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Benhammou JN, Leng M, Shah SC, Cholankeril G, Dong TS, Patel AA, Tong MJ. Exposure to Agent Orange and Hepatocellular Carcinoma Among US Military Personnel. JAMA Netw Open 2023; 6:e2346380. [PMID: 38048128 PMCID: PMC10696483 DOI: 10.1001/jamanetworkopen.2023.46380] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/24/2023] [Indexed: 12/05/2023] Open
Abstract
Importance Hepatocellular carcinoma (HCC) and its mortality are on the rise. Viral hepatitis and alcohol are leading risk factors; however, other risk factors among veterans are less defined, including Agent Orange (AO), an herbicide linked to several cancers. Objective To assess the association of AO exposure and HCC in a national cohort of Vietnam veterans. Design, Setting, and Participants This retrospective cohort study included Vietnam veterans who served between 1966 and 1975, were male, were older than 18 years at the time of deployment, and had established follow-up in the Veterans Affairs (VA) between 2000 and 2019. Veterans with AO exposure were identified in the disability data via validated clinical surveys. Relevant clinical risk factors for cirrhosis and HCC were collected. Patients were stratified based on cirrhosis status, as defined by consecutive diagnosis found by documented International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision scores or calculated Fibrosis-4 scores. Data were collected from January 1, 2019, to December 31, 2020, and analyzed from December 2020 to October 2023. Main Outcome and Measures Incident HCC was the primary outcome. AO and HCC association was estimated using a multivariable Cox regression analysis, with death and liver transplant as competing events. Results Of the 296 505 eligible veterans (222 545 [75.1%] White individuals and 44 342 [15.0%] Black individuals), 170 090 (57%) had AO exposure (mean [SD] age, 21.62 [3.49] years; 131 552 White individuals [83.2%] and 22 767 Black individuals [14.4%]) and 35 877 (12.1%) had cirrhosis. Veterans who were not exposed to AO were more likely to smoke (109 689 of 126 413 [86.8%] vs 146 061 of 170 090 [85.9%]); use alcohol (54 147 of 126 413 [42.8%] vs 71 951 of 170 090 [42.3%]) and have viral hepatitis (47 722 of 126 413 [37.8%] vs 58 942 of 170 090 [34.7%]). In a multivariable competing risk model, AO exposure was not associated with HCC. Among veterans with cirrhosis, self-identification as Hispanic individuals (aHR, 1.51; 95% CI, 1.30-1.75; P <.001) or Black individuals (aHR, 1.18; 95% CI, 1.05-1.32; P = .004), and having a diagnosis of viral hepatitis (aHR, 3.71; 95% CI, 3.26-4.24; P <.001), alcohol-associated liver disease (aHR, 1.32; 95% CI, 1.19-1.46; P <.001), and nonalcoholic fatty liver disease (NAFLD) (aHR, 1.92; 95% CI, 1.72-2.15; P <.001) were associated with HCC. Among veterans without cirrhosis, hypertension (aHR, 1.63; 95% CI, 1.23-2.15; P <.001) and diabetes (aHR, 1.52; 95% CI, 1.13-2.05; P = .005) were also associated with HCC. Early smoking and alcohol use were significant risk factors for HCC. Conclusions and Relevance In this large nationwide cohort study of Vietnam veterans, AO exposure was not associated with HCC. Smoking, alcohol, viral hepatitis, and NAFLD were the most important clinical risk factors for HCC.
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Affiliation(s)
- Jihane N. Benhammou
- Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles
| | - Mei Leng
- Greater Los Angeles Healthcare System, Los Angeles, California
- Biomathematics Department, University of California, Los Angeles
| | - Shailja C. Shah
- VA San Diego Healthcare System, La Jolla, California
- Division of Gastroenterology, University of California, San Diego, La Jolla
| | | | - Tien S. Dong
- Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Arpan A. Patel
- Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Myron J. Tong
- Huntington Medical Research Institutes, Pasadena, California
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2
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Pan CQ, Afdhal NH, Ankoma-Sey V, Bae H, Curry MP, Dieterich D, Frazier L, Frick A, Hann HW, Kim WR, Kwo P, Milligan S, Tong MJ, Reddy KR. First-line therapies for hepatitis B in the United States: A 3-year prospective and multicenter real-world study after approval of tenofovir alefenamide. Hepatol Commun 2022; 6:1881-1894. [PMID: 35445803 PMCID: PMC9315121 DOI: 10.1002/hep4.1964] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 12/28/2022] Open
Abstract
Real-world data are limited on tenofovir alafenamide (TAF). We aimed to study TAF real-world outcomes with other first-line regimens for chronic hepatitis B (CHB). We enrolled patients with CHB from 10 centers retrospectively and followed them for 36 months prospectively. We analyzed switching patterns of antiviral therapy and treatment outcomes of TAF, tenofovir disoproxil fumarate (TDF), and entecavir therapy. For efficacy and safety, we analyzed a subset of patients with complete data at 24 months after switching to TAF or remaining on TDF or entecavir. Among 1037 enrollees, 889 patients were analyzed. The mean age was 52%, and 72% were hepatitis B e antigen-negative. After enrollment, shifts in therapies were mostly in reduced use of TDF from 63% to 30% due to switching to TAF. Clinical parameters were compared at enrollment or initiation to measures at 24 months for patients remaining on TAF (187), TDF (229), or entecavir (181). At 24 months, a significantly higher portion of patients on TAF achieved hepatitis B virus (HBV) DNA ≤ 20 IU/ml (93% vs. 86%; p = 0.012) and normalized alanine aminotransferase (ALT) (66% vs. 56%; p = 0.031) with stable estimated glomerular filtration rates (eGFRs). However, a higher percentage of the patient with eGFR < 60 ml/mi/1.7 m2 was observed in the TDF-treated group (9% vs. 4%; p = 0.010). In patients who remained on entecavir or TDF for 24 months, ALT and HBV-DNA results did not differ significantly from baseline. Treatment of CHB in the United States has significantly shifted from TDF to TAF. Our data suggest that switching from TDF or entecavir to TAF may result in increased frequency of ALT normalization and potential clearance of viremia at the 24-month time point.
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Affiliation(s)
- Calvin Q Pan
- Beijing Ditan HospitalCapital Medical UniversityBeijingChina.,NYU Langone HealthNYU Grossman School of MedicineNew YorkNew YorkUSA
| | - Nezam H Afdhal
- Beth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | | | - Ho Bae
- St. Vincent Medical CenterAsian Pacific Liver CenterLos AngelesCaliforniaUSA
| | | | | | | | | | - Hie-Won Hann
- Thomas Jefferson University HospitalPhiladelphiaPennsylvaniaUSA
| | - W Ray Kim
- Stanford University School of MedicineStanfordCaliforniaUSA
| | - Paul Kwo
- Stanford University School of MedicineStanfordCaliforniaUSA
| | | | - Myron J Tong
- Huntington Medical Research InstitutesPasadenaCaliforniaUSA
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3
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Pan CQ, Jacobson IM, Martin P, Kwo P, Lim J, Han SHB, Hu KQ, Ahn J, Tong MJ. Letter to the editor: Both universal screening and vaccination are essential components of a multipronged approach to hepatitis B elimination. Hepatology 2022; 75:1664-1666. [PMID: 35092080 DOI: 10.1002/hep.32366] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 01/20/2022] [Indexed: 12/08/2022]
Affiliation(s)
- Calvin Q Pan
- Center of Liver DiseasesBeijing Ditan HospitalCapital Medical UniversityBeijingChina
- Division of Gastroenterology and HepatologyNYU Langone HealthNYU Grossman School of MedicineNew YorkNew YorkUSA
| | - Ira M Jacobson
- Division of Gastroenterology and HepatologyNYU Langone HealthNYU Grossman School of MedicineNew YorkNew YorkUSA
| | - Paul Martin
- Division of Digestive Health and Liver DiseasesMiller School of MedicineUniversity of MiamiMiamiFloridaUSA
| | - Paul Kwo
- Division of Gastroenterology and Hepatology, Stanford Health Care-Valley CareStanford University, School of MedicineStanfordCaliforniaUSA
| | - Joseph Lim
- Yale Digestive DiseasesYale New Haven HospitalYale School of MedicineNew HavenConnecticutUSA
| | - Steven-Huy B Han
- Pfleger Liver InstituteDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
| | - Ke-Qin Hu
- Division of Gastroenterology and HepatologyUCI HealthUniversity of California, Irvine School of MedicineIrvineCaliforniaUSA
| | - Joseph Ahn
- Division of Gastroenterology and HepatologyOregon Health & Science University, School of MedicinePortlandOregonUSA
| | - Myron J Tong
- Liver CenterHuntington Medical Research InstitutesPasadenaCaliforniaUSA
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Benhammou JN, Lin J, Aby ES, Markovic D, Raman SS, Lu DS, Tong MJ. Nonalcoholic fatty liver disease-related hepatocellular carcinoma growth rates and their clinical outcomes. Hepatoma Res 2021; 7. [PMID: 34966854 PMCID: PMC8713558 DOI: 10.20517/2394-5079.2021.74] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Aim: Nonalcoholic fatty liver disease (NAFLD)-associated hepatocellular carcinoma (HCC) is projected to become the leading indication for liver transplantation. Previous studies indicate that tumor growth rates (TGR) may predict survival and were helpful in determining HCC surveillance intervals. Therefore, we aimed to determine its usefulness in predicting clinical outcomes and treatments. Methods: We conducted a retrospective study of hepatitis B, C and NAFLD-HCC cases. TGR was measured using 2-consecutive pre-treatment contrast-enhanced imaging studies ≥ 25 days apart. A multivariate regression model was used to determine predictors of TGR. In addition, the Cox regression model was used to evaluate the relationship between TGR and overall survival. Results: From 2000–2019, the study cohort comprised 38, 60, and 47 HBV, HCV, and NAFLD patients, respectively, with TGRs. NAFLD-HCC tumor size was inversely correlated to the extent of liver disease as measured by Child-Pugh score (7.2 cm in non-cirrhosis; 3.7 cm, 2.6 cm, and 2.1 cm in Child A, B, and C, respectively; P < 0.001). After adjusting for baseline characteristics, the TGR per month was fastest in HBV (9.4%, 95%CI: 6.3%-12.5%) compared to HCV (4.9%, 95%CI: 2.8%-7%) and NAFLD patients (3.6%, 95%CI: 1.6%-6.7%). Predictors of TGR included elevated AFP, low albumin, and smaller tumor size. Fast TGR in viral etiologies had higher mortality [adj. hazard ratio (HR) = 2.6, 95%CI: 1.2–5.7, P = 0.02] than slow TGRs, independent of treatments. Fast TGR in NAFLD had a trend towards higher mortality (HR = 3.6, 95%CI: 0.95–13.3, P = 0.059). Conclusion: NAFLD-HCC patients have more indolent growths than viral-related HCC TGRs. The addition of TGR as a biomarker may assist in stratifying treatment options.
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Affiliation(s)
- Jihane N Benhammou
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, Los Angeles, CA 90095, USA.,Division of Gastroenterology, Hepatology and Parenteral Nutrition, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90075, USA.,Pfleger Liver Institute, University of California, Los Angeles, CA 90095, USA
| | - Jonathan Lin
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Elizabeth S Aby
- Gastroenterology, Hepatology, Liver Transplantation and Nutrition, University of Minnesota, Minneapolis, MN 55455, USA
| | - Daniela Markovic
- Department of Biomathematics, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Steven S Raman
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - David S Lu
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Myron J Tong
- Pfleger Liver Institute, University of California, Los Angeles, CA 90095, USA.,Liver Center, Huntington Medical Research Institutes, Pasadena, CA 91105, USA
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Benhammou JN, Aby ES, Shirvanian G, Manansala K, Hussain SK, Tong MJ. Improved survival after treatments of patients with nonalcoholic fatty liver disease associated hepatocellular carcinoma. Sci Rep 2020; 10:9902. [PMID: 32555268 PMCID: PMC7303220 DOI: 10.1038/s41598-020-66507-7] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/22/2020] [Indexed: 02/07/2023] Open
Abstract
Worldwide, nonalcoholic fatty liver disease (NAFLD) has reached epidemic proportions and in parallel, hepatocellular carcinoma (HCC) has become one of the fastest growing cancers. Despite the rise in these disease entities, detailed long-term outcomes of large NAFLD-associated HCC cohorts are lacking. In this report, we compared the overall and recurrence-free survival rates of NAFLD HCC cases to patients with HBV and HCV-associated HCC cases. Distinguishing features of NAFLD-associated HCC patients in the cirrhosis and non-cirrhosis setting were also identified. We conducted a retrospective study of 125 NAFLD, 170 HBV and 159 HCV HCC patients, utilizing clinical, pathological and radiographic data. Multivariate regression models were used to study the overall and recurrence-free survival. The overall survival rates were significantly higher in the NAFLD-HCC cases compared to HBV-HCC (HR = 0.35, 95% CI 0.15-0.80) and HCV-HCC (HR = 0.37, 95% CI 0.17-0.77) cases. The NAFLD-HCC patients had a trend for higher recurrence-free survival rates compared to HBV and HCV-HCC cases. Within the NAFLD group, 18% did not have cirrhosis or advanced fibrosis; Hispanic ethnicity (OR = 12.34, 95% CI 2.59-58.82) and high BMI (OR = 1.19, 95% CI 1.07-1.33) were significantly associated with having cirrhosis. NAFLD-HCC cases were less likely to exhibit elevated serum AFP (p < 0.0001). After treatments, NAFLD-related HCC patients had longer overall but not recurrence-free survival rates compared to patients with viral-associated HCC. Non-Hispanic ethnicity and normal BMI differentiated non-cirrhosis versus cirrhosis NAFLD HCC. Further studies are warranted to identify additional biomarkers to stratify NAFLD patients without cirrhosis who are at risk for HCC.
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Affiliation(s)
- Jihane N Benhammou
- Pfleger Liver Institute, University of California Los Angeles, Los Angeles, CA, USA.
| | - Elizabeth S Aby
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Gayaneh Shirvanian
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Kohlett Manansala
- Pfleger Liver Institute, University of California Los Angeles, Los Angeles, CA, USA
| | - Shehnaz K Hussain
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
- Department of Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Myron J Tong
- Pfleger Liver Institute, University of California Los Angeles, Los Angeles, CA, USA
- Liver Center, Huntington Medical Research Institutes, Pasadena, CA, USA
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6
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Myint A, Tong MJ, Beaven SW. Reactivation of Hepatitis B Virus: A Review of Clinical Guidelines. Clin Liver Dis (Hoboken) 2020; 15:162-167. [PMID: 32395244 PMCID: PMC7206320 DOI: 10.1002/cld.883] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [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: 05/24/2019] [Accepted: 08/25/2019] [Indexed: 02/04/2023] Open
Abstract
http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-4-reading-myint a video presentation of this article https://www.wileyhealthlearning.com/Activity/7088610/disclaimerspopup.aspx questions and earn CME.
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Affiliation(s)
- Anthony Myint
- Department of MedicineDavid Geffen School of MedicineUniversity of California, Los AngelesLos AngelesCA,The Vatche and Tamar Manoukian Division of Digestive DiseasesDepartment of MedicineDavid Geffen School of Medicine at UCLALos AngelesCA
| | - Myron J. Tong
- Department of MedicineDavid Geffen School of MedicineUniversity of California, Los AngelesLos AngelesCA,The Vatche and Tamar Manoukian Division of Digestive DiseasesDepartment of MedicineDavid Geffen School of Medicine at UCLALos AngelesCA
| | - Simon W. Beaven
- Department of MedicineDavid Geffen School of MedicineUniversity of California, Los AngelesLos AngelesCA,The Vatche and Tamar Manoukian Division of Digestive DiseasesDepartment of MedicineDavid Geffen School of Medicine at UCLALos AngelesCA,Division of Gastroenterology and HepatologyOlive View‐UCLA Medical CenterSylmarCA
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Saab S, Kardashian A, Saggi S, Choi G, Agopian V, Tong MJ. Use of hepatitis C-positive grafts in hepatitis C-negative liver transplant recipients is cost effective. Clin Transplant 2018; 32:e13383. [PMID: 30129981 DOI: 10.1111/ctr.13383] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 04/19/2018] [Revised: 07/02/2018] [Accepted: 08/16/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND The number of patients needing liver transplantation (LT) exceeds the number of available allografts. The current opioid epidemic in this country has increased the number of potential donors infected with hepatitis C (HCV). METHODS We assessed the incremental cost-effectiveness ratio (ICER) by comparing the costs and number of liver transplants performed using HCV-positive and HCV-negative grafts into patients without HCV infection in a decision analysis model with a 1-year time horizon. RESULTS The use of HCV-positive grafts was found to have an ICER below $50 000 across all MELD scores. Using our baseline cohort with a model for end-stage liver disease (MELD) score of 15-22, the ICER was $21 233/additional LT performed. As the MELD scores increased, the ICER decreased. Above a MELD score of 23, the use of HCV-positive grafts became cost saving (-$115 419). Our model was robust to all variables tested in the sensitivity analyses, except drug costs. CONCLUSION The results of our decision analysis model highlight the potential pharmacoeconomic benefit of utilizing HCV-positive grafts in LT candidates who are not infected with HCV. The use of HCV-positive grafts is at least cost effective and even cost saving in patients with MELD scores above 23.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, University of California, Los Angeles, California.,Department of Surgery, University of California, Los Angeles, California
| | - Ani Kardashian
- Department of Medicine, University of California, Los Angeles, California
| | - Satvir Saggi
- Department of Surgery, University of California, Los Angeles, California
| | - Gina Choi
- Department of Medicine, University of California, Los Angeles, California.,Department of Surgery, University of California, Los Angeles, California
| | - Vatche Agopian
- Department of Surgery, University of California, Los Angeles, California
| | - Myron J Tong
- Department of Surgery, University of California, Los Angeles, California
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Saab S, Ahn T, McDaniel T, Yanny B, Tong MJ. Economic Comparison of Serologic and Molecular Screening Strategies for Hepatitis C Virus. Gastroenterol Hepatol (N Y) 2018; 14:459-462. [PMID: 30302060 PMCID: PMC6170887] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Background: Hepatitis C virus (HCV) screening is traditionally performed using an enzyme-linked immunosorbent assay (ELISA), and HCV infection is confirmed by measuring the viral load using polymerase chain reaction (PCR). An alternative screening approach is to use only PCR, without the ELISA pretest. Methods: We compared the cost ratio of screening for HCV using 2 approaches: (1) ELISA followed by PCR testing, and (2) PCR testing alone. The results were analyzed using a decision analysis model. A sensitivity analysis and a threshold analysis were performed by varying both the prevalence of HCV infection (to encompass populations in which viral infection is overrepresented) as well as the costs of PCR testing. Results: Under baseline assumptions, the costs of PCR testing alone were substantially greater than the combination of ELISA and PCR testing. The cost per patient screened using combination testing was $42.30, whereas testing with only PCR cost $200.00 per patient. The prevalence of HCV had a greater impact on the cost ratio than did the costs of laboratory tests. The use of PCR testing alone became less costly only when the prevalence of HCV infection was greater than 69.5%. Otherwise, the costs of the 2 approaches were similar when the cost of PCR was 1% of that of ELISA. Conclusion: From a pharmacoeconomic basis, the current approach of HCV screening (ie, using ELISA and PCR testing) was found to be the less expensive screening strategy in a general US population and for most cohorts in which HCV infection was noted to be overrepresented. Screening for HCV is less costly using solely PCR testing only when the prevalence of HCV infection is greater than 69.5%.
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Affiliation(s)
- Sammy Saab
- Dr Saab is a professor in the Departments of Surgery and Medicine at the University of California at Los Angeles in Los Angeles, California
- Mr Ahn and Ms McDaniel are researchers in the Department of Surgery at the University of California at Los Angeles
- Dr Yanny is an attending physician in the Department of Medicine at the University of California at Los Angeles
- Dr Tong is a professor in the Department of Surgery at the University of California at Los Angeles and a professor in the Department of Medicine at the Huntington Research Institute in Pasadena, California
| | - Timothy Ahn
- Dr Saab is a professor in the Departments of Surgery and Medicine at the University of California at Los Angeles in Los Angeles, California
- Mr Ahn and Ms McDaniel are researchers in the Department of Surgery at the University of California at Los Angeles
- Dr Yanny is an attending physician in the Department of Medicine at the University of California at Los Angeles
- Dr Tong is a professor in the Department of Surgery at the University of California at Los Angeles and a professor in the Department of Medicine at the Huntington Research Institute in Pasadena, California
| | - Terina McDaniel
- Dr Saab is a professor in the Departments of Surgery and Medicine at the University of California at Los Angeles in Los Angeles, California
- Mr Ahn and Ms McDaniel are researchers in the Department of Surgery at the University of California at Los Angeles
- Dr Yanny is an attending physician in the Department of Medicine at the University of California at Los Angeles
- Dr Tong is a professor in the Department of Surgery at the University of California at Los Angeles and a professor in the Department of Medicine at the Huntington Research Institute in Pasadena, California
| | - Beshoy Yanny
- Dr Saab is a professor in the Departments of Surgery and Medicine at the University of California at Los Angeles in Los Angeles, California
- Mr Ahn and Ms McDaniel are researchers in the Department of Surgery at the University of California at Los Angeles
- Dr Yanny is an attending physician in the Department of Medicine at the University of California at Los Angeles
- Dr Tong is a professor in the Department of Surgery at the University of California at Los Angeles and a professor in the Department of Medicine at the Huntington Research Institute in Pasadena, California
| | - Myron J Tong
- Dr Saab is a professor in the Departments of Surgery and Medicine at the University of California at Los Angeles in Los Angeles, California
- Mr Ahn and Ms McDaniel are researchers in the Department of Surgery at the University of California at Los Angeles
- Dr Yanny is an attending physician in the Department of Medicine at the University of California at Los Angeles
- Dr Tong is a professor in the Department of Surgery at the University of California at Los Angeles and a professor in the Department of Medicine at the Huntington Research Institute in Pasadena, California
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Tong MJ, Theodoro CF, Salvo RT. Late development of hepatocellular carcinoma after viral clearance in patients with chronic hepatitis C: A need for continual surveillance. J Dig Dis 2018; 19:411-420. [PMID: 29889353 DOI: 10.1111/1751-2980.12615] [Citation(s) in RCA: 3] [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] [Received: 02/13/2018] [Revised: 05/25/2018] [Accepted: 06/07/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Eradication of chronic hepatitis C (CHC) infection decreases the incidence of hepatocellular carcinoma (HCC), but a risk remains. We aimed to investigate HCC development-associated factors in CHC patients with sustained virological response (SVR) after antiviral therapies. METHODS We compared CHC patients achieving SVR from 1996-2016 who did and did not develop HCC. Their median follow-up period was 8.01 years. RESULTS Compared with 164 non-HCC SVR patients, 22 who developed HCC were older at SVR (P = 0.032), had a higher incidence of diabetes (P = 0.013) and higher pre-antiviral treatment alpha-fetoprotein (AFP) levels (P = 0.016), more had fibrosis stage 3 and cirrhosis (P = 0.0009) and hepatitis B core antibody (anti-HBc) positivity (P = 0.006). Eight and seven of 22 patients, respectively, developed HCC at 4-10 years and 10 years after SVR. The longest duration from SVR to HCC was 18.7 years. Independent factors associated with HCC development were anti-HBc positivity (hazard ratio [HR] 5.57, P = 0.012), age at SVR (HR 1.08, P = 0.014), higher pre-antiviral treatment AFP levels (HR 1.01, P = 0.01) and Hispanic ethnicity (HR 12.9, P = 0.002). HCC risk was significantly less in genotype 2 patients (HR 0.2, P = 0.02) or in those with higher pre-antiviral treatment albumin levels (HR 0.33, P = 0.04). CONCLUSIONS The risk for HCC exists in a subset of CHC patients after SVR and may occur up to 18 years after viral clearance. Indefinite HCC surveillance is necessary in SVR patients with other risk factors.
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Affiliation(s)
- Myron J Tong
- Liver Center, Huntington Medical Research Institutes, Pasadena, California, USA.,Pfleger Liver Institute and the Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Rebecca T Salvo
- Liver Center, Huntington Medical Research Institutes, Pasadena, California, USA
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10
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Suraweera D, Fanous C, Jimenez M, Tong MJ, Saab S. Risk of Cardiovascular Events in Patients with Primary Biliary Cholangitis - Systematic Review. J Clin Transl Hepatol 2018; 6:119-126. [PMID: 29951355 PMCID: PMC6018312 DOI: 10.14218/jcth.2017.00064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 10/07/2017] [Revised: 12/14/2017] [Accepted: 01/02/2018] [Indexed: 01/25/2023] Open
Abstract
Background and Aims: Hypercholesterolemia is a common finding in patients with primary biliary cholangitis (PBC) and is a well-defined risk factor for cardiovascular disease. However, studies have been mixed on whether PBC patients do, in fact, have higher cardiovascular risk. The aim of this study is to review the current literature and provide an evidence-based assessment of cardiovascular risk in PBC patients. Methods: We performed a systematic literature search on PubMed regarding patients with PBC and cardiovascular events from the database inception to July 1, 2017. A total of 33 articles fulfilling our inclusion criteria were found. Results: The majority of the studies evaluated yielded no statistically significant difference in cardiovascular disease in the PBC population compared to the general public. However, some reports found a statistically significantly increase in coronary artery disease. Several studies have looked at the specific lipid profile of patients with PBC with hypocholesteremia. While these lipid abnormalities differ by stage of disease, there is evidence to suggest that the specific lipid profile in PBC may have lower atherogenicity than in patients with hypercholesterolemia without PBC. Studies looking at patients with PBC with other risk factors for cardiovascular disease, such as hypertension and metabolic syndrome, have consistently found a higher risk for cardiovascular disease in these patients. Statin treatment is effective in reducing lipid levels and possibly improving endothelial inflammation in patients with PBC with hypercholesterolemia. Conclusions: There is not enough evidence to suggest an increased risk of cardiovascular disease in patients with PBC with hypercholesterolemia, except for those individuals with concomitant features of metabolic syndrome. In patients with PBC with no additional cardiovascular risk factors, individual risk/benefit discussion on lipid-lowering treatment should be considered.
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Affiliation(s)
| | - Christina Fanous
- Department of Surgery at the University of California at Los Angeles, Los Angeles, CA, USA
| | - Melissa Jimenez
- Department of Surgery at the University of California at Los Angeles, Los Angeles, CA, USA
| | | | - Sammy Saab
- Department of Surgery at the University of California at Los Angeles, Los Angeles, CA, USA
- Department of Medicine at the University of California at Los Angeles, Los Angeles, CA, USA
- *Correspondence to: Sammy Saab, Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA 90095, USA. Tel: +1-310-206-6705, Fax: +1-310-206-4197, E-mail:
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11
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Affiliation(s)
- M J Tong
- Division of Digestive Diseases, Pfleger Liver Institute, David Geffen School of Medicine at UCLA, Pasadena, CA, USA
| | - C Q Pan
- Division of Gastroenterology, NYU Langone Health, NYU School of Medicine, NY, USA
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12
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Saab S, Le L, Saggi S, Sundaram V, Tong MJ. Toward the elimination of hepatitis C in the United States. Hepatology 2018; 67:2449-2459. [PMID: 29181853 DOI: 10.1002/hep.29685] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [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: 09/22/2017] [Revised: 11/13/2017] [Accepted: 11/20/2017] [Indexed: 12/12/2022]
Abstract
The emergence of effective direct-acting antiviral (DAA) agents has reignited discussion over the potential for hepatitis C elimination in the United States. Eliminating hepatitis C will require a critical examination of technical feasibility, economic considerations, and social/political attention. Tremendous advancement has been made with the availability of sensitive diagnostic tests and highly effective DAAs capable of achieving sustained viral response (SVR) in more than 95% of patients. Eliminating hepatitis C also requires escalating existing surveillance networks to monitor for new epidemics. All preventive interventions such as clean syringe and needle exchange programs, safe injection sites, opioid substitution therapies, and mental health services need to be expanded. Although costs of DAAs have raised budget concerns for hepatitis C elimination, studies have shown that eliminating hepatitis C will produce a savings of up to 6.5 billion USD annually along with other intangible benefits such as increased work productivity and quality of life. Economic models and meta-analyses strongly suggest universal hepatitis C screening for all adults rather than just for birth cohort and high-risk populations. Social and political factors are at least as important as technical feasibility and economic considerations. Due to lack of promotion and public awareness, HCV elimination efforts continue to receive inadequate funding. Social stigma continues to impede meaningful policy changes. Eliminating hepatitis C is an attainable public health goal that will require intense collaboration and sustained public support. (Hepatology 2018;67:2449-2459).
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Affiliation(s)
- Sammy Saab
- Department of Surgery, University of California Los Angeles, Los Angeles, CA
| | - Long Le
- Department of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Satvir Saggi
- Olive View Medical Center, University of California Los Angeles, Los Angeles, CA
| | - Vinay Sundaram
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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13
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Stevens CE, Toy P, Kamili S, Taylor PE, Tong MJ, Xia GL, Vyas GN. Eradicating hepatitis B virus: The critical role of preventing perinatal transmission. Biologicals 2017; 50:3-19. [DOI: 10.1016/j.biologicals.2017.08.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 08/12/2017] [Accepted: 08/14/2017] [Indexed: 12/19/2022] Open
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14
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Tong MJ, Rosinski AA, Huynh CT, Raman SS, Lu DSK. Long-term survival after surveillance and treatment in patients with chronic viral hepatitis and hepatocellular carcinoma. Hepatol Commun 2017; 1:595-608. [PMID: 29404481 PMCID: PMC5721434 DOI: 10.1002/hep4.1047] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 04/11/2017] [Accepted: 04/16/2017] [Indexed: 01/05/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the main cause of mortality in patients with chronic viral hepatitis (CVH). We determined the impact of surveillance and treatments on long‐term outcomes in patients with CVH who developed HCC. Between 1984 and 2014, 333 patients with HCC and with hepatitis B or hepatitis C virus infection were evaluated. An adjusted lead time bias interval was added to patients with HCC who presented with HCC (no surveillance), and their survival was compared to patients whose HCC was detected by surveillance. After HCC treatments, survival rates within and beyond 3 years of follow‐up were compared. In 175 (53%) patients, HCC was detected through surveillance using alpha‐fetoprotein and abdominal ultrasound examinations. Compared to 158 (47%) patients with HCC who had no surveillance, more patients with HCC detected by surveillance received surgical and locoregional treatments (P < 0.0001 to P < 0.001), and their 1‐, 3‐, and 5‐year overall and disease‐free survival rates were significantly higher (P < 0.001 for both). During the first 3 years of follow‐up, patients with HCC receiving liver transplantation had similar survival rates as those with liver resection or radiofrequency ablation (RFA); however, due to HCC recurrence, survival in resection and RFA patients became significantly less when followed beyond 3 years (P = 0.001 to P = 0.04). Factors associated with mortality included tumors beyond University of California at San Francisco criteria (hazard ratio [HR] 2.02; P < 0.0001), Child‐Pugh class B and C (HR, 1.58‐2.26; P = 0.043 to P = 0.015, respectively), alpha‐fetoprotein per log ng/mL increase (HR, 1.30; P < 0.0001), previous antiviral therapy in hepatitis B virus patients (HR, 0.62; P = 0.032), and treatments other than liver transplantation (HR, 2.38‐6.45; P < 0.0001 to P < 0.003). Conclusion. Patients with HCC detected by surveillance had prolonged survival. Due to HCC recurrence, survival rates after liver resection and RFA were lower when followed beyond 3 years after treatments. (Hepatology Communications 2017;1:595–608)
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Affiliation(s)
- Myron J Tong
- Liver Center, Huntington Medical Research Institutes Pasadena CA.,Pfleger Liver Institute, Division of Digestive Diseases Los Angeles CA
| | | | | | - Steven S Raman
- Department of Radiologic Sciences David Geffen School of Medicine, University of California Los Angeles CA
| | - David S K Lu
- Department of Radiologic Sciences David Geffen School of Medicine, University of California Los Angeles CA
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15
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Lee MW, Raman SS, Asvadi NH, Siripongsakun S, Hicks RM, Chen J, Worakitsitisatorn A, McWilliams J, Tong MJ, Finn RS, Agopian VG, Busuttil RW, Lu DSK. Radiofrequency ablation of hepatocellular carcinoma as bridge therapy to liver transplantation: A 10-year intention-to-treat analysis. Hepatology 2017; 65:1979-1990. [PMID: 28170115 DOI: 10.1002/hep.29098] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [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: 09/07/2016] [Revised: 01/26/2017] [Accepted: 01/30/2017] [Indexed: 12/14/2022]
Abstract
UNLABELLED In a long-term (10-year) study of radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) as bridging therapy in patients listed for orthotopic liver transplantation (LT), we evaluated the impact of RFA on waiting list dropout rate, post-LT tumor recurrence, and long-term intention-to-treat, disease-specific survival (DSS). From March 2004 to October 2014, RFA was performed as the initial stand-alone bridge therapy to LT for 121 patients (men/women ratio, 83:38; mean age, 60.0 years) with 156 de novo HCCs (mean size, 2.4 cm). Follow-up period from initial RFA ranged from 1.3 to 128.0 months (median, 42.9 months). We assessed the overall and tumor-specific waiting list dropout rates, post-LT tumor recurrence, and 10-year post-LT and intention-to-treat survival rates. Dropout from the waiting list due to tumor progression occurred in 7.4% of patients. HCC recurrence after LT occurred in 5.6% of patients. The post-LT overall survival (OS) rate at 5 and 10 years was 75.8% and 42.2%, respectively, and the recurrence-free survival (RFS) rate was 71.1% and 39.6%, respectively. Intention-to-treat OS, RFS, and DSS rates for the entire study population at 5 and 10 years were 63.5% and 41.2%, 60.8% and 37.7%, and 89.5% and 89.5%, respectively. CONCLUSION RFA as a first-line stand-alone bridge therapy to LT achieves excellent long-term overall and tumor-specific survivals, with a low dropout rate from tumor progression despite long wait list times and a sustained low tumor recurrence rate upon post-LT follow-up of up to 10 years. (Hepatology 2017;65:1979-1990).
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Affiliation(s)
- Min Woo Lee
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA.,Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Steven S Raman
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA
| | - Nazanin H Asvadi
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA
| | - Surachate Siripongsakun
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA.,Department of Radiology, Chulabhorn Hospital, Bangkok, Thailand
| | - Robert M Hicks
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA
| | - Jeffrey Chen
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA
| | - Akeanong Worakitsitisatorn
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA.,Department of Radiology, Chulabhorn Hospital, Bangkok, Thailand
| | - Justin McWilliams
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA
| | - Myron J Tong
- Division of Digestive Diseases, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Richard S Finn
- Department of Medicine, Division of Hematology/Oncology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Vatche G Agopian
- Department of Surgery, Dumont-UCLA Transplant and Liver Cancer Centers, Los Angeles, CA
| | - Ronald W Busuttil
- Department of Surgery, Dumont-UCLA Transplant and Liver Cancer Centers, Los Angeles, CA
| | - David S K Lu
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Los Angeles, CA
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16
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Saab S, Konyn PG, Viramontes MR, Jimenez MA, Grotts JF, Hamidzadah W, Dang VP, Esmailzadeh NL, Choi G, Durazo FA, El-Kabany MM, Han SHB, Tong MJ. Limited Knowledge of Acetaminophen in Patients with Liver Disease. J Clin Transl Hepatol 2016; 4:281-287. [PMID: 28097095 PMCID: PMC5225146 DOI: 10.14218/jcth.2016.00049] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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: 09/30/2016] [Revised: 12/02/2016] [Accepted: 12/22/2016] [Indexed: 12/11/2022] Open
Abstract
Background and Aims: Unintentional acetaminophen overdose remains the leading cause of acute liver failure in the United States. Patients with underlying liver disease are at higher risk of poor outcomes from acetaminophen overdose. Limited knowledge of acetaminophen may be a preventable contributor to elevated rates of overdose and thus acute liver failure. The purpose of this study is to assess knowledge of acetaminophen dosing and presence of acetaminophen in common combination products in patients with liver disease. Methods: We performed a cross-sectional study of patients with liver disease at the Pfleger Liver Institute at the University of California, Los Angeles between June 2015 and August 2016. Patients completed a demographic questionnaire and an acetaminophen knowledge survey. Additional information was obtained from the medical record. Results: Of 401 patients with liver disease, 30 (15.7%) were able to correctly identify that people without liver disease can safely take up to 4 g/day of acetaminophen. The majority of patients (79.9%-86.8%) did not know that Norco® (hydrocone/acetaminophen), Vicodin® (hydrocone/acetaminophen) and Percocet® (oxycodone/acetaminophen) contained acetaminophen. Only 45.3% of the patients knew that Tylenol® #3 contained acetaminophen. Conclusions: We conclude that patients with liver disease have critically low levels of knowledge of acetaminophen, putting them at risk both of acetaminophen overdose, as well as undermedication, and inadequate management of chronic pain. We recommend an increase in education efforts regarding acetaminophen dosage and its safety in the setting of liver disease. Increasing education for those at risk of low acetaminophen knowledge is essential to minimizing acetaminophen overdose rates and optimizing pain management.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
- Department of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
- *Correspondence to: Sammy Saab, Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA 90095, USA. Tel: +1-310-206-6705, Fax: +1-310-206-4197, E-mail:
| | - Peter G. Konyn
- Department of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Matthew R. Viramontes
- Department of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Melissa A. Jimenez
- Department of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Jonathan F. Grotts
- Department of Biostatistics, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Wally Hamidzadah
- Department of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Veronica P. Dang
- Department of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Negin L. Esmailzadeh
- Department of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Gina Choi
- Department of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
- Department of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Francisco A. Durazo
- Department of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
- Department of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Mohamed M. El-Kabany
- Department of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
- Department of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Steven-Huy B. Han
- Department of Medicine, the University of California at Los Angeles, Los Angeles, CA, USA
- Department of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
| | - Myron J. Tong
- Department of Surgery, the University of California at Los Angeles, Los Angeles, CA, USA
- California and Huntington Medical Research Institutes, Pasadena, CA, USA
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17
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Abstract
Liver transplant (LT) is now an established indication for patients with chronic hepatitis B, mainly because of the development and use of hepatitis B immunoglobulin (HBIG) and oral antivirals for prophylaxis. The combination of low-dose HBIG and antivirals has been considered the standard prophylaxis regimen to prevent post-LT recurrence of hepatitis B. The important remaining issues are related to the long-term cost of HBIG and the risk of escape hepatitis B virus (HBV) mutants. Strategies for prevention of HBV after LT are constantly improving. With the availability of new nucleoside/nucleotide analogues, new post-LT strategies also should emerge.
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Affiliation(s)
- Sammy Saab
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA; Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
| | - Ping-Yu Chen
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Clara E Saab
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Myron J Tong
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA; Huntington Medical Research Institutes, Pasadena, CA, USA
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18
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Saab S, Suraweera D, Au J, Saab EG, Alper TS, Tong MJ. Probiotics are helpful in hepatic encephalopathy: a meta-analysis of randomized trials. Liver Int 2016; 36:986-93. [PMID: 26561214 DOI: 10.1111/liv.13005] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [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: 09/16/2015] [Accepted: 11/02/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Hepatic encephalopathy (HE) is a major complication of cirrhosis and is associated with decreased survival and increased health care utilization. AIM The aim of this study was to evaluate the efficacy of probiotics in the management minimal hepatic encephalopathy HE (MHE) and overt HE (OHE) in comparison to no treatment/placebo and lactulose. METHODS The main outcomes measured were mortality, improvement in MHE, progression to OHE in patients with MHE and hospitalization. We calculated odds ratios (OR) with 95% confidence intervals (CI). Study heterogeneity was assessed using the I(2) statistic. RESULTS Fourteen studies totalling 1152 patients were included in the analysis. The use of probiotics had no impact on the overall mortality when compared to either lactulose (OR: 1.07, 95% CI: 0.47-2.44, P = 0.88) or no treatment/placebo (OR: 0.69, 95% CI: 0.42-1.14, P = 0.15). When probiotics was compared to no treatment/placebo, it was associated with a significant improvement in MHE (OR: 3.91, 95% CI: 2.25-6.80, P < 0.00001), decreased hospitalization rates (OR: 0.53, 95% CI: 0.33-0.86, P = 0.01) and decreased progression to overt hepatic encephalopathy (OR: 0.40, 95% CI: 0.26-0.60, P < 0.0001). However when compared to lactulose, probiotics did not show a significant difference in improvement of MHE (OR: 0.81, 95% CI: 0.52-1.27, P = 0.35), hospitalization rates (OR: 1.02, 95% CI: 0.52-1.99, P = 0.96) or progression to overt hepatic encephalopathy (OR: 1.24, 95% CI 0.73-2.10, P = 0.42). CONCLUSIONS Overall the use of probiotics was more effective in decreasing hospitalization rates, improving MHE and preventing progression to OHE in patients with underlying MHE than placebo, but similar to that seen with lactulose. The use of probiotics did not affect mortality rates.
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Affiliation(s)
- Sammy Saab
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | | | - Jennifer Au
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Elena G Saab
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Tori S Alper
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Myron J Tong
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Liver Center, Huntington Medical Research Institutes, Pasadena, CA, USA
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19
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Suraweera D, Saab EG, Tong MJ, Saab S. Timing of Hepatitis C Antiviral Therapy in Liver Transplant Recipients With Direct-acting Agents. EXP CLIN TRANSPLANT 2016; 14:243-251. [PMID: 27221717] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Chronic hepatitis C virus infection is a substantial health care burden worldwide and is the leading cause of liver transplant in adults. In patients with detectable hepatitis C virus RNA at the time of transplant, interferon-based therapies for hepatitis C virus were poorly tolerated with low virologic response rates. Although reinfection after transplant is inevitable, the recent advent of direct-acting antiviral agents has revolutionized treatment of hepatitis C virus in the pre- and posttransplant settings. These antiviral agents have been shown to have high-sustained virologic response rates, shorter courses of treatment, and decreased frequencies of adverse effects. Here, we review the current literature on the use of direct-acting agents for treatment of patients with hepatitis C virus before and after liver transplant.
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Affiliation(s)
- Duminda Suraweera
- From the Department of Medicine, Olive-View Medical Center, Sylmar, CA, USA
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20
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Saab S, Jimenez M, Fong T, Wu C, El Kabany M, Tong MJ. Timing of Antiviral Therapy in Candidates for Liver Transplant for Hepatitis C and Hepatocellular Carcinoma. EXP CLIN TRANSPLANT 2015; 14:66-71. [PMID: 26581477 DOI: 10.6002/ect.2015.0069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Hepatitis C virus infection is the most common underlying reason for hepatocellular carcinoma and indication for liver transplant. The increased availability of non-interferon-based therapy has expanded the number of treatment-eligible patients. MATERIALS AND METHODS We used a decision analysis model to compare 2 strategies of treating hepatitis C virus. Included patients were followed for 1 year after liver transplant. The probabilities and costs were obtained from a literature review, an expert panel, and our institution's experience. Sensitivity analyses were performed on all variables. RESULTS Our model demonstrated that it would be less costly to treat patients after liver transplant than to treat patients while they wait for transplant. When we compared baseline values, the cost difference between the 2 strategies was $25,011 per patient and $41,535 per sustained viral response. Overall survival was 60.1% for both strategies. Our model was robust across most of the variables tested in the sensitivity analysis. CONCLUSIONS Our results indicated that there is no substantial pharmacoeconomic or survival advantage of treating hepatitis C virus in patients with compensated cirrhosis and hepatocellular carcinoma before liver transplant versus after transplant.
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Affiliation(s)
- Sammy Saab
- From the Departments of Medicine and Surgery, University of California at Los Angeles, Los Angeles, USA
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21
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Fong TL, Tien A, Jo KJ, Chu D, Cheung E, Mena EA, Phan QQ, Yu AS, Mohammed W, Velasco A, LeDuc VH, Nguyen N, Han SB, Chang M, Bae HS, Cho YW, Tong MJ, Cooper SL. Durability of Hepatitis B e Antigen Seroconversion in Chronic Hepatitis B Patients Treated with Entecavir or Tenofovir. Dig Dis Sci 2015; 60:3465-72. [PMID: 26138653 PMCID: PMC4803449 DOI: 10.1007/s10620-015-3775-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [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: 04/23/2015] [Accepted: 06/17/2015] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Loss of HBeAg and development of anti-HBe (seroconversion) is seen as a milestone and endpoint in the treatment of HBeAg-positive patients with chronic hepatitis B (CHB). Among patients treated with nucleos(t)ide analogs (NA), recurrent viremia is common after discontinuation of therapy. Entecavir (ETV) and tenofovir (TDF) are highly potent NA. The durability of virological response and HBeAg seroconversion in patients treated with these agents is not well studied. METHODS We retrospectively studied the outcomes of 54 HBeAg-positive CHB patients who were treated with either ETV (n = 30) or TDF (23) or both (n = 1) that achieved virological response and underwent seroconversion and consolidation therapy before cessation of treatment. RESULTS Only 4 (7%) patients had sustained virological, serological, and biochemical remission. Thirteen patients (24%) continued to have HBV DNA levels below 2000 IU/mL and normal alanine aminotransferase activity (ALT). Thirty-seven patients (69%) developed HBV DNA >2000 IU/mL, with 20 having elevated ALT. Among these 37 patients, 23 (62%) remained HBeAg negative/anti-HBe positive, 12 (32%) became HBeAg positive, and 2 (5%) were HBeAg and anti-HBe negative. Duration of consolidation therapy did not correlate with low versus high level of virological relapse. CONCLUSIONS Durability of HBeAg seroconversion associated with ETV or TDF was not superior to that reported in patients treated with less potent NA. Our results, aggregated with others, suggest HBeAg seroconversion should not be considered as a treatment endpoint for most HBeAg-positive patients treated with NA. Future updates of treatment guidelines should reconsider HBeAg seroconversion as an endpoint to therapy.
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Affiliation(s)
- Tse-Ling Fong
- Asian Pacific Liver Center, Saint Vincent Medical Center, Los Angeles, CA, USA.
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, 2/F, Los Angeles, CA, 90033, USA.
| | - Andy Tien
- Asian Pacific Liver Center, Saint Vincent Medical Center, Los Angeles, CA, USA
| | - Kahee J Jo
- Liver Disease and Transplant Program, California Pacific Medical Center, San Francisco, CA, USA
| | | | - Eddie Cheung
- Division of Gastroenterology, University of California Davis, Davis, CA, USA
- Private Practice, Oakland, CA, USA
| | - Edward A Mena
- Liver Center, Huntington Research Institute, Pasadena, CA, USA
| | | | | | - Wafa Mohammed
- Asian Pacific Liver Center, Saint Vincent Medical Center, Los Angeles, CA, USA
| | - Andrew Velasco
- Asian Pacific Liver Center, Saint Vincent Medical Center, Los Angeles, CA, USA
| | - Vinh-Huy LeDuc
- Asian Pacific Liver Center, Saint Vincent Medical Center, Los Angeles, CA, USA
| | - Nickolas Nguyen
- Asian Pacific Liver Center, Saint Vincent Medical Center, Los Angeles, CA, USA
| | - Steven-Bui Han
- Division of Gastroenterology, Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Mimi Chang
- Asian Pacific Liver Center, Saint Vincent Medical Center, Los Angeles, CA, USA
| | - Ho S Bae
- Asian Pacific Liver Center, Saint Vincent Medical Center, Los Angeles, CA, USA
| | - Yong-Won Cho
- Asian Pacific Liver Center, Saint Vincent Medical Center, Los Angeles, CA, USA
| | - Myron J Tong
- Liver Center, Huntington Research Institute, Pasadena, CA, USA
| | - Stewart L Cooper
- Liver Disease and Transplant Program, California Pacific Medical Center, San Francisco, CA, USA
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22
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Saab S, Jimenez M, Bau S, Goo T, Zhao D, Durazo F, Han S, El Kabany M, Kaldas F, Tong MJ, Busuttil RW. Treating fibrosing cholestatic hepatitis C with sofosbuvir and ribavirin: a matched analysis. Clin Transplant 2015; 29:813-9. [PMID: 26147216 DOI: 10.1111/ctr.12584] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Fibrosing cholestatic hepatitis (FCH) is an uncommon but potentially fatal complication of recurrent hepatitis C (HCV) in liver transplant recipients. METHODS We matched the treatment outcomes of 10 liver transplant recipients who developed FCH with those of 10 recipients with recurrent HCV without FCH treated with sofosbuvir and ribavirin. RESULTS Baseline mean alanine transaminase, aspartate transaminase, alkaline phosphatase, and total bilirubin were 186 U/L, 197 U/L, 243 U/L, and 6.7 mg/dL, respectively, in the FCH recipients and 82 U/L, 60 U/L, 110 U/L, and 0.99 mg/dL, respectively, in non-FCH recipients. The sustained viral response in FCH and non-FCH recipients was 40% and 80%, respectively. One-yr patient and graft survival rates were 90% and 80%, respectively, in FCH recipients, and 100% in non-FCH recipients. Seven FCH and six non-FCH recipients were treated for anemia with blood transfusion and/or erythropoietin growth factors. CONCLUSION Our results suggest that the use of sofosbuvir and ribavirin is effective and tolerable in liver transplant recipients treated for recurrent FCH. There is a trend of lower sustained viral response, patient survival, and graft survival in the FCH recipients.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Melissa Jimenez
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Sherona Bau
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Tyralee Goo
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Difan Zhao
- Department of Biostatistics, University of California at Los Angeles, Los Angeles, CA, USA
| | - Francisco Durazo
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Steven Han
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Mohammed El Kabany
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Fady Kaldas
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Myron J Tong
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA.,Liver Center, Huntington Medical Research Institutes, Pasadena, CA, USA
| | - Ronald W Busuttil
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
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Saab S, Lalezari D, Pruthi P, Alper T, Tong MJ. The impact of obesity on patient survival in liver transplant recipients: a meta-analysis. Liver Int 2015; 35:164-70. [PMID: 24313970 DOI: 10.1111/liv.12431] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [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: 09/05/2013] [Accepted: 12/02/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS It is controversial if obesity has an impact on overall survival after liver transplantation (LT). The goal of this study was to determine if obesity impacts liver transplant recipient survival. Through subgroup analysis, we also evaluated different body mass index (BMI) thresholds and the confounding effect of ascites on survival. METHODS A systematic literature search from 1990 until July 2013. The main outcome was to evaluate the impact of obesity on survival in adult LT recipients. Dochotomous outcomes were reported as relative risk (RR) with 95% confidence intervals (CI). RESULTS Thirteen studies with a total 2275 obese and 72 212 non obese patients were included in the analysis. The combined analysis showed no difference in mortality between control and increased weight patients (RR = 0.97, 95% CI [0.82, 1.13], P = 0.66) at last follow-up. Moreover, no differences in mortality were noted in subgroup analysis comparing different BMI thresholds. There was also no differences in survival when BMI was adjusted for ascites or in studies where the liver disease severity was similar. Obese patients had worse survival than nonobese patients in pooled analysis of studies which had similar causes of liver disease (RR = 0.69, 95% CI [0.52, 0.92], P = 0.01). CONCLUSION The results of our pools analysis suggest that BMI does not specifically impact patient survival. However, obese patients have worse survival when analysis was performed in studies whose cohorts of obese and nonobese patients had similar causes of liver disease.
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Affiliation(s)
- Sammy Saab
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA; Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
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Abstract
Coffee is one of the most commonly consumed beverages in the world. Its health benefits including improved overall survival have been demonstrated in a variety of disease states. To examine the association of coffee consumption with liver disease, a systematic review of studies on the effects of coffee on liver associated laboratory tests, viral hepatitis, nonalcoholic fatty liver disease (NAFLD), cirrhosis and hepatocellular carcinoma (HCC) was performed. Coffee consumption was associated with improved serum gamma glutamyltransferase, aspartate aminotransferase and alanine aminotransferase values in a dose dependent manner in individuals at risk for liver disease. In chronic liver disease patients who consume coffee, a decreased risk of progression to cirrhosis, a lowered mortality rate in cirrhosis patients, and a lowered rate of HCC development were observed. In chronic hepatitis C patients, coffee was associated with improved virologic responses to antiviral therapy. Moreover, coffee consumption was inversely related to the severity of steatohepatitis in patients with non-alcoholic fatty liver disease. Therefore, in patients with chronic liver disease, daily coffee consumption should be encouraged.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, CA, USA; Department of Surgery, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, CA, USA
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Siripongsakun S, Wei SH, Lin S, Chen J, Raman SS, Sayre J, Tong MJ, Lu DS. Evaluation of alpha-fetoprotein in detecting hepatocellular carcinoma recurrence after radiofrequency ablation. J Gastroenterol Hepatol 2014; 29:157-64. [PMID: 24354994 DOI: 10.1111/jgh.12438] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [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] [Accepted: 09/11/2013] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIM The performance of alpha-fetoprotein (AFP) in the detection of hepatocellular carcinoma (HCC) recurrence after radiofrequency ablation was analyzed. METHODS One hundred and forty-six solitary HCC lesions treated by radiofrequency ablation were evaluated. Using the AFP cutoff level at ≥ 20 ng/mL, tumors were categorized into AFP or non-AFP-producing HCC. Factors associated with true and false interpretations for cancer recurrence including analysis of elevated alanine aminotransferase (ALT) were evaluated. The performance of AFP using different cutoff levels adjusted for abnormal ALT was compared. RESULTS Of 146 HCCs, 103 demonstrated no HCC recurrence while 43 had local recurrence. In non-recurrence HCC cases, increased AFP levels (false positive) were associated with concomitant ALT elevations, while those with normal AFP (true negative) had correspondingly normal ALT values (P < 0.001). The AFP false positive rate in cases of elevated ALT was significantly higher than those with normal ALT levels (31.9% vs 5.4%, P = 0.001). Among all positive AFP tests, those with false positive values (non-recurrence) had a significantly lower AFP level than the true positive (recurrence) HCC cases (39.8 ng/mL vs 372 ng/mL, P < 0.001). At the 20 ng/mL cutoff level, the sensitivities of AFP for detecting recurrence in non-AFP-producing HCC and AFP-producing HCC were 12.0%, and 72.2%, respectively. Using a modified AFP criteria of ≥ 100 ng/mL for cases where ALT ≥ 40 U/L, the sensitivity and specificity in AFP-producing tumors increased from 72.2% and 56% to 100% and 85%, respectively. CONCLUSION Serum AFP is a useful test in the detection of HCC recurrence in AFP-producing HCC. The performance in AFP-producing HCC was significantly improved after adjusting for elevation of serum ALT.
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Affiliation(s)
- Surachate Siripongsakun
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; Department of Radiology, Chalubhorn Hospital, Bangkok, Thailand
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Abstract
OBJECTIVE Hepatitis B virus (HBV) inactive carriers are HBV e antigen (HBeAg)-negative patients with normal alanine aminotransferase (ALT) levels and HBV DNA of ≤ 10000 copies/mL. We aimed to determine the clinical impact of ALT and HBV DNA elevations during the course of HBV infection. METHODS From January 1989 to January 2012, 146 inactive carriers were prospectively followed every 6-12 months with ALT and HBV DNA measurements and with hepatocellular carcinoma (HCC) surveillance. RESULTS During the follow-up of 8 ± 6.3 years, 56 of the 146 patients maintained ALT ≤ 40 U/L and HBV DNA ≤ 10000 copies/mL. However, 39 had rises of ALT > 40-80 U/L and 4 had ALT > 80 U/L; all except one reverted to baseline values. Also, during follow up, 69 (47.3%) inactive carriers had increases in HBV DNA of > 10000-999999 copies/mL; 38 of these patients' HBV DNA returned to baseline levels, while the remaining 31 patients maintained elevated HBV DNA values but had corresponding ALT of ≤ 40 U/L. There were four liver-related outcomes: 129 (88.4%) remained "inactive carriers", 13 (8.9%) had loss of hepatitis B surface antigen (HBsAg), one (0.7%) had a spontaneous reactivation to HBeAg-negative chronic hepatitis, and two (1.4%) developed HCC. CONCLUSIONS Although the prognosis of inactive carrier is favorable, transient ALT and HBV DNA elevations may be observed but have minimal clinical significance. Moreover, continuous HCC surveillance remains necessary since the risk of development still exists.
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Affiliation(s)
- Myron J Tong
- Liver Center, Huntington Medical Research Institutes, Pasadena, California 91105, USA.
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Tong MJ, Kowdley KV, Pan C, Hu KQ, Chang TT, Han KH, Yoon SK, Goodman ZD, Beebe S, Iloeje U, Tang H. Improvement in liver histology among Asian patients with chronic hepatitis B after long-term treatment with entecavir. Liver Int 2013; 33:650-1. [PMID: 23489906 DOI: 10.1111/liv.12121] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Myron J. Tong
- Pfleger Liver Institute; University of California-Los Angeles; Los Angeles CA USA
| | - Kris V. Kowdley
- Center for Liver Disease; Digestive Disease Institute; Virginia Mason Medical Center; Seattle WA USA
| | - Calvin Pan
- Division of Gastroenterology; Mount Sinai School of Medicine; New York NY USA
| | - Ke-Qin Hu
- Division of Gastroenterology; University of California; Irvine Medical Center; Irvine CA USA
| | | | - Kwang-Hyub Han
- Department of Internal Medicine; Yonsei University College of Medicine; Seoul South Korea
| | - Seung-Kew Yoon
- Department of Internal Medicine; Kangnam St. Mary Hospital; Catholic University Medical School; Seoul South Korea
| | | | - Suzanne Beebe
- Research & Development; Bristol-Myers Squibb Company; Wallingford CT USA
| | - Uchenna Iloeje
- Research & Development; Bristol-Myers Squibb Company; Wallingford CT USA
| | - Hong Tang
- Research & Development; Bristol-Myers Squibb Company; Plainsboro NJ USA
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Lu DS, Siripongsakun S, Kyong Lee J, Wei SH, Cheng PM, Sabounchi S, Lee JS, Raman S, Tong MJ, Busuttil RW, Sayre J. Complete tumor encapsulation on magnetic resonance imaging: a potentially useful imaging biomarker for better survival in solitary large hepatocellular carcinoma. Liver Transpl 2013; 19:283-91. [PMID: 23280814 DOI: 10.1002/lt.23597] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [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: 08/30/2012] [Accepted: 12/13/2012] [Indexed: 02/07/2023]
Abstract
The aim of this study was to determine the prognostic value of complete tumor encapsulation as visualized on magnetic resonance imaging (MRI) in patients with a solitary large hepatocellular carcinoma (HCC) beyond the Milan criteria for liver transplantation (LT). Between December 2000 and March 2011, 57 patients who had a solitary HCC exceeding 5 cm in diameter at the time of initial MRI before any treatment were identified. MRI images of the patients were independently reviewed by 2 experienced readers for the presence of complete tumoral encapsulation. The medical records of the patients were reviewed for an outcome analysis. Thirty of the 57 patients had completely encapsulated HCC according to MRI. There was excellent interobserver agreement between the 2 readers for the assessment of complete encapsulation (κ=0.86). Overall survival was significantly longer for patients with completely encapsulated HCC versus patients with incompletely or nonencapsulated tumors (P<0.001), and this included a subanalysis of 33 patients who received locoregional treatment (LRT; P=0.04). The presence of complete encapsulation was a strong predictor for survival in these patients according to both univariate [hazard ratio (HR)=0.24, 95% confidence interval (CI)=0.12-0.52, P<0.001] and multivariate analyses (HR=0.25, 95% CI=0.07-0.85, P=0.03). The rates of down-staging (P<0.001) and eventual LT (P=0.02) after LRT were also significantly higher in the patients with completely encapsulated tumors. In conclusion, complete tumor encapsulation on MRI is a potentially useful predictor for favorable biology in patients with a solitary large HCC. This new imaging biomarker may have a role in treatment selection for patients whose tumors exceed the Milan criteria size limits.
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Affiliation(s)
- David S Lu
- Department of Radiology, University of California Los Angeles, Los Angeles, CA 90095, USA.
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29
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Tong MJ. Improved understanding of risk factors could help to reduce the incidence of hepatocellular carcinoma. Gastroenterol Hepatol (N Y) 2012; 8:320-321. [PMID: 22933863 PMCID: PMC3424427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Myron J Tong
- Hepatology University of California-Los Angeles, Los Angeles, California, USA.
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30
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Pan CQ, Duan ZP, Bhamidimarri KR, Zou HB, Liang XF, Li J, Tong MJ. An algorithm for risk assessment and intervention of mother to child transmission of hepatitis B virus. Clin Gastroenterol Hepatol 2012; 10:452-9. [PMID: 22079509 DOI: 10.1016/j.cgh.2011.10.041] [Citation(s) in RCA: 181] [Impact Index Per Article: 15.1] [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: 08/22/2011] [Revised: 10/11/2011] [Accepted: 10/30/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Despite immunoprophylaxis, mother to child transmission (MTCT) of hepatitis B virus (HBV) still occurs in infants born to hepatitis B surface antigen (HBsAg)-positive mothers. We analyzed methods of risk assessment and interventions for MTCT. METHODS We reviewed 63 articles and abstracts published from 1975-2011 that were relevant to MTCT; articles were identified using the PubMed bibliographic database. RESULTS Administration of HB immunoglobulin and HB vaccine to infants at birth (within 12 hours), followed by 2 additional doses of vaccines within 6-12 months, prevented approximately 95% of HBV transmission from HBsAg-positive mothers to their infants. However, HBV was still transmitted from 8%-30% of mothers with high levels of viremia. It is important to assess the risk for MTCT and identify mothers who are the best candidates for intervention. The most important risk factor is maternal level of HBV DNA >200,000 IU (10(6) copies)/mL; other factors include a positive test result for the HB e antigen, pregnancy complications such as threatened preterm labor or prolonged labor, and failure of immunoprophylaxis in prior children. Antiviral therapy during late stages of pregnancy is the most effective method to reduce transmission from mothers with high levels of viremia, but elective cesarean section might also be effective. Antepartum administration of HB immunoglobulin, giving infants a double dose of HB vaccine, or avoiding breastfeeding had no impact on MTCT. CONCLUSIONS HBsAg-positive mothers should be assessed for risk of MTCT, and infants should receive immunoprophylaxis. Pregnant women with levels of HBV DNA >200,000 IU/mL should be considered for strategies to reduce the risk for MTCT. We propose an algorithm for risk assessment and patient management that is based on a review of the literature and the opinion of a panel of physicians with expertise in preventing MTCT.
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Affiliation(s)
- Calvin Q Pan
- Division of Liver Diseases, Mount Sinai Medical Center, Mount Sinai School of Medicine, New York, New York 11355, USA.
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31
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Tong MJ, Pan CQ, Hann HW, Kowdley KV, Han SHB, Min AD, Leduc TS. The management of chronic hepatitis B in Asian Americans. Dig Dis Sci 2011; 56:3143-62. [PMID: 21935699 DOI: 10.1007/s10620-011-1841-5] [Citation(s) in RCA: 42] [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: 05/18/2011] [Accepted: 07/15/2011] [Indexed: 12/14/2022]
Abstract
Hepatitis B virus (HBV) infection is common with major clinical consequences worldwide. In Asian Americans, the HBsAg carrier rate ranges from 7 to 16%; HBV is the most important cause of chronic hepatitis, cirrhosis, and hepatocellular carcinoma (HCC). Patients are first diagnosed at different stages of clinical disease, which is categorized by biochemical and virologic tests. Patients at risk for liver complications should be identified and offered antiviral therapy. The two antiviral agents recommended for first-line treatment of chronic hepatitis B (CHB) are entecavir and tenofovir. The primary goal of therapy is sustained suppression of viral replication to achieve clinical remission, reverse fibrosis, and prevent and reduce progression to end-stage liver disease and HCC. Asian patients with chronic hepatitis, either HBeAg-positive or -negative, with HBV DNA levels >10(4) copies/mL (>2,000 IU/mL) and alanine aminotransferase (ALT) values above normal are candidates for antiviral therapy. HBeAg-negative patients with HBV DNA >10(4) copies/mL (>2,000 IU/mL) and normal ALT levels but who have either serum albumin ≤3.5 g/dL or platelet count ≤130,000 mm(3), basal core promoter mutations, or who have first-degree relatives with HCC should be offered treatment. Patients with cirrhosis and detectable HBV DNA must receive antiviral therapy. Considerations for treatment include pregnant women with high viremia, coinfected patients, and those requiring immunosuppressive therapy. In HBsAg-positive patients with risk factors, lifelong surveillance for HCC with alpha-fetoprotein testing and abdominal ultrasound examination at 6-month intervals is required. These recommendations are based on a review of relevant literature and the opinion of a panel of Asian American physicians with expertise in hepatitis B treatment.
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Affiliation(s)
- Myron J Tong
- Pfleger Liver Institute, Division of Digestive Diseases, University of California School of Medicine, Los Angeles, CA, USA.
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Hong JC, Jones CM, Duffy JP, Petrowsky H, Farmer DG, French S, Finn R, Durazo FA, Saab S, Tong MJ, Hiatt JR, Busuttil RW. Comparative analysis of resection and liver transplantation for intrahepatic and hilar cholangiocarcinoma: a 24-year experience in a single center. ACTA ACUST UNITED AC 2011; 146:683-9. [PMID: 21690444 DOI: 10.1001/archsurg.2011.116] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To compare the survival difference between 2 surgical modalities in the treatment of locally advanced intrahepatic and hilar cholangiocarcinoma (CCA) and to identify factors that predict mortality. DESIGN Retrospective study. SETTING University transplant center. PATIENTS Of the 132 patients with a diagnosis of CCA treated from February 1, 1985, through June 30, 2009, 75 had metastatic disease at presentation and were excluded from the study, whereas 57 patients were candidates for surgical therapy. Tumor type was intrahepatic in 37 patients and hilar in 20 patients. Surgical therapy included orthotopic liver transplant (OLT) in 38 patients and combined radical bile duct resection with partial hepatectomy (RR) in 19 patients. RESULTS Tumors were locally advanced in 35 of 37 patients (95%) with intrahepatic tumors and 16 of 20 patients (80%) with hilar tumors. Adjunctive therapy was used in 35 patients (61%). The 5-year tumor recurrence-free patient survival was significantly higher in the OLT group compared with the RR group (33% vs 0%; P = .05). In the OLT group, neoadjuvant and adjuvant therapies resulted in better patient survival compared with no therapy or adjuvant therapy only (47% vs 20% vs 33%, respectively; P = .03). Multivariate factors predictive of worse survival outcomes included hilar CCA, multifocal tumors, perineural invasion, and RR as the treatment modality compared with OLT. Tumor sizes--5 cm or larger for intrahepatic and 3 cm or larger for hilar CCA--were not predictors of poor outcome. CONCLUSION Orthotopic liver transplant in combination with neoadjuvant and adjuvant therapies is superior to RR with adjuvant therapy in locally advanced intrahepatic and hilar CCA.
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Affiliation(s)
- Johnny C Hong
- Dumont-UCLA Transplant Center, Pfleger Liver Institute, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA 90095, USA.
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Tabibian JH, Lazo M, Durazo FA, Yeh HC, Tong MJ, Clark JM. Nonalcoholic fatty liver disease across ethno-racial groups: do Asian-American adults represent a new at-risk population? J Gastroenterol Hepatol 2011; 26:501-9. [PMID: 21332546 PMCID: PMC4937792 DOI: 10.1111/j.1440-1746.2010.06443.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [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: 02/06/2023]
Abstract
BACKGROUND AND AIM Nonalcoholic fatty liver disease (NAFLD) is increasingly common worldwide. We explored clinical, laboratory, and histological features of NAFLD as well as risk factors for histologically advanced disease among under-represented ethno-racial groups. METHODS Patient records from one NAFLD clinic in California from 1998-2008 were reviewed. Biopsies were graded using Brunt criteria by a hepatopathologist blinded to clinical data. We used multivariate logistic regression to assess associations between ethno-racial group and histological severity of NAFLD, while controlling for other factors. RESULTS We identified 90 biopsy-proven cases of NAFLD. Mean age was 49 years (standard deviation [SD]= 11.6), and half were female. 52% of patients were Caucasian, 20% Latino-American, 18% Asian-American, and 10% Middle Eastern-American. There were significant differences among groups with respect to age, weight, body mass index (BMI), and grade of hepatic steatosis (all P < 0.05). In multivariate analysis, older age was associated with severe (Brunt ≥ 2) inflammation (odds ratio [OR] 1.1, P = 0.002) and severe (Brunt ≥ 3) fibrosis (OR 1.2, P = 0.001), diabetes was associated with severe inflammation (OR 3.18, P = 0.07) and severe fibrosis (OR 8.81, P = 0.002), and increased BMI was associated with severe fibrosis (OR 2.43, P = 0.07). Additionally, compared to Caucasians, Asian-Americans showed a trend toward an association with severe (Brunt > 2) steatosis (OR 3.83, P = 0.08) and severe inflammation (OR 5.42, P = 0.06). CONCLUSIONS The findings from this ethno-racially diverse clinic-based cohort are consistent with prior studies and also suggest that Asian-Americans may be at risk for advanced NAFLD. This may have implications for the prevention, evaluation, and treatment of patients with NAFLD that merit further study.
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Affiliation(s)
- James H. Tabibian
- Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA,Dumont-UCLA Liver Transplant Center, Los Angeles, California, USA
| | - Mariana Lazo
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Hsin-Chieh Yeh
- Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Myron J. Tong
- Dumont-UCLA Liver Transplant Center, Los Angeles, California, USA
| | - Jeanne M. Clark
- Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Yu NC, Chaudhari V, Raman SS, Lassman C, Tong MJ, Busuttil RW, Lu DSK. CT and MRI improve detection of hepatocellular carcinoma, compared with ultrasound alone, in patients with cirrhosis. Clin Gastroenterol Hepatol 2011; 9:161-7. [PMID: 20920597 DOI: 10.1016/j.cgh.2010.09.017] [Citation(s) in RCA: 178] [Impact Index Per Article: 13.7] [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: 08/11/2010] [Accepted: 09/22/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In patients with cirrhosis, hepatocellular carcinoma (HCC) is detected by ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MRI); US is recommended for screening and surveillance. We performed a retrospective analysis of the abilities of these cross-sectional imaging modalities to detect HCC. METHODS We analyzed data from 638 consecutive adult patients with cirrhosis who received liver transplants within 6 months of imaging at a tertiary care institution. Imaging reports and serum alpha-fetoprotein levels were compared with results from pathology analysis of explants as the reference standard. Sensitivities of US, CT, and MRI were calculated overall and in defined size categories. False-positive imaging results and patient-based specificities were evaluated. RESULTS Of the 638 patients, 225 (35%) had HCC, confirmed by pathology analysis of liver explants. In 23 cases, the lesions were infiltrative or extensively multifocal. In the remaining 202 explants (337 numerable, discrete nodules), respective lesion-based sensitivities of US, CT, and MRI were 46%, 65%, and 72% overall and 21%, 40%, and 47% for small (<2 cm) HCC. The sensitivity of US increased with the availability of CT or MRI data (P = .049); sensitivity values were 62% and 85% for lesions 2-4 and ≥ 4 cm, respectively. Patient-based specificities of US, CT, and MRI were 96%, 96%, and 87%, respectively. CONCLUSIONS US, CT, and MRI did not detect small HCC lesions with high levels of sensitivity, although CT and MRI provide substantial improvements over unenhanced US in patients with cirrhosis who received liver transplants.
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Affiliation(s)
- Nam C Yu
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA
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Gish RG, Abou-Alfa GK, Tong MJ. Clinical roundtable monograph. Integrating recent data in managing adverse events in the treatment of hepatocellular carcinoma. Clin Adv Hematol Oncol 2010; 8:2-15. [PMID: 21598749] [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] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Hepatocellular carcinoma (HCC) is a major cause of cancer-related morbidity and mortality worldwide. In the United States, HCC is the main cause of death in patients with cirrhosis, and the incidence of this malignancy is on the rise. Because HCC is associated with a particularly poor prognosis, emphasis is placed on surveillance of high-risk patients. Early detection allows a greater chance of diagnosing HCC before it has spread, thus increasing the chances that the patient can be potentially cured with surgical techniques such as resection and transplantation. However, most cases of HCC are not diagnosed until at least some of the cancer has spread or multiple nodules exist. For these patients, treatment options include percutaneous and transarterial ablation, as well as systemic chemotherapy. Systemic therapy is now considered the standard of care for patients with advanced tumors. Traditional treatment was based on cytotoxic chemotherapeutic agents, such as doxorubicin. This approach was associated with minimal benefit and a high rate of toxicity. Recently, targeted agents have proven more effective and safer in this setting. The oral multikinase inhibitor sorafenib is now approved for the treatment of unresectable HCC and is currently the only approved agent for advanced HCC. In order to maximize the benefit of sorafenib and other investigational agents for patients with advanced disease, effective interventions have been designed to mitigate their associated adverse events, such as hand-foot skin reactions and hypertension.
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Affiliation(s)
- Robert G Gish
- California Pacific Medical Center, University of California, San Francisco, San Francisco, California, USA
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Gish RG, Abou-Alfa GK, Tong MJ. Integrating recent data in managing adverse events in the treatment of hepatocellular carcinoma. Gastroenterol Hepatol (N Y) 2010; 6:1-16. [PMID: 22423222 PMCID: PMC3302169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Hepatocellular carcinoma (HCC) is a major cause of cancer-related morbidity and mortality worldwide. In the United States, HCC is the main cause of death in patients with cirrhosis, and the incidence of this malignancy is on the rise. Because HCC is associated with a particularly poor prognosis, emphasis is placed on surveillance of high-risk patients. Early detection allows a greater chance of diagnosing HCC before it has spread, thus increasing the chances that the patient can be potentially cured with surgical techniques such as resection and transplantation. However, most cases of HCC are not diagnosed until at least some of the cancer has spread or multiple nodules exist. For these patients, treatment options include percutaneous and transarterial ablation, as well as systemic chemotherapy. Systemic therapy is now considered the standard of care for patients with advanced tumors. Traditional treatment was based on cytotoxic chemotherapeutic agents, such as doxorubicin. This approach was associated with minimal benefit and a high rate of toxicity. Recently, targeted agents have proven more effective and safer in this setting. The oral multikinase inhibitor sorafenib is now approved for the treatment of unresectable HCC and is currently the only approved agent for advanced HCC. In order to maximize the benefit of sorafenib and other investigational agents for patients with advanced disease, effective interventions have been designed to mitigate their associated adverse events, such as hand-foot skin reactions and hypertension.
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Affiliation(s)
- Robert G Gish
- Medical Director, Specialty Services Medical Director, Complex GI California Pacific Medical Center San Francisco, California Clinical Professor of Medicine University of California, San Francisco San Francisco, California
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Abstract
Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world and the third leading cause of cancer-related deaths. More than 80% of HCC cases are from the Asian and African continents, and more than 50% of cases are from mainland China. Approximately 350 million to 400 million persons are chronically infected with hepatitis B virus (HBV), and this virus is the most common cause of HCC worldwide. It is estimated that more than 50% of liver cancers worldwide are attributable to HBV and up to 89% of HBV-related HCC are from developing countries. Recently, increasing trends in HCC incidence have been reported from several Western countries, including France, Australia, and the United States.
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Affiliation(s)
- Amy C McClune
- Dumont-UCLA Liver Transplant Center, David Geffen School of Medicine at UCLA, The Pfleger Liver Institute, Los Angeles, CA 90095-7302, USA.
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Saab S, Hunt DR, Stone MA, McClune A, Tong MJ. Timing of hepatitis C antiviral therapy in patients with advanced liver disease: a decision analysis model. Liver Transpl 2010; 16:748-59. [PMID: 20517909 DOI: 10.1002/lt.22072] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [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: 12/21/2022]
Abstract
Antiviral therapy for the treatment of hepatitis C virus (HCV) infection is used before and after liver transplantation. The objective of this study was to determine the most cost-effective timing for pegylated interferon/ribavirin therapy in patients with advanced liver disease infected with genotype 1 HCV. A Markov model was constructed to compare treatment strategies: (1) no treatment, (2) antiviral therapy in patients with compensated cirrhosis, (3) antiviral therapy in patients with decompensated cirrhosis, and (4) antiviral therapy in patients with progressive fibrosis due to recurrent HCV post-transplantation. Outcomes of interest included the total cost per patient, number of quality-adjusted life years (QALYs) saved, cost per QALY saved, number of deaths and hepatocellular carcinomas (HCCs), and number of transplants required. Compared to the no-antiviral treatment strategy, treatment during compensated cirrhosis increased QALYs by 0.950 and saved $55,314. Treatment during decompensated cirrhosis increased QALYs by 0.044 and saved $5511. Treatment during posttransplant advanced recurrence increased QALYs by 0.061 and saved $3223. Treatment of patients with compensated cirrhosis resulted in 119 fewer deaths, 54 fewer HCCs, and 66 fewer transplants with respect to the no-treatment strategy. The model was sensitive to the rate of graft failure in patients with and without sustained virological response. The model was otherwise robust to all variables tested in sensitivity analysis. In conclusion, the treatment of patients with compensated cirrhosis was found to be the most cost-effective strategy and resulted in improved survival and decreased cost in comparison with all other strategies. This study provides pharmacoeconomic evidence in support of treating HCV in patients with compensated cirrhosis before progression to more advanced liver disease.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA 90095, USA.
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Saab S, Waterman B, Chi AC, Tong MJ. Comparison of different immunoprophylaxis regimens after liver transplantation with hepatitis B core antibody-positive donors: a systematic review. Liver Transpl 2010; 16:300-7. [PMID: 20209589 DOI: 10.1002/lt.21998] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.6] [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: 01/10/2023]
Abstract
Orthotopic liver transplantation (OLT) recipients without hepatitis B virus (HBV) infection who receive liver grafts from antibody to hepatitis B core antigen-positive [HBcAb(+)], hepatitis B surface antigen-negative [HBsAg(-)] donors have an increased risk of developing de novo hepatitis B infection. We compared the 2 most commonly employed prophylactic regimens-lamivudine (LAM) monotherapy and hepatitis B immunoglobulin (HBIG)+LAM combination therapy-to determine the relative efficacies of these 2 protocols in preventing de novo hepatitis B infection. A comprehensive search of the Cochrane Database of Systematic Reviews, MEDLINE (1966 to June 2009), and bibliographies of retrieved trials was conducted. Eligible studies included OLT recipients who received HBcAb(+) liver grafts and were treated prophylactically with either LAM monotherapy or HBIG+LAM combination therapy. 13 studies were identified as meeting the eligibility criteria. The rates of de novo hepatitis B infection, mortality, and mortality due to de novo hepatitis B infection were assessed. The incidence of de novo hepatitis B infection was 2.7% (n = 73) in patients receiving LAM-only prophylaxis versus 3.6% (n = 110) in patients receiving HBIG+LAM combination therapy. In the HBIG+LAM group, the dose and duration of HBIG therapy were highly variable. The median follow-up time for the LAM monotherapy group was 25.4 months with a range of 14.78 to 27.6 months, whereas the median follow-up time for the LAM+HBIG group was 31.1 months with a range of 15.3 to 38.5 months. The risk of developing de novo hepatitis B infection based on the pretransplant recipient HBV serology in each treatment group could not be calculated because of incomplete data and the limited number of de novo hepatitis B infection cases in the series reviewed. In conclusion, on the basis of these findings, we conclude that published studies have not shown HBIG+LAM combination therapy to be more effective than LAM-only treatment. Nucleoside analogue monotherapy should therefore be considered when one is treating HBV(-) patients who have received liver allografts from HBcAb(+) donors.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
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Tabibian JH, Asham EH, Han S, Saab S, Tong MJ, Goldstein L, Busuttil RW, Durazo FA. Endoscopic treatment of postorthotopic liver transplantation anastomotic biliary strictures with maximal stent therapy (with video). Gastrointest Endosc 2010; 71:505-12. [PMID: 20189508 DOI: 10.1016/j.gie.2009.10.023] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [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: 05/14/2009] [Accepted: 10/14/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND The optimal endoscopic protocol for treating postorthotopic liver transplantation (OLT) anastomotic biliary strictures (ABSs) has not been established. OBJECTIVE To review the technique and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) with maximal stenting for post-OLT ABSs at our institution. DESIGN Retrospective study. SETTING Tertiary-care center. PATIENTS Eighty-three patients with a diagnosis of ABS. INTERVENTIONS ERCP with balloon dilation and maximal stenting. MAIN OUTCOME MEASUREMENTS Stricture resolution, stricture recurrence, and complication rates. RESULTS Of 83 patients, 69 completed treatment, of whom 65 (94%) achieved resolution and 4 (6%) required hepaticojejunostomy (HJ). The remaining 14 patients who did not achieve a study endpoint were excluded (9 deaths or redo OLT unrelated to biliary disease, and 5 without follow-up). Comparing the resolution group and the HJ group, there were, respectively, 8.0 and 3.5 total stents (P = .021), 2.5 and 1.3 stents per ERCP (P = .018) (maximum = 9), 4.2 and 2.8 ERCPs (P = .15), and 20 and 22 months from OLT to ABS diagnosis (P = .19). There were 2 cases of ERCP pancreatitis (0.7%) and 2 cases of periprocedural bacteremia of 286 total ERCPs and no episodes of cholangitis caused by stent occlusion. In a median follow-up of 11 months (range 0-39), 2 (3%) patients had ABS recurrence that was successfully re-treated with ERCP. A multivariate Cox model demonstrated that treatment success was directly related to the number of stents used in total and per ERCP. LIMITATIONS Retrospective study, single endoscopist. CONCLUSIONS Our maximal stenting protocol for ABSs is effective, safe, rarely associated with ABS recurrence, and conducive to less frequent stent exchange and therefore fewer ERCPs compared with conventional treatment.
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Affiliation(s)
- James H Tabibian
- Dumont-UCLA Liver Transplant Center, Los Angeles, California, USA.
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Saab S, Yeganeh M, Nguyen K, Durazo F, Han S, Yersiz H, Farmer DG, Goldstein LI, Tong MJ, Busuttil RW. Recurrence of hepatocellular carcinoma and hepatitis B reinfection in hepatitis B surface antigen-positive patients after liver transplantation. Liver Transpl 2009; 15:1525-34. [PMID: 19877207 DOI: 10.1002/lt.21882] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [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: 12/12/2022]
Abstract
Hepatitis B virus (HBV) reinfection and recurrence of hepatocellular carcinoma (HCC) after orthotopic liver transplantation (OLT) are associated with increased graft failure and reduced patient survival. We evaluated the effects of both HCC recurrence and HBV reinfection on the long-term survival of these patients after OLT. One hundred seventy-five patients underwent OLT for HBV-related liver diseases and were the subjects of this retrospective study. We assessed risk factors for HBV reinfection, HCC recurrence, and survival post-OLT using univariate and multivariate analyses. During a mean follow-up of 43.0 +/- 42.0 months, 88 of 175 (50.3%) patients transplanted for HBV-related liver disease had HCC prior to OLT. Thirteen (14.8%) of these patients had HCC recurrence after OLT. The mean time for recurrence of HCC was 26.1 +/- 31.9 months. Twelve of 175 (6.9%) patients developed HBV reinfection after liver transplantation. The mean time for HBV reinfection was 28.7 +/- 26.4 months. Ten of these 12 (83.3%) patients had HCC prior to OLT, and 5 (50%) developed recurrence of HCC. On multivariate analyses, pre-OLT HCC and recurrence of HCC post-OLT were significantly associated with HBV reinfection after transplantation (P = 0.031 and P < 0.001, respectively). HCC recurrence after OLT was associated with lymphovascular invasion (P < 0.001) and post-OLT chemotherapy (P < or = 0.001). The 3- and 5-year survival rates were significantly decreased in patients with HBV reinfection (P = 0.007) and in patients with HCC recurrence after OLT (P = 0.03). In conclusion, pre-OLT HCC and HCC recurrence after transplantation were associated with HBV reinfection and with decreased patient survival. Hepatitis B immunoglobulin and antiviral therapy was only partially effective in preventing HBV reinfection in patients with HCC recurrence.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, University of California, Los Angeles, CA, USA.
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Tabibian JH, Asham EH, Goldstein L, Han SH, Saab S, Tong MJ, Busuttil RW, Durazo FA. Endoscopic treatment with multiple stents for post-liver-transplantation nonanastomotic biliary strictures. Gastrointest Endosc 2009; 69:1236-43. [PMID: 19249040 DOI: 10.1016/j.gie.2008.09.057] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [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: 06/09/2008] [Accepted: 09/24/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Over the past decade, ERCP has become the preferred method of treatment for biliary strictures in patients after orthotopic liver transplantation (OLT). Although data strongly support ERCP for treating anastomotic strictures, the little information available for the role of ERCP in the treatment of nonanastomotic strictures (NAS) has been unpromising. OBJECTIVE We investigated the efficacy and safety of using balloon dilation and multiple biliary stents to treat NAS. DESIGN A retrospective study. SETTING A tertiary-care medical center. PATIENTS Fifteen patients who were diagnosed with post-OLT NAS between January 2003 and June 2007. INTERVENTIONS ERCP with balloon dilation and multiple stenting. MAIN OUTCOME MEASUREMENTS Resolution, complication, and recurrence rates. RESULTS Eleven of the 15 patients completed endoscopic treatment, of whom 9 had cholangiographic improvement, biochemical normalization, and cholestatic symptom relief (treatment success), and 1 required retransplantation (treatment failure). None of the 9 successfully treated patients experienced NAS recurrence in a mean follow-up of 17 months. Of the remaining 4 patients, 1 died of nonbiliary causes and 3 were still undergoing treatment with stents in place, of whom 2 have near-normalized total serum bilirubin and were cholestatic symptom free. LIMITATIONS A retrospective study, small sample size, single endoscopist. CONCLUSIONS Endoscopic treatment of NAS with balloon dilation and multiple stents appears to be safe and effective, and it may reduce the need for retransplantation because of NAS. Larger studies are still required to confirm its utility as a mainstay for treating NAS and to determine what factors are associated with endoscopic treatment success.
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Affiliation(s)
- James H Tabibian
- Dumont-University of California Los Angeles Liver Transplant Center and UCLA Division of Digestive and Liver Diseases, Los Angeles, California, USA.
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Liaw YF, Gane E, Leung N, Zeuzem S, Wang Y, Lai CL, Heathcote EJ, Manns M, Bzowej N, Niu J, Han SH, Hwang SG, Cakaloglu Y, Tong MJ, Papatheodoridis G, Chen Y, Brown NA, Albanis E, Galil K, Naoumov NV. 2-Year GLOBE trial results: telbivudine Is superior to lamivudine in patients with chronic hepatitis B. Gastroenterology 2009; 136:486-95. [PMID: 19027013 DOI: 10.1053/j.gastro.2008.10.026] [Citation(s) in RCA: 468] [Impact Index Per Article: 31.2] [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: 08/29/2008] [Revised: 09/30/2008] [Accepted: 10/09/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The GLOBE trial has compared the efficacy and safety of telbivudine versus lamivudine treatment over 2 years in patients with chronic hepatitis B. METHODS Hepatitis B e antigen (HBeAg)-positive (n = 921) and HBeAg-negative (n = 446) patients received telbivudine or lamivudine once daily for 104 weeks. The primary outcome, assessed in the intent-to-treat population, was therapeutic response (hepatitis B virus DNA <5 log(10) copies/mL and either HBeAg loss or normalization of alanine aminotransferase [ALT] level). RESULTS The therapeutic response to telbivudine was superior to that of lamivudine in HBeAg-positive (63% vs 48%; P < .001) and HBeAg-negative (78% vs 66%; P = .007) patients. HBeAg-positive patients given telbivudine also had better outcomes compared with lamivudine in terms of nondetectable viremia (< 300 copies/mL) at 55.6% versus 38.5% (P < .001), HBeAg loss at 35.2% versus 29.2% (P = .056), and viral resistance at 25.1% versus 39.5% (P < .001). Hepatitis B e antigen seroconversion was 29.6% versus 24.7% (P = .095) in all patients and 36% versus 27% (P = .022) in patients with baseline ALT level > or = 2 times normal. Telbivudine-treated HBeAg-negative patients showed higher rates of nondetectable viremia compared with lamivudine at 82.0% versus 56.7% (P < .001) and less resistance at 10.8% versus 25.9% (P < .001). Adverse events occurred with similar frequency, whereas grade 3/4 increases in creatine kinase levels were more common in patients given telbivudine (12.9% vs 4.1%, P < .001). Multivariate logistic regression analyses identified telbivudine treatment, among other variables, as an independent predictor of better week 104 outcomes. CONCLUSIONS Telbivudine is superior to lamivudine in treating patients with chronic hepatitis B over a 2-year period.
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Affiliation(s)
- Yun-Fan Liaw
- Liver Research Unit, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan.
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Durazo FA, Blatt LM, Corey WG, Lin JH, Han S, Saab S, Busuttil RW, Tong MJ. Des-gamma-carboxyprothrombin, alpha-fetoprotein and AFP-L3 in patients with chronic hepatitis, cirrhosis and hepatocellular carcinoma. J Gastroenterol Hepatol 2008; 23:1541-8. [PMID: 18422961 DOI: 10.1111/j.1440-1746.2008.05395.x] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.3] [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: 12/14/2022]
Abstract
BACKGROUND AND AIM Hepatocellular carcinoma (HCC) is a common complication in patients with chronic viral hepatitis. Detection of HCC at an early stage is critical for a favorable clinical outcome. The study aim was to: (i) compare the levels of des-gamma-carboxyprothrombin (DCP), alpha-fetoprotein (AFP) and AFP-L3 in HCC patients and in chronic viral hepatitis patients without HCC; (ii) define the level of each tumor marker with the best sensitivity and specificity for HCC diagnosis; and (iii) to correlate the levels of these markers with respect to size and tumor burden. METHODS Two hundred and forty patients with either hepatitis B virus (HBV) or hepatitis C virus (HCV) infection were studied. These included 144 with HCC, 47 with chronic hepatitis (fibrosis stage I-III on liver biopsy) and 49 with cirrhosis. RESULTS Levels of DCP, AFP and AFP L-3 were significantly higher in patients with HCC than in those without HCC (P < or = 0.0001). Receiver-operating curves (ROC) indicated that the cut-off value with the best sensitivity and specificity for each test was > or =84 mAU/mL for DCP, > or =25 ng/mL for AFP and > or =10% for AFP-L3. The sensitivity, specificity and positive predictive value (PPV) for DCP was 87%, 85% and 86.8%, for AFP 69%, 87% and 69.8%, and for AFP-L3 56%, 90% and 56.1%, respectively. DCP levels were below the ROC cut-off in all patients without HCC. In patients with single lesions, there was a direct correlation of DCP to tumor size. High levels of AFP correlated with diffuse type of HCC. All three markers were significantly elevated in the presence of metastatic HCC. No advantage was observed by combining two or three markers for HCC diagnosis. CONCLUSION DCP had the highest sensitivity and PPV for HCC diagnosis, had a direct correlation with tumor size, and was not elevated in any patients without HCC. DCP should be used as the main serum test for HCC detection.
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Affiliation(s)
- Francisco A Durazo
- The Pfleger Liver Institute, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA.
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Saab S, Ibrahim AB, Surti B, Durazo F, Han S, Yersiz H, Farmer DG, Ghobrial RM, Goldstein LI, Tong MJ, Busuttil RW. Pretransplant variables associated with quality of life in liver transplant recipients. Liver Int 2008; 28:1087-94. [PMID: 18662279 DOI: 10.1111/j.1478-3231.2008.01831.x] [Citation(s) in RCA: 5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
OBJECTIVE With an increasing number of liver transplant recipients living, understanding quality-of-life issues is essential. Our goal is to identify pretransplant variables associated with post-transplant quality of life in liver transplant recipients. METHODS Three hundred and eight liver transplant recipients were administered the Short Form 36 and a basic demographical questionnaire. Variables associated with post-transplant quality of life were studied in a multivariate regression analysis. Interaction terms were used to examine effect modification. RESULTS Male gender, longer pretransplant work hours and interaction term between work hours and male gender were independently associated with Physical Functioning. Work hours positively correlated with Role-Physical, while viral hepatitis and ascites were negatively associated with Role-Physical. Ascites and viral hepatitis were independently negatively associated with Bodily Pain. Encephalopathy, hepatocellular carcinoma and viral hepatitis were independently associated with General Health. Ascites was also negatively associated with Social Functioning, Role-Emotional, Bodily Pain, General Health and Vitality. Viral hepatitis was negatively correlated with Vitality and Mental Functioning. CONCLUSIONS Pretransplant variables such as ascites, encephalopathy, hepatocellular carcinoma, viral hepatitis, work hours, time unable to work and gender were significantly associated with post-transplant quality of life in liver transplant recipients. Interventions addressing these issues may be initiated to improve the post-transplant quality of life.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, University of California, Los Angeles, CA 90095, USA.
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Abstract
BACKGROUND AND AIM Autoimmune hepatitis (AIH) is an idiopathic disease with diverse clinical manifestations. The aims of the present study were: (i) to describe the clinical characteristics of AIH patients in a community clinic setting; and (ii) to determine factors which were associated with poor clinical outcomes. METHODS A retrospective review was performed on 72 AIH patients who: (i) had pretreatment sera: (ii) were treatment-naïve at presentation; and (iii) had a minimum of 24 months of follow up. RESULTS On initial presentation, 22 (30%) had an acute onset of symptoms simulating acute viral hepatitis, 34 (47%) had chronic symptoms of greater than 6 months duration, and the remaining 16 (22%) were asymptomatic. Twenty-six (36%) had coexisting autoimmune diseases. Anti-nuclear antibody (ANA) was positive in 73% of the patients, and antismooth muscle antibody was positive in 15% of ANA-negative patients. Those few patients who tested positive for soluble liver antigen, anti-liver-kidney, microsomal antibody type-1, and anti-mitochondrial antibody were all also ANA positive. The median (range) duration of follow up was 98 (24-331) months. After immunosuppressive therapy, 26 of 72 (36%) remained in remission without further treatment. However, 46 (64%) required maintenance immunosuppression. Three patients who presented under the age of 20 years progressed to liver failure while on therapy and died while waiting for liver transplantation. Two other patients developed hepatocellular carcinoma (HCC) while on therapy and died. CONCLUSIONS A majority of AIH patients have an excellent prognosis. However, presentation at a younger age is a predictor of poor disease outcome and, although uncommon, HCC may develop during the late stages of cirrhosis.
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Affiliation(s)
- Suk Seo
- Medicine and Surgery, David Geffen School of Medicine at UCLA, The Pfleger Liver Institute, Los Angeles, California 90095-7302, USA.
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Gish R, Marrero JB, Tong MJ. Medical therapies to extend survival in hepatocellular carcinoma. Clin Adv Hematol Oncol 2008; 6:1-15. [PMID: 18833600] [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] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Hepatocellular carcinoma (HCC) is a serious malignancy with 21,000 new cases estimated for 2008. Several common diseases are associated with an increased risk of the development of HCC, including viral hepatitis, cirrhosis, and other chronic liver diseases. Most patients present with advanced disease, and therefore have only limited therapeutic options. However, advancements in screening and surveillance have allowed more patients to be identified and diagnosed with earlier-stage disease, increasing their therapeutic options. Several treatment modalities exist for early- and intermediate-stage disease, including ablative techniques and embolization methods. Additionally, advances in targeted therapy have resulted in the approval of the oral multitargeted tyrosine kinase inhibitor sorafenib, resulting in improved length of survival. In this roundtable discussion, the current epidemic of HCC is addressed, including factors contributing to an increased rate of occurrence. Additionally, the optimal screening and diagnosis of HCC patients is discussed, and the appropriate treatment modalities for each stage of HCC are presented.
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Affiliation(s)
- Robert Gish
- Liver Transplant Program, California Pacific Medical Center, University of California, San Francisco, USA
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Zimmerman MA, Ghobrial RM, Tong MJ, Hiatt JR, Cameron AM, Hong J, Busuttil RW. Recurrence of hepatocellular carcinoma following liver transplantation: a review of preoperative and postoperative prognostic indicators. Arch Surg 2008. [PMID: 18283144 DOI: 10.1001/archsurg.2007.39143/2/182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To review the preoperative and postoperative variables that predict hepatocellular carcinoma (HCC) recurrence following orthotopic liver transplantation (OLT). DATA SOURCES A collective review of the literature was conducted by searching the MEDLINE database using several key words: hepatocellular carcinoma, recurrence, liver transplantation, and salvage transplantation. STUDY SELECTION Reviews and original articles containing basic scientific observations and long-term clinical outcomes were included. DATA EXTRACTION Critical observations from peer-reviewed sources were incorporated in this review. DATA SYNTHESIS Overall, 11 studies were reviewed to determine the incidence of HCC recurrence following OLT and to identify prognostic variables of recurrence. Four studies were evaluated to determine the efficacy of salvage transplantation following liver resection. CONCLUSIONS Liver transplantation is a viable treatment option for select patients with HCC and end-stage liver disease. However, in approximately 20% of patients, recurrent HCC is the rate-limiting factor for long-term survival. Despite identification of clinical parameters that may stratify patients at high risk and exhaustive preoperative staging, cancer recurrence is likely the result of microscopic extrahepatic disease. With a desperate donor organ shortage, locoregional ablation techniques and resection are being employed in patients on the waiting list to serve as a bridge to OLT. Furthermore, some have advocated aggressive surgical resection of isolated metastasis in both the liver and extrahepatic viscera. Whether these creative strategies confer a survival advantage is unknown; it will require long-term follow-up to determine their efficacy.
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Affiliation(s)
- Michael A Zimmerman
- Dumont-University of California, Los Angeles, Transplant Center, 77-120 CHS, Box 957054, 10833 Le Conte Ave, Los Angeles, CA 90095-7054, USA
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Zimmerman MA, Ghobrial RM, Tong MJ, Hiatt JR, Cameron AM, Hong J, Busuttil RW. Recurrence of hepatocellular carcinoma following liver transplantation: a review of preoperative and postoperative prognostic indicators. ACTA ACUST UNITED AC 2008; 143:182-8; discussion 188. [PMID: 18283144 DOI: 10.1001/archsurg.2007.39] [Citation(s) in RCA: 203] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To review the preoperative and postoperative variables that predict hepatocellular carcinoma (HCC) recurrence following orthotopic liver transplantation (OLT). DATA SOURCES A collective review of the literature was conducted by searching the MEDLINE database using several key words: hepatocellular carcinoma, recurrence, liver transplantation, and salvage transplantation. STUDY SELECTION Reviews and original articles containing basic scientific observations and long-term clinical outcomes were included. DATA EXTRACTION Critical observations from peer-reviewed sources were incorporated in this review. DATA SYNTHESIS Overall, 11 studies were reviewed to determine the incidence of HCC recurrence following OLT and to identify prognostic variables of recurrence. Four studies were evaluated to determine the efficacy of salvage transplantation following liver resection. CONCLUSIONS Liver transplantation is a viable treatment option for select patients with HCC and end-stage liver disease. However, in approximately 20% of patients, recurrent HCC is the rate-limiting factor for long-term survival. Despite identification of clinical parameters that may stratify patients at high risk and exhaustive preoperative staging, cancer recurrence is likely the result of microscopic extrahepatic disease. With a desperate donor organ shortage, locoregional ablation techniques and resection are being employed in patients on the waiting list to serve as a bridge to OLT. Furthermore, some have advocated aggressive surgical resection of isolated metastasis in both the liver and extrahepatic viscera. Whether these creative strategies confer a survival advantage is unknown; it will require long-term follow-up to determine their efficacy.
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Affiliation(s)
- Michael A Zimmerman
- Dumont-University of California, Los Angeles, Transplant Center, 77-120 CHS, Box 957054, 10833 Le Conte Ave, Los Angeles, CA 90095-7054, USA
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Zimmerman MA, Ghobrial RM, Tong MJ, Hiatt JR, Cameron AM, Busuttil RW. Antiviral prophylaxis and recurrence of hepatocellular carcinoma following liver transplantation in patients with hepatitis B. Transplant Proc 2008; 39:3276-80. [PMID: 18089370 DOI: 10.1016/j.transproceed.2007.07.085] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2006] [Revised: 04/09/2007] [Accepted: 07/21/2007] [Indexed: 12/15/2022]
Abstract
BACKGROUND Orthotopic liver transplantation (OLT) is a viable treatment option for patients with hepatitis B (HBV) and concomitant hepatocellular carcinoma (HCC). However, cancer recurrence following transplantation approaches 20%. This study sought to identify the clinical and pathological factors associated with post-OLT survival. METHODS Univariate and multivariate analyses considered the following variables: combination viral prophylaxis, HBV recurrence, tumor stage, vascular invasion, distribution, nodularity, pre- and post-OLT tumor size, pre-OLT alpha-fetoprotein (AFP), Milan and UCSF criteria, and Asian race. RESULTS Cumulatively, HCC recurrence-free survival was 77%, 62%, and 53% at 1, 3, and 5 years, respectively, and was significantly better in patients who were free of viral recurrence post-OLT. Similarly, patients treated with combination prophylaxis had a significantly lower mortality than those who were not. CONCLUSIONS Multivariate analysis revealed that AFP>500 ng/mL, presence of vascular invasion by explant, HBV recurrence, and combination prophylaxis were independent predictors of HCC recurrence-free survival.
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Affiliation(s)
- M A Zimmerman
- Department of Surgery, Division of Liver and Pancreas Transplantation, The Pfleger Liver Institute, The Dumont-UCLA Transplant Center, The David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, California 90095-7054, USA
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