LIVER FAILURE. Neurology 2008; 71:685-6. [DOI: 10.1212/01.wnl.0000324604.11657.c6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Mukhtar SA, Hoffman NE, MacQuillan G, Semmens JB. The Hospital Mortality Project: A Tool for Using Administrative Data for Continuous Clinical Quality Assurance. HEALTH INF MANAG J 2008; 37:9-18. [DOI: 10.1177/183335830803700202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The increasing demand for greater clinical accountability requires development of convenient tools to measure healthcare safety and quality, which are able to provide information contemporaneously. The purpose of this paper is to describe the development of the Hospital Mortality Project, a quality assurance initiative designed to encourage and facilitate clinical accountability for hospital mortality by all clinical departments and clinicians. The project was carried out in two stages. Part 1: After registration of in-hospital patient deaths (1 May 2004 to 31 December 2007), the consultant in charge of patient care was notified and requested to assign the death to a predefined category. This categorisation leads to further investigation as appropriate. Part 2: Hospital administrative data from 1 April 1997 to 31 December 2007 were used to assess a defined index, the Hospital Mortality Index (HMI), which was the expressed in the form of an Attribute Control Chart ( p-CHART) and then used as a performance indicator for hospital departments and clinicians. Summary data are reported to the clinical departments and to the hospital executive via the Quality Improvement Committee on quarterly basis. The clinical review was complete for 2,990 of 3,132 (95%) inpatient deaths till 31 December 2007, while a further 142 (5%) deaths are still in the process of being reviewed as of 7 April 2008. The median age of all the cases was 78 years (IQR 67-86) of which 1,657 (53%) were male. The Poisson regression analysis showed that since 1997 departments with a minimum of 100 deaths in total showed no clinically significant change in HMI over time. The Hospital Mortality Project provides a simple and efficient tool to analyse data for clinical managers to facilitate accountability.
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Affiliation(s)
- S Aqif Mukhtar
- S Aqif Mukhtar MSc, GradDipPH, Research Fellow, Centre for Population Health Research, School of Public Health, Curtin University of Technology, GPO Box U1987, Perth WA 6845, Phone: 61-8-9266 1851, Fax: 61-8-9266 1866
| | - Neville E Hoffman
- Neville E Hoffman MBBS, MD, PhD, FRACP, Former Director, Clinical Governance Unit, Sir Charles Gairdner Hospital, Nedlands WA 6009, AUSTRALIA, Tel: 61-8-9386 3301, Fax: N/A
| | - Gerry MacQuillan
- Gerry MacQuillan MBBS, PhD, FRACP, Consultant Physician, Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Nedlands WA 6009, Tel: 61-8- 9346 3228, Fax: 61-8-9346 3098
| | - James B Semmens
- James B Semmens MSc, PhD, Professor, Centre for Population Health Research, School of Public Health, Curtin University of Technology, GPO Box U1987, Perth WA 6845, Tel: 61-8-9266 1856, Fax: 61-8-9266 1866
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Mitchell A, Adams LA, MacQuillan G, Tibballs J, vanden Driesen R, Delriviere L. Bevacizumab reverses need for liver transplantation in hereditary hemorrhagic telangiectasia. Liver Transpl 2008; 14:210-3. [PMID: 18236396 DOI: 10.1002/lt.21417] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease characterized by mucocutaneous and visceral telangiectasia. Hepatic involvement with vascular malformations may lead to portal hypertension, biliary ischemia, and high-output cardiac failure. Liver transplantation is indicated for life-threatening disease but carries significant risk from surgery and chronic immunosuppression. We report a case of a 47-year-old woman with HHT successfully treated with the vascular endothelial growth factor (VEGF) antibody bevacizumab. The patient was referred for consideration of liver transplantation because of hepatic HHT leading to high-output cardiac failure, diuretic resistant ascites, cholestasis, and malnutrition. As she was considered a high-risk candidate for transplantation, she underwent 6 courses of bevacizumab (5 mg/kg) over 12 weeks. A dramatic improvement in her clinical state was observed after 3 months with reversal of cholestasis, resolution of cardiac failure and ascites, and improvement in nutritional status with a 10% dry weight increase. Treatment induced a marked reduction in liver vascularity and halving of her liver volume from 4807 to 2269 mL over 6 months. This was associated with normalization of her cardiac output from 10.2 to 5.1 L/minute. Correspondingly, she ceased diuretic medications, returned to full-time work, and was delisted as a transplant candidate. She remains well 6 months after completing treatment. In conclusion, antagonism of VEGF receptors led to a dramatic regression of hepatic vascular malformations and reversal of high-output cardiac failure and complications of portal hypertension in this patient with HHT. Bevacizumab may potentially alleviate the need for liver transplantation in this group of patients.
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Affiliation(s)
- Andrew Mitchell
- Western Australian Liver Transplant Service, Sir Charles Gairdner Hospital, Nedlands, Australia
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Jeffrey GP, MacQuillan G, Chua F, Galhenage S, Bull J, Young E, Hulse G, O'Neil G. Hepatitis C virus eradication in intravenous drug users maintained with subcutaneous naltrexone implants. Hepatology 2007; 45:111-7. [PMID: 17187435 DOI: 10.1002/hep.21470] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
UNLABELLED The effectiveness of HCV antiviral therapy in patients who have undergone recent drug dependency treatment and continue to inject drugs sporadically is presently not clear. Patients attending a community-based drug rehabilitation and naltrexone implant clinic from October 2002 until March 2005 were screened for HCV infection and if positive offered further assessment and treatment with interferon and ribavirin therapy. The first 50 patients to commence HCV therapy and complete at least 6 months follow-up were prospectively studied. ETR response (HCV PCR negative) was 34/50 (68%) and SVR 6 months post-treatment was 31/50 (62%). Viral eradication was maintained in those 22 patients that have had 12 months or more post-treatment follow-up. Eleven (22%) patients stopped therapy early due to side effects or poor compliance. Only two patients with an ETR likely reinfected due to unsafe injection practices. One was re-treated and achieved an SVR. Of the patients achieving a 6-month SVR, 17 of 31 patients reported no further IDU and 13 of 31 patients occasional IDU during treatment and this was maintained after HCV treatment cessation. 46% of patients received antidepressant and/or antipsychotic medication during treatment. CONCLUSION This study of HCV treatment in a community-based subcutaneous naltrexone implant clinic found antiviral therapy resulted in a 62% SVR. This result is comparable to that reported in hospital-based clinics in non-IDU patients. The side effect profile and compliance was also similar. HCV antiviral therapy should be offered to this large and currently under treated group.
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Affiliation(s)
- Gary P Jeffrey
- School of Medicine and Pharmacology, The University of Western Australia, Perth, Western Australia, Australia.
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Rossi E, Adams L, Prins A, Bulsara M, de Boer B, Garas G, MacQuillan G, Speers D, Jeffrey G. Validation of the FibroTest biochemical markers score in assessing liver fibrosis in hepatitis C patients. Clin Chem 2003; 49:450-4. [PMID: 12600957 DOI: 10.1373/49.3.450] [Citation(s) in RCA: 182] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Determining the stage of fibrosis by liver biopsy is important in managing patients with hepatitis C virus infection. We investigated the predictive value of the proprietary FibroTest score to accurately identify significant fibrosis in Australian hepatitis C patients. METHODS Serum obtained from 125 confirmed hepatitis C patients before antiviral therapy was analyzed for haptoglobin, alpha(2)-macroglobulin, apolipoprotein A1, bilirubin, and gamma-glutamyltransferase activity, and the FibroTest score was computed. Liver fibrosis pathology was staged according to a defined system on a scale of F0 to F4. We used predictive values and a ROC curve to assess the accuracy of FibroTest scores. RESULTS The prevalence of significant fibrosis defined by liver biopsy was 0.38. The most useful single test for predicting significant fibrosis was serum alpha(2)-macroglobulin (cutoff value, 2.52 g/L; sensitivity, 75%; specificity, 67%). The negative predictive value of a FibroTest score <0.1 was 85%, and the positive predictive value of a score >0.6 was 78%. Although 33 of the 125 patients had FibroTest scores <0.1 and were therefore deemed unlikely to have fibrosis, 6 (18%) had significant fibrosis. Conversely, of the 24 patients with scores >0.6 who were likely to have significant fibrosis, 5 (21%) had mild fibrosis. Of the 125 patients in the cohort, 57 (46%) could have avoided liver biopsy, but discrepant results were recorded in 11 of those 57 (19%). CONCLUSION The FibroTest score could not accurately predict the presence or absence of significant liver fibrosis.
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Affiliation(s)
- Enrico Rossi
- Clinical Biochemistry, PathCentre, Nedlands, Western Australia, Australia.
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Affiliation(s)
- M B Lewis
- St. James's University Hospital, Leeds, UK.
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Affiliation(s)
- M E Hill
- Queen Elizabeth Hospital, Birmingham
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