1
|
Quispel R, Schutz HM, Keultjes AWP, Erler NS, Janssen QP, van Hooft JE, Venneman NG, Honkoop P, Hol L, Scheffer RC, Bisseling TM, Voermans RP, Vleggaar FP, Schwartz MP, Verdonk RC, Hoge CV, Kuiken SD, Curvers WL, van Vilsteren FGI, Poen AC, Spanier MB, Bruggink AH, Smedts FM, van Velthuysen MLF, van Eijck CH, Besselink MG, Veldt BJ, Koerkamp BG, van Driel LMJW, Bruno MJ. Diagnostic accuracy of endoscopic ultrasonography-guided tissue acquisition prior to resection of pancreatic carcinoma: a nationwide analysis. HPB (Oxford) 2023; 25:1438-1445. [PMID: 37550169 DOI: 10.1016/j.hpb.2023.07.900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 12/21/2022] [Revised: 05/18/2023] [Accepted: 07/20/2023] [Indexed: 08/09/2023]
Abstract
INTRODUCTION Endoscopic ultrasonography guided tissue acquisition (EUS + TA) is used to provide a tissue diagnosis in patients with suspected pancreatic cancer. Key performance indicators (KPI) for these procedures are rate of adequate sample (RAS) and sensitivity for malignancy (SFM). AIM assess practice variation regarding KPI of EUS + TA prior to resection of pancreatic carcinoma in the Netherlands. PATIENTS AND METHODS Results of all EUS + TA prior to resection of pancreatic carcinoma from 2014-2018, were extracted from the national Dutch Pathology Registry (PALGA). Pathology reports were classified as: insufficient for analysis (b1), benign (b2), atypia (b3), neoplastic other (b4), suspected malignant (b5), and malignant (b6). RAS was defined as the proportion of EUS procedures yielding specimen sufficient for analysis. SFM was calculated using a strict definition (malignant only, SFM-b6), and a broader definition (SFM-b5+6). RESULTS 691 out of 1638 resected patients (42%) underwent preoperative EUS + TA. RAS was 95% (range 89-100%), SFM-b6 was 44% (20-77%), and SFM-b5+6 was 65% (53-90%). All centers met the performance target RAS>85%. Only 9 out of 17 met the performance target SFM-b5+6 > 85%. CONCLUSION This nationwide study detected significant practice variation regarding KPI of EUS + TA procedures prior to surgical resection of pancreatic carcinoma. Therefore, quality improvement of EUS + TA is indicated.
Collapse
Affiliation(s)
- Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, the Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, the Netherlands.
| | - Hannah M Schutz
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, the Netherlands; Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Augustinus W P Keultjes
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Epidemiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Quisette P Janssen
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Centre, Rotterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Pieter Honkoop
- Department of Gastroenterology and Hepatology, Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | - Lieke Hol
- Department of Gastroenterology and Hepatology, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | - Robert C Scheffer
- Department of Gastroenterology and Hepatology, Jeroen Bosch Ziekenhuis, 's Hertogenbosch, the Netherlands
| | - Tanya M Bisseling
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, Utrecht University Medical Centre, Utrecht, the Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Centre, Amersfoort, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Chantal V Hoge
- Department of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Frederike G I van Vilsteren
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Alexander C Poen
- Department of Gastroenterology and Hepatology, Isala Hospital, Zwolle, the Netherlands
| | - Marcel B Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, the Netherlands
| | | | - Frank M Smedts
- Department of Pathology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | | | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Centre, Rotterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Bart J Veldt
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Bas G Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Centre, Rotterdam, the Netherlands
| | - Lydi M J W van Driel
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| |
Collapse
|
2
|
Schutz HM, Quispel R, Veldt BJ, Smedts FM, Anten MPG, Hoogduin KJ, Honkoop P, van Nederveen FH, Hol L, Kliffen M, Fitzpatrick CE, Erler NS, Bruno MJ, van Driel LM. Cumulative sum learning curves guiding multicenter multidisciplinary quality improvement of EUS-guided tissue acquisition of solid pancreatic lesions. Endosc Int Open 2022; 10:E549-E557. [PMID: 35433206 PMCID: PMC9010081 DOI: 10.1055/a-1766-5259] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 09/03/2021] [Accepted: 12/03/2021] [Indexed: 11/25/2022] Open
Abstract
Background and study aims In this study, we evaluated the performance of community hospitals involved in the Dutch quality in endosonography team regarding yield of endoscopic ultrasound (EUS)-guided tissue acquisition (TA) of solid pancreatic lesions using cumulative sum (CUSUM) learning curves. The aims were to assess trends in quality over time and explore potential benefits of CUSUM as a feedback-tool. Patients and methods All consecutive EUS-guided TA procedures for solid pancreatic lesions were registered in five community hospitals between 2015 and 2018. CUSUM learning curves were plotted for overall performance and for performance per center. The American Society of Gastrointestinal Endoscopy-defined key performance indicators, rate of adequate sample (RAS), and diagnostic yield of malignancy (DYM) were used for this purpose. Feedback regarding performance was provided on multiple occasions at regional interest group meetings during the study period. Results A total of 431 EUS-guided TA procedures in 403 patients were included in this study. The overall and per center CUSUM curves for RAS improved over time. CUSUM curves for DYM revealed gradual improvement, reaching the predefined performance target (70 %) overall, and in three of five contributing centers in 2018. Analysis of a sudden downslope development in the CUSUM curve of DYM in one center revealed temporary absence of a senior cytopathologist to have had a temporary negative impact on performance. Conclusions CUSUM-derived learning curves allow for assessment of best practices by comparison among peers in a multidisciplinary multicenter quality improvement initiative and proved to be a valuable and easy-to-interpret means to evaluate EUS performance over time.
Collapse
Affiliation(s)
- Hannah M. Schutz
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Bart J. Veldt
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Frank M.M. Smedts
- Department of Cyto- and Histopathology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Marie-Paule G.F. Anten
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, the Netherlands
| | - Klaas J. Hoogduin
- Department of Cyto- and Histopathology, Pathan B.V., Rotterdam, the Netherlands
| | - Pieter Honkoop
- Department of Gastroenterology and Hepatology, Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | | | - Lieke Hol
- Department of Gastroenterology and Hepatology, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | - Mike Kliffen
- Department of Cyto- and Histopathology, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | - Claire E. Fitzpatrick
- Department of Gastroenterology and Hepatology, IJsselland Ziekenhuis, Capelle aan den Ijssel, the Netherlands
| | - Nicole S. Erler
- Department of Biostatistics, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Lydi M.J.W. van Driel
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | | |
Collapse
|
3
|
Quispel R, Schutz HM, Hallensleben ND, Bhalla A, Timmer R, van Hooft JE, Venneman NG, Erler NS, Veldt BJ, van Driel LM, Bruno MJ. Do endosonographers agree on the presence of bile duct sludge and the subsequent need for intervention? Endosc Int Open 2021; 9:E911-E917. [PMID: 34079877 PMCID: PMC8159618 DOI: 10.1055/a-1452-8919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 09/25/2020] [Accepted: 01/20/2021] [Indexed: 11/11/2022] Open
Abstract
Background and study aims Endoscopic ultrasonography (EUS) is a tool widely used to diagnose bile duct lithiasis. In approximately one out of five patients with positive findings at EUS, sludge is detected in the bile duct instead of stones. The objective of this study was to establish the agreement among endosonographers regarding: 1. presence of common bile duct (CBD) stones, microlithiasis and sludge; and 2. the need for subsequent treatment. Patients and methods 30 EUS videos of patients with an intermediate probability of CBD stones were evaluated by 41 endosonographers. Experience in EUS and endoscopic retrograde cholangiopancreatography, and the endosonographers' type of practices were recorded. Fleiss' kappa statistics were used to quantify the agreement. Associations between levels of experience and both EUS ratings and treatment decisions were investigated using mixed effects models. Results A total of 1230 ratings and treatment decisions were evaluated. The overall agreement on EUS findings was fair (Fleiss' κ 0.32). The agreement on presence of stones was moderate (κ 0.46). For microlithiasis it was fair (κ 0.25) and for sludge it was slight (κ 0.16). In cases with CBD stones there was an almost perfect agreement for the decision to subsequently perform an ERC + ES. In case of presumed microlithiasis or sludge an ERC was opted for in 78 % and 51 % of cases, respectively. Differences in experience and types of practice appear unrelated to the agreement on both EUS findings and the decision for subsequent treatment. Conclusions There is only slight agreement among endosonographers regarding the presence of bile duct sludge. Regarding the need for subsequent treatment of bile duct sludge there is no consensus.
Collapse
Affiliation(s)
- Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, Netherlands
| | - Hannah M. Schutz
- Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, Netherlands
| | - Nora D. Hallensleben
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, HAGA Hospital, Den Haag, Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands,Department of Gastroenterology and Hepatology, Leiden University Medical Center Leiden, Netherlands
| | - Niels G. Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Nicole S. Erler
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Bart J. Veldt
- Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, Netherlands
| | - Lydi M.J.W. van Driel
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| |
Collapse
|
4
|
van Riet PA, Quispel R, Cahen DL, Erler NS, Snijders-Kruisbergen MC, Van Loenen P, Poley JW, van Driel LMJW, Mulder SA, Veldt BJ, Leeuwenburgh I, Anten MPGF, Honkoop P, Thijssen AY, Hol L, Hadithi M, Fitzpatrick CE, Schot I, Bergmann JF, Bhalla A, Bruno MJ, Biermann K. Optimizing cytological specimens of EUS-FNA of solid pancreatic lesions: A pilot study to the effect of a smear preparation training for endoscopy personnel on sample quality and accuracy. Diagn Cytopathol 2020; 49:295-302. [PMID: 33098625 PMCID: PMC7820998 DOI: 10.1002/dc.24645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 10/06/2020] [Accepted: 10/09/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND In the absence of rapid on-side pathological evaluation, endoscopy staff generally "smears" endoscopic ultrasound guided fine needle aspiration (EUS-FNA) specimens on a glass slide. As this technique is vulnerable to preparation artifacts, we assessed if its quality could be improved through a smear-preparation-training for endoscopy staff. METHODS In this prospective pilot study, 10 endosonographers and 12 endoscopy nurses from seven regional EUS-centers in the Netherlands were invited to participate in a EUS-FNA smear-preparation-training. Subsequently, post training slides derived from solid pancreatic lesions were compared to pre-training "control" slides. Primary outcome was to assess if the training positively affects smear quality and, consequently, diagnostic accuracy of EUS-FNA of solid pancreatic lesions. RESULTS Participants collected and prepared 71 cases, mostly pancreatic head lesions (48%). Sixty-eight controls were selected from the pretraining period. The presence of artifacts was comparable for smears performed before and after training (76% vs 82%, P = .36). Likewise, smear cellularity (≥50% target cells) before and after training did not differ (44% (30/68) vs 49% (35/71), P = .48). Similar, no difference in diagnostic accuracy for malignancy was detected (P = .10). CONCLUSION In this pilot EUS-FNA smear-preparation-training for endoscopy personnel, smear quality and diagnostic accuracy were not improved after the training. Based on these results, we plan to further study other training programs and possibilities.
Collapse
Affiliation(s)
- Priscilla A van Riet
- Department of Gastroenterology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rutger Quispel
- Deparment of Hepatology and Gastroenterology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Djuna L Cahen
- Department of Gastroenterology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Petri Van Loenen
- Department of Pathology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Lydi M J W van Driel
- Deparment of Hepatology and Gastroenterology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Sanna A Mulder
- Deparment of Hepatology and Gastroenterology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Bart J Veldt
- Deparment of Hepatology and Gastroenterology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Ivonne Leeuwenburgh
- Department of Gastroenterology and Hepatology, Sint Franciscus Hospital, Rotterdam, The Netherlands
| | - Marie-Paule G F Anten
- Department of Gastroenterology and Hepatology, Sint Franciscus Hospital, Rotterdam, The Netherlands
| | - Pieter Honkoop
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Annemieke Y Thijssen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Lieke Hol
- Department of Gastroenterology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Mohammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Claire E Fitzpatrick
- Department of Gastroenterology and Hepatology, IJsselland Hospital, Rotterdam, The Netherlands
| | - Ingrid Schot
- Department of Gastroenterology and Hepatology, IJsselland Hospital, Rotterdam, The Netherlands
| | - Jilling F Bergmann
- Department of Gastroenterology and Hepatology, HAGA, The Hague, The Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, HAGA, The Hague, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Katharina Biermann
- Department of Pathology, Erasmus MC University Medical Center Rotterdam, the Netherlands and Institute for Pathology, Dueren, Germany
| |
Collapse
|
5
|
van Riet PA, Quispel R, Cahen DL, Snijders-Kruisbergen MC, van Loenen P, Erler NS, Poley JW, van Driel LMJW, Mulder SA, Veldt BJ, Leeuwenburgh I, Anten MPGF, Honkoop P, Thijssen AY, Hol L, Hadithi M, Fitzpatrick CE, Schot I, Bergmann JF, Bhalla A, Bruno MJ, Biermann K. Diagnostic yield and agreement on fine-needle specimens from solid pancreatic lesions : comparing the smear technique to liquid-based cytology. Endosc Int Open 2020; 8:E155-E162. [PMID: 32010748 PMCID: PMC6976322 DOI: 10.1055/a-1038-4103] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/15/2019] [Indexed: 02/08/2023] Open
Abstract
Background and study aims The traditional "smear technique" for processing and assessing endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is sensitive to artifacts. Processing and evaluation of specimens collected in a liquid medium, liquid-based cytology (LBC) may be a solution. We compared the diagnostic value of EUS-FNA smears to LBC in pancreatic solid lesions in the absence of rapid on-site evaluation (ROSE). Patients and methods Consecutive patients who required EUS-FNA of a solid pancreatic lesion were included in seven hospitals in the Netherlands and followed for at least 12 months. Specimens from the first pass were split into two smears and a vial for LBC (using ThinPrep and/or Cell block). Smear and LBC were compared in terms of diagnostic accuracy for malignancy, sample quality, and diagnostic agreement between three cytopathologists. Results Diagnostic accuracy for malignancy was higher for LBC (82 % (58/71)) than for smear (66 % (47/71), P = 0.04), but did not differ when smears were compared to ThinPrep (71 % (30/42), P = 0.56) or Cell block (62 % (39/63), P = 0.61) individually. Artifacts were less often present in ThinPrep (57 % (24/42), P = 0.02) or Cell block samples (40 % (25/63), P < 0.001) than smears (76 % (54/71)). Agreement on malignancy was equally good for smears and LBC (ĸ = 0.71 versus ĸ = 0.70, P = 0.98), but lower for ThinPrep (ĸ = 0.26, P = 0.01) than smears. Conclusion After a single pass, LBC provides higher diagnostic accuracy than the conventional smear technique for EUS-FNA of solid pancreatic lesions in the absence of ROSE. Therefore, LBC, may be an alternative to the conventional smear technique, especially in centers lacking ROSE.
Collapse
Affiliation(s)
- Priscilla A. van Riet
- Department of Gastroenterology, Erasmus MC University Medical Center Rotterdam, the Netherlands,Corresponding author P. A. van Riet, MD Dept. of Gastroenterology and HepatologyErasmus MC University Medical Center RotterdamP.O Box 20403015 CE Rotterdamthe Netherlands+31107032908
| | - Rutger Quispel
- Deparment of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Djuna L. Cahen
- Department of Gastroenterology, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | | | - Petri van Loenen
- Department of Pathology, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Nicole S. Erler
- Department of Biostatistics, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Lydi M. J. W. van Driel
- Deparment of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Sanna A. Mulder
- Deparment of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Bart J. Veldt
- Deparment of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Ivonne Leeuwenburgh
- Department of Gastroenterology and Hepatology, Sint Franciscus Hospital, Rotterdam, The Netherlands
| | - Marie-Paule G. F. Anten
- Department of Gastroenterology and Hepatology, Sint Franciscus Hospital, Rotterdam, The Netherlands
| | - Pieter Honkoop
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Annemieke Y. Thijssen
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Lieke Hol
- Department of Gastroenterology, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Mohammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Claire E. Fitzpatrick
- Department of Gastroenterology and Hepatology, IJsselland Hospital, Rotterdam, The Netherlands
| | - Ingrid Schot
- Department of Gastroenterology and Hepatology, IJsselland Hospital, Rotterdam, The Netherlands
| | - Jilling F. Bergmann
- Department of Gastroenterology and Hepatology, HAGA, The Hague, The Netherlands
| | - Abha Bhalla
- Department of Gastroenterology and Hepatology, HAGA, The Hague, The Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Katharina Biermann
- Department of Pathology, Erasmus MC University Medical Center Rotterdam, the Netherlands
| |
Collapse
|
6
|
Quispel R, van Driel LM, Honkoop P, Hadithi M, Anten MP, Smedts F, Kerkmeer MC, Veldt BJ, Bruno MJ. Collaboration of community hospital endosonographers improves diagnostic yield of endoscopic ultrasonography guided tissue acquisition of solid pancreatic lesions. Endosc Int Open 2019; 7:E800-E807. [PMID: 31198843 PMCID: PMC6561772 DOI: 10.1055/a-0898-3389] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 01/03/2019] [Accepted: 04/01/2019] [Indexed: 12/18/2022] Open
Abstract
Background and study aims Endoscopic ultrasound (EUS)-guided tissue acquisition (TA) is the method of choice for establishing a pathological diagnosis of solid pancreatic lesions. Data on quality and yield of EUS-guided TA performed in community hospitals are lacking. A study was performed to determine and improve the diagnostic yield of EUS-guided TA in a group of community hospitals. Methods Following analysis of the last 20 EUS-guided TA procedures of solid pancreatic lesions performed in each of four community hospitals, a collaborative EUS interest group was formed and a prospective registry was started. During meetings of the interest group, feedback on results per center were provided and strategies for improvement were discussed. Results In the BEFORE team formation cohort, 80 procedures were performed in 66 patients. In the AFTER team formation cohort, 133 procedures were performed in 125 patients. After team formation, the rate of adequate sample increased from 80 % (95 %CI [0.7 - 0.9]) to 95 % (95 %CI [0.9 - 1.0]) , diagnostic yield of malignancy improved from 28 % (95 %CI [0.2 - 0.4]) to 64 % (95 % CI [0.6 - 0.7]), and sensitivity of malignancy improved from 63 % (95 %CI [0.4 - 0.8]) to 84 % (95 %CI [0.8 - 0.9]). Multivariate regression analysis revealed team formation to be the only variable significantly associated with an increased rate of adequate sample. Conclusions Formation of a regional EUS interest group with regular feedback on results per center, and discussions on methods and techniques used, significantly improved the outcome of EUS-guided TA procedures in patients with solid pancreatic lesions in community hospitals.
Collapse
Affiliation(s)
- Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, The Netherlands.
| | - Lydi M.J.W. van Driel
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Pieter Honkoop
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands.
| | - Mohamad Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, The Netherlands.
| | - Marie-Paule Anten
- Department of Gastroenterology and Hepatology, Sint Franciscus Hospital, Rotterdam, The Netherlands.
| | - Frank Smedts
- Department of Pathology, Reinier de Graaf Gasthuis, Delft, The Netherlands.
| | - Margreet C. Kerkmeer
- Department of Biostatistics and Education, “het Leerhuis”, Reinier de Graaf Gasthuis, Delft, The Netherlands.
| | - Bart J. Veldt
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft, The Netherlands.
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands.
| | | |
Collapse
|
7
|
Alferink LJ, Kiefte-de Jong JC, Erler NS, Veldt BJ, Schoufour JD, de Knegt RJ, Ikram MA, Metselaar HJ, Janssen HLA, Franco OH, Darwish Murad S. Association of dietary macronutrient composition and non-alcoholic fatty liver disease in an ageing population: the Rotterdam Study. Gut 2019; 68:1088-1098. [PMID: 30064987 DOI: 10.1136/gutjnl-2017-315940] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [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: 12/28/2017] [Revised: 06/28/2018] [Accepted: 07/01/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE A healthy lifestyle is the first-line treatment in non-alcoholic fatty liver disease (NAFLD), but specific dietary recommendations are lacking. Therefore, we aimed to determine whether dietary macronutrient composition is associated with NAFLD. DESIGN Participants from the Rotterdam Study were assessed on (1) average intake of macronutrients (protein, carbohydrate, fat, fibre) using a Food Frequency Questionnaire and (2) NAFLD presence using ultrasonography, in absence of excessive alcohol, steatogenic drugs and viral hepatitis. Macronutrients were analysed using the nutrient density method and ranked (Q1-Q4). Logistic regression analyses were adjusted for sociodemographic, lifestyle and metabolic covariates. Moreover, analyses were adjusted for and stratified by body mass index (BMI) (25 kg/m2). Also, substitution models were built. RESULTS In total, 3882 participants were included (age 70±9, 58% female). NAFLD was present in 1337 (34%) participants of whom 132 were lean and 1205 overweight. Total protein was associated with overweight NAFLD after adjustment for sociodemographic and lifestyle covariates (ORQ4vsQ1 1.40; 95% CI 1.11 to 1.77). This association was driven by animal protein (ORQ4vsQ1 1.54; 95% CI 1.20 to 1.98). After adjustment for metabolic covariates, only animal protein remained associated with overweight NAFLD (ORQ4vsQ1 1.36; 95% CI 1.05 to 1.77). Monosaccharides and disaccharides were associated with lower overall NAFLD prevalence (ORQ4vsQ1 0.66; 95% CI 0.52 to 0.83) but this effect diminished after adjustment for metabolic covariates and BMI. No consistent associations were observed for fat subtypes or fibre. There were no substitution effects. CONCLUSION This large population-based study shows that high animal protein intake is associated with NAFLD in overweight, predominantly aged Caucasians, independently of well-known risk factors. Contrary to previous literature, our results do not support a harmful association of monosaccharides and disaccharides with NAFLD.
Collapse
Affiliation(s)
- Louise Jm Alferink
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Jessica C Kiefte-de Jong
- Department of Epidemiology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands.,Department of Global Public Health, Leiden University College, The Hague, The Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Bart J Veldt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Josje D Schoufour
- Department of Epidemiology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - M Arfan Ikram
- Department of Epidemiology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Harry LA Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands.,Toronto Centre of Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Oscar H Franco
- Department of Epidemiology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| |
Collapse
|
8
|
van der Meer AJ, Feld JJ, Hofer H, Almasio PL, Calvaruso V, Fernández-Rodríguez CM, Aleman S, Ganne-Carrié N, D'Ambrosio R, Pol S, Trapero-Marugan M, Maan R, Moreno-Otero R, Mallet V, Hultcrantz R, Weiland O, Rutter K, Di Marco V, Alonso S, Bruno S, Colombo M, de Knegt RJ, Veldt BJ, Hansen BE, Janssen HLA. Risk of cirrhosis-related complications in patients with advanced fibrosis following hepatitis C virus eradication. J Hepatol 2017; 66:485-493. [PMID: 27780714 DOI: 10.1016/j.jhep.2016.10.017] [Citation(s) in RCA: 189] [Impact Index Per Article: 27.0] [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: 12/24/2015] [Revised: 09/24/2016] [Accepted: 10/13/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS The risk of hepatocellular carcinoma (HCC) is reduced but not eradicated among patients with hepatitis C virus (HCV)-induced advanced hepatic fibrosis who attained sustained viral response (SVR). We aimed to assess the risk of cirrhosis-related complications in this specific group of patients. METHODS Data from previously reported Western cohort studies including patients with chronic HCV infection and bridging fibrosis or cirrhosis who attained SVR were pooled for survival analyses on the individual patient level. The primary endpoint was HCC and the secondary endpoint was clinical disease progression, defined as liver failure, HCC or death. RESULTS Included were 1000 patients with SVR. Median age was 52.7 (IQR 45.1-59.7) years, 676 (68%) were male and 842 (85%) had cirrhosis. Median follow-up was 5.7 (IQR 2.9-8.0) years. Fifty-one patients developed HCC and 101 had clinical disease progression. The cumulative 8-year HCC incidence was 1.8 (95% CI 0.0-4.3) among patients with bridging fibrosis and 8.7% (95% CI 6.0-11.4) among those with cirrhosis (p=0.058). Within the cirrhosis group, the 8-year HCC incidence was 2.6% (95% CI 0.0-5.5) among patients <45years, 9.7% (95% CI 5.8-13.6) among patients from 45-60years, and 12.2% (95% CI 5.3-19.1) among patients >60years of age at start of therapy (p=0.006). Multivariable Cox analyses indicated that higher age, lower platelet count and diabetes mellitus were independently associated with development of HCC. After 8years 4.2% (95% CI 0.1-8.3) of patients with bridging fibrosis and 15.8% (95% CI 12.3-19.3) of patients with cirrhosis experienced clinical disease progression (p=0.007). CONCLUSIONS Patients with HCV-induced cirrhosis and SVR showed an annual risk of approximately 1% for HCC and 2% for clinical disease progression. Therefore, to prevent HCC surveillance, chronic HCV infection should preferably be treated before cirrhosis has developed. LAY SUMMARY Patients with cirrhosis who were able to eradicate their chronic HCV infection remain at substantial risk of primary liver cancer. The risk of liver cancer increases with higher age, laboratory makers suggesting more severe liver disease, and presence of diabetes mellitus. Also after successful antiviral therapy patients with HCV-induced cirrhosis should thus remain included in follow-up for early detection of liver cancer.
Collapse
Affiliation(s)
- Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Jordan J Feld
- The Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Harald Hofer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Piero L Almasio
- Gastrointestinal & Liver Unit, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
| | - Vincenza Calvaruso
- Gastrointestinal & Liver Unit, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
| | | | - Soo Aleman
- Departments of Gastroenterology and Hepatology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Nathalie Ganne-Carrié
- Unité d'Hépatologie, APHP Hôspital Jean Verdier, Université Paris 13, Inserm UMR 1162, France
| | - Roberta D'Ambrosio
- A.M. and A. Migliavacca Center for Liver Disease, First Division of Gastroenterology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Stanislas Pol
- Unité d'Hépatologie, APHP Hôpital Cochin, Université Paris Descartes, Inserm U1016, Paris, France
| | - Maria Trapero-Marugan
- Gastroenterology-Hepatology Department, University Hospital La Princesa and Princesa Research Institute, Autonomous University of Madrid, Madrid, Spain
| | - Raoel Maan
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ricardo Moreno-Otero
- Gastroenterology-Hepatology Department, University Hospital La Princesa and Princesa Research Institute, Autonomous University of Madrid, Madrid, Spain
| | - Vincent Mallet
- Unité d'Hépatologie, APHP Hôpital Cochin, Université Paris Descartes, Inserm U1016, Paris, France
| | - Rolf Hultcrantz
- Departments of Gastroenterology and Hepatology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Ola Weiland
- Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Karoline Rutter
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Vito Di Marco
- Gastrointestinal & Liver Unit, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
| | - Sonia Alonso
- Unit of Gastroenterology and Liver Diseases, University Hospital Fundación Alcorcón, Madrid, Spain
| | - Savino Bruno
- Department of Internal Medicine, Humanitas University and IRCCS Istituto Clinico Humanitas, Rozzano (Milan), Italy
| | - Massimo Colombo
- A.M. and A. Migliavacca Center for Liver Disease, First Division of Gastroenterology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bart J Veldt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands; The Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
9
|
Maan R, Zaim R, van der Meer AJ, Feld JJ, Wedemeyer H, Dufour JF, Lammert F, Manns MP, Zeuzem S, Hansen BE, Janssen HLA, Veldt BJ, de Knegt RJ, Uyl-de Groot CA. Real-world medical costs of antiviral therapy among patients with chronic HCV infection and advanced hepatic fibrosis. J Gastroenterol Hepatol 2016; 31:1851-1859. [PMID: 26990109 DOI: 10.1111/jgh.13373] [Citation(s) in RCA: 4] [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: 11/30/2015] [Revised: 03/08/2016] [Accepted: 03/10/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS Very potent direct acting antivirals for the treatment of chronic hepatitis C virus infection were recently introduced into daily clinical practice. Currently, treatment uptake is hampered by their high costs, eliciting prioritization of treatment. We aimed to evaluate the direct medical costs during interferon (IFN)-based antiviral treatment and the costs per sustained virological response (SVR) among patients with advanced hepatic fibrosis. METHODS This retrospective cohort study included all consecutive patients with chronic hepatitis C virus infection and biopsy-proven bridging fibrosis or cirrhosis (Ishak 4-6) treated with IFN-based regimens in five hepatology units of tertiary care centers in Europe and Canada. Direct medical costs, expressed in 2013 Euros, during therapy were assessed. The components of care were quantified by three distinct categories: treatment, safety/ monitoring, and complications. Cost per SVR was calculated by dividing the mean cost by the SVR rate. RESULTS In total, 672 interferon-based treatments administered to 455 patients were included. Total medical costs per patient were averaged to €14 559 (95% confidence interval [CI], €13 323-€15 836). The mean cost per SVR was €38 514 (95% CI, €35 244-€41 892). The costs per SVR were €26 105 (95% CI, €23 068-€29 296) for patients with a normal platelet count and €50 907 (95% CI, €44 151-€59 612) for patients with thrombocytopenia, with the costs per SVR of €74 961 (95% CI, €55 463-€103 541) among those patients with a platelet count below 100 * 109 /L. CONCLUSIONS Because of the lower SVR rates, the cost per SVR of IFN-based treatment increased when patients with more advanced liver disease were treated. Additional costs of IFN-free therapy could be limited among these patients.
Collapse
Affiliation(s)
- Raoel Maan
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Remziye Zaim
- Institute for Medical Technology Assessment, Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jordan J Feld
- Liver Centre, Toronto Western & General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, and Endocrinology, Medical School Hannover, Hannover, Germany
| | - Jean-François Dufour
- Hepatology, Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology, and Endocrinology, Medical School Hannover, Hannover, Germany
| | - Stefan Zeuzem
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harry LA Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.,Liver Centre, Toronto Western & General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Bart J Veldt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Carin A Uyl-de Groot
- Institute for Medical Technology Assessment, Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| |
Collapse
|
10
|
Abstract
Thrombocytopenia (platelet count <150 × 109/L) often complicates chronic liver disease, impeding optimal management of these patients. The prevalence of this manifestation ranges from 6 % among non-cirrhotic patients with chronic liver disease to 70 % among patients with liver cirrhosis. It has also been shown that the severity of liver disease is associated with both prevalence and level of thrombocytopenia. Its development is often multifactorial, although thrombopoietin is thought to be a major factor. The discovery of and ability to clone thrombopoietin led to new treatment opportunities for this clinical manifestation. This review discusses data on the three most important thrombopoietin receptor agonists: eltrombopag, avatrombopag, and romiplostim. Currently, only eltrombopag is approved for usage among patients with thrombocytopenia and chronic hepatitis C virus infection in order to initiate and maintain interferon-based antiviral treatment. Nevertheless, the optimal management of hematologic abnormalities among patients with chronic liver disease, and its risk for bleeding complications, is still a matter of discussion. Thrombocytopenia definitely contributes to hemostatic defects but is often counterbalanced by the enhanced presence of procoagulant factors. Therefore, a thorough assessment of the patient’s risk for thrombotic events is essential when the use of thrombopoietin receptor agonists is considered among patients with chronic liver disease and thrombocytopenia.
Collapse
Affiliation(s)
- Raoel Maan
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, 's Gravendijkwal 230, Room Ha 206, 3015 CE, Rotterdam, The Netherlands.
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, 's Gravendijkwal 230, Room Ha 206, 3015 CE, Rotterdam, The Netherlands.
| | - Bart J Veldt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, 's Gravendijkwal 230, Room Ha 206, 3015 CE, Rotterdam, The Netherlands.
| |
Collapse
|
11
|
van der Meer AJ, Maan R, Veldt BJ, Feld JJ, Wedemeyer H, Dufour JF, Lammert F, Duarte-Rojo A, Manns MP, Zeuzem S, Hofmann WP, de Knegt RJ, Hansen BE, Janssen HLA. Improvement of platelets after SVR among patients with chronic HCV infection and advanced hepatic fibrosis. J Gastroenterol Hepatol 2016; 31:1168-76. [PMID: 26647353 DOI: 10.1111/jgh.13252] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [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: 09/08/2015] [Revised: 11/05/2015] [Accepted: 11/25/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Patients with chronic hepatitis C virus (HCV) infection may develop cirrhosis with portal hypertension, reflected by decreased platelet count and splenomegaly. This retrospective cohort study aimed to assess changes in platelet counts after antiviral therapy among chronic HCV-infected patients with advanced fibrosis. METHODS Platelet counts and spleen sizes were recorded in an international cohort of patients with Ishak 4-6 fibrosis who started antiviral therapy between 1990 and 2003. Last measured platelet counts and spleen sizes were compared with their pre-treatment values (within 6 months prior to the start of therapy). All registered platelet count measurements from 24-week following cessation of antiviral therapy were included in repeated measurement analyses. RESULTS This study included 464 patients; 353 (76%) had cirrhosis and 187 (40%) attained sustained virological response (SVR). Among patients with SVR, median platelet count, increased by 35 × 10(9) /L (IQR 7-62, P < 0.001). In comparison, patients without SVR showed a median decline of 17 × 10(9) /L (IQR -5-47, P < 0.001). In a subgroup of 209 patients, median decrease in spleen size was 1.0 cm (IQR 0.3-2.0) for patients with SVR, while median spleen size increased with 0.6 cm (IQR -0.1-2.0, P < 0.001) among those without SVR. The changes in spleen size and platelet count were significantly correlated (R = -0.41, P < 0.001). CONCLUSIONS Among chronic HCV-infected patients with advanced hepatic fibrosis, the platelet counts improved following SVR and the change in platelets correlated with the change in spleen size following antiviral therapy. These results suggest that HCV eradication leads to reduced portal pressure.
Collapse
Affiliation(s)
- Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Raoel Maan
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bart J Veldt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jordan J Feld
- The Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, and Endocrinology, Medical School Hannover, Hannover, Germany
| | - Jean-François Dufour
- Hepatology, Department of Clinical research, University of Bern, Bern, Switzerland
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Arkansas, USA
| | - Michael P Manns
- Department of Gastroenterology, Hepatology, and Endocrinology, Medical School Hannover, Hannover, Germany
| | - Stefan Zeuzem
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
| | - W Peter Hofmann
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harry LA Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.,The Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
12
|
Maan R, van der Meer AJ, Brouwer WP, Plompen EPC, Sonneveld MJ, Roomer R, van der Eijk AA, Groothuismink ZMA, Hansen BE, Veldt BJ, Janssen HLA, Boonstra A, de Knegt RJ. ITPA Polymorphisms Are Associated with Hematological Side Effects during Antiviral Therapy for Chronic HCV Infection. PLoS One 2015; 10:e0139317. [PMID: 26441325 PMCID: PMC4595504 DOI: 10.1371/journal.pone.0139317] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 09/11/2015] [Indexed: 02/08/2023] Open
Abstract
Background/Objective Genetic polymorphisms in the inosine triphosphatase (ITPA) gene have been associated with the protection from early ribavirin(RBV)-induced hemolytic anemia among patients with chronic hepatitis C virus (HCV) infection. The aim of the present study was to investigate the association between the functional ITPA variants and hematological side effects during antiviral therapy with pegylated interferon (PegIFN) and RBV. Patients and Methods This cohort study included all consecutive Caucasian patients treated for chronic HCV infection with PegIFN and RBV between 2000 and 2009 for whom a serum sample was available for genetic testing. The predicted inosine triphosphate pyrophosphatase (ITPase) activity was based on the genotypes of the SNPs rs1127354 and rs7270101. Decline in hemoglobin (Hb) during antiviral therapy, as well as dose reductions, blood transfusions and use of erythropoietin were assessed. Results In total, 213 patients were included. The predicted ITPase activity was normal among 152 (71%) patients; 61 (29%) patients had ITPase deficiency. By multivariable linear regression, RBV dose in mg per kilogram (Beta 0.09, 95%CI 0.04–0.13, p<0.001) and normal ITPase activity (Beta 0.89, 95%CI 0.64–1.14, p<0.001) were associated with more Hb decline at week 4 of treatment. Patients with normal ITPase activity underwent more dose adjustments of RBV than patients with ITPase deficiency (19(13%) vs 1(2%),p = 0.014) and received erythropoietin more frequently (12 (8%) vs 0 (0%),p = 0.024). Conclusion Genetic variants in the ITPA gene protected against RBV treatment-induced anemia among Caucasian patients with chronic HCV infection. Patients with normal ITPase activity underwent more dose reductions of RBV and received erythropoietin more frequently.
Collapse
Affiliation(s)
- Raoel Maan
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
- * E-mail:
| | - Adriaan J. van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Willem Pieter Brouwer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Elisabeth P. C. Plompen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Milan J. Sonneveld
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Robert Roomer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Annemiek A. van der Eijk
- Department of Viroscience, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Zwier M. A. Groothuismink
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Bettina E. Hansen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Bart J. Veldt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Harry L. A. Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
- Toronto Centre for Liver Disease, Toronto Western & General Hospital, University Health Network, Toronto, Canada
| | - Andre Boonstra
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Robert J. de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| |
Collapse
|
13
|
Maan R, Toes-Zoutendijk E, Veldt BJ, Hansen BE, van der Meer AJ, de Knegt RJ. Epidemiological trends among the population with chronic HCV infection in the Netherlands. Antivir Ther 2015; 21:207-15. [PMID: 26436201 DOI: 10.3851/imp2996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND As the field of antiviral therapy for chronic HCV infection is rapidly evolving, this study aimed to assess the epidemiological changes in patient and disease characteristics among individuals with chronic HCV infection. METHODS This study included all consecutive patients with chronic HCV monoinfection who were referred between 1990 and 2013 to the Erasmus MC University Medical Center Rotterdam, a large tertiary centre in the Netherlands. To identify trends over time, the study population was divided into six equal eras based on date of first visit to the outpatient clinic. RESULTS A total of 1,779 patients were diagnosed with chronic HCV infection. Mean age increased over time from 43.6 (sd 13.8) years to 51.7 (sd 11.2) years (P<0.001). The number of patients who were referred with cirrhosis increased over time, from 31 (25%) patients in Era 1 to 118 (42%) patients in Era 6 (P<0.001), respectively. More patients were referred with HCV genotype 1a and 3 in the last era, with 27 (48.2%) and 15 (14.0%) patients in Era 1 and 58 (54.2%) and 60 (21.8%) patients in Era 6 (P<0.001 both), respectively. The vast majority of patients (69.5%) were born between 1950 to 1975, with 62.5% of the patients being born between 1945 and 1965. CONCLUSIONS The HCV-infected population is ageing and is more often referred with severe liver disease. This study stresses the importance of urgently implementing national HCV screening programmes in order to be able to decrease the future burden of chronic HCV infection in the Netherlands.
Collapse
Affiliation(s)
- Raoel Maan
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | | | | | | | | | | |
Collapse
|
14
|
Wieten E, Brouwer JT, Quispel R, Veldt BJ. Letter: scoring models in alcoholic hepatitis. Aliment Pharmacol Ther 2015; 42:126. [PMID: 26040528 DOI: 10.1111/apt.13224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 12/08/2022]
Affiliation(s)
- E Wieten
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, The Netherlands. .,Department of Gastroenterology &Hepatology and Internal Medicine, Reinier de Graaf Hospital, Delft, The Netherlands.
| | - J T Brouwer
- Department of Gastroenterology &Hepatology and Internal Medicine, Reinier de Graaf Hospital, Delft, The Netherlands
| | - R Quispel
- Department of Gastroenterology &Hepatology and Internal Medicine, Reinier de Graaf Hospital, Delft, The Netherlands
| | - B J Veldt
- Department of Gastroenterology &Hepatology and Internal Medicine, Reinier de Graaf Hospital, Delft, The Netherlands
| |
Collapse
|
15
|
Maan R, van der Meer AJ, Hansen BE, Feld JJ, Wedemeyer H, Dufour JF, Lammert F, Manns MP, Zeuzem S, Janssen HLA, de Knegt RJ, Veldt BJ. Risk of infections during interferon-based treatment in patients with chronic hepatitis C virus infection and advanced hepatic fibrosis. J Gastroenterol Hepatol 2015; 30:1057-64. [PMID: 25682797 DOI: 10.1111/jgh.12929] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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] [Accepted: 01/16/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND & AIM Pegylated interferon-based treatment is still the backbone of current hepatitis C therapy and is associated with bone marrow suppression and an increased risk of infections. The aim of this retrospective cohort study was to assess the risk of infections during interferon-based treatment among patients with chronic hepatitis C virus (HCV) infection and advanced hepatic fibrosis and its relation to treatment-induced neutropenia. METHODS This cohort study included all consecutive patients with chronic HCV infection and biopsy-proven bridging fibrosis or cirrhosis (Ishak 4-6) who started treatment between 1990 and 2003 in five large hepatology units in Europe and Canada. Neutrophil counts between 500-749/μL and below 500/μL were considered as moderate and severe neutropenia, respectively. RESULTS This study included 723 interferon-based treatments, administered to 490 patients. In total, 113 infections were reported during 88 (12%) treatments, of which 24 (21%) were considered severe. Only one patient was found to have moderate neutropenia and three patients were found to have severe neutropenia at the visit before the infection. Three hundred and twelve (99.7%) visits with moderate neutropenia and 44 (93.6%) visits with severe neutropenia were not followed by an infection. Multivariable analysis showed that cirrhosis (odds ratio [OR] 2.85, 95% confidence interval [CI] 1.38-5.90, P=0.005) and severe neutropenia at the previous visit (OR 5.42, 95% CI 1.34-22.0, P=0.018) were associated with the occurrence of infection, while moderate neutropenia was not. Among a subgroup of patients treated with pegylated interferon, severe neutropenia was not significantly associated (OR 1.63, 95% CI 0.19-14.2, P=0.660). CONCLUSIONS In this large cohort of patients with bridging fibrosis and cirrhosis, infections during interferon-based therapy were generally mild. Severe interferon-induced neutropenia rarely occurred, but was associated with on-treatment infection. Moderate neutropenia was not associated with infection, suggesting that current dose reduction guidelines might be too strict.
Collapse
Affiliation(s)
- Raoel Maan
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
van der Meer AJ, Hansen BE, Fattovich G, Feld JJ, Wedemeyer H, Dufour JF, Lammert F, Duarte-Rojo A, Manns MP, Ieluzzi D, Zeuzem S, Hofmann WP, de Knegt RJ, Veldt BJ, Janssen HLA. Reliable prediction of clinical outcome in patients with chronic HCV infection and compensated advanced hepatic fibrosis: a validated model using objective and readily available clinical parameters. Gut 2015; 64:322-31. [PMID: 24815676 DOI: 10.1136/gutjnl-2013-305357] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [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: 12/17/2022]
Abstract
OBJECTIVE Reliable tools to predict long-term outcome among patients with well compensated advanced liver disease due to chronic HCV infection are lacking. DESIGN Risk scores for mortality and for cirrhosis-related complications were constructed with Cox regression analysis in a derivation cohort and evaluated in a validation cohort, both including patients with chronic HCV infection and advanced fibrosis. RESULTS In the derivation cohort, 100/405 patients died during a median 8.1 (IQR 5.7-11.1) years of follow-up. Multivariate Cox analyses showed age (HR=1.06, 95% CI 1.04 to 1.09, p<0.001), male sex (HR=1.91, 95% CI 1.10 to 3.29, p=0.021), platelet count (HR=0.91, 95% CI 0.87 to 0.95, p<0.001) and log10 aspartate aminotransferase/alanine aminotransferase ratio (HR=1.30, 95% CI 1.12 to 1.51, p=0.001) were independently associated with mortality (C statistic=0.78, 95% CI 0.72 to 0.83). In the validation cohort, 58/296 patients with cirrhosis died during a median of 6.6 (IQR 4.4-9.0) years. Among patients with estimated 5-year mortality risks <5%, 5-10% and >10%, the observed 5-year mortality rates in the derivation cohort and validation cohort were 0.9% (95% CI 0.0 to 2.7) and 2.6% (95% CI 0.0 to 6.1), 8.1% (95% CI 1.8 to 14.4) and 8.0% (95% CI 1.3 to 14.7), 21.8% (95% CI 13.2 to 30.4) and 20.9% (95% CI 13.6 to 28.1), respectively (C statistic in validation cohort = 0.76, 95% CI 0.69 to 0.83). The risk score for cirrhosis-related complications also incorporated HCV genotype (C statistic = 0.80, 95% CI 0.76 to 0.83 in the derivation cohort; and 0.74, 95% CI 0.68 to 0.79 in the validation cohort). CONCLUSIONS Prognosis of patients with chronic HCV infection and compensated advanced liver disease can be accurately assessed with risk scores including readily available objective clinical parameters.
Collapse
Affiliation(s)
- Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Jordan J Feld
- Liver Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Heiner Wedemeyer
- Departments of Gastroenterology, Hepatology, and Endocrinology, Medical School Hannover, Hannover, Germany
| | - Jean-François Dufour
- Hepatology, Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Andres Duarte-Rojo
- Liver Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael P Manns
- Departments of Gastroenterology, Hepatology, and Endocrinology, Medical School Hannover, Hannover, Germany
| | | | - Stefan Zeuzem
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
| | - W Peter Hofmann
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bart J Veldt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands Liver Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
17
|
Hotho DM, Bezemer G, Hansen BE, Van Gool AR, de Knegt RJ, Janssen HLA, Veldt BJ. Effects of escitalopram prophylaxis during antiviral treatment for chronic hepatitis C in patients with a history of intravenous drug use and depression. J Clin Psychiatry 2014; 75:1069-77. [PMID: 25188436 DOI: 10.4088/jcp.12m07837] [Citation(s) in RCA: 3] [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] [Received: 04/06/2012] [Accepted: 01/10/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We aimed to identify those patients with hepatitis C virus who benefit most from prophylactic treatment with selective serotonin reuptake inhibitors (SSRIs) during antiviral therapy. METHOD We performed post hoc analyses on a prospective randomized controlled trial (n = 79) of escitalopram versus placebo during antiviral therapy with pegylated interferon and ribavirin, conducted between August 2005 and June 2008. Our primary outcome measure was the association of baseline characteristics with the development of depression and/or depressive symptoms. Further, we studied effects of prophylactic escitalopram on depressive symptoms. Presence of a major depression was diagnosed using Mini-International Neuropsychiatric Interview (MINI), a short, structured interview used to diagnose DSM-IV-TR and ICD-10 disorders. Depressive symptoms were monitored during treatment by using the depression scale of Symptom Checklist-90 (SCL-90), Montgomery-Asberg Depression Rating Scale (MADRS), and Beck Depression Inventory (BDI) at baseline and weeks 4, 12, and 24 of antiviral therapy. RESULTS Depression occurred in 14 patients receiving placebo and in 5 patients receiving escitalopram (Pearson χ², P = .01). Combination of history of depression and intravenous drug use was associated with depression (odds ratio = 12.60; 95% CI, 2.47-64.34; P < .01). Moreover, treatment with selective serotonin reuptake inhibitor compared to placebo was associated with a significant reduction in estimated mean depressive symptoms measured by SCL-90 (P = .03) and BDI (P = .048), but not with MADRS (P = .64). CONCLUSIONS Patients infected by hepatitis C virus with a history of depression and intravenous drug use carry the highest risk to develop interferon-induced depression. In this subset of patients, prophylaxis with escitalopram results in the most substantial decrease of interferon-induced depressive symptoms on the SCL-90 depression scale and the BDI.
Collapse
Affiliation(s)
- Daphne M Hotho
- Departments of Gastroenterology and Hepatology the Netherlands
| | | | | | | | | | | | | |
Collapse
|
18
|
Maan R, van der Meer AJ, Hansen BE, Feld JJ, Wedemeyer H, Dufour JF, Zangneh HF, Lammert F, Manns MP, Zeuzem S, Janssen HLA, de Knegt RJ, Veldt BJ. Effect of thrombocytopenia on treatment tolerability and outcome in patients with chronic HCV infection and advanced hepatic fibrosis. J Hepatol 2014; 61:482-91. [PMID: 24780302 DOI: 10.1016/j.jhep.2014.04.021] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 04/08/2014] [Accepted: 04/16/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pegylated interferon is still the backbone of hepatitis C treatment and may cause thrombocytopenia, leading to dose reductions, early discontinuation, and eventually worse clinical outcome. We assessed associations between interferon-induced thrombocytopenia and bleeding complications, interferon dose reductions, early treatment discontinuation, as well as SVR and long-term clinical outcome. METHODS All consecutive patients with chronic HCV infection and biopsy-proven advanced hepatic fibrosis (Ishak 4-6) who initiated interferon-based therapy between 1990 and 2003 in 5 large hepatology units in Europe and Canada were included. RESULTS Overall, 859 treatments were administered to 546 patients. Baseline platelets (in 10(9)/L) were normal (⩾150) in 394 (46%) treatments; thrombocytopenia was moderate (75-149) in 324 (38%) and severe (<75) in 53 (6%) treatments. Thrombocytopenia-induced interferon dose reductions occurred in 3 (1%); 46 (16%), and 15 (30%) treatments respectively (p<0.001); interferon was discontinued due to thrombocytopenia in 1 (<1%), 8 (3%), and in 8 (16%) treatments respectively (p<0.001). In total, 104 bleeding events were reported during 53 treatments. Only two severe bleeding complications occurred. Multivariate analysis showed that cirrhosis and a platelet count below 50 were associated with on-treatment bleeding. Within thrombocytopenic patients, patients attaining SVR had a lower occurrence of liver failure (p<0.001), hepatocellular carcinoma (p<0.001), liver related death or liver transplantation (p<0.001), and all-cause mortality (p=0.001) compared to patients without SVR. CONCLUSIONS Even in thrombocytopenic patients with chronic HCV infection and advanced hepatic fibrosis, on-treatment bleedings are generally mild. SVR was associated with a marked reduction in cirrhosis-related morbidity and mortality, especially in patients with baseline thrombocytopenia.
Collapse
Affiliation(s)
- Raoel Maan
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto Western & General Hospital, University Health Network, Toronto, Canada
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, and Endocrinology, Medical School Hannover, Hannover, Germany
| | - Jean-François Dufour
- Hepatology, Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Hooman F Zangneh
- Toronto Centre for Liver Disease, Toronto Western & General Hospital, University Health Network, Toronto, Canada
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology, and Endocrinology, Medical School Hannover, Hannover, Germany
| | - Stefan Zeuzem
- Medizinische Klinik 1, Klinikum der Johann Wolfgang Goethe-Universität, Frankfurt am Main, Germany
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands; Toronto Centre for Liver Disease, Toronto Western & General Hospital, University Health Network, Toronto, Canada
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bart J Veldt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| |
Collapse
|
19
|
van der Meer AJ, Veldt BJ, Feld JJ, Wedemeyer H, Dufour JF, Lammert F, Duarte-Rojo A, Manns MP, Zeuzem S, Hofmann WP, de Knegt RJ, Hansen BE, Janssen HLA. The number needed to treat to prevent mortality and cirrhosis-related complications among patients with cirrhosis and HCV genotype 1 infection. J Viral Hepat 2014; 21:568-77. [PMID: 24118177 DOI: 10.1111/jvh.12185] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 07/20/2013] [Indexed: 12/12/2022]
Abstract
Cirrhotic patients with chronic hepatitis C virus (HCV) infection remain at risk for complications following sustained virological response (SVR). Therefore, we aimed to evaluate treatment efficacy with the number needed to treat (NNT) to prevent clinical endpoints. Mortality and cirrhosis-related morbidity were assessed in an international multicentre cohort of consecutively treated patients with HCV genotype 1 infection and cirrhosis. The NNT to prevent death or clinical disease progression (any cirrhosis-related event or death) in one patient was determined with the adjusted (event-free) survival among patients without SVR and adjusted hazard ratio of SVR. Overall, 248 patients were followed for a median of 8.3 (IQR 6.2-11.1) years. Fifty-nine (24%) patients attained SVR. Among patients without SVR, the adjusted 5-year survival and event-free survival were 94.4% and 80.0%, respectively. SVR was associated with reduced all-cause mortality (HR 0.15, 95% CI 0.05-0.48, P = 0.002) and clinical disease progression (HR 0.16, 95% CI 0.07-0.36, P < 0.001). The NNT to prevent one death in 5 years declined from 1052 (95% CI 937-1755) at 2% SVR (interferon monotherapy) to 61 (95% CI 54-101) at 35% SVR (peginterferon and ribavirin). At 50% SVR, which might be expected with triple therapy, the estimated NNT was 43 (95% CI 38-71). The NNT to prevent clinical disease progression in one patient in 5 years was 302 (95% CI 271-407), 18 (95% CI 16-24) and 13 (95% CI 11-17) at 2%, 35% and 50% SVR, respectively. In conclusion, the NNT to prevent clinical endpoints among cirrhotic patients with HCV genotype 1 has declined enormously with the improvement of antiviral therapy.
Collapse
Affiliation(s)
- A J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Affiliation(s)
- Raoel Maan
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Bart J Veldt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto Western & General Hospital, University Health Network, Toronto, Canada; Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| |
Collapse
|
21
|
Duarte-Rojo A, Budhraja V, Veldt BJ, Goldstein DD, Watt KD, Heimbach JK, McHutchison JG, Tillman HL, Poterucha JJ, Charlton MR. Interleukin-28B and fibrosing cholestatic hepatitis in posttransplant hepatitis C: a case-control study and literature review. Liver Transpl 2013; 19:1311-7. [PMID: 24039107 DOI: 10.1002/lt.23733] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 07/26/2013] [Indexed: 12/14/2022]
Abstract
Chronic hepatitis C (CHC)-related cirrhosis is the leading indication for liver transplantation (LT). However, the recurrence of a hepatitis C virus (HCV) infection after transplantation is universal and is associated with worse outcomes. Fibrosing cholestatic hepatitis (FCH) is a particularly severe manifestation of a recurrent HCV infection and frequently results in graft failure and death. The identification of risk factors for FCH is important but has been limited by the low frequency of FCH. The interleukin-28B (IL-28B) genotype is important in an HCV infection: it is related to the clinical severity of an acute infection and may play a role in the development of FCH as well. Two hundred seventy-two consecutive LT cases for CHC were studied at a single institution. Consensus criteria were used to define an FCH cohort. The remainder of the study population served as a control group. The IL-28B genotype (at the rs12979860 locus) from both the donor and the recipient was determined, and other clinically relevant data were tabulated. A nonparametric statistical analysis was performed. Twelve cases of FCH were identified, and they were compared to a control group of 260 LT cases without FCH. A detailed analysis of clinical characteristics, including treatment responses and outcomes, was tabulated. FCH was associated with the earlier recurrence of HCV infections, higher HCV viral loads, and lower levels of immunosuppressive medications. There was a nonsignificant increase in recipient IL-28B non-CC genotypes in cases developing FCH. In conclusion, a high HCV viral load and earlier recurrence were identified as risk factors for FCH. It is still unclear what role immunosuppression plays in the pathogenesis of FCH and whether IL-28B polymorphisms constitute a risk factor. Collaborative studies with larger numbers of study subjects are needed in order to define these issues.
Collapse
Affiliation(s)
- Andres Duarte-Rojo
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN; University of Arkansas for Medical Sciences, Little Rock, AR
| | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
|
23
|
van der Meer AJ, Veldt BJ, Feld JJ, Wedemeyer H, Dufour JF, Lammert F, Duarte-Rojo A, Heathcote EJ, Manns MP, Kuske L, Zeuzem S, Hofmann WP, de Knegt RJ, Hansen BE, Janssen HLA. Association between sustained virological response and all-cause mortality among patients with chronic hepatitis C and advanced hepatic fibrosis. JAMA 2012; 308:2584-93. [PMID: 23268517 DOI: 10.1001/jama.2012.144878] [Citation(s) in RCA: 1128] [Impact Index Per Article: 94.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Chronic hepatitis C virus (HCV) infection outcomes include liver failure, hepatocellular carcinoma (HCC), and liver-related death. OBJECTIVE To assess the association between sustained virological response (SVR) and all-cause mortality in patients with chronic HCV infection and advanced hepatic fibrosis. DESIGN, SETTING, AND PATIENTS An international, multicenter, long-term follow-up study from 5 large tertiary care hospitals in Europe and Canada of 530 patients with chronic HCV infection who started an interferon-based treatment regimen between 1990 and 2003, following histological proof of advanced hepatic fibrosis or cirrhosis (Ishak score 4-6). Complete follow-up ranged between January 2010 and October 2011. MAIN OUTCOME MEASURES All-cause mortality. Secondary outcomes were liver failure, HCC, and liver-related mortality or liver transplantation. RESULTS The 530 study patients were followed up for a median (interquartile range [IQR]) of 8.4 (6.4-11.4) years. The baseline median (IQR) age was 48 (42-56) years and 369 patients (70%) were men. The Ishak fibrosis score was 4 in 143 patients (27%), 5 in 101 patients (19%), and 6 in 286 patients (54%). There were 192 patients (36%) who achieved SVR; 13 patients with SVR and 100 without SVR died (10-year cumulative all-cause mortality rate, 8.9% [95% CI, 3.3%-14.5%] with SVR and 26.0% [95% CI, 20.2%-28.4%] without SVR; P < .001). In time-dependent multivariate Cox regression analysis, SVR was associated with reduced risk of all-cause mortality (hazard ratio [HR], 0.26; 95% CI, 0.14-0.49; P < .001) and reduced risk of liver-related mortality or transplantation (HR, 0.06; 95% CI, 0.02-0.19; P < .001), the latter occurring in 3 patients with SVR and 103 without SVR. The 10-year cumulative incidence rate of liver-related mortality or transplantation was 1.9% (95% CI, 0.0%-4.1%) with SVR and 27.4% (95% CI, 22.0%-32.8%) without SVR (P < .001). There were 7 patients with SVR and 76 without SVR who developed HCC (10-year cumulative incidence rate, 5.1%; 95% CI, 1.3%-8.9%; vs 21.8%; 95% CI, 16.6%-27.0%; P < .001), and 4 patients with SVR and 111 without SVR experienced liver failure (10-year cumulative incidence rate, 2.1%; 95% CI, 0.0%-4.5%; vs 29.9%; 95% CI, 24.3%-35.5%; P < .001). CONCLUSION Among patients with chronic HCV infection and advanced hepatic fibrosis, sustained virological response to interferon-based treatment was associated with lower all-cause mortality.
Collapse
Affiliation(s)
- Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Duarte-Rojo A, Veldt BJ, Goldstein DD, Tillman HL, Watt KD, Heimbach JK, McHutchison JG, Poterucha JJ, Vargas-Vorackova F, Charlton MR. The course of posttransplant hepatitis C infection: comparative impact of donor and recipient source of the favorable IL28B genotype and other variables. Transplantation 2012; 94:197-203. [PMID: 22766768 DOI: 10.1097/tp.0b013e3182547551] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS The IL28B genotype has been linked to sustained virological response (SVR) in hepatitis C virus (HCV). Its role on disease biology and progression is less clear. We characterized the effects of IL28B genotype on HCV recurrence, allograft histology, rate of SVR, and survival after liver transplantation (LT) in HCV. METHODS Consecutive patients who underwent LT with HCV were studied. The rs12979860 genotype from both the donor was and recipient was determined. Measured endpoints included histologic HCV recurrence (inflammatory grade and fibrosis stage), acute cellular rejection, SVR, retransplantation, and death. RESULTS The study cohort comprised 272 consecutive LT in 255 patients. C-allele frequency was 56% in recipients and 70% in donors (P<0.001). Recipient IL28B CC genotype was associated with lower alanine aminotransferase levels and viral load at recurrence and a lower frequency of F≥2 on liver biopsy at 1 year after LT, when compared with the non-CC genotype (P=0.012). The opposite was observed in LT with donor CC genotype (P=0.003). Both recipient and donor CC genotype favored SVR, and when the two of them occurred together, the SVR rate reached 90%. Survival analysis after 5.5 years of follow-up showed a higher rate of progression to cirrhosis (hazard ratio, 5.96; 95% confidence interval, 1.29-27.6), liver-related death, or retransplantation among liver transplant recipients with a CC genotype donor. CONCLUSIONS The IL28B genotype is predictive not only of SVR but also of the histologic diagnosis of posttransplant hepatitis C, with donor CC genotype favoring inflammation and fibrosis, and adverse outcomes during long-term follow-up. A favorable effect of donor CC genotype is manifest only after antiviral therapy.
Collapse
Affiliation(s)
- Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Veldt BJ, Duarte-Rojo A, Thompson AJ, Watt KD, Heimbach JK, Tillmann HL, Goldstein DD, McHutchison JG, Charlton MR. Recipient IL28B polymorphism is an important independent predictor of posttransplant diabetes mellitus in liver transplant patients with chronic hepatitis C. Am J Transplant 2012; 12:737-44. [PMID: 22300408 DOI: 10.1111/j.1600-6143.2011.03843.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
IL28B polymorphisms are strongly associated with response to treatment for HCV infection. IL28B acts on interferon-stimulated genes via the JAK-STAT pathway, which has been implicated in development of insulin resistance. We investigated whether IL28B polymorphisms are associated with posttransplant diabetes mellitus (DM). Consecutive HCV patients who underwent liver transplantation between 1-1995 and 1-2011 were studied. Genotyping of the polymorphism rs12979860 was performed on DNA collected from donors and recipients. Posttransplant DM was screened for by fasting blood glucoses every 1-3 months. Of 221 included patients, 69 developed posttransplant DM (31%). Twenty-two patients with recipient IL28B genotype TT (48%), 25 with IL28B genotype CT (25%) and 22 with IL28B genotype CC (29%) developed posttransplant DM. TT genotype was statistically significantly associated with posttransplant DM over time (log rank p = 0.012 for TT vs. CT and p = 0.045 for TT vs. CC). Multivariate Cox regression analysis correcting for donor age, body mass index, baseline serum glucose, baseline serum cholesterol, recipient age and treated rejection, showed that recipient IL28B genotype TT was independently associated with posttransplant DM (hazard ratio 2.51; 95% confidence interval 1.17-5.40; p = 0.011). We conclude that the risk of developing posttransplant DM is significantly increased in recipients carrying the TT polymorphism of the IL28B gene.
Collapse
Affiliation(s)
- B J Veldt
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Abstract
OBJECTIVE Intramural hematoma of the small intestine is a complication of anticoagulant treatment with an estimated incidence of 1 case per 2500 anticoagulated patients per year. Patients may present with signs of small bowel obstruction or, in case of a ruptured hematoma, with upper gastrointestinal tract hemorrhage and hypovolemic shock. MATERIAL AND METHODS Case report and review of the literature. RESULTS We present a case of a 73-year-old male who was referred for a protruding mass in the duodenum and subsequently developed hematemesis and melena caused by a ruptured hematoma of the duodenal wall. CONCLUSIONS Although intramural hematoma of the duodenum is a rare complication of anticoagulant therapy, early diagnosis with subsequent correction of coagulation parameters is of vital importance.
Collapse
Affiliation(s)
- Bart J Veldt
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | | | | | | |
Collapse
|
27
|
Charlton MR, Thompson A, Veldt BJ, Watt K, Tillmann H, Poterucha JJ, Heimbach JK, Goldstein D, McHutchison J. Interleukin-28B polymorphisms are associated with histological recurrence and treatment response following liver transplantation in patients with hepatitis C virus infection. Hepatology 2011; 53:317-24. [PMID: 21254179 PMCID: PMC3835596 DOI: 10.1002/hep.24074] [Citation(s) in RCA: 171] [Impact Index Per Article: 13.2] [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] [Indexed: 12/20/2022]
Abstract
UNLABELLED Polymorphism in the interleukin-28B (IL28B) gene region, encoding interferon (IFN)-λ3, is strongly predictive of response to antiviral treatment in the nontransplant setting. We sought to determine the prevalence and impact on clinical outcomes of donor and recipient IL28B genotypes among liver transplant recipients. The cohort study included 189 consecutive patients infected with hepatitis C virus (HCV) who underwent liver transplantation between January 1, 1995, and January 1, 2005, at the Mayo Clinic, Rochester, MN. Genotyping of the polymorphism rs12979860 was performed on DNA collected from all donors and recipients in the cohort. Sixty-five patients received IFN-based antiviral therapy. The CC IL28B variant was less common in the chronic HCV-infected recipients than in non-HCV donor livers (33% versus 47%, P = 0.03). IL28B recipient genotype was significantly predictive of fibrosis stage, with TT genotype being associated with more rapid fibrosis (Pearson chi-square P = 0.024 for the comparison G versus A). Donor and recipient IL28B genotype were independently associated with sustained virologic response (P < 0.005). The presence of IL28B CC variant in either the recipient (R) or donor (D) liver was associated with increased rate of sustained virologic response (D-non-CC/R-non-CC = 3/19 [16%] versus D-CC/R-non-CC = 11/22 [50%] versus D-non-CC/R-CC = 5/12 [42%] versus R-CC/D-CC = 6/7 [86%], P = 0.0095). IL28B genotype was not significantly associated with survival (overall/liver-related). CONCLUSION Recipient IL28B TT genotype is associated with more severe histological recurrence of HCV. Recipient and donor liver IL28B genotype are strongly and independently associated with IFN-based treatment response in patients after orthotopic liver transplantation. The data suggest that CC donor livers might be preferentially allocated to patients with HCV infection.
Collapse
Affiliation(s)
- Michael R Charlton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Veldt BJ, Poterucha JJ, Watt KDS, Wiesner RH, Hay JE, Rosen CB, Heimbach JK, Janssen HLA, Charlton MR. Insulin resistance, serum adipokines and risk of fibrosis progression in patients transplanted for hepatitis C. Am J Transplant 2009; 9:1406-13. [PMID: 19459812 DOI: 10.1111/j.1600-6143.2009.02642.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In the nontransplant setting diabetes mellitus is a risk factor for disease progression in patients with chronic hepatitis C virus (HCV) infection. The impact of early insulin resistance on the development of advanced fibrosis, even in the absence of clinically apparent diabetes mellitus, is not known. Our aim was to determine whether the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) can be used to identify insulin-resistant patients at risk for rapid fibrosis progression. Cohort study including patients transplanted for chronic HCV between January 1, 1995 and January 1, 2005. One hundred sixty patients were included; 25 patients (16%) were treated for diabetes mellitus and 36 patients (23%) were prediabetic, defined as HOMA-IR >2.5. Multivariate Cox regression analysis showed that insulin resistance (hazard ratio (HR) 2.07; confidence interval (CI) 1.10-3.91, p = 0.024), donor age (HR 1.33;CI 1.08-1.63, p = 0.007) and aspartate aminotransferase (HR 1.03;CI 1.01-1.05, p < 0.001) were significantly associated with a higher probability of developing advanced fibrosis, i.e. Knodell fibrosis stage 3 or 4, whereas steatosis (HR 0.94;CI 0.46-1.92, p = 0.87) and acute cellular rejection (HR 1.72;CI 0.88-3.36, p = 0.111) were not. In conclusion, posttransplant insulin resistance is strongly associated with more severe recurrence of HCV infection. HOMA-IR is an important tool for the identification of insulin resistance among patients at risk for rapid fibrosis progression after liver transplantation for HCV.
Collapse
Affiliation(s)
- B J Veldt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Veldt BJ, Poterucha JJ, Watt KDS, Wiesner RH, Hay JE, Kremers WK, Rosen CB, Heimbach JK, Charlton MR. Impact of pegylated interferon and ribavirin treatment on graft survival in liver transplant patients with recurrent hepatitis C infection. Am J Transplant 2008; 8:2426-33. [PMID: 18727694 DOI: 10.1111/j.1600-6143.2008.02362.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Recurrent hepatitis C virus (HCV) infection is a major cause of morbidity and mortality after liver transplantation for HCV-related end stage liver disease. Although previous studies have shown a short-term effect of interferon-based treatment on fibrosis progression, it is unclear whether this translates to improved graft survival. We evaluated whether treatment of recurrent HCV leads to an improved graft survival. Cohort study included consecutive HCV patients who underwent liver transplantation between 1 January 1995 and 1 January 2005 in the Mayo Clinic, Rochester, MN. Two hundred and fifteen patients were included in the study. During a median follow-up of 4.4 years (interquartile range 2.2-6.6), 165 patients (77%) had biopsy-proven recurrent HCV infection confirmed by serum HCV RNA testing. Seventy-eight patients were treated. There were no differences in MELD-score, fibrosis stage or time towards HCV recurrence between treated and untreated patients at time of recurrence. There was a trend for greater frequency of acute cellular rejection among untreated patients. The incidence of graft failure was lower for patients treated within 6 months of recurrence compared to patients not treated within this time-period (log rank p = 0.002). Time-dependent multivariate Cox regression analysis showed that treatment of recurrent HCV infection was statistically significantly associated with a decreased risk of overall graft failure (hazard ratio 0.34; CI 0.15-0.77, p = 0.009) and a decreased risk of graft failure due to recurrent HCV (hazard ratio 0.24; CI 0.08-0.69, p = 0.008). In conclusion, although a cause and effect relationship cannot be established, treatment of recurrent HCV infection after liver transplantation is associated with a reduced risk of graft failure.
Collapse
Affiliation(s)
- B J Veldt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Veldt BJ, Chen W, Heathcote EJ, Wedemeyer H, Reichen J, Hofmann WP, de Knegt RJ, Zeuzem S, Manns MP, Hansen BE, Schalm SW, Janssen HLA. Increased risk of hepatocellular carcinoma among patients with hepatitis C cirrhosis and diabetes mellitus. Hepatology 2008. [PMID: 18506898 DOI: 10.1002/hep.22251.] [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: 11/07/2022]
Abstract
UNLABELLED Recent studies suggest that diabetes mellitus increases the risk of developing hepatocellular carcinoma (HCC). The aim of this study is to quantify the risk of HCC among patients with both diabetes mellitus and hepatitis C in a large cohort of patients with chronic hepatitis C and advanced fibrosis. We included 541 patients of whom 85 (16%) had diabetes mellitus. The median age at inclusion was 50 years. The prevalence of diabetes mellitus was 10.5% for patients with Ishak fibrosis score 4, 12.5% for Ishak score 5, and 19.1% for Ishak score 6. Multiple logistic regression analysis showed an increased risk of diabetes mellitus for patients with an elevated body mass index (BMI) (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.00-1.11; P = 0.060) and a decreased risk of diabetes mellitus for patients with higher serum albumin levels (OR, 0.81; 95% CI, 0.63-1.04; P = 0.095). During a median follow-up of 4.0 years (interquartile range, 2.0-6.7), 11 patients (13%) with diabetes mellitus versus 27 patients (5.9%) without diabetes mellitus developed HCC, the 5-year occurrence of HCC being 11.4% (95% CI, 3.0-19.8) and 5.0% (95% CI, 2.2-7.8), respectively (P = 0.013). Multivariate Cox regression analysis of patients with Ishak 6 cirrhosis showed that diabetes mellitus was independently associated with the development of HCC (hazard ratio, 3.28; 95% CI, 1.35-7.97; P = 0.009). CONCLUSION For patients with chronic hepatitis C and advanced cirrhosis, diabetes mellitus increases the risk of developing HCC.
Collapse
Affiliation(s)
- Bart J Veldt
- Erasmus MC University Medical Center, Department of Gastroenterology and Hepatology, Rotterdam, the Netherlands
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Veldt BJ, Chen W, Heathcote EJ, Wedemeyer H, Reichen J, Hofmann WP, de Knegt RJ, Zeuzem S, Manns MP, Hansen BE, Schalm SW, Janssen HLA. Increased risk of hepatocellular carcinoma among patients with hepatitis C cirrhosis and diabetes mellitus. Hepatology 2008; 47:1856-62. [PMID: 18506898 DOI: 10.1002/hep.22251] [Citation(s) in RCA: 206] [Impact Index Per Article: 12.9] [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] [Indexed: 12/16/2022]
Abstract
UNLABELLED Recent studies suggest that diabetes mellitus increases the risk of developing hepatocellular carcinoma (HCC). The aim of this study is to quantify the risk of HCC among patients with both diabetes mellitus and hepatitis C in a large cohort of patients with chronic hepatitis C and advanced fibrosis. We included 541 patients of whom 85 (16%) had diabetes mellitus. The median age at inclusion was 50 years. The prevalence of diabetes mellitus was 10.5% for patients with Ishak fibrosis score 4, 12.5% for Ishak score 5, and 19.1% for Ishak score 6. Multiple logistic regression analysis showed an increased risk of diabetes mellitus for patients with an elevated body mass index (BMI) (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.00-1.11; P = 0.060) and a decreased risk of diabetes mellitus for patients with higher serum albumin levels (OR, 0.81; 95% CI, 0.63-1.04; P = 0.095). During a median follow-up of 4.0 years (interquartile range, 2.0-6.7), 11 patients (13%) with diabetes mellitus versus 27 patients (5.9%) without diabetes mellitus developed HCC, the 5-year occurrence of HCC being 11.4% (95% CI, 3.0-19.8) and 5.0% (95% CI, 2.2-7.8), respectively (P = 0.013). Multivariate Cox regression analysis of patients with Ishak 6 cirrhosis showed that diabetes mellitus was independently associated with the development of HCC (hazard ratio, 3.28; 95% CI, 1.35-7.97; P = 0.009). CONCLUSION For patients with chronic hepatitis C and advanced cirrhosis, diabetes mellitus increases the risk of developing HCC.
Collapse
Affiliation(s)
- Bart J Veldt
- Erasmus MC University Medical Center, Department of Gastroenterology and Hepatology, Rotterdam, the Netherlands
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Veldt BJ, Heathcote EJ, Wedemeyer H, Reichen J, Hofmann WP, Zeuzem S, Manns MP, Hansen BE, Schalm SW, Janssen HLA. Sustained virologic response and clinical outcomes in patients with chronic hepatitis C and advanced fibrosis. Ann Intern Med 2007; 147:677-84. [PMID: 18025443 DOI: 10.7326/0003-4819-147-10-200711200-00003] [Citation(s) in RCA: 435] [Impact Index Per Article: 25.6] [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: 12/21/2022] Open
Abstract
BACKGROUND Clinical outcomes of chronic hepatitis C infection in patients with advanced fibrosis include liver failure, hepatocellular carcinoma, and death. OBJECTIVE To investigate whether sustained virologic response to treatment for hepatitis C is associated with improved clinical outcomes. DESIGN Retrospective cohort study. SETTING 5 hepatology units of tertiary care centers in Europe and Canada caring for patients with chronic hepatitis C treated between 1990 and 2003. PATIENTS Consecutively treated patients with chronic hepatitis C who had biopsy-proven advanced fibrosis or cirrhosis (Ishak score, 4 to 6). MEASUREMENTS Sustained virologic response, defined as absence of detectable hepatitis C virus RNA at 24 weeks after the end of treatment, and clinical outcomes, defined as death (liver-related or non-liver-related), liver failure, and hepatocellular carcinoma. RESULTS Of 479 patients, 29.6% had sustained virologic response and 70.3% did not. Median follow-up was 2.1 years (interquartile range, 0.8 to 4.9 years). Four patients with and 83 without sustained virologic response had at least 1 outcome event. Sustained virologic response was associated with a statistically significant reduction in the hazard of events (adjusted hazard ratio, 0.21 [95% CI, 0.07 to 0.58]; P = 0.003). The effect was largely attributable to a reduction in liver failure, which developed in no patients with and 42 patients without sustained virologic response (5-year occurrence, 0% vs. 13.3% [CI, 8.4% to 18.2%]; unadjusted hazard ratio, 0.03 [CI, 0.00 to 0.91]). LIMITATIONS Because few events occurred in the sustained virologic response group, the study had limited ability to detect differences between groups in individual outcomes. In addition, the study was retrospective; selection and survival biases may therefore influence estimates of effect. CONCLUSION Sustained virologic response to treatment is associated with improved clinical outcomes, mainly prevention of liver failure, in patients with chronic hepatitis C and advanced fibrosis.
Collapse
Affiliation(s)
- Bart J Veldt
- Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Veldt BJ, van der Vliet HJJ, von Blomberg BME, van Vlierberghe H, Gerken G, Nishi N, Hayashi K, Scheper RJ, de Knegt RJ, van den Eertwegh AJM, Janssen HLA, van Nieuwkerk CMJ. Randomized placebo controlled phase I/II trial of alpha-galactosylceramide for the treatment of chronic hepatitis C. J Hepatol 2007; 47:356-65. [PMID: 17599630 DOI: 10.1016/j.jhep.2007.04.018] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2006] [Revised: 03/02/2007] [Accepted: 04/02/2007] [Indexed: 01/12/2023]
Abstract
BACKGROUND/AIMS The glycosphingolipid alpha-galactosylceramide has been shown to activate invariant natural killer T cells when presented in the context of CD1d and induces powerful antiviral immune responses via the production of inflammatory cytokines. The aim of this study was to investigate the safety and the antiviral activity of alpha-galactosylceramide as a novel class of treatment for chronic hepatitis C patients. METHODS International multicenter dose-escalating randomized placebo-controlled phase I/II trial. RESULTS Forty patients were allocated to a dose of 0.1 microg/kg (n=9), 1 microg/kg (n=9), 10 microg/kg (n=11) or to placebo (n=11). alpha-Galactosylceramide was well tolerated and no patients were withdrawn due to side effects. Although most patients showed a decrease in invariant natural killer T cells after administration, no clinically relevant suppression of viral replication was observed. Only one patient, a previous non-responder to peginterferon and ribavirin with high baseline invariant natural killer T cell levels, showed profound signs of immune activation, accompanied by a transient 1.3 log decrease in HCV-RNA and a concomitant increase in ALT after the first administration. CONCLUSIONS alpha-Galactosylceramide used as monotherapy for interferon-refractory patients in doses of 0.1-10 microg/kg is safe and it exerts moderate immunomodulatory effects. However, in its current form it has no significant effect on HCV-RNA levels.
Collapse
Affiliation(s)
- Bart J Veldt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Room Ca 326a, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Veldt BJ, Schalm SW, Janssen HLA. Severe allergic eczema due to pegylated alpha-interferon may abate after switching to daily conventional alpha-interferon. J Clin Gastroenterol 2007; 41:432. [PMID: 17413616 DOI: 10.1097/01.mcg.0000225599.24072.46] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
|
35
|
Lukasiewicz E, Hellstrand K, Westin J, Ferrari C, Neumann AU, Pawlotsky JM, Schalm SW, Zeuzem S, Veldt BJ, Hansen BE, Verhey-Hart E, Lagging M. Predicting treatment outcome following 24 weeks peginterferon alpha-2a/ribavirin therapy in patients infected with HCV genotype 1: utility of HCV-RNA at day 0, day 22, day 29, and week 6. Hepatology 2007; 45:258-9. [PMID: 17187414 DOI: 10.1002/hep.21505] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
|
36
|
Veldt BJ, Hansen BE, Ikeda K, Verhey E, Suzuki H, Schalm SW. Long-term clinical outcome and effect of glycyrrhizin in 1093 chronic hepatitis C patients with non-response or relapse to interferon. Scand J Gastroenterol 2006; 41:1087-94. [PMID: 16938723 DOI: 10.1080/00365520600641365] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Patients with chronic hepatitis C who do not respond to interferon can be treated with glycyrrhizin to reduce disease activity. The objective of this study was to evaluate the effect of glycyrrhizin on the incidence of hepatocellular carcinoma (HCC) during long-term follow-up after non-response to interferon. MATERIAL AND METHODS We analyzed individual patient data of all consecutive patients treated with interferon in 12 major Japanese hospitals between 1990 and 1995 who showed no sustained response. RESULTS The study comprised 1093 patients. During a mean follow-up of 6.1 +/- 1.8 years, 107 patients developed HCC. The Cox regression analysis with time-dependent variables showed that older age, male gender, higher alanine aminotransferase (ALAT) and higher fibrosis stage were significantly associated with a higher risk of developing HCC. Response to glycyrrhizin, defined as ALAT < 1.5 x upper limit of normal, was significantly associated with a decreased incidence of HCC: hazard ratio 0.39 (95% CI 0.21-0.72; p < 0.01). G-estimation, used to correct for ALAT as the confounder, showed no significant benefit of glycyrrhizin in the overall study population. CONCLUSIONS This study provides some evidence to show that interferon non-responder patients with chronic hepatitis C and fibrosis stage 3 or 4 may have a reduced incidence of HCC if glycyrrhizin therapy leads to normalization of ALAT levels.
Collapse
Affiliation(s)
- Bart J Veldt
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, The Netherlands
| | | | | | | | | | | |
Collapse
|
37
|
Veldt BJ, Zuidgeest DMH, de Beijer-Dominicus JA, Dees A. Loss of vision as a presenting sign of cobalamin deficiency: An eye-opener. Eur J Intern Med 2006; 17:292-4. [PMID: 16762783 DOI: 10.1016/j.ejim.2005.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/25/2005] [Revised: 10/15/2005] [Accepted: 11/17/2005] [Indexed: 11/21/2022]
Abstract
We describe a patient who presented with loss of vision that turned out to be caused by cobalamin deficiency. Both her vision and her visual field improved upon supplementation of cobalamin. It is, therefore, important to consider cobalamin deficiency as a treatable cause of loss of vision.
Collapse
Affiliation(s)
- Bart J Veldt
- Ikazia Hospital, Department of Internal Medicine, Montessoriweg 1, 3083 AN Rotterdam, The Netherlands; Erasmus MC University Medical Center, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands
| | | | | | | |
Collapse
|
38
|
Veldt BJ, Hansen BE, Eijkemans MJC, de Knegt RJ, Stijnen T, Habbema JDF, Schalm SW. Dynamic decision analysis to determine optimal treatment duration in chronic hepatitis C. Aliment Pharmacol Ther 2005; 21:539-47. [PMID: 15740537 DOI: 10.1111/j.1365-2036.2005.02377.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
BACKGROUND Current guidelines for stopping treatment of chronic hepatitis C are based on hepatitis C ribonucleic acid measurements at 12 and 24 weeks. AIM To explore an alternative approach for making individualized recommendations about treatment duration, based on simple alanine aminotransferase tests and on cost-per-cure. METHODS We analysed individual patient data from 13 randomized, controlled trials with interferon alone or combined with ribavirin. Using multiple logistic regression, we built a model that estimated the probability of sustained virological response for treatment durations of 24 and 48 weeks. Decisions to prolong treatment were based on an increase in probability of sustained virological response. If the increase was 10%, the cost-per-cure became decisive with a limit of 50,000. RESULTS Noncirrhotics with genotype 2 or 3 did not benefit when treatment was continued beyond 24 weeks. Sustained virological response rates in cirrhotic patients increased by 14-47% if treatment was continued up to 48 weeks. In noncirrhotic genotype 1 or 4 patients who had elevated alanine aminotransferase levels at week 4, the probability of sustained virological response increased by <10% if treatment was continued up to 48 weeks; the cost-per-cure for these patients would exceed 50,000. CONCLUSION The dynamics of alanine aminotransferase levels and cost-per-cure provides a useful alternative to determine the duration of therapy in chronic hepatitis C.
Collapse
Affiliation(s)
- B J Veldt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
39
|
Veldt BJ, Saracco G, Boyer N, Cammà C, Bellobuono A, Hopf U, Castillo I, Weiland O, Nevens F, Hansen BE, Schalm SW. Long term clinical outcome of chronic hepatitis C patients with sustained virological response to interferon monotherapy. Gut 2004; 53:1504-8. [PMID: 15361504 PMCID: PMC1774235 DOI: 10.1136/gut.2003.038257] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.5] [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] [Received: 03/11/2004] [Accepted: 03/31/2004] [Indexed: 12/15/2022]
Abstract
BACKGROUND The key end point for treatment efficacy in chronic hepatitis C is absence of detectable virus at six months after treatment. However, the incidence of clinical events during long term follow up of patients with sustained virological response is still poorly documented and may differ between the Eastern and Western world. AIMS To assess clinical end points during long term follow up of European patients with a sustained virological response to interferon monotherapy. METHODS Meta-analysis of individual patient data from eight European protocolled follow up studies of interferon treatment for chronic hepatitis C. RESULTS A total of 286 sustained virological responders and 50 biochemical responders (detectable virus but normal alanine aminotransferase levels) were followed up for 59 months. Fifteen sustained virological responders (5.2%) had cirrhosis before treatment and 112 (39%) had genotype 1. The late virological relapse rate after five years of follow up was 4.7% (95% confidence interval (CI) 2.0-7.4) among sustained virological responders; all late relapses occurred within four years after treatment. Among sustained virological responders, the rate of decompensation after five years of follow up was 1.0% (95% CI 0.0-2.3) and none developed hepatocellular carcinoma (HCC). Survival was comparable with the general population, matched for age and sex, the standard mortality ratio being 1.4 (95% CI 0.3-2.5). Clinical outcome of patients with cirrhosis was similar to other sustained virological responders. For biochemical responders, the rates of development of decompensation and HCC during long term follow up were 9.1% (95% CI 0.5-17.7) and 7.1% (95% CI 0-15.0), respectively. CONCLUSIONS Five year survival of European sustained virological responders was similar to the overall population, matched for age and sex. No HCCs were detected during long term follow up.
Collapse
Affiliation(s)
- B J Veldt
- Erasmus MC, Department of Gastroenterology and Hepatology, Room CA 326, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
BACKGROUND The current NIH and French consensus provide physicians with clear guidelines on how to care best for patients with hepatitis C. METHODS Review and discussion. RESULTS Confirming the diagnosis and guiding the initial investigations have become straightforward. The standard treatment and its monitoring have been described in many publications. Recommending therapy to patients with moderate fibrosis has been the custom since the 1999 EASL guidelines. The 2002 guidelines have widened the spectrum of patients with chronic hepatitis C that should be considered for antiviral therapy. Patient categories not previously considered for therapy, such as alcoholics, intravenous drug users, prison inmates and social subgroups of society that lack adequate medical care, can now be offered therapy provided they are well supported in specific programmes. Liver physicians have learned throughout the years to manage side effects successfully and encourage patient adherence. This is reflected in the higher sustained viral response rates with standard interferon and ribavirin reported in the pegylated interferon registration trials compared with the interferon-ribavirin trials. Reducing the dose rather than stopping therapy is the key issue. Antidepressive agents have their place in the management of mood disorders prior to or during therapy. CONCLUSION Every patient with chronic hepatitis C should be considered for antiviral therapy. It is probably best for a patient to be treated by a physician who has experience in managing possible side effects and in coaching a patient through his 6 or 12 months of treatment.
Collapse
Affiliation(s)
- H Orlent
- Dept. of Hepatology and Gastroenterology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | | |
Collapse
|
41
|
Vrolijk JM, de Knegt RJ, Veldt BJ, Orlent H, Schalm SW. The treatment of hepatitis C: history, presence and future. Neth J Med 2004; 62:76-82. [PMID: 15209471] [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: 04/29/2023]
Abstract
The treatment of chronic hepatitis C has made remarkable progress over the past two decades. For interferon-alpha monotherapy, sustained virological response rates were between 2 and 9% in genotype 1 and between 16 and 23% in genotypes 2 and 3. By adjusting treatment duration up to 48 weeks for genotype 1 and combining regular interferon-alpha with ribavirin, sustained response rates could be improved to 28 to 31% in genotype 1 and around 65% in genotypes 2 and 3. Attempts to further increase efficacy included the addition of amantadine without conclusive evidence up till now. With the recent introduction of long-acting pegylated interferon-alpha in combination with ribavirin, sustained virological response rates of 8o% can be obtained in genotypes 2 and 3. However, sustained virological response rates for patients with either genotype 1, nonresponse to prior treatment, cirrhosis or a combination of these characteristics are still less than 50%. In view of results with daily high-dose interferon-alpha induction in combination with prolongation of treatment duration up to 18 months, such patients might benefit from induction and prolonged PEG-IFN-alpha treatment and should be treated in an experimental setting.
Collapse
Affiliation(s)
- J M Vrolijk
- Department of Gastroenterology and Hepatology (Ca326), Erasmus Medical Centre, Rotterdam, the Netherlands
| | | | | | | | | |
Collapse
|
42
|
|
43
|
Veldt BJ, Brouwer JT, Adler M, Nevens F, Michielsen P, Delwaide J, Hansen BE, Schalm SW. Retreatment of hepatitis C non-responsive to interferon. A placebo controlled randomized trial of ribavirin monotherapy versus combination therapy with Ribavirin and Interferon in 121 patients in the Benelux [ISRCTN53821378]. BMC Gastroenterol 2003; 3:24. [PMID: 12948399 PMCID: PMC222984 DOI: 10.1186/1471-230x-3-24] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2003] [Accepted: 08/29/2003] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evidence based medicine depends on unbiased selection of completed randomized controlled trials. For completeness it is important to publish all trials. This report describes the first large randomised controlled trial where combination therapy was compared to placebo therapy and to ribavirin monotherapy, which has not been published until now. METHODS One hundred and twenty one patients with chronic hepatitis C and elevated transaminases who did not respond to previous treatment with standard interferon monotherapy, were included from 16 centers in Belgium, the Netherlands and Luxembourg between 1992 and 1996. Patient poor-response characteristics were: genotype 1 (69%), HCV RNA above 2 x 10(6) copies/ml (55%) and cirrhosis (38%). Patients were randomized to 6 months combination therapy with interferon alpha-2b (3 MU tiw) and ribavirin (1000-1200 mg/day), 6 months ribavirin monotherapy (1000-1200 mg/day) or 6 months ribavirin placebo. The study was double blinded for the ribavirin/placebo component. One patient did not fit the entry criteria, and 3 did not start. All 117 patients who received at least one dose of treatment were included in the intention to treat analysis. RESULTS At the end of treatment, HCV RNA was undetectable in 35% of patients on combination therapy and in none of the patients treated with ribavirin monotherapy or placebo. The sustained virological response rate at 6 months after therapy was 15% for patients treated with interferon and ribavirin. During the 6 months treatment period 13% of patients on interferon ribavirin combination therapy, 13% of patients on ribavirin monotherapy and 11% of patients on placebo withdrew due to side effects or noncompliance. At 24 weeks of treatment the mean Hb level was 85% of the baseline value, which means a mean decrease from 9.1 mmol/l to 7.8 mmol/l. The Hb levels at the end of treatment were not significantly different from patients treated with ribavirin monotherapy (p = 0.76). End of treatment WBC was significantly lower in patients treated with combination therapy, compared to ribavirin (p < 0.01) as well as for patients treated with ribavirin monotherapy compared to placebo (p < 0.01). DISCUSSION This belated report on the only placebo controlled study of interferon ribavirin combination therapy in non responders to standard doses of interferon monotherapy documents the effectiveness, be it limited, of this approach as well as the dynamics of the effects on blood counts.
Collapse
Affiliation(s)
- Bart J Veldt
- Departments of Gastroenterology and Hepatology of the Erasmus Medical Center Rotterdam, the Netherlands
| | - Johannes T Brouwer
- Departments of Gastroenterology and Hepatology of the Reinier de Graaf Hospital Group Delft, the Netherlands
| | - Michael Adler
- Departments of Gastroenterology and Hepatology of the Erasme University Hospital Brussels, Belgium
| | - Frederik Nevens
- Departments of Gastroenterology and Hepatology of the University Hospital Leuven, Belgium
| | - Peter Michielsen
- Departments of Gastroenterology and Hepatology of the University Hospital Antwerp, Belgium
| | - Jean Delwaide
- Departments of Gastroenterology and Hepatology of the University Hospital Liège, Belgium
| | - Bettina E Hansen
- Departments of Gastroenterology and Hepatology of the Erasmus Medical Center Rotterdam, the Netherlands
- Department of Biostatistics, Erasmus Medical Center Rotterdam, the Netherlands
| | - Solko W Schalm
- Departments of Gastroenterology and Hepatology of the Erasmus Medical Center Rotterdam, the Netherlands
| | | |
Collapse
|