[Show abstract][Hide abstract] ABSTRACT: Conclusions:
HIV infection had no impact on recurrence of HCC or survival after LT. Our results support the indication of LT in HIV-infected patients with HCC. This article is protected by copyright. All rights reserved.
[Show abstract][Hide abstract] ABSTRACT: Introduction. To assess the clinical profile and management of patients with hepatitis C (HCV) infection in an observational study in Spanish hospitals. Methods. The study included an initial cross-sectional phase (study phase I), in which investigators at 48 hospitals from 14 Spanish regions collected data from approximately 20 consecutive patients each (a total of 1,000 patients) to assess the general features of HCV-infected patients of any genotype. During the second phase (study phase II), data from 878 patients that were infected exclusively with genotype 1 HCV were assessed retrospectively. Eight pre-defined clinical profiles were established, in order to assess clinical and previous treatments characteristics. Results. Among the HCV-infected individuals that were analysed during the first part, HCV genotype 1 was found to be predominant (with a prevalence of 76.6%), prevailing the subtype 1b (69.8%), with other significant groups infected by genotype 3 (12.3%) and 4 (7.4%). In the second part of the study, 44% of the HCV genotype 1-infected patients were at a F3/F4 fibrosis stage. 15.9% had never been treated, and previously unsuccessfully treated patients that were no longer receiving anti-HCV treatment accounted for 50.8% of cases. Individuals with a sustained virologic response (SVR) to previous dual therapies (based on Interferon and Ribavirin) were only 14.5% and patients under treatment during the study accounted for the remaining 18.8%. A total of 713 patients (81.2%) in the second phase were not receiving any type of therapy over the period analysed, mainly due to the anticipation of new anti-HCV drugs (41.8%), SVR achievement (17.8%) and unresponsiveness to therapies available at the time of the study (9.5%). Conclusions. HCV genotype 1, predominately 1b, is the most prevalent type in Spain. Advanced fibrosis or cirrhosis is frequent in this group, mainly patients not yet cured.
[Show abstract][Hide abstract] ABSTRACT: Background & Aims: Cardiovascular (CV) events represent major impediments to liver transplant (LT) long-term survival. The aim was to assess whether the Framingham risk score (FRS) at transplantation can predict the development of post-LT CV events.Methods: Patients transplanted between 2006 and 2008 were included. Baseline features, CV risk factors and CV events occurring post-LT (ischemic heart disease, stroke, heart failure, de novo arrhythmias, peripheral arterial disease) were recorded.Results: 250 patients, 69.5% men, median age 56 (range 18-68) yrs were included. At transplantation, 34.5%, 32.5% and 33% of patients respectively had a low, moderate and high FRS, with a median FRS of 15 (range: .09 – 30). 14% of LT recipients developed at least one CV event at a median of 2.5 (range: 0.005 - 7) yrs. In the univariate analysis, factors associated with the development of CV events were continuous-FRS at LT (p= .003), age (p= .007), creatinine clearance (eGFR) (p= .020) and MMF use at discharge (p=.011). In the multivariate analysis, only the eGFR (HR: .98, 95/CI: .97-1.00; p= .009) and FRS (HR: 1.06, 95/CI: 1.02-1.10, p= .002) remained in the model. Moreover, an association was also found between the FRS and overall survival (p= .014) with a 5 yr-survival rate of 82.5%, 78% and 61.5% in the low, moderate and high-risk groups, respectively. Continuous-FRS, eGFR and HCV infection were independent risk factors of overall mortality.Conclusions: In our series, the FRS and eGFR at LT were able to predict the development of post-LT CV events and poor outcome. This article is protected by copyright. All rights reserved.
No preview · Article · Mar 2015 · Liver Transplantation
[Show abstract][Hide abstract] ABSTRACT: Chronic hepatitis C (CHC) is an important cause of cirrhosis and hepatocellular carcinoma and a common indication of liver transplantation (LT). Recurrence of hepatitis C occurs universally after LT with an accelerated course of the natural history of CHC in the graft. Treatment of hepatitis C before transplantation is the most effective strategy because it prevents graft reinfection, but applicability is low with pegylated interferon regimens. Treatment after LT is the strategy more frequently used. A sustained viral response (SVR) is achieved by one-third of those treated with dual therapy and is associated with better outcomes after LT. Triple therapy with protease inhibitors after LT has efficacy to 60%-70% of SVR but is associated with higher rates of secondary effects and drug-drug interactions that require an intensified and frequent monitoring of calcineurin inhibitors during treatment. In the near future, interferon-free regimens with new oral antiviral drugs will likely prevent viral reinfection before or after LT, and shorter treatment regimens and less toxicity are expected.
No preview · Article · Nov 2014 · Transplantation Proceedings
[Show abstract][Hide abstract] ABSTRACT: To evaluate the results of the treatment with pegylated interferon and ribavirin for recurrence of hepatitis C after liver transplantation in HCV/HIV-coinfected patients.
No preview · Article · Aug 2014 · Journal of Hepatology
[Show abstract][Hide abstract] ABSTRACT: Recent approval of new protease inhibitors (boceprevir and telaprevir) for the treatment of chronic hepatitis C, genotype 1, has meant a significant increase in the sustained viral response both in naive and previously treated patients. However, such efficacy increase has been accompanied by an increase in adverse events, sometimes serious, and new practical issues including different approaches to stop treatment and drug interactions that recommend a close follow-up of patients. The efficacy and safety of triple therapy in special populations such as cirrhotic and transplanted patients is less known and has some particulars, meaning that its administration requires an exhaustive monitoring.
No preview · Article · Nov 2013 · Medicina Clínica
[Show abstract][Hide abstract] ABSTRACT: Haemophagocytic syndrome (HS) is a rare disease that is often fatal despite treatment. HS is characterized by fevers, lymphadenopathy, hepatosplenomegaly, cytopenias and hyperferritinaemia due to deregulated activation and proliferation of macrophages, leading to uncontrolled phagocytosis of platelets, erythrocytes, lymphocytes, and their hematopoietic precursors throughout the reticuloendothelial system. Mycobacterium tuberculosis-associated HS is a rare and underdiagnosed association with only 39 cases reported. We describe a case of HS associated with disseminated Mycobacterium tuberculosis in the setting of post-liver transplantation anti-hepatitis C therapy with pegylated interferon (pegIFN), ribavirin (RBV) and telaprevir (TVR). Despite the delay in the etiologic diagnosis, the patient was treated properly with corticosteroids, cyclosporine and tuberculostatic agents. It is unknown whether telaprevir, a drug that only recently has been started off-label in liver transplant recipients, may have contributed to the development of the HS. Unfortunately, as in many reported cases of HS, the outcome was unfavourable resulting in the death of the patient.
No preview · Article · Nov 2013 · Annals of hepatology: official journal of the Mexican Association of Hepatology
[Show abstract][Hide abstract] ABSTRACT: There are few studies focusing on long-term complications in liver transplant (LT) recipients. The aim of this study was to define the outcome of LT recipients having survived at least 10 years from LT. Of 323 adult LT done between 1991 and 1997, the 167(52%) alive >10 years post-LT (baseline time) formed the study population. Long-term outcome measures included the following: immunosuppression, metabolic complications [obesity, arterial hypertension (AH), diabetes, dislypidemia], cardiovascular events (CVE), chronic renal dysfunction-CRD, and de novo tumors. Median age at LT was 50 years. Most common indication was postnecrotic cirrhosis (89%), mostly because of HCV (46%). At study-baseline (10 years post-LT), 29% were obese and AH, diabetes, dislypidemia, and CRD were present in 75%, 30%, 42%, and 36%, respectively. In most cases, these complications were already present 1 year post-LT; less than one quarter developed them onward. The 6 year cumulative survival since baseline reached 84% (n = 24 deaths), with most deaths related to recurrent graft diseases (mostly HCV) followed by de novo tumors or CVE. 1, 3, 5 and 10 years cumulative rates of CVE and de novo tumors since baseline were 2%, 5%, 10% and 17%, and 1%, 3%, 6% and 13%, respectively. Chronic renal impairment was independently associated with survival and development of CVE since baseline. The medium-term survival of 'long-term survivors', i.e. patients alive 10 years after LT is good, but metabolic complications and CRD are common and continue to increase afterwards. Cardiovascular events and de novo tumors increase gradually over time and represent a major cause of late mortality.
No preview · Article · Apr 2013 · Transplant International
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Chronic renal impairment is an emerging problem in the management of patients after liver transplantation (LT). METHODS: We prospectively analyzed predictors of chronic kidney disease (CKD) after LT in 179 patients followed for a median of 63 months. Diagnosis of CKD was based on an estimated glomerular filtration rate (GFR) of less than 60 mL/min according to the current position statement from the Kidney Disease Improving Global Outcome. Pretransplantation risk factors were evaluated. A Cox regression analysis, with time-dependent variables evaluated during follow-up, was applied to realize a prognostic model for CKD, and a prognostic index was also calculated. The validity of the model was tested in 149 independent LT patients with a median follow-up of 46 months. RESULTS: The cumulative incidence of CKD was 45% at 5 years after LT. Estimated GFR at LT was the only pretransplantation independent risk factor (beta, 0.33; standard error (beta), 0.07; 95% confidence interval, 0.95-0.98). Development of arterial hypertension (hazards ratio [HR], 1.83), episodes of severe infection (HR, 2.15), and estimated GFR (HR, 0.89) after LT were identified as independent prognostic factors at the Cox regression time-dependent analysis. The model was able to identify the patients at higher risk for the development of CKD in the validation set. CONCLUSIONS: Lower renal function at transplantation is associated with a higher risk of CKD after transplantation. A predictive model based on the variation of posttransplantation variables during the course of follow-up can help the clinicians to estimate the probability of CKD in the next 12 months.
[Show abstract][Hide abstract] ABSTRACT: Recurrence of hepatitis C virus (HCV) infection following liver transplantation is a major source of morbidity and mortality. The natural history of hepatitis C in the transplant setting is shortened. Overall, one third of HCV-infected recipients have developed allograft cirrhosis due to HCV recurrence by the 5(th)-7(th) year post-transplantation. The most significant variables which determine disease progression are the use of organs from old donors, the use of an inadequate immunosuppression (too low, inducing treatment rejection episodes, too potent or too rapidly changing), and the presence of comorbid conditions that also impact the quality of the graft (biliary complications, metabolic syndrome). The only factor consistently shown to modify the natural history of recurrent disease is antiviral therapy. A sustained viral response, achieved by one third of those treated with dual therapy, is associated with improved histology, reduced liver-related complications and increased survival. Variables associated with enhanced viral response with dual therapy include an adequate genetic background (IL28B C/C of both donor and recipient), good treatment adherence (full doses of ribavirin, treatment duration), lack of graft cirrhosis at baseline, and viral genotype non-1. Data with triple therapy are encouraging. Response rates of about 60% at end-of-therapy have been described. Drug-drug interactions with calcineurin inhibitors are present but easily manageable with strict trough levels monitoring. Side effects are frequent and severe, particularly anemia, infections and acute renal insufficiency. In the future new oral antivirals will likely prevent viral reinfection. In this review, we will cover the most significant but also controversial aspects regarding recurrent HCV infection, including the natural history, retransplantation, antiviral therapy, and outcome in HIV-HCV patients.
Full-text · Article · Mar 2013 · Annals of Gastroenterology