Alan Hoi Lun Yau’s research while affiliated with University of British Columbia and other places

Background: xpert guidelines recommend hepatocellular carcinoma (HCC) surveillance among patients with high-risk chronic hepatitis B (CHB); however, physician screening practices are often variable. Methods: An online survey of HCC screening practice was distributed to members of the Canadian Association for the Study of the Liver. Data were analyzed using appropriate statistical tests with p < .05 significance. Results: Of 71 respondents, 86% (n = 61) were gastroenterologists or hepatologists, and 72% (n = 51) reported having been in clinical practice for more than 5 years. A significant number of survey respondents performed HCC screening without consideration of concomitant non-alcoholic fatty liver disease (50.7%); non-Asian, non-African ethnicity (46.4%); and family history of HCC (28.6%). Most (67.6%) performed screening with ultrasound (US) at the time of specialty clinic visits, 28.2% had an automatic recall system, and only 2.8% referred back to primary care physicians to organize screening. More than half (54.9%) included alpha-fetoprotein in screening. Obstacles to screening included lack of an automatic recall system (42.9%), patient non-compliance (30.0%), and limited US/MRI access (17.1%). Conclusions: HCC screening practices with hepatitis B patients vary widely among Canadian specialists, especially in unique populations with limited data to inform screening recommendations. Implementation of an automatic recall system could potentially increase HCC surveillance.

Background: Cirrhotic patients undergoing liver transplantation are at risk of cardiac complications. Brain natriuretic peptide (BNP) and amino terminal brain natriuretic peptide (NT-BNP) are used in cardiac risk stratification. Their significance in predicting mortality risk in cirrhotic patients during or after liver transplantation is unknown. We conducted a systematic review and meta-analysis to answer this question. Methods: An electronic search of EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews (2005-September 2016), Google Scholar, and study bibliographies was conducted. Study quality was determined, and demographic and outcome data were gathered. Random effects meta-analyses of mortality-based BNP and NT-BNP level or presence of post-transplant heart failure were conducted. Results: Seven studies including 2,010 patients were identified. Demographics were similar between patients with high or low BNP or NT-BNP levels. Hepatitis C was the most prevalent etiology of cirrhosis (38%). Meta-analysis revealed a pooled relative risk of 3.1 (95% CI 1.9% to 5.0%) for post-transplant mortality based on elevated BNP or NT-BNP level. Meta-analysis also revealed a pooled relative risk of 1.6 (95% CI 1.3% to 2.1%) for post-transplant mortality if patients had demonstrated post-transplant heart failure. Conclusions: Our analysis suggests that BNP or NT-BNP measurement may help in risk stratification and provides data on post-operative mortality in cirrhotic patients undergoing liver transplantation. Discriminatory thresholds are higher in cirrhotic patients relative to prior studies with non-cirrhotic patients. However, the number of analyzed studies is limited, and our findings should be validated further through larger, prospective studies.

Background The goal of treating chronic hepatitis C virus (HCV) infection is sustained virologic response (SVR). There is concern that despite achieving SVR, replication-competent HCV may be sequestered at low levels within the liver and could theoretically reactivate with immunosuppression. Aims We report transplantation of a HCV seropositive liver donor, who achieved SVR, into a seronegative patient without HCV reactivation despite profound immunosuppression. Methods Retrospective chart review. Results We present a 21-year-old male who was HCV seronegative and received a liver transplant from a donor who had been treated for HCV and achieved SVR. The liver recipient, despite developing severe acute graft rejection and undergoing intense immunosuppression with T-cell depleting antibodies, did not become HCV RNA positive with a follow up period of 8 months. The recipient was HCV seronegative before transplant, but became HCV seropositive immediately post-transplant. The antibodies were undetectable after 97 days, in keeping with a passive antibody transmission or B lymphocyte transmission with the graft. Conclusions To the best of our knowledge, this is the first reported case of an HCV seropositive liver allograft transplanted into a HCV negative recipient. This case, therefore, is an encouraging and novel step in liver transplantation, and demonstrates that SVR may be closer to a true “cure” of HCV in the donor population and that, even in circumstances of very potent immunosuppression in the recipient, this SVR is sustained. To our knowledge, this case also contains the first documented example of an HCV antibody decay phenomenon in the recipient post-liver organ transplant. Funding Agencies None

Background Current guidelines recommend HCC surveillance in certain chronic HBV carriers: Asian male age > 40, Asian female age > 50, African/Non-African blacks, family history of HCC and cirrhosis. Aims To determine the HCC screening practices among Canadian gastroenterologists and hepatologists. Methods An online survey was performed. Results At this point, 22 responded (5 hepatologists, 17 gastroenterologists) and their years in practice were: < 5 (18.2%), 6–10 (22.7%), 11–15 (13.6%), 16–20 (4.5%), and > 21 (40.9%). The number of HBV patients seen per year was: < 10 (31.8%), 10–100 (36.4%), 100–200 (18.2%), 200–500 (4.5%), and > 500 (9.1%). All hepatologists and 12 (70.6%) gastroenterologists treat HBV. 77.3% (17/22) order US about every 6 months at the time of clinic visits, while 13.6% (3/22) have an automatic recall system and 9.1% (2/22) refer back to primary care physicians. 54.5% (12/22) include alpha-fetoprotein (AFP) with ultrasound. For non-Asian, non-African HBV patients, 36.4% (8/22) screen them the same way as in Asians, 31.8% (7/22) screen with US every 6 months starting at an older age, 13.6% (3/22) screen with annual US at the same age, 9.1% (2/22) screen with annual US at an older age, and 9.1% (2/22) screen only cirrhotic. For young (age < 40) non-African HBV patients with a family history of HCC, 36.4% (8/22) screen with US every 6 months regardless of age, 27.3% (6/22) screen with US and AFP every 6 months regardless of age, 18.2% (4/22) screen with annual US regardless of age, and 18.2% (4/22) screen the same way as those without a family history. For HBV patients with non-alcoholic fatty liver disease (NAFLD): 50% (11/22) screen the same way as those without NAFLD, 31.8% (7/22) start screening with US every 6 months regardless of age if advanced liver fibrosis (≥F3) is present, 9.1% (2/22) screen with MRI every 6 months regardless of age if advanced fibrosis (≥F3) is present, and 9.1% (2/22) screen with US every 6 months regardless of age and stage of fibrosis. Obstacles to HCC screening reported: lack of an automatic recall system (54.5%; 12), patient non-compliance (31.8%; 7), and limited access to US/MRI (13.6%; 3). Conclusions HCC screening practice vary widely among gastroenterologists and hepatologists for HBV patients with non-Asian, non-African descent, family history of HCC, and NAFLD. Incidence of HCC in these populations is unknown and HCC screening guidelines are desperately needed for these patients. Implementation of an automatic recall system could potentially facilitate HCC screening. Funding Agencies None

Background. The goal of treating chronic hepatitis C virus (HCV) infection is sustained virologic response (SVR). There is concern that despite achieving SVR, replication-competent HCV may be sequestered at low levels within the liver and could theoretically reactivate with immunosuppression. We report transplantation of a HCV-seropositive liver donor, who achieved SVR, into a seronegative patient without HCV reactivation despite profound immunosuppression. Method. Retrospective chart review. Results. We present a 21-year-old male who was HCV seronegative and received a liver transplant from a donor who had been treated for HCV and achieved SVR. The liver recipient, despite developing severe acute graft rejection and undergoing intense immunosuppression with T cell–depleting antibodies, did not become HCV RNA-positive with a follow up period of 8 months. The recipient was HCV seronegative before transplant, but became HCV seropositive immediately posttransplant. The antibodies were undetectable after 97 days, in keeping with a passive antibody transmission or B lymphocyte transmission with the graft. Conclusions. To the best of our knowledge, this is the first reported case of an HCV seropositive liver allograft transplanted into an HCV-negative recipient who subsequently received intense immunosuppression. This case, therefore, is an encouraging and novel step in liver transplantation, and demonstrates that SVR may be closer to a true “cure” of HCV in the donor population and that, even in circumstances of very potent immunosuppression in the recipient, this SVR is sustained.

Our study examined hepatitis B virus (HBV) awareness and knowledge in Asian communities in British Columbia (BC). Methods. A statistical random sample representation of Chinese, Korean, Filipino, South Asian, and Southeast Asian populations in Greater Vancouver was surveyed by telephone. Multiple logistic regression analysis was performed to identify predictors of HBV knowledge. Results. General awareness of HBV was reported in 78.8% (798/1013). HBV awareness was the highest in Chinese (89%) and Filipino (88%) populations and the lowest in the South Asian (56%) population. “Reasonable” knowledge of HBV was elicited in 76.8% (778/1013). Higher HBV knowledge was associated with younger age ( p = 0.014 ), higher education ( p < 0.0001 ), Chinese ethnicity ( p < 0.0001 ), and use of media ( p = 0.01 ) and Internet ( p = 0.024 ) for health information. Compared to the Chinese (OR = 1.0) population, “reasonable” knowledge of HBV was lower in Korean (OR = 0.3, 95% CI: 0.1–0.5), Filipino (OR = 0.3, 95% CI: 0.2–0.6), South Asian (OR = 0.3, 95% CI: 0.2–0.4), and Southeast Asian (OR = 0.3, 95% CI: 0.1–0.6) populations. 54.8% (555/1013) felt that HBV education was inadequate and 80.1% (811/1013) preferred HBV education in their native languages. Conclusion. Compared to the Chinese population, other Asian communities in BC have lower HBV awareness and knowledge. Public education should target older and less educated and Korean, Filipino, South Asian, and Southeast Asian populations in their native languages via media and Internet.