Dilip Moonka

Henry Ford Health System, Detroit, Michigan, United States

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Publications (60)239.04 Total impact

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    ABSTRACT: Patients with detectable hepatitis C virus (HCV) RNA at the time of liver transplantation universally experience recurrent HCV infection. Antiviral treatment before transplantation can prevent HCV recurrence, but existing interferon-based regimens are poorly tolerated and are either ineffective or contraindicated in most patients. We performed a trial to determine whether sofosbuvir and ribavirin treatment before liver transplantation could prevent HCV recurrence afterward.
    Gastroenterology 09/2014; · 12.82 Impact Factor
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    ABSTRACT: While experimental evidence has indicated that ischemia–reperfusion injury of the liver stimulates growth of micrometastases and adhesion of tumor cells, the clinical impact of ischemia-reperfusion injury on the recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) has not been fully investigated. To study this issue, we conducted a retrospective review of the medical records of 391 patients from two transplant centers who underwent LT for HCC. Ischemia times along with other tumor/recipient variables were analyzed as risk factors for recurrence of HCC. Subgroup analysis focused on patients with HCC who had pathologically proven vascular invasion because of the associated increased risk of micrometastasis. Recurrence occurred in 60 patients (15.3%) with median time to recurrence of 0.9 years (40days–4.6years). Cumulative recurrence curves according to CIT at 2hour intervals and WIT at 10min intervals showed that CIT>10hours and WIT>50min were associated with significantly increased recurrence (P=0.015 and 0.036, respectively). Multivariate Cox regression analysis identified prolonged cold (>10hours; P=0.03, hazard ratio [HR]=1.9) and warm (>50min; P=0.003, HR=2.84) ischemia times as independent risk factors for HCC recurrence, along with tumor factors including poor differentiation, micro- and macrovacular invasion, exceeding Milan criteria, and AFP>200ng/dl. Prolonged cold (P=0.04, HR=2.24) and warm (P=0.001, HR=5.1) ischemia times were also significantly associated with early (within 1yr) recurrence. In the subgroup analysis prolonged cold (P=0.01, HR=2.6) and warm (P=0.01, HR=3.23) ischemia times were independent risk factors for recurrence in patients with vascular invasion, whereas there was no association between ischemia times and HCC recurrence in patients with no vascular invasion. Conclusion: Reducing ischemia time may be a useful strategy to decrease HCC recurrence after LT, especially in those with other risk factors. (Hepatology 2014;)
    Hepatology 08/2014; · 12.00 Impact Factor
  • Liver Transplantation 08/2014; · 3.94 Impact Factor
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    ABSTRACT: Sirolimus (SRL) is an immunosuppressive agent used in liver transplantation (LT), in part, to mitigate renal insuffi ciency associated with calcineurin inhibitors (CIs). SRL can cause hyperlipidemia but its association with coronary artery disease (CAD) and cerebrovascular accidents (CVA) is unclear. The purpose of this study is to assess the risk of CAD and CVA associated with the use of SRL in LT recipients. We conducted a chart review of 1053 patients who received a LT at our program between the years 2000 and 2011. Patients with combined liver-kidney transplant, multiple liver transplants, everolimus therapy or post-transplant survival < 3 months were excluded. The remaining 803 patients were divided into 3 groups; 1) 134 patients (16.7%) who received and tolerated SRL; 2) 604 patients (75.2%) who did not receive SRL at any point; and 3) 65 patients (8.1%) who were initiated on SRL but did not tolerate it or discontinued it. The primary composite outcome was the development of CAD or CVA occurring beyond 4 months post-transplant using time dependent Kaplan-Meier analysis. Demographic and transplant data were used to perform multivariate cox regression modeling of signifi cant factors. In Group 1, there were a total of 6 CAD and 2 CVA events, in Group 2, 27 CAD and 16 CVA events, and in Group 3 there were 10 CAD and 2 CVA events. The time dependent event free survival for CAD/CVA at 1, 3 and 5 years was 100%, 98.1% and 97.2% respectively for Group 1; 99.7%, 98.4% and 96.1% for Group 2; and 92.3%, 92.3% and 85.6% for Group 3. On an unadjusted basis, compared to Group 2, there was no difference in CAD/CVA rates in Group 1 (HR 0.92; NS) but there was an increase in CAD/CVA in Group 3 (HR 2.94: p=0.0019). However, on multivariate analysis, the only variables associate with an increase risk of CAD/CVA after LT was age at transplant (HR 1.06; p=0.001) and diabetes prior to transplant (p=0.011). Our analysis shows that patients receiving SRL after LT had no increased risk of CAD/CVA events when compared to patients maintained on a CI. The risk of CAD/CVA should not be a factor in avoiding SRL. Donor age and diabetes prior to transplant are risk factors for CAD/CVA and these patients may warrant closer scrutiny and intervention.
    American Journal of Transplantation 06/2014; 14(S3):161. · 6.19 Impact Factor
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    Transplantation 03/2014; 97(6):e33-4. · 3.78 Impact Factor
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    ABSTRACT: To help decrease mortality on the liver transplant waitlist, transplant centers are using living donors (LD) and high risk donors (HRD) in addition to standard risk donors (SRD). HRD is defined as having a donor risk index score higher than 1.6, which suggests a great risk of graft failure. Recent studies have examined survival rates between HRD and SRD recipients; however, little is known about outcomes other than survival, specifically psychosocial outcomes. The purpose of this preliminary, prospective study was to compare post-transplant psychosocial and recovery outcomes between SRD and LD and HRD liver recipients. These outcomes include cognitive functioning, psychological distress, quality of life, and self-reported and objective measures of recovery. Eighty-four patients provided baseline and 6 month post-transplant data. There were generally no statistically significant differences at baseline or the 6 month follow-up suggesting that patients receiving HRD livers have similar outcomes to those who receive SRD livers. However, some effect sizes suggest potential advantages for LD recipients compared to SRD recipients. Transplant centers may be more willing to encourage patients to accept HRD or LD livers knowing that they may have comparable outcomes to SRD recipients, which also has implications for the transplant waitlist.This article is protected by copyright. All rights reserved.
    Clinical Transplantation 03/2014; · 1.63 Impact Factor
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    ABSTRACT: Absolute lymphocyte count (ALC) is considered a surrogate marker for the level of immunosuppression and nutritional status of patients and a prognostic factor for survival and recurrence in several cancers. The aim of this study was to investigate the prognostic value of peritransplant ALC for the recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT). HCC patients who underwent LT between 2000 and 2010 were evaluated. Exclusion criteria were combined HCC and cholangiocarcinoma. Peritransplant ALCs (before LT and 2 weeks and 1 month after LT) were analyzed along with tumor, operative, and donor characteristics to identify risk factors for the recurrence of HCC. HCC developed in 27 of the 173 LT patients investigated for risk factors (15.6%). The median time to recurrence was 1.14 years. Low ALCs before and after LT were associated with a higher recurrence rate in a continuous manner (before LT: hazard ratio=1.12, P=0.003; 2 weeks after LT: hazard ratio=1.14, P=0.008; 1 month after LT: hazard ratio=1.06, P=0.055) (increased risk per 100/μL down). On multivariate Cox regression analysis, peritransplant persistent lymphopenia (<1000/μL before LT and <500/μL at 2 weeks and 1 month after LT) was an independent risk factor for cancer recurrence (hazard ratio=7.05, P<0.001), along with tumor characteristics. Peritransplant lymphopenia is a powerful prognostic factor for the recurrence of HCC after LT, which suggests that maintaining ALCs in LT patients might improve cancer outcome.
    Transplantation 11/2013; · 3.78 Impact Factor
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    ABSTRACT: There has been little research examining the effects of mental health prior to liver transplantation on quality of life and recovery after transplant. Therefore, the purpose of the current study was to examine how pre-transplant depression and anxiety affect mental health, quality of life, and recovery after transplant. Eighty-two transplant recipients completed data when they were listed for transplant and six months post-transplant. Pre-transplant anxiety predicted post-transplant anxiety (p <.001) and there was a trend in predicting post-transplant depression (p =.06). Pre-transplant depression predicted post-transplant depression (p =.03), and there was a trend in predicting post-transplant anxiety (p =.06). Additionally, pre-transplant anxiety predicted post-transplant quality of life for several domains including body pain, role limitations due to emotional problems, mental health, and the mental health composite score (p <.05). However, pre-transplant depression independently predicted outcomes for more domains of quality of life than anxiety, which included physical functioning, role limitations due to physical problems, general health, vitality, social functioning, and the physical composite score (p <.05). Patients with depression at baseline were more likely to report an incomplete recovery 6 months after transplantation (p <.001). With regards to baseline anxiety, there was a trend suggesting that these patients were also more likely to report an incomplete recovery (p =.09). These findings highlight the importance of evaluating transplant candidates both pre- and post-transplant for anxiety and depressive symptoms. Once patients with these symptoms are identified, they can be referred to treatment, which may lead to better post-transplant outcomes for mental health, quality of life, and recovery. Liver Transpl , 2013. © 2013 AASLD.
    Liver Transplantation 08/2013; · 3.94 Impact Factor
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    ABSTRACT: Lymphocytes play an active role in natural immunity against hepatitis C (HCV). We hypothesized that a lower absolute lymphocyte count (ALC) may alter HCV outcome after liver transplantation (LT). The aim of this study was to investigate the impact of peri-transplant ALC on HCV recurrence following LT. A total of 289 LT patients between 2005 and 2011 were evaluated. Peri-transplant ALC (pre-LT, two-week and one-month post-LT) and immunosuppression were analyzed along with recipient and donor factors in order to determine risk factors for HCV recurrence based on METAVIR fibrosis score. When stratifying patients according to pre- and post-LT ALC (<500/µL vs. 500-1,000/µL vs. >1,000/µL), lymphopenia was significantly associated with higher rates of HCV recurrence with fibrosis (F2-4). Multivariate Cox regression analysis showed post-transplant ALC at one month remained an independent predictive factor for recurrence (P=0.02, hazard ratio=2.47 for <500/µL). When peri-transplant ALC was persistently low (<500/μL pre-LT, two-week, and one-month post-LT), patients were at significant risk of developing early advanced fibrosis secondary to HCV recurrence (F3-4 within two years) (P=0.02, hazard ratio=3.16). Furthermore, severe pre-transplant lymphopenia (<500/μL) was an independent prognostic factor for overall survival (P=0.01, hazard ratio=3.01). The use of rabbit anti-thymocyte globulin induction (RATG) had a remarkable protective effect on HCV recurrence (P=0.02, hazard ratio=0.6) despite its potential to induce lymphopenia. Subgroup analysis indicated that negative effects of post-transplant lymphopenia at one month (<1,000/µL) were significant regardless of RATG use and the protective effects of RATG were independent of post-transplant lymphopenia. CONCLUSION: Peri-transplant ALC is a novel and useful surrogate marker for prediction of HCV recurrence and patient survival. Immunosuppression protocols and peri-transplant management should be scrutinized depending on peri-transplant ALC. (HEPATOLOGY 2013.).
    Hepatology 08/2013; · 12.00 Impact Factor
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    ABSTRACT: Mycophenolate mofetil (MMF) and sirolimus (SRL) have been used for calcineurin inhibitor (CNI) minimization to reduce nephrotoxicity after liver transplantation. In this prospective, open-label, multicenter study, patients undergoing transplantation from July 2005 to June 2007 who were maintained on MMF/CNI were randomized 4 to 12 weeks after transplantation to receive MMF/SRL (n = 148) or continue MMF/CNI (n = 145). The primary efficacy endpoints were the mean percentage change in the calculated glomerular filtration rate (GFR) and a composite of biopsy-proven acute rejection (BPAR), graft loss, death, and loss to follow-up 12 months after transplantation. Patients were followed for a median of 519 days after randomization. MMF/SRL was associated with a significantly greater renal function improvement from the baseline with a mean percentage change in GFR of 19.7 ± 40.6 (versus 1.2 ± 39.9 for MMF/CNI, P = 0.002). The composite endpoint demonstrated the noninferiority of MMF/SRL versus MMF/CNI (16.4% versus 15.4%, 90% confidence interval = -7.1% to 9.0%). The incidence of BPAR was significantly greater with MMF/SRL (12.2%) versus MMF/CNI (4.1%, P = 0.02). Graft loss (including death) occurred in 3.4% of the MMF/SRL-treated patients and in 8.3% of the MMF/CNI-treated patients (P = 0.04). Malignancy-related deaths were less frequent with MMF/SRL. Adverse events caused withdrawal for 34.2% of the MMF/SRL-treated patients and for 24.1% of the MMF/CNI-treated patients (P = 0.06). The use of MMF/SRL is an option for liver transplant recipients who can benefit from improved renal function but is associated with an increased risk of rejection (but not graft loss). Liver Transpl, 2013. © 2013 AASLD.
    Liver Transplantation 06/2013; · 3.94 Impact Factor
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    ABSTRACT: BACKGROUND: Venous thromboembolism (VTE) is a potentially fatal complication of major abdominal operations. Liver transplantation is carried out as a treatment for end-stage liver disease (ESLD). It is not well studied whether this population is at increased or decreased risk of a VTE event after a liver transplantation. This study was to determine the frequency of VTE in this population and identify possible predictors. METHODS: Retrospective review of 917 patients over 15 years at a single tertiary center was conducted. Liver transplant recipients with symptomatic VTE occurring up to 1 year after liver transplantation were included. Upper and lower extremities deep vein thrombosis (DVT) was identified. The diagnosis of DVT and pulmonary embolism (PE) was made by appropriate diagnostic imaging. Data regarding known risk factors of VTE such as thrombophilia, recent hospitalization, malignancy, and other comorbid conditions were collected. RESULTS: Among 917 patients, a total of 45 events occurred in 42 (4.58%) patients. Twelve had PE and 33 had DVT events. On Cox regression analysis the absence of an alcoholism diagnosis (Hazard Ratio [HR], -0.33; 95% confidence interval [CI], 0.13-0.83), the presence of diabetes (HR, -3.36; 95% CI, 1.76-6.42), a history of VTE (HR, -8.06; 95% CI, 3.37-19.3), and the presence of end-stage renal disease (ESRD; HR, 3.68; 95% CI, 1.34-10.01) were significant predictors of a VTE outcome. No particular diagnosis, history of malignancy, or presence of thrombophilia were associated with increased risk of VTE. CONCLUSION: The 4.58 % incidence of VTE is comparable with the reported incidence after major abdominal procedures (5%-10%). This data also shows that there is increased risk of VTE in transplant recipients with comorbid conditions of diabetes, previous VTE, and ESRD. This study suggests that a more aggressive strategy for prophylaxis of VTE should be used in liver transplant recipients as with other major abdominal procedures.
    Transplantation Proceedings 09/2012; · 0.95 Impact Factor
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    ABSTRACT: Non-alcoholic steatohepatitis (NASH) and cryptogenic cirrhosis (CC) are increasing indications for orthotopic liver transplantation (OLT). The aim of this study is to describe our outcomes and delineate predictors of recurrence of NASH and CC after OLT. This is a retrospective study from 1996 to 2008. Donor and recipient demographics, metabolic profile, insulin and steroid intake, immunosuppression regimen, operative factors, outcomes, and pathologies were reviewed. Fisher's exact test, Cox regression models, and Kaplan-Meier plots were used. A total of 83 patients were included. Recurrence occurred in 20 patients. Thirty-four percent of the patients with metabolic syndrome (MS) had recurrence of NASH or CC compared with 13% of the patients without MS (p = 0.05). Recurrence also occurred in 32% of the patients with hypertension (HTN) vs. 12% in those without HTN (p = 0.05). Thirty-seven percent of those on insulin had recurrence vs. 6% of those not on insulin (p = 0.05). Five-yr survival probability for patients with MS, HTN, and insulin use was 52%, 61%, and 58%, respectively. Higher recurrence of NASH and CC was associated with presence of MS, HTN and insulin use. Recurrence should be further evaluated in larger studies, with special emphasis on management of MS and prevention strategies.
    Clinical Transplantation 09/2012; 26(5):E505-12. · 1.63 Impact Factor
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    ABSTRACT: Transjugular intrahepatic portosystemic shunt (TIPS) has been fairly effective in managing portal hypertension in the setting of cirrhosis. The aim is to study the safety and efficacy of TIPS in liver transplant (LT) recipients. Fifteen patients underwent TIPS insertion following LT. Indications were refractory ascites (12), hepatic hydrothorax (2), and bleeding esophageal varices (1). Seven patients (46.6%) had complete (C) resolution of ascites, while eight (53.4%) had partial or no (PN) resolution. Portal pressure and portal-right atrial pressure gradients post-TIPS were comparable. Ammonia levels were significantly higher in the PN group. Encephalopathy occurred in two patients (PN group). Four patients required re-transplantation and seven patients expired. The five-yr survival probability was 60.0% for the C group and 66.7% for the PN group. Currently, six patients are alive without clinical evidence of ascites. Two patients are alive but require re-transplantation. TIPS is a safe and effective method to control refractory ascites after LT. Portal pressure changes did not seem to correlate with resolution of ascites. Earlier allograft dysfunction is more likely with PN resolution of ascites after TIPS, and thus early re-transplantation should be considered. Re-transplantation in the context of organ dysfunction and graft failure should be a priority when considering TIPS.
    Clinical Transplantation 02/2012; 26(4):657-61. · 1.63 Impact Factor
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    ABSTRACT: This prospective, longitudinal study investigated change in physical and mental health quality of life (QoL) in a sample of 65 end-stage liver disease patients before and after liver transplantation. Physical and mental health QoL were assessed using the SF-36 Physical Health Summary and Mental Health Summary, respectively. Baseline data were collected prior to transplant and follow-up data were collected at 1 and 6 months after transplantation. Repeated-measures analysis of variance results indicate that physical QoL did not improve significantly between baseline and 1-month follow-up (F = .031, P = .860) but did between 1- and 6-month follow-up (F = 20.873, P < .001). Significant between-subject effects suggested attenuated improvement for patients with alcohol abuse histories (F = 6.213, P = .017). Physical QoL did not improve between 1- and 6-month follow-up for patients with alcohol abuse history (t((13)) = -1.074, P = .112). By contrast, mental health QoL improved significantly between baseline and 1-month follow-up (F = 13.840, P < .001), but not between 1- and 6-month follow-up (F = .750, P = .391). No significant differences were found on the Mental Health Summary index based on alcohol abuse history for either time period. Post hoc multivariate analysis of variance results suggested worse functioning (F = 2.674, P = .013) for individuals with alcohol abuse history on SF-36 Physical Functioning (F = 5.55, P = .021), Body Pain (F = 13.578, P < .001), Vitality (F = 4.337, P = .040), and Social Functioning (F = 10.50, P = .002) subscales. For liver transplant patients, improvements in psychosocial functioning and QoL precede improvements in physical QoL. Attenuated physical QoL improvements for patients with alcohol abuse histories are related to greater pain and physical deficits.
    Transplantation Proceedings 12/2010; 42(10):4145-7. · 0.95 Impact Factor
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    ABSTRACT: Several studies have demonstrated mixed results regarding the influence of donor race on patient and graft survival in patients infected with hepatitis C virus (HCV) after liver transplant. However, few studies have looked at the impact of donor race on recurrent HCV. This study is a retrospective analysis of the influence of patient and donor race on the severity of recurrent HCV at a single center. Of patients transplanted at our center between 2000 and 2006, 222 were infected with HCV. Of these, 165 were eligible to be evaluated for recurrent HCV after transplant. We excluded those with patient and graft loss within 1 year that was not related to recurrent HCV, patients with advanced fibrosis from other causes, those who did not undergo posttransplant liver biopsy, and those lost to follow-up. Patients were given a recurrent HCV score of 1, 2, or 3. A score of 1 was assigned if the patient had no more than mild portal fibrosis at 1 year and no bridging fibrosis at any point. A score of 2 was defined as moderate portal fibrosis or focal bridging fibrosis at 1 year or bridging fibrosis or cirrhosis after 3 years. A score of 3 was defined as bridging fibrosis, cirrhosis, or graft loss from HCV within 3 years. Baseline characteristics including donor and recipient age, race, sex, body mass index, ischemia time, hypertension, and diabetes were recorded. Analysis was performed with ordinal multivariate logistic regression modeling. Of the 165 patients with a recurrent HCV score, 105 (64%) had a score of 1, 29 patients (17%) had a score of 2, and 31 patients (19%) had a score of 3. In all, 132 recipients (80%) had white donors, and 26 (16%) had African American donors, 115 patients (70%) were white and 40 (24%) were African American. The mean recurrent HCV scores for the patient donor and recipient race combinations are as follows: white donor and white recipient, 1.54; white donor and African American recipient, 1.89; African American donor and white recipient, 1.18; and African American donor and African American recipient, 1.23. Having a white donor also significantly associated with a higher recurrent HCV score regardless of recipient race (odds ratio 2.93, P = .044) in African American patients, having a white donor had an odds ratio of 4.62 (P = .046). After adjusting for donor age and sex and patient age and sex, having a white donor was still found to be associated with a higher recurrent HCV score (4.48, P = .0275) on multivariate analysis. For all 222 patients, donor race was not associated with overall patient and graft survival. Patients receiving white donor grafts had significantly worse recurrent HCV than those receiving grafts from African American donors regardless of recipient race. This difference was especially marked in African American recipients and persisted on multivariate analysis. These data suggest a graft from a white donor is potentially one more important variable in identifying patients at risk for more aggressive recurrent HCV after orthotopic liver transplant.
    Transplantation Proceedings 12/2010; 42(10):4175-7. · 0.95 Impact Factor
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    ABSTRACT: Donation-after-death liver transplantation (DCD-LT) carries higher complication rates compared with donation-after-brain death liver transplantation (DBD-LT). In this report we describe our experience with biliary complications in DCD-LT with emphasis on anatomical patterns and outcomes. We performed retrospective review of patients' medical records from August 2004 to December 2008, during which time total of 26 DCD-LTs were performed. Mean follow-up was 29 months (range 3 to 51 months). Biliary complications occurred in 12 patients (46%), of whom 9 were related to DCD (35%). Four patients had more than 1 biliary complication, and 4 had concomitant arterial problems (stricture/thrombosis). Treatment of complications included: ERCP (n = 5, 3 resolved), conversion to roux (n = 5, 2 resolved), revision of roux (n = 1), percutaneous transhepatic cholangiography (n = 1), artery revision (n = 3). Three patients with casts had operative extraction of casts depicting a mummified biliary tree; histology showed casts and fibrosis and anastomotic suture material. Six patients underwent retransplantation (23%). Among retransplanted patients, 2 deaths occurred (7.7%). Our experience with DCD-LT reveals a high prevalence of biliary complications with a new and wide spectrum of clinicopathologic findings. Better strategies for prevention of these unique biliary complications are needed to better justify the added risks and costs for performance of DCD-LT.
    Transplantation Proceedings 11/2010; 42(9):3392-8. · 0.95 Impact Factor
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    ABSTRACT: Chronic infection with hepatitis C virus (HCV) confers increased risk for chronic renal disease, and numerous reports suggest an association with renal cell carcinoma (RCC), a cancer with rapidly rising global incidence. We sought to determine whether HCV infection confers an increased risk for developing RCC. With the use of administrative data from a large, integrated, and ethnically diverse healthcare system, we did a cohort study of 67,063 HCV-tested patients between 1997 and 2006 who were followed for the development of RCC until April 2008. A search of the health system cancer registry for patients with the diagnosis of kidney cancer showed that RCC was diagnosed in 0.6% (17 of 3,057) of HCV-positive patients versus 0.3% (177 of 64,006) of HCV-negative patients. The mean age at RCC diagnosis was much younger in HCV-positive individuals (54 versus 63; P < 0.001). The univariate hazard ratio for RCC among HCV patients was 2.20 (95% confidence interval, 1.32-3.67; P = 0.0025). In a multivariate model that included the risk factors age, African-American race, male gender, and chronic kidney disease, the overall hazard ratio for RCC among HCV patients was 1.77 (95% confidence interval, 1.05-2.98; P = 0.0313). Chronic HCV infection confers a risk for the development of RCC. Clinicians should consider newly identified renal lesions in patients with chronic HCV infection with a heightened suspicion for neoplasm, and newly diagnosed cases of RCC may require more careful surveillance for the presence of HCV infection. Additional studies are required to confirm these findings and to explore potential mechanisms of oncogenesis.
    Cancer Epidemiology Biomarkers &amp Prevention 03/2010; 19(4):1066-73. · 4.56 Impact Factor
  • Transplantation 01/2010; 90. · 3.78 Impact Factor
  • Transplantation 01/2010; 90. · 3.78 Impact Factor

Publication Stats

230 Citations
239.04 Total Impact Points

Institutions

  • 2001–2014
    • Henry Ford Health System
      • • Behavioral Health Services
      • • Division of Gastroenterology
      Detroit, Michigan, United States
    • Henry Ford Hospital
      • Surgery
      Detroit, Michigan, United States
  • 2008
    • Case Western Reserve University
      • Center for AIDS Research
      Cleveland, Ohio, United States
  • 1997–1998
    • University of Pennsylvania
      • Division of Gastroenterology
      Philadelphia, PA, United States