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Braga MH, Cançado GGL, Bittencourt PL, Couto CA, Guedes LV, Lima AMC, Ferraz MLG, Villela-Nogueira CA, Nardelli MJ, Faria LC, Gomes NMDF, Oliveira EMG, Rotman V, Oliveira MB, da Cunha SMCF, Cunha-Silva M, Mendes LSC, Ivantes CAP, Codes L, de Almeida E Borges VF, Pace FHDL, Pessoa MG, Signorelli IV, Coral GP, Filho JG, Chagas AL, Terrabuio DRB, Cançado ELR. Risk factors for cancer in patients with primary biliary cholangitis and autoimmune hepatitis and primary biliary cholangitis overlap syndrome. Ann Hepatol 2023; 28:101105. [PMID: 37088418 DOI: 10.1016/j.aohep.2023.101105] [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: 11/29/2022] [Revised: 03/01/2023] [Accepted: 03/16/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION AND OBJECTIVES Primary biliary cholangitis (PBC) and autoimmune hepatitis (AIH) and PBC overlap syndrome (AIH/PBC) have been associated with a higher risk of hepatocellular carcinoma (HCC) and extra-hepatic malignancy (EHM). This study aims to assess potential risk factors associated with cancer development in PBC and AIH/PBC. MATERIALS AND METHODS The Brazilian Cholestasis Study Group database was reviewed to compare clinical and laboratory features of PBC patients with HCC and EHM with those without cancer. RESULTS Among the 752 PBC patients enrolled, 64 of them with AIH/PBC, 87 cancers were identified in 72 patients, including 20 cases of HCC and 67 of EHM. Patients with HCC had a higher prevalence of cirrhosis (95% vs. 32.5% of those subjects without cancer, p=<0.001), smoking (55% vs. 12.3%, p=<0.001), CREST syndrome (30% vs 7.6%, p=0.003) and prior azathioprine (30% vs 8%, p= 0.005) and prednisone (35% vs 14%, p= 0.018) use, whereas patients with EHM had a higher prevalence of smoking (42.3% vs 12.4% of those subjects without cancer, p= <0.001), AMA positivity (96.6% vs 80.1%, p=<0.001), azathioprine therapy (21% vs 7.9%, p= 0.01) and concurrent other autoimmune diseases. In multivariate analysis, cirrhosis, obesity and prior azathioprine therapy were independent risk factors for HCC, while Sjogren syndrome and psoriasis were associated with EHM. Fibrates reduced EHM risk. CONCLUSIONS The prevalence of EHM is higher when compared to HCC in PBC patients. Cirrhosis, obesity, prior azathioprine use, and concurrent autoimmune diseases were significantly associated with cancer in PBC.
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Affiliation(s)
- Michelle Harriz Braga
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Guilherme Grossi Lopes Cançado
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.; Hospital da Polícia Militar de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil..
| | - Paulo Lisboa Bittencourt
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil;; Hospital Português, Salvador, Bahia, Brazil
| | - Cláudia Alves Couto
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Laura Vilar Guedes
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - André Mourão Costa Lima
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Maria Lucia Gomes Ferraz
- Disciplina de Gastroenterologia, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Cristiane Alves Villela-Nogueira
- Hospital Universitário Clementino Fraga Filho e Departamento de Clínica Médica da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mateus Jorge Nardelli
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Luciana Costa Faria
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | | | - Vivian Rotman
- Hospital Universitário Clementino Fraga Filho e Departamento de Clínica Médica da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria Beatriz Oliveira
- Ambulatório Municipal de Hepatites Virais de São José dos Campos, São José dos Campos, São Paulo, Brazil
| | | | - Marlone Cunha-Silva
- Divisão de Gastroenterologia (Gastrocentro), Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, São Paulo, Brazil
| | | | | | | | - Valéria Ferreira de Almeida E Borges
- Instituto de Gastroenterologia, Endoscopia e Proctologia, Uberlândia, Minas Gerais, Brazil.; Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil
| | - Fabio Heleno de Lima Pace
- Serviço de Gastroenterologia e Hepatologia, Universidade Federal de Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - Mario Guimarães Pessoa
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Izabelle Venturini Signorelli
- Hospital Universitário Cassiano Antônio Moraes, Universidade Federal do Espírito Santo, Vitória, Espírito Santo, Brazil
| | - Gabriela Perdomo Coral
- Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - João Galizzi Filho
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Aline Lopes Chagas
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | | | - Eduardo Luiz Rachid Cançado
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
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Cançado GGL, Couto CA, Terrabuio DRB, Cançado ELR, Villela-Nogueira CA, Ferraz MLG, Braga MH, Nardelli MJ, Faria LC, de Faria Gomes NM, Oliveira EMG, Rotman V, Oliveira MB, da Cunha SMCF, Cunha-Silva M, Mendes LSC, Ivantes CAP, Codes L, de Almeida E Borges VF, de Lima Pace FH, Pessoa MG, Guedes LV, Signorelli IV, Coral GP, Levy C, Bittencourt PL. Response to Ursodeoxycholic Acid May Be Assessed Earlier to Allow Second-Line Therapy in Patients with Unresponsive Primary Biliary Cholangitis. Dig Dis Sci 2023; 68:514-520. [PMID: 35989386 DOI: 10.1007/s10620-022-07654-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 01/20/2022] [Accepted: 07/31/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Response to ursodeoxycholic acid (UDCA) in primary biliary cholangitis (PBC) has been traditionally assessed 1 to 2 years after treatment initiation. With the development of new drugs, some patients may benefit from an earlier introduction of second-line therapies. AIMS This study aims to identify whether well-validated response criteria could correctly identify individuals likely to benefit from add-on second-line therapy at 6 months. METHODS Analysis of a multicenter retrospective cohort which included only patients with clear-cut PBC. RESULTS 206 patients with PBC (96.6% women; mean age 54 ± 12 years) were included. Kappa concordance was substantial for Toronto (0.67), Rotterdam (0.65), Paris 1 (0.63) and 2 (0.63) criteria at 6 and 12 months, whereas Barcelona (0.47) and POISE trial (0.59) criteria exhibited moderate agreement. Non-response rates to UDCA was not statistically different when assessed either at 6 or 12 months using Toronto, Rotterdam or Paris 2 criteria. Those differences were even smaller or absent in those subjects with advanced PBC. Mean baseline alkaline phosphatase was 2.73 ± 1.95 times the upper limit of normal (× ULN) among responders versus 5.05 ± 3.08 × ULN in non-responders (p < 0.001). CONCLUSIONS After 6 months of treatment with UDCA, the absence of response by different criteria could properly identify patients who could benefit from early addition of second-line therapies, especially in patients with advanced disease or high baseline liver enzymes levels.
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Affiliation(s)
- Guilherme Grossi Lopes Cançado
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, Belo Horizonte, Minas Gerais, 30130-100, Brazil.
- Hospital da Polícia Militar de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Cláudia Alves Couto
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | | | - Eduardo Luiz Rachid Cançado
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Cristiane Alves Villela-Nogueira
- Hospital Universitário Clementino Fraga Filho e Departamento de Clínica Médica da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria Lucia Gomes Ferraz
- Disciplina de Gastroenterologia, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Michelle Harriz Braga
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Mateus Jorge Nardelli
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Luciana Costa Faria
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | | | | | - Vivian Rotman
- Hospital Universitário Clementino Fraga Filho e Departamento de Clínica Médica da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria Beatriz Oliveira
- Ambulatório Municipal de Hepatites Virais de São José dos Campos, São José dos Campos, São Paulo, Brazil
| | | | - Marlone Cunha-Silva
- Divisão de Gastroenterologia (Gastrocentro), Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, São Paulo, Brazil
| | | | | | - Liana Codes
- Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, Bahia, Brazil
- Hospital Português, Salvador, Bahia, Brazil
| | - Valéria Ferreira de Almeida E Borges
- Instituto de Gastroenterologia, Endoscopia e Proctologia, Uberlândia, Minas Gerais, Brazil
- Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil
| | - Fabio Heleno de Lima Pace
- Serviço de Gastroenterologia e Hepatologia, Universidade Federal de Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - Mario Guimarães Pessoa
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Laura Vilar Guedes
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Izabelle Venturini Signorelli
- Hospital Universitário Cassiano Antônio Moraes, Universidade Federal do Espírito Santo, Vitoria, Espírito Santo, Brazil
| | - Gabriela Perdomo Coral
- Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Paulo Lisboa Bittencourt
- Hospital Português, Salvador, Bahia, Brazil
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
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Chagas AL, Leal CRG, Mello VBD, Barros FMDR, Bittencourt PL, Mattos AA, Aroucha D, Fonseca LGD, Silva JRLD, Dottori MF, Teixeira R, Mendes LSC, Rezende REF, Filgueira NA, Coutinho AK, Araújo Neto JMD, Coelho HSM, Pessoa MG, Cheinquer H, Parise ER, França A, Álvares-DA-Silva MR, Carrilho FJ, Coral GP, Pinto PDTA, Pereira LMMB, Paraná R, Alves RCP, Brandão-Mello CE. BRAZILIAN SOCIETY OF HEPATOLOGY UPDATED RECOMMENDATIONS FOR SYSTEMIC TREATMENT OF HEPATOCELLULAR CARCINOMA. Arq Gastroenterol 2023; 60:106-131. [PMID: 37194769 DOI: 10.1590/s0004-2803.202301000-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 01/13/2023] [Indexed: 05/18/2023]
Abstract
Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related mortality worldwide. The Brazilian Society of Hepatology (SBH) published in 2020 the updated recommendations for the diagnosis and treatment of HCC. Since then, new data have emerged in the literature, including new drugs approved for the systemic treatment of HCC that were not available at the time. The SBH board conducted an online single-topic meeting to discuss and review the recommendations on the systemic treatment of HCC. The invited experts were asked to conduct a systematic review of the literature on each topic related to systemic treatment and to present the summary data and recommendations during the meeting. All panelists gathered together for discussion of the topics and elaboration of the updated recommendations. The present document is the final version of the reviewed manuscript containing the recommendations of SBH and its aim is to assist healthcare professionals, policy-makers, and planners in Brazil and Latin America with systemic treatment decision-making of patients with HCC.
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Affiliation(s)
- Aline Lopes Chagas
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Divisão de Gastroenterologia Clínica e Hepatologia, São Paulo, SP, Brasil
| | - Cassia Regina Guedes Leal
- Hospital Federal dos Servidores do Estado, Departamento de Gastroenterologia e Hepatologia, Rio de Janeiro, RJ, Brasil
| | - Vivianne Barreto de Mello
- Assistência Multidisciplinar em Oncologia, Rede DASA, Clínica AMO, Departamento de Oncologia do Aparelho Digestivo, Salvador, BA, Brasil
| | | | | | - Angelo A Mattos
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Medicina - Hepatologia, Porto Alegre, RS, Brasil
| | - Dayse Aroucha
- Universidade de Pernambuco, Faculdade de Ciências Médicas de Pernambuco, Disciplina de Gastroenterologia, Recife, PE, Brasil
| | - Leonardo G da Fonseca
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Departamento de Oncologia Clínica, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brasil
| | | | - Mariana Fonseca Dottori
- Hospital Federal dos Servidores do Estado, Departamento de Gastroenterologia e Hepatologia, Rio de Janeiro, RJ, Brasil
| | - Rosangela Teixeira
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Faculdade de Medicina, Departamento de Clínica Médica, Instituto Alfa de Gastroenterologia, Belo Horizonte, MG, Brasil
| | | | - Rosamar Eulira Fontes Rezende
- Divisão de Gastroenterologia, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | | | - Anelisa K Coutinho
- Assistência Multidisciplinar em Oncologia, Rede DASA, Clínica AMO, Departamento de Oncologia do Aparelho Digestivo, Salvador, BA, Brasil
| | | | | | - Mario Guimarães Pessoa
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Divisão de Gastroenterologia Clínica e Hepatologia, São Paulo, SP, Brasil
| | - Hugo Cheinquer
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Serviço de Hepatologia, Porto Alegre, RS, Brasil
| | - Edison Roberto Parise
- Universidade Federal de São Paulo, Disciplina de Gastroenterologia, São Paulo, SP, Brasil
| | - Alex França
- Universidade Federal de Sergipe, Departamento de Medicina, Sergipe, SE, Brasil
| | - Mário Reis Álvares-DA-Silva
- Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Divisão de Gastroenterologia e Hepatologia, Porto Alegre, RS, Brasil
| | - Flair José Carrilho
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Divisão de Gastroenterologia Clínica e Hepatologia, São Paulo, SP, Brasil
| | - Gabriela P Coral
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Medicina - Hepatologia, Porto Alegre, RS, Brasil
| | | | - Leila M M Beltrão Pereira
- Universidade de Pernambuco, Faculdade de Ciências Médicas de Pernambuco, Disciplina de Gastroenterologia, Recife, PE, Brasil
| | - Raymundo Paraná
- Faculdade de Medicina da Universidade Federal da Bahia, Departamento de Medicina, Salvador, BA, Brasil
| | | | - Carlos Eduardo Brandão-Mello
- Escola de Medicina e Cirurgia do Rio de Janeiro, Hospital Universitário Gaffrée e Guinle, Departamento de Clínica Médica, Unidade de Gastroenterologia e Doenças do Fígado, Rio de Janeiro, RJ, Brasil
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Cançado GGL, Braga MH, Ferraz MLG, Villela-Nogueira CA, Terrabuio DRB, Cançado ELR, Nardelli MJ, Faria LC, de Faria Gomes NM, Oliveira EMG, Rotman V, Oliveira MB, da Cunha SMCF, Cunha-Silva M, Mendes LSC, Ivantes CAP, Codes L, de Almeida E Borges VF, de Lima Pace FH, Pessoa MG, Signorelli IV, Coral GP, Bittencourt PL, Levy C, Couto CA. Anti-mitochondrial Antibody-Negative Primary Biliary Cholangitis Is Part of the Same Spectrum of Classical Primary Biliary Cholangitis. Dig Dis Sci 2022; 67:3305-3312. [PMID: 34181166 DOI: 10.1007/s10620-021-07122-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 04/13/2021] [Accepted: 06/16/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Primary biliary cholangitis (PBC) is a chronic cholestatic liver disease in which anti-mitochondrial antibodies (AMA) are the diagnostic hallmark. Whether AMA-negative PBC patients represent a different phenotype of disease is highly debated. AIMS The purpose of our study was to compare AMA-positive and AMA-negative PBC patients in a large non-white admixed Brazilian cohort. METHODS The Brazilian Cholestasis Study Group multicentre database was reviewed to assess demographics, clinical features and treatment outcomes of Brazilian PBC patients, stratifying data according to AMA status. RESULTS A total of 464 subjects (95.4% females, mean age 56 ± 5 years) with PBC were included. Three hundred and eighty-four (83%) subjects were AMA-positive, whereas 80 (17%) had AMA-negative PBC. Subjects with AMA-negative PBC were significantly younger (52.2 ± 14 vs. 59.6 ± 11 years, p = 0.001) and had their first symptom at an earlier age (43.2 ± 13 vs. 49.5 ± 12 years, p = 0.005). Frequency of type 2 diabetes was significantly increased in subjects with AMA-negative PBC (22.5% vs. 12.2%, p = 0.03). Lower IgM (272.2 ± 183 vs. 383.2 ± 378 mg/dL, p = 0.01) and triglycerides (107.6 ± 59.8 vs.129.3 ± 75.7 mg/dL, p = 0.025) and higher bilirubin (3.8 ± 13.5 vs. 1.8 ± 3.4 mg/dL, p = 0.02) levels were also observed in this subgroup. Response to ursodeoxycholic acid varied from 40.5 to 63.3% in AMA-positive and 34 to 62.3% in AMA-negative individuals, according to different response criteria. Outcomes such as development of liver-related complications, death and requirement for liver transplantation were similar in both groups. CONCLUSIONS AMA-negative PBC patients are similar to their AMA-positive counterparts with subtle differences observed in clinical and laboratory features.
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Affiliation(s)
- Guilherme Grossi Lopes Cançado
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, Belo Horizonte, Minas Gerais, 30130-100, Brazil.
- Hospital da Polícia Militar de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Michelle Harriz Braga
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Maria Lucia Gomes Ferraz
- Disciplina de Gastroenterologia, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Cristiane Alves Villela-Nogueira
- Hospital Universitário Clementino Fraga Filho e Departamento de Clínica Médica da Faculdade de Medicina, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Eduardo Luiz Rachid Cançado
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Mateus Jorge Nardelli
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Luciana Costa Faria
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | | | | | - Vivian Rotman
- Hospital Universitário Clementino Fraga Filho e Departamento de Clínica Médica da Faculdade de Medicina, Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria Beatriz Oliveira
- Ambulatório Municipal de Hepatites Virais de São José Dos Campos, São José dos Campos, São Paulo, Brazil
| | | | - Marlone Cunha-Silva
- Divisão de Gastroenterologia (Gastrocentro), Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, São Paulo, Brazil
| | | | | | - Liana Codes
- Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, Bahia, Brazil
- Hospital Português, Salvador, Bahia, Brazil
| | - Valéria Ferreira de Almeida E Borges
- Instituto de Gastroenterologia, Endoscopia e Proctologia, Uberlândia, Minas Gerais, Brazil
- Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil
| | - Fabio Heleno de Lima Pace
- Serviço de Gastroenterologia e Hepatologia, Universidade Federal de Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - Mario Guimarães Pessoa
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Izabelle Venturini Signorelli
- Hospital Universitário Cassiano Antônio Moraes, Universidade Federal do Espírito Santo, Vitória, Espírito Santo, Brazil
| | - Gabriela Perdomo Coral
- Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Paulo Lisboa Bittencourt
- Hospital Português, Salvador, Bahia, Brazil
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Cláudia Alves Couto
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, Belo Horizonte, Minas Gerais, 30130-100, Brazil
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5
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Cançado GGL, Braga MH, Ferraz MLG, Villela-Nogueira CA, Terrabuio DRB, Cançado ELR, Nardelli MJ, Faria LC, Gomes NMDF, de Oliveira EMG, Rotman V, de Oliveira MB, da Cunha SMCF, Mazo DFDC, Mendes LSC, Ivantes CAP, Codes L, de Almeida E Borges VF, Pace FHDL, Pessoa MG, Signorelli IV, Coral GP, Bittencourt PL, Levy C, Couto CA. Clinical features and treatment outcomes of primary biliary cholangitis in a highly admixed population. Ann Hepatol 2022; 27:100546. [PMID: 34600142 DOI: 10.1016/j.aohep.2021.100546] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 07/28/2021] [Revised: 09/04/2021] [Accepted: 09/07/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION AND OBJECTIVES Little is known about primary biliary cholangitis (PBC) in non-whites. The purpose of this study was to evaluate clinical features and outcomes of PBC in a highly admixed population. MATERIAL AND METHODS The Brazilian Cholestasis Study Group multicentre database was reviewed to assess demographics, clinical features and treatment outcomes of Brazilian patients with PBC. RESULTS 562 patients (95% females, mean age 51 ± 11 years) with PBC were included. Concurrent autoimmune diseases and overlap with autoimmune hepatitis (AIH) occurred, respectively, in 18.9% and 14%. After a mean follow-up was 6.2 ± 5.3 years, 32% had cirrhosis, 7% underwent liver transplantation and 3% died of liver-related causes. 96% were treated with ursodeoxycholic acid (UDCA) and 12% required add-on therapy with fibrates, either bezafibrate, fenofibrate or ciprofibrate. Response to UDCA and to UDCA/fibrates therapy varied from 39%-67% and 42-61%, respectively, according to different validated criteria. Advanced histological stages and non-adherence to treatment were associated with primary non-response to UDCA, while lower baseline alkaline phosphatase (ALP) and aspartate aminotransferase (AST) levels correlated with better responses to both UDCA and UDCA/fibrates. CONCLUSIONS Clinical features of PBC in highly admixed Brazilians were similar to those reported in Caucasians and Asians, but with inferior rates of overlap syndrome with AIH. Response to UDCA was lower than expected and inversely associated with histological stage and baseline AST and ALP levels. Most of patients benefited from add-on fibrates, including ciprofibrate. A huge heterogeneity in response to UDCA therapy according to available international criteria was observed and reinforces the need of global standardization.
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Affiliation(s)
- Guilherme Grossi Lopes Cançado
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, Belo Horizonte 30130-100, Minas Gerais, Brazil; Hospital da Polícia Militar de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Michelle Harriz Braga
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Cristiane Alves Villela-Nogueira
- Hospital Universitário Clementino Fraga Filho e Departamento de Clínica Médica da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Mateus Jorge Nardelli
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | - Luciana Costa Faria
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, Belo Horizonte 30130-100, Minas Gerais, Brazil
| | | | | | - Vivian Rotman
- Hospital Universitário Clementino Fraga Filho e Departamento de Clínica Médica da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria Beatriz de Oliveira
- Ambulatório Municipal de Hepatites Virais de São José dos Campos, São José dos Campos, São Paulo, Brazil
| | | | - Daniel Ferraz de Campos Mazo
- Divisão de Gastroenterologia (Gastrocentro), Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, São Paulo, Brazil
| | | | | | - Liana Codes
- Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, Bahia, Brazil; Hospital Português, Salvador, Bahia, Brazil
| | - Valéria Ferreira de Almeida E Borges
- Instituto de Gastroenterologia, Endoscopia e Proctologia, Uberlândia, Minas Gerais, Brazil; Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil
| | - Fabio Heleno de Lima Pace
- Serviço de Gastroenterologia e Hepatologia, Universidade Federal de Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - Mario Guimarães Pessoa
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Izabelle Venturini Signorelli
- Hospital Universitário Cassiano Antônio Moraes, Universidade Federal do Espírito Santo, Vitória, Espírito Santo, Brazil
| | - Gabriela Perdomo Coral
- Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Paulo Lisboa Bittencourt
- Hospital Português, Salvador, Bahia, Brazil; Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Cláudia Alves Couto
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, Belo Horizonte 30130-100, Minas Gerais, Brazil
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Cançado GGL, Couto CA, Guedes LV, Braga MH, Terrabuio DRB, Cançado ELR, Ferraz MLG, Villela-Nogueira CA, Nardelli MJ, Faria LC, de Oliveira EMG, Rotman V, Mazo DFDC, Borges VFDAE, Mendes LSC, Codes L, Pessoa MG, Signorelli IV, Levy C, Bittencourt PL. Fibrates for the Treatment of Primary Biliary Cholangitis Unresponsive to Ursodeoxycholic Acid: An Exploratory Study. Front Pharmacol 2022; 12:818089. [PMID: 35126149 PMCID: PMC8811361 DOI: 10.3389/fphar.2021.818089] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/15/2021] [Indexed: 12/12/2022] Open
Abstract
Aim: Up to 40% of patients with primary biliary cholangitis (PBC) will have a suboptimal biochemical response to ursodeoxycholic acid (UDCA), which can be improved by the addition of fibrates. This exploratory study aims to evaluate the long-term real-life biochemical response of different fibrates, including ciprofibrate, in subjects with UDCA-unresponsive PBC. Methods: The Brazilian Cholestasis Study Group multicenter database was reviewed to assess the response rates to UDCA plus fibrates in patients with UDCA-unresponsive PBC 1 and 2 years after treatment initiation by different validated criteria. Results: In total, 27 patients (100% women, mean age 48.9 ± 9.2 years) with PBC were included. Overall response rates to fibrates by each validated criterion varied from 39 to 60% and 39–76% at 12 and 24 months after treatment combination, respectively. Combination therapy resulted in a significant decrease in ALT and ALP only after 2 years, while GGT significantly improved in the first year of treatment. Treatment response rates at 1 and 2 years appear to be comparable between ciprofibrate and bezafibrate using all available criteria. Conclusion: Our findings endorse the efficacy of fibrate add-on treatment in PBC patients with suboptimal response to UDCA. Ciprofibrate appears to be at least as effective as bezafibrate and should be assessed in large clinical trials as a possibly new, cheaper, and promising option for treatment of UDCA-unresponsive PBC patients.
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Affiliation(s)
- Guilherme Grossi Lopes Cançado
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Hospital da Polícia Militar de Minas Gerais, Belo Horizonte, Brazil
- *Correspondence: Guilherme Grossi Lopes Cançado,
| | - Cláudia Alves Couto
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Laura Vilar Guedes
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Michelle Harriz Braga
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | | | | - Cristiane Alves Villela-Nogueira
- Hospital Universitário Clementino Fraga Filho e Departamento de Clínica Médica da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mateus Jorge Nardelli
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Luciana Costa Faria
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Vivian Rotman
- Hospital Universitário Clementino Fraga Filho e Departamento de Clínica Médica da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Daniel Ferraz de Campos Mazo
- Divisão de Gastroenterologia (Gastrocentro), Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, Brazil
| | | | | | - Liana Codes
- Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
- Hospital Português, Salvador, Brazil
| | - Mario Guimarães Pessoa
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Paulo Lisboa Bittencourt
- Hospital Português, Salvador, Brazil
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil
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Ferraz ML, Strauss E, Perez RM, Schiavon LL, Ono SK, Pessoa MG, Ferreira AP, Nabuco L, Carvalho-Filho R, Tovo CV, Souto F, Abrão P, Reuter T, Dantas T, Vigani A, Porta G, Ferreira MS, Paraná R, Cimerman S, Bittencourt PL. Brazilian Society of Hepatology and Brazilian Society of Infectious Diseases Guidelines for the Diagnosis and Treatment of Hepatitis B. Braz J Infect Dis 2020; 24:434-451. [PMID: 32926839 PMCID: PMC9392086 DOI: 10.1016/j.bjid.2020.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/28/2020] [Accepted: 07/31/2020] [Indexed: 12/04/2022] Open
Abstract
Chronic hepatitis B is an important health problem that can progress to cirrhosis and complications such as hepatocellular carcinoma. There is approximately 290 million of people with chronic hepatitis B virus (HBV) infection worldwide, however only 10% of patients are currently identified. Most part of Brazil is considered of low prevalence of HBV infection but there are some regions with higher frequency of carriers. Unfortunately, many infected patients are not yet identified nor evaluated for treatment. The Brazilian Society of Infectious Diseases (SBI) and the Brazilian Society of Hepatology worked together to elaborate a guideline for diagnosis and treatment of hepatitis B. The document includes information regarding the population to be tested, diagnostic tools, indications of treatment, therapeutic schemes and also how to handle HBV infection in specific situations (pregnancy, children, immunosuppression, etc). Delta infection is also part of the guideline, since it is an important infection in some parts of the country.
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Affiliation(s)
| | - Edna Strauss
- Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | | | | | | | - Leticia Nabuco
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Cristiane Valle Tovo
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | | | - Paulo Abrão
- Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Tania Reuter
- Universidade Federal do Espírito Santo, Vitória, ES, Brazil
| | - Thor Dantas
- Universidade Federal do Acre, Rio Branco, AC, Brazil
| | - Aline Vigani
- Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Gilda Porta
- Hospital Menino Jesus, Hospital Sírio Libanês e Hospital A C Camargo Câncer Center, São Paulo, SP, Brazil
| | | | | | - Sergio Cimerman
- Instituo de Infectologia Emilio Ribas, São Paulo, SP, Brazil
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8
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Benzaken AS, Girade R, Catapan E, Pereira GFM, Almeida ECD, Vivaldini S, Fernandes N, Razavi H, Schmelzer J, Ferraz ML, Ferreira PRA, Pessoa MG, Martinelli A, Souto FJD, Walsh N, Mendes-Correa MC. Hepatitis C disease burden and strategies for elimination by 2030 in Brazil. A mathematical modeling approach. Braz J Infect Dis 2019; 23:182-190. [PMID: 31145876 PMCID: PMC9428180 DOI: 10.1016/j.bjid.2019.04.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 04/19/2019] [Indexed: 12/16/2022] Open
Abstract
Introduction and aim Hepatitis C is a key challenge to public health in Brazil. The objective of this paper was to describe the Brazilian strategy for hepatitis C to meet the 2030 elimination goal proposed by World Health Organization (WHO). Methods A mathematical modeling approach was used to estimate the current HCV-infected Brazilian population, and to evaluate the relative costs of two different scenarios to address HCV disease burden in Brazil: (1) if no further changes are made to the HCV treatment program in Brazil; (2) where the WHO targets for 2030 elimination are met through diagnosis and treatment efforts peaking before 2024. Results An anti-HCV prevalence of 0.53% was calculated for the total population. It was estimated that the number of HCV-RNA+ individuals in Brazil in 2017 was 632,000 (0.31% of the population). Scale-up of treatment and diagnosis over time will be necessary in order to achieve WHO targets beginning in 2018. Direct costs (diagnostic, treatment and healthcare costs) are projected to increase significantly during the scale-up of treatment and diagnosis in the initial years of the intervention scenario, but then fall below the base case on an annual basis by 2025–2036, once HCV is eliminated, due to health sectors savings from the prevention of HCV liver-related morbidity and mortality. Conclusion Achieving the WHO targets is technically feasible in Brazil with a scale-up of treatment and diagnosis over time, beginning in 2018. However, elimination of hepatitis C requires policy changes to substantially scale-up prevention, screening and treatment of HCV, together with public health advocacy to raise awareness among affected populations and healthcare providers.
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Affiliation(s)
- Adele Schwartz Benzaken
- Ministry of Health, Prevention and Control of STI, HIV/AIDS and Viral Hepatitis, Department of Surveillance, Brasília, DF, Brazil; Tropical Medicina Foundation Heitor Vieira Dourado, Manaus, Amazon, AM, Brazil
| | - Renato Girade
- Ministry of Health, Prevention and Control of STI, HIV/AIDS and Viral Hepatitis, Department of Surveillance, Brasília, DF, Brazil
| | - Elisa Catapan
- Ministry of Health, Prevention and Control of STI, HIV/AIDS and Viral Hepatitis, Department of Surveillance, Brasília, DF, Brazil
| | - Gerson Fernando Mendes Pereira
- Ministry of Health, Prevention and Control of STI, HIV/AIDS and Viral Hepatitis, Department of Surveillance, Brasília, DF, Brazil
| | - Elton Carlos de Almeida
- Ministry of Health, Prevention and Control of STI, HIV/AIDS and Viral Hepatitis, Department of Surveillance, Brasília, DF, Brazil
| | - Simone Vivaldini
- Ministry of Health, Prevention and Control of STI, HIV/AIDS and Viral Hepatitis, Department of Surveillance, Brasília, DF, Brazil
| | - Neide Fernandes
- Ministry of Health, Prevention and Control of STI, HIV/AIDS and Viral Hepatitis, Department of Surveillance, Brasília, DF, Brazil
| | - Homie Razavi
- Center for Disease Analysis Foundation, Polaris Observatory, Lafayette, CO, USA
| | - Jonathan Schmelzer
- Center for Disease Analysis Foundation, Polaris Observatory, Lafayette, CO, USA
| | - Maria Lucia Ferraz
- Federal University of São Paulo, Gastroenterology Division, São Paulo, SP, Brazil
| | | | - Mario Guimarães Pessoa
- University of São Paulo School of Medicine, Division of Gastroenterology and Hepatology, São Paulo, SP, Brazil
| | - Ana Martinelli
- University of São Paulo School of Medicine, Department of Medicine, Ribeirão Preto, São Paulo, SP, Brazil
| | | | - Nick Walsh
- Pan American Health Organization (PAHO), Department of Communicable Diseases and Environmental Determinants of Health, Washington, DC, USA
| | - Maria Cassia Mendes-Correa
- Ministry of Health, Prevention and Control of STI, HIV/AIDS and Viral Hepatitis, Department of Surveillance, Brasília, DF, Brazil; University of São Paulo School of Medicine, Lim/52, Tropical Medicine Institute, São Paulo, SP, Brazil.
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9
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Barbosa MED, Zaninotto AL, de Campos Mazo DF, Pessoa MG, de Oliveira CPMS, Carrilho FJ, Farias AQ. Hepatitis C virus eradication improves immediate and delayed episodic memory in patients treated with interferon and ribavirin. BMC Gastroenterol 2017; 17:122. [PMID: 29178838 PMCID: PMC5702148 DOI: 10.1186/s12876-017-0679-5] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 11/15/2017] [Indexed: 12/11/2022] Open
Abstract
Background Chronic hepatitis C virus (HCV) infection is associated with impairment of cognitive function and mood disorders. Our aim was to evaluate the impact of sustained virological response (SVR) on cognitive function and mood disorders. Method A prospective exploratory one arm study was conducted. Adult clinically compensated HVC patients were consecutively recruited before treatment with interferon and ribavirin for 24 to 48 weeks, according to HCV genotype. Clinical, neurocognitive and mood assessments using the PRIME-MD and BDI instruments were performed at baseline, right after half of the expected treatment has been reached and 6 months after the end of antiviral treatment. Exclusion criteria were the use of illicit psychotropic substances, mental confusion, hepatic encephalopathy, hepatocellular carcinoma, severe anemia, untreated hypothyroidism, Addison syndrome and major depression before treatment. Results Thirty six patients were enrolled and 21 completed HCV treatment (n = 16 with SVR and n = 5 without). Regardless of the viral clearance at the end of treatment, there was a significant improvement in the immediate verbal episodic memory (p = 0.010), delayed verbal episodic memory (p = 0.007), selective attention (p < 0.001) and phonemic fluency (p = 0.043). Patients with SVR displayed significant improvement in immediate (p = 0.045) and delayed verbal episodic memory (p = 0.040) compared to baseline. The baseline frequency of depression was 9.5%, which rose to 52.4% during treatment, and returned to 9.5% 6 months after the end of treatment, without significant difference between patients with and without SVR. Depressive symptoms were observed in 19.1% before treatment, 62% during (p = 0.016) and 28.6% 6 months after the end of treatment (p = 0.719). Conclusions Eradication of HCV infection improved cognitive performance but did not affect the frequency of depressive symptoms at least in the short range.
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Affiliation(s)
- Mary Ellen Dias Barbosa
- Division of Psychology, Clinics Hospital, University of Sao Paulo School of Medicine, Avenida Dr. Eneas Carvalho de Aguiar, 255, São Paulo, 05403-900, Brazil. .,Division of Clinical Gastroenterology and Hepatology, Clinics Hospital, Department of Gastroenterology, University of São Paulo School of Medicine, Avenida Dr. Eneas Carvalho de Aguiar, 255, sala 9159, São Paulo, 05403-900, Brazil. .,Department of Gastroenterology, University of Sao Paulo School of Medicine, Av. Dr. Enéas de Carvalho Aguiar n° 255, São Paulo, 05403-000, Brazil.
| | - Ana Luiza Zaninotto
- Division of Psychology, Clinics Hospital, University of Sao Paulo School of Medicine, Avenida Dr. Eneas Carvalho de Aguiar, 255, São Paulo, 05403-900, Brazil
| | - Daniel Ferraz de Campos Mazo
- Division of Clinical Gastroenterology and Hepatology, Clinics Hospital, Department of Gastroenterology, University of São Paulo School of Medicine, Avenida Dr. Eneas Carvalho de Aguiar, 255, sala 9159, São Paulo, 05403-900, Brazil.,Division of Gastroenterology, School of Medical Sciences, University of Campinas, Rua Carlos Chagas, 420, Campinas, 13083-878, Brazil
| | - Mario Guimarães Pessoa
- Division of Clinical Gastroenterology and Hepatology, Clinics Hospital, Department of Gastroenterology, University of São Paulo School of Medicine, Avenida Dr. Eneas Carvalho de Aguiar, 255, sala 9159, São Paulo, 05403-900, Brazil
| | - Cláudia Pinto Marques Souza de Oliveira
- Division of Clinical Gastroenterology and Hepatology, Clinics Hospital, Department of Gastroenterology, University of São Paulo School of Medicine, Avenida Dr. Eneas Carvalho de Aguiar, 255, sala 9159, São Paulo, 05403-900, Brazil
| | - Flair José Carrilho
- Division of Clinical Gastroenterology and Hepatology, Clinics Hospital, Department of Gastroenterology, University of São Paulo School of Medicine, Avenida Dr. Eneas Carvalho de Aguiar, 255, sala 9159, São Paulo, 05403-900, Brazil
| | - Alberto Queiroz Farias
- Division of Clinical Gastroenterology and Hepatology, Clinics Hospital, Department of Gastroenterology, University of São Paulo School of Medicine, Avenida Dr. Eneas Carvalho de Aguiar, 255, sala 9159, São Paulo, 05403-900, Brazil
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10
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Alves R, Queiroz ATL, Pessoa MG, da Silva EF, Mazo DFC, Carrilho FJ, Carvalho-Filho RJ, de Carvalho IMVG. The presence of resistance mutations to protease and polymerase inhibitors in Hepatitis C virus sequences from the Los Alamos databank. J Viral Hepat 2013; 20:414-21. [PMID: 23647958 DOI: 10.1111/jvh.12051] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [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] [Received: 09/25/2012] [Accepted: 11/15/2012] [Indexed: 12/14/2022]
Abstract
Several new direct-acting antiviral (DAA) drugs are in development for chronic hepatitis C viral (HCV) infection, and NS3-NS4A serine protease and the NS5B RNA-dependent RNA polymerase have been the major targets. HCV variants displaying drug-resistant phenotypes have been observed both in vitro and during clinical trials. Our aim was to characterize amino acid changes at positions previously associated with resistance in protease (NS3) and polymerase (NS5B) regions from treatment-naïve HCV patients infected with genotypes 1a, 1b and 3a. All 1383 NS3 protease sequences (genotype 1a = 680, 1b = 498 and 3a = 205) and 806 NS5B polymerase sequences (genotypes 1a = 471, 1b = 329, 3a = 6) were collected from Los Alamos databank. Genotype 3a protease sequences showed the typical low-level resistance mutation V36L. NS3 sequences from other genotypes presented mutations on positions 36, 39, 41, 43, 54, 80, 109, 155 and 168 in a frequency lower than 2%, except for the mutation Q80R found in 35% of genotype 1a isolates. Polymerase sequences from genotype 3a patients showed five typical mutations: L419I, I424V, I482L, V499A and S556G. Two positions presented high polymorphism in the NS5B region from genotype 1a (V499A) and genotype 1b (C316N) subjects. Our results demonstrated a natural profile of genotype 3a that can be associated with the pre-existence of HCV variants resistant to first-generation protease inhibitors and to non-nucleoside polymerase inhibitors. Likewise, genotype 1b isolates and genotype 1a sequences exhibited pre-existing mutations associated with resistance to Palm II and Thumb I polymerase inhibitors, respectively.
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Affiliation(s)
- R Alves
- Laboratório de Hepatologia Molecular Aplicada, Setor de Hepatites, Divisão de Gastroenterologia, Universidade Federal de São Paulo, Sao Paulo, Brazil
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11
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Pessoa MG, Bzowej N, Berenguer M, Phung Y, Kim M, Ferrell L, Hassoba H, Wright TL. Evolution of hepatitis C virus quasispecies in patients with severe cholestatic hepatitis after liver transplantation. Hepatology 1999; 30:1513-20. [PMID: 10573532 DOI: 10.1002/hep.510300610] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Evolution of hepatitis C quasispecies may be one mechanism by which fibrosing cholestatic hepatitis develops after liver transplantation. In this study, we compared changes in quasispecies complexity and/or divergence in (1) hepatitis C-infected immunosuppressed transplant recipients and in immunocompetent controls; (2) transplant recipients with mild recurrence, and in those with the most severe form of posttransplantation recurrence. Quasispecies were measured in 12 hepatitis C-infected patients pretransplantation and posttransplantation (6 with mild and 6 with severe recurrence), and in 5 immunocompetent patients with similar follow-up, and characterized by heteroduplex mobility and sequence analysis of the hypervariable region. Although the number of variants (complexity) did not change with time in either group, there was a qualitative change in the variants with time (divergence) in immunocompromised, but not in immunocompetent patients. These changes were most marked with severe recurrence, and preceded the development of severe disease. Phylogenetic analysis confirmed that most posttransplantation variants were unrelated to those detected pretransplantation. These observations suggest that in the absence of immune suppression, there is minor evolution of quasispecies. With immune suppression, divergence of quasispecies is enhanced, resulting in selection/emergence of many new variants, particularly in those with fibrosing cholestatic hepatitis. Thus, quasispecies may influence disease progression in immune suppressed populations.
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Affiliation(s)
- M G Pessoa
- Department of Veterans Affairs Medical Center, University of California, San Francisco 94121, USA
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12
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Pessoa MG, Wright TL. Overview of HBV therapy. Adv Exp Med Biol 1999; 458:1-10. [PMID: 10549374 DOI: 10.1007/978-1-4615-4743-3_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Affiliation(s)
- M G Pessoa
- Department of Veterans Affairs Medical Center, San Francisco, California 94121, USA
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13
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Hassoba HM, Bzowej N, Berenguer M, Kim M, Zhou S, Phung Y, Grant R, Pessoa MG, Wright TL. Evolution of viral quasispecies in interferon-treated patients with chronic hepatitis C virus infection. J Hepatol 1999; 31:618-27. [PMID: 10551384 DOI: 10.1016/s0168-8278(99)80340-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [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: 12/04/2022]
Abstract
BACKGROUND/AIMS To evaluate whether interferon treatment failure/relapse is related to changes in hepatitis C virus quasispecies complexity (number of variants) or diversity (genetic relatedness of variants). METHODS We analyzed hypervariable region heterogeneity in hepatitis C virus-infected patients by heteroduplex mobility assay and by phylogenetic analysis of sequenced clones. Sera from 11 patients were tested. Response was defined biochemically and virologically. Patients were treated with 3 or 6 MIU interferon for 6 months and followed up for 6 months. Four patients were non-responders, four were transient responders and three untreated patients served as controls. Three time points were studied for the non-responders (pre-interferon, end of interferon, end of 6 months of follow-up), two for the transient responders (pre-interferon and post follow-up) and two for the controls (1 year apart). A total of 260 clones were examined by heteroduplex mobility assay and 144 clones were sequenced. RESULTS A linear correlation between heteroduplex mobility and nucleotide substitutions was observed, validating this method for assessment of quasispecies diversity. Although complexity at each time point was similar in all groups, diversity increased significantly with interferon treatment. The percentage of new variants in follow up was significantly higher in non-responders than in controls. These new variants exhibited a greater change in heteroduplex mobility, a higher percentage of changes in amino acids in non-responders compared to controls and were found to cluster separately from pretreatment variants when analyzed phylogenetically. These changes were less marked in transient responders. CONCLUSIONS These mutations may allow hepatitis C virus to escape antiviral effects of interferon therapy.
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Affiliation(s)
- H M Hassoba
- Department of Veterans Affairs Medical Center, University of California, San Francisco 94121, USA
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14
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Abstract
Chronic hepatitis B infection is a worldwide public health problem, which is particularly important in countries of Asia. Interferon has long been available for the treatment of patients with active replication (hepatitis B virus (HBV) e antigen and HBV-DNA positive) with evidence of chronic liver disease (elevated serum alanine aminotransferase and chronic hepatitis on liver biopsy). Doses of interferon of 10 MU, t.i.w. or 5 MU, q day for 16 weeks result in e antigen and HBV-DNA loss in approximately one-third of individuals who meet these treatment criteria. The major limitations of interferon are: (i) side effects of influenza-like symptoms; (ii) need for parenteral administration; and (iii) concerns about safety in patients with hepatic decompensation. Nucleoside and nucleotide analogues have potent antiviral activity. The largest experience is with lamivudine (3-thiacytadine), a reverse transcriptase inhibitor that was recently approved by the USA Federal Drug Administration. At doses of 100 mg/day for 52 weeks, suppression of HBV replication is almost universal, with e antigen loss and improvement in histology being achieved in one-third and two-thirds of patients, respectively. The major advantages of lamivudine are: (i) good tolerability; (ii) oral route of administration; and (iii) safety in patients with hepatic decompensation. The major disadvantage is drug resistance, which is observed with increasing frequency following prolonged administration. New agents, such as adefovir dipivoxil, offer promise either alone or in combination with lamivudine in the treatment of individuals who are 'treatment naive' as well as in the treatment individuals who have developed lamivudine resistance.
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Affiliation(s)
- M G Pessoa
- Department of Veterans Affairs Medical Center, University of California, San Francisco 94121, USA
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15
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Pessoa MG, Terrault NA, Ferrell LD, Detmer J, Kolberg J, Collins ML, Viele M, Lake JR, Roberts JP, Ascher NL, Wright TL. Hepatitis after liver transplantation: the role of the known and unknown viruses. Liver Transpl Surg 1998; 4:461-8. [PMID: 9791156 DOI: 10.1002/lt.500040603] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This study was designed to determine the cause of posttransplantation hepatitis in patients undergoing transplantation for liver disease of nonviral cause; the role of acquired hepatitis B virus (HBV), hepatitis C virus (HCV), and hepatitis G virus (HGV) in posttransplantation hepatitis; and the course of posttransplantation hepatitis of unknown cause. Two hundred forty-three patients underwent transplantation for nonviral liver diseases (mean age, 48 years; 103 men, 140 women). Serological and virological assays for HBV and HCV were performed pretransplantation to exclude preexisting infection and posttransplantation to investigate the cause of posttransplantation hepatitis. Histology was graded on all available biopsy specimens; posttransplantation hepatitis was assessable in 150 patients. Posttransplantation hepatitis was present in 29% (44 of 150) of the patients after a median follow-up of 47 months (range, 1 to 101 months). Actuarial survival was significantly lower in patients with posttransplantation hepatitis compared with patients without (71% v 89% at 5-year follow-up; P = .03). HCV and HBV were identified posttransplantation in 14% and 9% of patients with hepatitis, respectively. After the exclusion of HCV and HBV infection, 22% (33 of 150) of the patients had posttransplantation hepatitis of unknown cause. HGV was present in 58% of these patients, but HGV was equally prevalent in patients without posttransplantation hepatitis. When patients with HBV and HCV were excluded, there was no difference in survival between patients with posttransplantation hepatitis compared with patients without (P = .08, log-rank test). Posttransplantation hepatitis was present in approximately 30% of the patients undergoing transplantation for nonviral diseases, with a median follow-up of 47 months. Known hepatitis viruses (HBV, HCV) were present in one fourth of the patients with posttransplantation hepatitis; 22% (33 of 150) of the patients had hepatitis of unknown cause, suggesting that other, as yet undiscovered, hepatitis viruses may exist.
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Affiliation(s)
- M G Pessoa
- Departments of Medicine, University of California, San Francisco, USA
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Hassoba HM, Pessoa MG, Terrault NA, Lewis NJ, Hayden M, Hunt JC, Qiu X, Lou SC, Wright TL. Antienvelope antibodies are protective against GBV-C reinfection: evidence from the liver transplant model. J Med Virol 1998; 56:253-8. [PMID: 9783694] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
An assay for the detection of antibody against the second envelope (E2) protein of GB virus type C (GBV-C) has been developed. Early reports suggested that this antibody was a marker of viral clearance, yet it is unknown whether anti-E2 is protective against further GBV-C infection. The primary aims were to determine (1) if posttransplantation immunosuppression alters the prevalence of anti-E2; and (2) if anti-E2 positivity pretransplantation protects against acquisition of GBV-C infection posttransplantation. Fifty-four recipients who underwent orthotopic liver transplantation for end-stage liver disease of nonviral etiologies were tested for GBV-C RNA using a PCR-based assay and anti-E2 antibodies by an enzyme-linked immunoassay. Anti-E2 was present in 35% and in 46% of patients pre- and posttransplantation, respectively. Anti-E2 positivity pretransplantation was strongly associated with anti-E2 positivity after transplantation (P < 0.001); 83% of patients with anti-E2 prior to transplantation remained anti-E2-positive after transplantation. A negative association between presence of GBV-C viremia and presence of anti-E2 was found in all patients tested either prior to or following transplantation (P=0.03). Acquisition of GBV-C infection was significantly lower in patients who were anti-E2-positive prior to transplantation (2/13) compared to those who were anti-E2-negative (12/26) (P=0.05). It is concluded that immunosuppression does not reduce the prevalence of anti-E2 after transplantation in those who are seroreactive prior to transplantation. Anti-E2 appears to be a neutralizing antibody whose presence at the time of liver transplantation protects against acquisition of GBV-C infection in the peritransplantation period.
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Affiliation(s)
- H M Hassoba
- Department of Medicine, University of California, Department of Veterans Affairs Medical Center, San Francisco, USA
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Pessoa MG, Terrault NA, Detmer J, Kolberg J, Collins M, Hassoba HM, Wright TL. Quantitation of hepatitis G and C viruses in the liver: evidence that hepatitis G virus is not hepatotropic. Hepatology 1998; 27:877-80. [PMID: 9500722 DOI: 10.1002/hep.510270335] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hepatitis G virus (HGV) is prevalent in patients with chronic liver disease and has been previously detected in liver specimens. However, it is unknown whether the virus is replicating in the liver or is simply a contaminant from serum. We sought to determine whether HGV was hepatotropic and to determine whether coinfection with HGV and hepatitis C virus (HCV) influenced the level of either virus. Virus was quantitated using branched DNA (bDNA) assay for both HGV and HCV in the liver explants and pretransplant serum samples from 30 transplant recipients: Group I, HGV/HCV coinfection (n = 10); group II, HCV infection alone, (n = 8); group III, HGV alone (n = 12). In patients with coinfection HCV (RNA) titers in liver were consistently higher than those for HGV RNA (median 1.13 x 10(8) and 360,000 Eq/g respectively, P < .01). The ratio of liver/serum viral RNA was significantly higher for HCV than for HGV (median 129 and 0.3 respectively, P < .01). Levels of HCV RNA were similar in patients with HCV infection alone versus those with HGV/HCV coinfection (median; liver = 1.15 x 10(7) vs. 1.13 x 10(8) Eq/g, serum = 500,000 vs. 200,000 Eq/mL) and levels of HGV RNA in liver and serum were similar in patients with HGV infection alone compared to those with HGV/HCV coinfection (median; liver = 1.2 x 10(6) vs. 4.0 x 10(5) Eq/g, serum = 4.5 x 106 vs. 2.6 x 10(6) Eq/mL). Levels of either virus appeared unaffected by the presence of an additional virus. The high ratio of HCV RNA levels in liver compared to serum is consistent with its known hepatotropism, but this pattern was not observed for HGV. The median liver/serum ratio of HGV RNA was less than unity, a finding consistent with serum contamination of liver tissue. Thus we conclude that the liver is not the main site of HGV replication.
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Affiliation(s)
- M G Pessoa
- Department of Medicine, University of California, San Francisco, USA
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Abstract
This review emphasizes the role of HCV in the transplant setting. Prolonged HCV infection results in end-stage liver disease and as such represents a common indication for liver transplantation. Recurrence of infection is almost universal after transplantation in those with viremia before transplantation. Acquired disease is uncommon but nevertheless important, particularly in organ populations in whom screening for infection is not routine. The natural history of post-transplantation disease suggests that the effect on graft or patient survival is minor, at least during short-term follow-up. Long-term follow-up is needed, as well as more detailed study of the factors contributing to severity of post-transplantation disease. Kidney transplant recipients are commonly infected with HCV prior to transplantation. HCV infection after transplantation is associated with an increased risk of liver disease and infectious complications, but its effect on survival is still controversial. Similarly, observations in recipients of other solid organ transplants, such as heart and lung, and bone marrow patients suggest that HCV infection usually is not a major cause of mortality in the first 5 to 10 years of follow-up. Many issues still need to be addressed. The most important is the identification of factors that contribute to disease progression. Finally, effective therapies to eradicate infection and prevent disease progression are awaited.
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Affiliation(s)
- M G Pessoa
- Division of Gastroenterology, University of California San Francisco, San Francisco, California, USA
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Pessoa MG, Terrault NA, Ferrell LD, Kim JP, Kolberg J, Detmer J, Collins ML, Yun AJ, Viele M, Lake JR, Roberts JP, Ascher NL, Wright TL. Hepatitis G virus in patients with cryptogenic liver disease undergoing liver transplantation. Hepatology 1997; 25:1266-70. [PMID: 9141450 DOI: 10.1002/hep.510250535] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
To examine the prevalence of hepatitis G virus (HGV) in end-stage liver disease of unknown cause and the role of HGV infection in posttransplantation hepatitis, we studied 46 patients undergoing liver transplantation (mean age, 50 years; M:F, 18:28) with cryptogenic cirrhosis. HGV RNA was detected by polymerase chain reaction (PCR) and was quantified by a branched DNA (bDNA) assay. The prevalence of HGV RNA was determined in samples collected before and after liver transplantation and was found to be 22% and 67%, respectively. We evaluated the prevalence of posttransplantation hepatitis in 25 patients, 16 of whom were HGV-positive and 9 were HGV-negative. The proportion of patients with hepatitis was not significantly different in the two groups (38% in HGV-positive and 22% in HGV-negative patients). The median histological scores were significantly higher in liver biopsies from patients with HGV infection than in those without HGV infection (2 [range, 0-14] and 1 [range, 0-3]; P = .01), but the histological scores were low overall. The duration of follow-up was similar in the two groups. HGV RNA levels were not correlated with the severity of liver disease based on histological score (r = -.08). Graft survival and patient survival were not significantly different. We concluded that liver disease was frequent (32%) after transplantation in patients with a pretransplantation diagnosis of cryptogenic cirrhosis, although the disease was generally mild. Although HGV RNA was demonstrable in the majority (67%) of patients after transplantation, there was no relationship between the presence of HGV RNA and the presence of posttransplantation liver disease. The finding of posttransplantation hepatitis in the absence of known viruses (A-G), suggests that other, as-yet-unidentified viruses may be important.
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Affiliation(s)
- M G Pessoa
- Department of Medicine, Department of Veterans Affairs Medical Center and University of California, San Francisco 94121, USA
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Affiliation(s)
- M G Pessoa
- Department of Veterans Affairs Medical Center, San Francisco, CA, USA
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