Recurrent primary biliary cirrhosis

Transplantation has become the accepted form of therapy for patients with end-stage liver disease. The diagnosis of recurrent disease in the allograft has been a matter of controversy, partly because of the difficulties in making the diagnosis in the allograft situation. The conventional criteria for diagnosing PBC may be inappropriate and there are many causes of bile duct damage in the graft. That the PBC-specific autoantibodies [such as antimitochondrial antibody (AMA) and gp-210] persist after transplantation is universally found, and some have reported the aberrant distribution of E2 in the allograft that is typical of PBC in the native liver, whether or not there is histological evidence of PBC recurrence. Most studies now accept that histological features of PBC, such as granulomatous bile duct damage, ductopenia and biliary-type fibrosis, may be found in the allograft; the histological features of PBC are variable and do not mirror the liver tests. The rate of recurrence increases with time, so that by 10 years, recurrence may be found in 30-50% of biopsies. There are no clear factors which identify those at risk of recurrence, but the pattern and degree of immunosuppression may be implicated. Cirrhosis has only rarely been reported. In the medium term, recurrence of PBC has little clinical impact. Ursodeoxycholic acid is used in some centres but there is no clear evidence for benefit.

Liver transplantation

Since the first human liver transplant done in 1963, the procedure has become a routine procedure with an excellent outcome in terms both of quality and of length of survival. The development and introduction into clinical practice of a variety of immunosuppressive agents has given the clinician a bewildering array of therapeutic options but with a lack of evidence on which to select for optimal immunosuppression. Tolerance can be reliably achieved in some animal transplants but remains to be achieved in humans. One of the major challenges facing the transplant community is the shortage of donor organs: imaginative approaches to overcome this problem include more effective use of marginal donor livers, splitting livers and development of living related transplants. While advances have been made in the field of xenotransplantation, there remain many hurdles to be overcome before this approach can be introduced into human transplantation. In the meanwhile, there are difficulties in determining the optimal criteria for listing patients for transplantation and for treating some of the complications arising after transplantation such as recurrence of disease and complications of immunosuppression, e.g. renal failure, malignancy and vascular disease.

URSO-panacea or placebo?

BACKGROUND

Ursodeoxycholic acid (UDCA) is the only approved treatment for primary biliary cirrhosis, but its effect on disease progression is uncertain. The aim of this study was to clarify the efficacy of UDCA in primary biliary cirrhosis.

METHODS

A systematic review, including the use of meta-analysis, was done for the randomised and switch-over phases of trials comparing UDCA with placebo, obtained from Medline and Embase databases, and from manual searches derived from review articles and abstracts of major international meetings. All trials had more than a mean of 6 months' follow-up and only included patients with primary biliary cirrhosis (PBC) according to established diagnostic criteria.

FINDINGS

17 relevant articles were identified: 11 randomised controlled trials, including 1272 patients, and six reports of the switch-over phases. UCDA had a favourable effect on liver biochemistry in most of the studies but not on symptoms or the progression of histological stage; two studies did not assess survival, liver transplantation, or complications of liver disease. Meta-analysis showed no difference between UDCA and placebo in the incidence of death (odds ratio 1.21, 95% CI 0.71-2.04), liver related death (0.72, 0.22-2.32), liver transplantation (1.72, 0.78-2.07), death or transplantation (1.26, 0.87-1.82) and in the development of complications of liver disease (1.11, 0.64-1.92). With the primary end-point defined by the authors (a combined end-point in three studies, and death or liver transplantation in the others) an odds ratio of 1.53 (0.97-2.42) was obtained. Assessment of the switch-over phases, during which there was a longer follow-up, did not change the results of the meta-analysis.

INTERPRETATION

Published randomised controlled trials of UDCA do not show evidence of therapeutic benefit in PBC and its use as standard therapy needs to be re-examined.

Undetectable serum caeruloplasmin in a woman with chronic hepatitis C infection

There are many causes of a low serum caeruloplasmin. Not only may this be a feature of Wilson's disease, but a low level may be found in association with chronic liver disease of any cause. We report here a case where undetectable serum caeruloplasmin was found during routine investigation of a woman with hepatitis C viral infection.

The educated patient: new challenges for the medical profession

The medical profession is facing significant changes in the way the rest of society relates to it. Mass education, mass media and mass consumerism have boomed in the 20th century, putting an increasing amount of pressure on professionals to meet rising public expectations. If doctors are to continue to provide a service that meets the demands of citizens and taxpayers, they need to develop a new relationship with patients, acting not as instructors but as guides, to help people make decisions about their own health. They will have to be more accountable for the quality of care they provide and work with a wider range of health and non-health professionals to meet patients' needs. Doctors need not only to accept the consumer society but also, I will argue, to encourage it. They can work to ensure that the benefits of the information revolution are felt by people excluded from consumerism because of poverty and social isolation, working to create an empowered, informed public whose members are given the best opportunity to look after their own health.

A randomized trial of solvent/detergent-treated and standard fresh-frozen plasma in the coagulopathy of liver disease and liver transplantation

BACKGROUND

Virus inactivation of pooled fresh-frozen plasma (FFP) by the solvent/detergent (SD) method results in a loss of approximately 20 percent of factor VIII. This study aimed to assess the efficacy of SD-treated plasma in correcting the coagulopathy associated with liver disease and liver transplantation.

STUDY DESIGN AND METHODS

Forty-nine patients with coagulation deficits due to liver disease, who required FFP for invasive procedures or liver transplantation, were randomly assigned to receive either FFP or SD-treated plasma. Patients were assessed for side effects, correction of coagulopathy over 24 hours, and seroconversion for viral markers 6 to 18 months after treatment.

RESULTS

In the liver disease group, equal correction of clotting factors and partial thromboplastin time was seen with FFP and SD-treated plasma, with a similar return to baseline values over 24 hours. There was greater correction of the International Normalised Ratio in patients receiving SD-treated plasma (p = 0.037), but this patient group had higher baseline values than recipients of FFP (p = 0.024). Liver transplant patients also showed equivalent correction of coagulopathy with the same dose of FFP and SD-treated plasma. The use of other blood components during transplantation was identical in the two treatment groups. No seroconversions were seen for HIV or hepatitis B or C virus. One patient who had received FFP seroconverted for human parvovirus B19. Apparent seroconversion for hepatitis A virus seen at 9 to 13 months in four other patients was probably due to detection of passively transferred antibodies, as later testing of these patients gave negative results. Minor side effects were rare in both groups.

CONCLUSION

SD-treated plasma is an efficacious source of coagulation factors for patients with liver disease who are undergoing biopsy or transplantation. Assessment of seroconversion for viral markers in recipients of plasma-derived products and plasma components should include consideration of the possibility that passively transferred antibodies were detected.

Incidence, timing, and risk factors for acute and chronic rejection

Rejection of the liver allograft may be classified as massive hemorrhagic necrosis or acute and chronic rejection. Massive hemorrhagic necrosis is now rarely seen; it occurs within the first few days after transplantation and is associated with transplantation across the blood-type groups. Early acute rejection (within 28 days of transplantation) is usually of little clinical significance and responds well to additional immunosuppression, whereas later rejection is associated with a greater risk for progression to graft loss. The incidence of early, acute rejection is dependent on the immunosuppressive regimen used and will vary between 20% and 70%. Patients who undergo transplantation for hepatitis B viral infection and alcohol-related liver disease have a lower incidence of rejection compared with those who undergo transplantation for cholestatic diseases, such as primary sclerosing cholangitis and primary biliary cirrhosis. Other factors that influence the incidence of acute rejection include age, race of recipient, and preservation injury. The incidence of chronic rejection is declining; most centers report current rates of 4% to 8%, whereas in earlier series, rates of 15% to 20% were observed. The reasons for this decline are unknown, but may relate to better immunosuppression. Chronic rejection usually presents within the first year posttransplantation. The greatest risk factor for chronic rejection is transplantation for chronic rejection; other factors include indication (especially primary sclerosing cholangitis, primary biliary cirrhosis, and autoimmune hepatitis); cytomegalovirus infection, and low levels of immune suppression.

Pretransplant prediction of prognosis after liver transplantation in primary sclerosing cholangitis using a Cox regression model

Liver transplantation remains the only treatment for patients with end-stage primary sclerosing cholangitis (PSC); however, selection criteria for the procedure and its timing remains uncertain. The aim of this study was to identify pretransplant variables associated with survival after transplantation and to devise a Cox regression model for prediction of post-transplant survival. We studied 118 patients transplanted for PSC at the Queen Elizabeth Hospital, Birmingham, UK, being followed for up to 91/4 years after the procedure. The association between pretransplant data and the post-transplant survival up to 1 year was studied using the logrank test (univariate analyses) and Cox multiple regression analysis. Univariate analyses showed the following variables to be associated with a decreased post-transplant survival: high serum creatinine, high serum bilirubin, biliary tree malignancy, previous upper abdominal surgery, hepatic encephalopathy, ascites, and Crohn's disease, whereas ulcerative colitis was associated with increased post-transplant survival (all P </=.05). The final multiple Cox regression model included the following significant variables: inflammatory bowel disease, ascites, previous upper abdominal surgery, serum creatinine, and biliary tree malignancy (all P <.03). Biliary tree malignancy could be omitted from the Cox model with only slight loss of information. The results were validated using the data of 30 independent PSC patients from another center. These results can improve selection of patients with PSC for liver transplantation. The developed prognostic model for transplantation can be used in parallel with previously published prognostic models for nontransplantation. The obtained prognostic estimates will provide additional information that is useful for optimal timing of liver transplantation in the individual patient.

Optimal timing of liver transplantation for patients with primary biliary cirrhosis: use of prognostic modelling

BACKGROUND/AIMS

Liver transplantation remains the only definitive treatment for patients with end-stage primary biliary cirrhosis, although the optimal timing of the procedure remains uncertain. The aim of the study was to use prognostic modelling to determine the optimal timing of transplantation for patients with primary biliary cirrhosis.

METHODS

A prognostic model for predicting the survival of patients after transplantation was generated using the Cox regression model with data from 312 patients transplanted for primary biliary cirrhosis at the Queen Elizabeth Hospital, Birmingham. The prognosis after transplantation was compared to that without transplantation (using a previously published prognostic index for non-transplantation) both in these patients and in 98 non-transplanted primary biliary cirrhosis patients dying from the liver disease, in order to establish at what stage the prognosis with transplantation was better than without transplantation.

RESULTS

The prognostic index for transplantation included the following significant prognostic variables: serum bilirubin, serum albumin, age, year of transplantation, and the presence of ascites or treatment with diuretics. Comparison of prognosis with and without transplantation showed that the predicted gain in survival after transplantation becomes increasingly positive when the 6-month survival probability in the absence of transplantation falls below 0.85. In the non-transplanted patients this occurs on average about 8 months before death.

CONCLUSIONS

Comparison of the prognosis with and without transplantation provides a rational method for determining the optimum timing of the procedure which occurs approximately when the predicted 6-month survival probability without transplantation falls below 0.85.

A randomized trial of solvent/detergent and standard fresh frozen plasma in the treatment of the coagulopathy seen during Orthotopic Liver Transplantation

BACKGROUND

Viral transmission remains a residual risk in single unit blood component therapy. Virus inactivation of pooled fresh frozen plasma (FFP) by the solvent/detergent (SD) method can be used to reduce this risk but results in some loss of factor activity including factor VIII and (2-antiplasmin. This study was aimed at assessing the clinical effectiveness solvent/detergent treated pooled fresh frozen plasma (SDFFP) in the correction of the coagulopathy seen during Orthotopic Liver Transplantation (OLT) as compared with standard FFP.

METHOD

Twenty eight patients with an underlying derangement of coagulation and who were due to undergo OLT were randomized to receive either FFP or SDFFP. They were assessed for side effects, correction of coagulopathy, and seroconversion for viral markers.

RESULTS

Patients undergoing OLT showed equal correction of clotting factors and partial thromboplastin time (PTT) when treated with FFP or SDFFP. There was also a similar time course to return to baseline values in each group. There was no significant difference in correction of INR in either group. Usage of other blood components during the operation was identical in the two groups. No seroconversions were seen for HIV, HBC or HCV but only 12 patients were available for long term follow-up.

CONCLUSION

SDFFP is an efficacious and safe source of coagulation factors for patients with liver disease undergoing Orthotopic Liver Transplantation. No adverse effects were seen during its administration. Further work is required to ascertain long term possibilities of seroconversion.

A randomized trial of solvent/detergent and standard fresh frozen plasma in the treatment of the coagulopathy seen during Orthotopic Liver Transplantation

BACKGROUND

Viral transmission remains a residual risk in single unit blood component therapy. Virus inactivation of pooled fresh frozen plasma (FFP) by the solvent/detergent (SD) method can be used to reduce this risk but results in some loss of factor activity including factor VIII and (2-antiplasmin. This study was aimed at assessing the clinical effectiveness solvent/detergent treated pooled fresh frozen plasma (SDFFP) in the correction of the coagulopathy seen during Orthotopic Liver Transplantation (OLT) as compared with standard FFP.

METHOD

Twenty eight patients with an underlying derangement of coagulation and who were due to undergo OLT were randomized to receive either FFP or SDFFP. They were assessed for side effects, correction of coagulopathy, and seroconversion for viral markers.

RESULTS

Patients undergoing OLT showed equal correction of clotting factors and partial thromboplastin time (PTT) when treated with FFP or SDFFP. There was also a similar time course to return to baseline values in each group. There was no significant difference in correction of INR in either group. Usage of other blood components during the operation was identical in the two groups. No seroconversions were seen for HIV, HBC or HCV but only 12 patients were available for long term follow-up.

CONCLUSION

SDFFP is an efficacious and safe source of coagulation factors for patients with liver disease undergoing Orthotopic Liver Transplantation. No adverse effects were seen during its administration. Further work is required to ascertain long term possibilities of seroconversion.

Transplantation for alcoholic liver disease: a perspective from Europe

It is now accepted that patients who receive a liver transplant for alcohol-related liver disease have a rate of survival similar to those who receive grafts for other indications. Abstinence from alcohol before liver transplantation is important in ensuring that the liver will not recover, but the period of abstinence required before transplantation is undertaken is uncertain. Prognostic models for assessing patients with alcoholic liver disease have been developed but correlate poorly with each other. A return to alcohol consumption after transplantation is not uncommon, although graft failure or damage is uncommon. However, alcohol-related liver disease is becoming an increasing indication for liver transplantation. As the number of potential candidates exceeds the supply of donors, some form of rationing will be required. The general public places a lower priority on transplantation for alcoholic liver disease than for other indications, and this will need to be considered by those who allocate the donor livers.

Halothane hepatitis

Halothane, an effective and usually safe anaesthetic agent, is rarely associated with the development of fulminant hepatic failure. Guidelines have been developed to reduce the probability of a patient developing halothane hepatitis. However, cases continue to occur and, in some cases, the guidelines have been ignored. Stricter adherence to the guidelines will reduce, but not totally prevent, further cases from occurring. Once halothane hepatitis has developed, there are no specific treatments and liver replacement may be required. Halothane hepatitis is a paradigm for immune mediated adverse drug reactions. The mechanism appears to be related to development of sensitization to both autoantigens (including CYP2D6) and halothane-altered liver cell determinants.

Assessing priorities for allocation of donor liver grafts: survey of public and clinicians

OBJECTIVES

To compare the priorities of the general public, family doctors, and gastroenterologists in allocating donor livers to potential recipients of liver allograft.

DESIGN

Representative quota sampling of 1000 members of the general public and 200 family doctors, and a postal questionnaire of 100 gastroenterologists.

SUBJECTS

Respondents were given eight hypothetical case histories (based on real patients) and asked to select recipients for four donor livers. Cases were selected to identify controversial areas such as extremes of age, misuse of alcohol, and intravenous drugs. Respondents were also asked to select the least deserving case and which of seven possible factors (time on waiting list, outcome, age, value to society, return to work, previous use of illicit drugs, and involvement of alcohol in the liver damage) should be used to select patients already listed for transplantation. Focus groups were also held to explore further the reasons for the choices given.

RESULTS

There were considerable differences between the three groups in the choice of the recipients, although alcohol use and antisocial behaviour always rated low. For selection of recipients the general public thought that, in decreasing order of importance, age, outcome, and time on the waiting list were the most important factors in selecting recipients; family doctors rated outcome, age, and likely work status after transplantation and the gastroenterologists outcome, work status, and non-involvement of alcohol in the cause of the liver disease as the most important factors.

CONCLUSIONS

The views of the public are at variance with those of clinicians. Further debate is required to ensure an equitable and appropriate distribution of a scarce resource.

Patterns of alcohol consumption after liver transplantation

BACKGROUND

Uncertainty exists about the extent and consequences of a return to alcohol consumption after liver transplantation for alcoholic liver disease (ALD).

AIMS

To determine the prevalence and consequences of alcohol consumption in patients transplanted for ALD.

METHODS

A retrospective case controlled study of all patients transplanted for ALD at the Queen Elizabeth Hospital, Birmingham, between 1987 and 1996.

RESULTS

Seventy patients with ALD were transplanted, of which 59 survived more than three months; 56 were interviewed. Twenty eight had consumed some alcohol after transplantation; for the nine "heavy drinkers" (HD), the median time to resumption of alcohol intake was six months and for the 19 "moderate drinkers" (MD) it was eight months. There was no significant difference in episodes of acute rejection or compliance with medication between those who were abstinent, MD, or HD. Histological evidence of liver injury was common in ALD patients who had returned to drink. Mild fatty change was found in 1/11 biopsy specimens from abstinent patients but moderate to severe fatty change and ballooned hepatocytes were seen in 3/5 MD and 2/5 HD specimens. Two HD patients had early fibrosis. One HD patient had died of alcohol related complications.

CONCLUSIONS

Moderate to heavy alcohol consumption occurs in patients transplanted for ALD. Patient recall of abstinence advice is unreliable, and patients return to alcohol mainly within the first year after liver transplantation. Return to alcohol consumption after liver transplantation is associated with rapid development of histological liver injury including fibrosis.

Symptomatic carpal tunnel syndrome after orthotopic liver transplantation: a retrospective analysis

BACKGROUND

Carpal tunnel syndrome (CTS) is an entrapment neuropathy of the median nerve and has been reported after renal transplantation; there are no reports of CTS after liver transplantation.

METHODS

The incidence of and the risk factors for CTS were assessed in 1350 liver allograft recipients.

RESULTS

Seventeen women and two men with CTS were identified. Women developed symptoms at a median time of 6.8 months, and all but one received transplants because of primary biliary cirrhosis (PBC). All 17 patients were taking cyclosporine. The only risk factor for CTS was the pretransplant diagnosis of PBC (6.7% of 240 PBC patients surviving 6 months or more compared with 0.4% of 717 patients who received grafts for other indications).

CONCLUSIONS

CTS may occur in patients early after liver transplantation; because in many cases the symptoms were attributed to cyclosporine neurotoxicity, the diagnosis should be considered, especially in patients who received grafts because of PBC.

Prognostic models--what is their future?

Estimation of prognosis for an individual patient is a valuable tool for the clinician. During the last decade, there has been an increasing number of prognostic models developed. Such models identify variables which have a statistical correlation with a clinically useful end-point (such as death). However, confidence limits of estimates are often wide, and over-reliance on prognostic models may be inappropriate. Ideally, models should be useful, intuitive and simple to use.

Transplantation for primary biliary cirrhosis

Primary biliary cirrhosis (PBC) remains one of the commoner indications for orthotopic liver replacement. The two main indications for transplantation are poor quality of life (because of the liver) or end-stage liver disease. A number of prognostic models have identified risk factors indicating poor prognosis, but in practice serum bilirubin greater than 150 mumol/L is used most commonly. Other indications for transplantation include progression of hepatopulmonary syndrome, increasing osteoporosis, evidence of malnutrition, and development of hepatocellular carcinoma. Postoperatively, patients do well. Recurrence of PBC remains controversial, but an increasing number of centers now report that a proportion of patients develop evidence of recurrent disease in the allograft. As yet PBC recurrence remains of little practical importance, although as survival increases beyond 10 years, this may become more relevant.

Clinical economics review: cost-effectiveness in the therapy of liver disease

There have been many advances made in the management of patients with liver disease both in diagnosis and in the treatment of underlying liver disease and its complications, although comparatively few of these have been rigorously subjected to full cost-effectiveness evaluation. In this review, we have analysed a small number of the therapeutic interventions; while these have been well evaluated clinically, very few have been analysed from the viewpoint of cost-effectiveness and, thus, it is difficult to make many definitive claims. It is hoped that future studies will consider these aspects as well.

Review article: methotrexate in gastroenterology--dangerous villain or simply misunderstood?

Methotrexate has a place in the treatment of an increasing number of diseases. Its emerging role in the treatment of primary biliary cirrhosis and inflammatory bowel disease still requires further evaluation. Its toxicity profile is wide and is affected by a variety of factors. Hepatotoxicity from long-term use in patients with psoriasis and rheumatoid arthritis holds particular concern for the physician. Appropriate monitoring guidelines for hepatotoxicity can only be made after careful evaluation of available data and consideration of cost-to-benefit models.