Prior hospital attendances in deceased Australian patients with alcohol-related liver disease: a multicentre project

BACKGROUND AND AIMS

To establish the hospital visit history of patients who die with alcohol-related liver disease (ArLD). To determine if patients with ArLD present to hospital early or in the terminal phase of their disease.

METHODS

Retrospective cohort study of patients with a history of ArLD who died as an inpatient at three tertiary Western Australian hospitals from February 2015 to February 2017. Hospital records were reviewed to identify the number and cause of emergency department (ED), inpatient and outpatient attendances in all Western Australian public hospitals in the 10 years prior to death.

RESULTS

One hundred fifty-nine patients (23% female) had a total of 753 ED, 3535 outpatient appointments, 1602 hospital admissions and 10 755 admission days. Twelve months prior to death, 82% of patients had a public hospital contact and 74% an admission. Patients who had their first hospital contact within 12 months prior to death were significantly more likely to have a liver-related cause of death (P < 0.01). Aboriginal and Torres Strait Islander patients (15% of cohort) died at a significantly younger age (M = 49.2, SD = 10.5 years) than non-Aboriginal and Torres Strait Islander patients (M = 59.9, SD = 10.2 years, P < 0.01). Despite having more ED attendances and hospital admissions, Aboriginal and Torres Strait Islander patients had significantly less (P = 0.04) outpatient appointments (Mdn = 5.5, interquartile range [IQR] = 1-18 vs Mdn = 11, IQR = 3-33).

CONCLUSIONS

Most patients with ArLD have multiple early attendances, which present an opportunity for early interventions. There are missed opportunities for Aboriginal and Torres Strait Islander patients for outpatient hospital engagement.

Glycogenic hepatopathy is an under-recognised cause of hepatomegaly and elevated liver transaminases in type 1 diabetes mellitus

Glycogenic hepatopathy (GH) is an under-recognised complication of type 1 diabetes mellitus (T1DM) not controlled to target resulting in hepatomegaly and elevated liver transaminases. We report the case of a 19-year-old man with T1DM not controlled to target who presented with abdominal pain, hepatomegaly and deranged liver transaminases. He was subsequently diagnosed with GH on liver biopsy, with the mainstay of treatment being reduction in caloric intake and insulin.

Successful treatment of patients with hepatitis C in rural and remote Western Australia via telehealth

Rural and remote patients at the Royal Perth Hospital were reviewed and treated for hepatitis C by a hepatologist and nurse practitioner using telehealth (videoconferencing). Over a four-year period, 50 patients were treated with pegylated interferon and ribavirin, and participated in a total of more than 500 telehealth sessions. Sustained virological response rates (SVRs) were compared to those in face-to-face (FTF) clinics to assess treatment outcomes. Treatment through telehealth was found to be non-inferior to FTF clinics. Telehealth patients with genotype 1 infection achieved a higher rate of SVR than those attending FTF clinics (73% versus 54%, respectively), although the difference was not significant. SVR rates for genotype 2 and 3 of 72% were similar in telehealth to FTF rates of 74%. A total of 35 telehealth patients completed a satisfaction questionnaire and most indicated that they were happy with the programme and would participate again in the future. The study confirmed that telehealth is an effective option for the treatment of hepatitis C in rural and remote areas.

Resolution of severe hepato-pulmonary syndrome following transjugular portosystemic shunt procedure

The hepato-pulmonary syndrome (HPS) is a relatively common complication of hepatic disease that leads to hypoxaemia and dyspnoea secondary to pulmonary shunting. A number of pharmacological therapies have been trialled, yet liver transplantation remains the only definitive treatment. The use of a transjugular intrahepatic portosystemic shunt (TIPS) to reduce portal hypertension and improve oxygenation remains controversial in HPS due to the lack of large clinical series or randomised controlled trials. We present a case of HPS successfully treated with TIPS and review the relevant literature.

Interferon-induced thyroid dysfunction in chronic hepatitis C

BACKGROUND

Treatment of chronic hepatitis C with interferon is known to be associated with thyroid dysfunction (TD) in 5-14% of patients. We studied the incidence, types, outcome and risk factors predictive of thyroid dysfunction.

METHODS

A retrospective analysis was performed on all patients treated with interferon alpha (IFN) or pegylated interferon alpha (PEG-IFN) +/- ribavirin (RBV), who developed abnormal thyroid function tests (TFTs). These cases were compared with treatment-matched controls to identify factors predictive of thyroid dysfunction. Statistical methods consisted of: chi(2) test, Fischer's exact test, Welch's t-test, and multivariate analysis.

RESULTS

From a total of 511 patients, 45 cases with TD were identified (8.8%). Pegylated interferon alpha was associated with higher rates of TD than IFN (14.1% vs 6.0%, P = 0.0029). Female sex (OR 5.6, 95% CI 1.1-7) and Asian ethnicity (OR 2.7, 95% CI 1.4-22) were independent predictors of developing TD. Cytology was obtained in 13 patients: benign follicular pattern (8); thyroiditis (3); and normal (2). Thyroid peroxidase (TPO) antibodies (P = 0.004) and earlier onset of dysfunction (P = 0.03) were associated with need for treatment. Sixteen patients had persistent TD by the end of the follow-up period, predicted by female sex, non-Asian ethnicity, prior history of TD and TPO antibodies.

CONCLUSIONS

Pegylated interferon alpha, female sex and Asian ethnicity are independent risk factors for TD. Thyroid peroxidase antibodies and earlier TD within the course of IFN are associated with the requirement for treatment. Thyroid function tests should be monitored during and after IFN-based therapy. The most common cytological finding is a benign follicular pattern.

Chronic ductopenic rejection in patients with recurrent hepatitis C virus treated with pegylated interferon alfa-2a and ribavirin

BACKGROUND

Interferon use for post liver transplantation (LT) recurrent hepatitis C (HCV) has not consistently been associated with acute cellular rejection (ACR). We examined the incidence of chronic ductopenic rejection (CR) in patients receiving pegylated interferon alfa-2a and ribavirin (PEG) to treat recurrent HCV.

METHODS

A chart review of 12 patients developing CR while receiving an escalating dose regimen of PEG with protocol liver biopsies every 6 months was conducted. Values are shown as median (range).

RESULTS

Twelve of the 70 patients treated with PEG developed CR. Median age at LT was 53 (37-63) years; immunosuppression consisted of tacrolimus or cyclosporine with prednisone. PEG was started at 3.6 (0.2-13.5) years after LT. Two patients had one episode of ACR before PEG. Four patients had first ACR while receiving PEG. CR was diagnosed after 12 (4-17) months of PEG; by then 8 patients had undetectable HCV-RNA. Tacrolimus and cyclosporine levels (ng/mL) were 7.9 (3.2-18.9) and 76 (71-93) before PEG, and 6.9 (3.7-9.7) and 130 (81-153) at CR. Six patients were treated more than 1 year with PEG; three had undetectable HCV-RNA when CR was diagnosed. Five patients are being treated for CR; one has been listed for LT; two patients were retransplanted. Five patients died as a result of sepsis partially related to CR.

CONCLUSIONS

Treatment with pegylated-interferon alpha-2a and ribavirin may trigger rapidly progressive CR in patients with therapeutic immunosuppressive trough levels, with or without first inducing ACR.

Impact of donor age on survival and fibrosis progression in patients with hepatitis C undergoing liver transplantation using HCV+ allografts

Studies have suggested that the use of hepatitis C virus (HCV)-positive (HCV+) donor allografts has no impact on survival. However, no studies have examined the effect that HCV+ donor histology has upon recipient and graft survival. We evaluated the clinical outcome and impact of histological features in HCV patients transplanted using HCV+ livers. We reviewed all patients transplanted for HCV at our institution from 1988 to 2004; 39 received HCV+ allografts and 580 received HCV-negative (HCV-) allografts. Survival curves compared graft and patient survival. Each HCV+ allograft was stringently matched to a control of HCV- graft recipients. No significant difference in survival was noted between recipients of HCV+ livers and controls. Patients receiving HCV+ allografts from older donors (age > or =50 yr) had higher rates of graft failure (hazard ratio, 2.74) and death rates (hazard ratio, 2.63) compared to HCV- allograft recipients receiving similarly-aged older donor livers. Matched case-control analysis revealed that recipients of HCV+ allografts had more severe fibrosis post-liver transplantation than recipients of HCV- livers (P = 0.008). More advanced fibrosis was observed in HCV+ grafts from older donors compared to HCV+ grafts from younger donors (P = 0.012). In conclusion, recipients of HCV+ grafts from older donors have higher rates of death and graft failure, and develop more extensive fibrosis than HCV- graft recipients from older donors. Recipients of HCV+ grafts, regardless of donor age, develop more advanced liver fibrosis than recipients of HCV- grafts.

Diabetes mellitus is associated with hepatic encephalopathy in patients with HCV cirrhosis

OBJECTIVES

An increased ammonia level of gut bacterial origin is an important mediator in the pathogenesis of hepatic encephalopathy (HE), and constipation is a frequent precipitant of hepatic coma. Because diabetes mellitus (DM) may be associated with delayed gastrointestinal transit, we speculated that its presence in patients with HCV-related cirrhosis would predispose to and exacerbate HE.

METHODS

Sixty-five patients (50 men, 15 women) with HCV-related cirrhosis attending a liver transplantation clinic were assessed for severity of liver disease and presence of DM in a cross-sectional study. A modified Child-Pugh score that excluded HE was calculated. Frequency and severity of HE (absent, mild, and severe) in diabetic and nondiabetic patients were assessed. Clinical severity of cirrhosis and results of neuropsychometric testing in diabetic and nondiabetic patients with mild and severe HE were compared.

RESULTS

Fifty-four patients (83%) had HE (33 mild, 21 severe). Twenty patients (31%) had DM. HE was present in 19 (95%) patients with diabetes and 35 (78%) patients without diabetes (p = 0.087). Severity of HE was greater in diabetic (35% mild, 60% severe) than in nondiabetic patients (58% mild, 20% severe) (p = 0.007). In both the mild and severe HE categories, severity of liver disease in diabetic patients was otherwise milder than in the nondiabetic patients.

CONCLUSIONS

Diabetic patients with HCV cirrhosis have more severe HE. Diabetic patients have severe HE at earlier stages of biochemical decompensation and portal hypertension compared with nondiabetic patients.

Pegylated interferon-induced immune-mediated hepatitis post-liver transplantation

A 55-year-old Caucasian male developed a well characterized autoimmune hepatitis after completing treatment with pegylated interferon and ribavirin for recurrent hepatitis C. We hypothesize that pegylated interferon triggered a severe form of immune-mediated hepatitis.

Management of chronic Hepatitis C virus in patients with HIV

The life expectancy of HIV seropositive persons is approaching the life expectancy of those who are uninfected with HIV. Hepatitis C virus (HCV) infection has emerged as a worldwide epidemic. Given the similar transmission route between HCV and HIV, there has been an explosion in the number of individuals infected with both viruses. Because of the successful introduction of antiretroviral therapy, patients are more susceptible to new opportunistic infections such as HCV. HCV leads to a more rapid progression to end-stage liver disease in patients with HIV, and the morbidity and mortality related to HCV in co-infected patients is on the rise. Therefore, it has become imperative to treat both HIV and HCV in co-infected patients. The primary goal of HCV therapy is permanent eradication of the virus. Secondary goals include reduction in hepatic fibrosis progression, development of decompensated cirrhosis, and hepatocellular carcinoma. Early studies using standard interferon-alfa for the treatment of HCV in co-infected individuals were discouraging, as poor outcomes, high discontinuation rates, and severe adverse events were observed. The current standard of care for treatment of HCV is pegylated-interferon and ribavirin. New studies have recently demonstrated a higher sustained virologic response rate and a better adverse event profile than previously reported in co-infected patients. As a result, we recommend considering all co-infected patients for HCV therapy while watching closely for unique treatment-related toxicities. The treatment of HCV in co-infected patients should be a high priority for all providers.

Treatment of hepatitis C virus in HIV patients: a review

BACKGROUND

Survival in HIV infection has improved dramatically in the last decade due to antiretroviral therapy (ART). Due to shared routes of transmission, HCV is found in approximately 30% of HIV infected patients. HCV infection has emerged as a major issue in this population as manifest by a major increase in liver-related mortality. ART-associated hepatotoxicity has been demonstrated to occur more frequently in co-infected individuals and may be severe or fatal in some instances. Thus treatment of HCV has become a priority in HIV infected individuals.

OBJECTIVES

The main aims of this review are to summarise and illustrate the current evidence based management of anti-HCV therapy in HIV-infected patients.

METHODS

A systematic review of the literature was performed using Pubmed and Medline searches.

CONCLUSION

All HIV-infected patients should be screened for HCV infection via anti-HCV antibody and HCV RNA polymerase chain reaction. If HCV infection is present, treatment should be considered in those patients with evidence of liver inflammation and fibrosis. Recent studies have demonstrated the safety and efficacy of anti-HCV therapy in HIV-infected individuals with pegylated interferon and ribavirin combination therapy. HCV genotype is predictive of response to therapy and increasing the duration of therapy to 48 weeks has proven to be more effective in patients with genotypes 2 and 3. HCV treatment with interferon based therapy is associated with many unique side effects and toxicities in this population of which the clinician must be aware.

Alcoholic Hepatitis

Alcoholic hepatitis (AH) is a common disease associated with significant morbidity and mortality. Most often the diagnosis is suggested by a history of heavy alcohol excess in a patient with features of hepatic decompensation. In its purest form, AH is a histologic diagnosis of acute hepatic inflammation in response to alcohol. The primary objective of treatment for AH is to support long-term alcohol abstinence and to achieve adequate nutrition with lifestyle modification; goal setting and education are integral to long-term medical management. Severity at presentation (calculated by way of the Maddrey score) determines outcome. Patients with AH represent a heterogeneous group with regard to severity and pathogenesis, with various therapeutic interventions assessed in patients with severe AH. To date, corticosteroids have been studied most, and despite remaining controversial, warrant a place in the treatment of selected patients. Recent advances in unraveling the aspects of disease pathogenesis in AH have raised the possibility of targeted therapies, such as anti-tumor necrosis factor-a monoclonals and pentoxifylline. Orthotopic liver transplantation is not recommended for patients with severe acute AH, as most have an unclear long-term prognosis in the context of ongoing excess alcohol ingestion at presentation.

HIV/HCV coinfection in clinical practice

Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) frequently co-exist due to shared routes of transmission. In the past, the impact of HCV on overall morbidity and mortality of coinfected patients was minimal due to the poor prognosis of HIV. However, since the introduction of highly active antiretroviral therapy (HAART), HCV has become a significant pathogen in this population. HIV clearly exacerbates HCV infection and accelerates progression to cirrhosis, end-stage liver disease, and hepatocellular carcinoma. There is debate over whether HCV influences the natural history of HIV. Given the high prevalence of coinfection and the accelerated liver damage, HCV treatment has become a priority in these patients. There are new data on pegylated interferon (PEG-IFN) and ribavirin (RBV) therapy for HCV in coinfected patients. The therapy is well tolerated and safe, although it appears to be slightly less effective than in monoinfected patients. The risk of HAART-related hepatotoxicity is greater in coinfected patients and therefore requires special consideration and close monitoring.

Diagnosis of 6 mercaptopurine hepatotoxicity post liver transplantation utilizing metabolite assays

Azathioprine and 6-mercaptopurine (6 MP) are commonly used as immunosuppression postsolid organ transplantation. Recently, a better understanding of the metabolism of these drugs has developed. 6 Mercaptopurine is metabolized by thiopurine methyl transferase (TPMT) which is under the control of a common genetic polymorphism. Genetic testing and measurement of levels of 6 MP metabolites allow identification of patients at risk of toxicity. We report two cases of cholestatic hepatocellular injury associated with 6 MP toxicity occurring after orthotopic liver transplantation. Cholestasis developed after the introduction of 6 MP. Patients underwent extensive investigation and 6 MP toxicity was considered only after all other causes had been excluded. Thiopurine methyl transferase alleles identified on genetic testing were normal as were the 6 thioguanine levels. However, 6-methyl mercaptopurine levels were significantly elevated into the toxic range. Cholestasis resolved within a few weeks of drug withdrawal. 6 Mercaptopurine hepatotoxicity can present with a variety of clinical, biochemical and histological manifestations post OLT and should be considered as a cause of liver enzyme elevation. Monitoring of 6 MP metabolite levels in addition to TPMT allele testing is useful to prevent 6 MP toxicity and to help guide therapy.

Current status of the use of growth factors and other adjuvant medications in patients receiving peginterferon and ribavirin

Hepatitis C virus (HCV) is the most common chronic infection in the United States, affecting almost 3.9 million Americans. The most effective treatment for chronic HCV infection is combination antiviral therapy with peginterferon and ribavirin. However, combination therapy is also associated with significant adverse effects and is contraindicated in certain patient populations. Hematological adverse effects are common and are a frequent cause of dose reduction and interruption or discontinuation of therapy. Currently there are no approved treatments for the hematological adverse events associated with HCV therapy. However, emerging data suggest that utilization of hematopoietic growth factors can provide a useful adjunct to treatment and optimize sustained virologic response rates.

Outcome, tolerability and compliance of compassionate use interferon and ribavirin for hepatitis C infection in a shared care hospital clinic

BACKGROUND AND AIMS

To determine response rate, side-effects and compliance in patients with chronic hepatitis C virus (HCV) infection following treatment with interferon-alpha-2b and ribavirin in a 'shared care' hospital clinic.

METHODS

Data were collected prospectively on 81 patients treated with combination therapy for chronic HCV infection between 1999 and 2001. All had biochemical and virological evidence of active infection. All patients had undergone liver biopsy except haemophiliac patients. Patients infected with genotype 1 were treated for 12 months. Patients infected with genotypes 2 and 3 were treated for 6 months. Patient care was shared with the referring general practitioner. Intention to treat, end of treatment and sustained virological response (SVR) rates, side-effects and compliance were assessed.

RESULTS

Eighty-one patients with chronic HCV infection were treated with combination therapy. The majority of HCV patients were genotype 1 (n = 46; 57%). There were 12 patients (15%) with cirrhosis. SVR rates were: (i) 24% for genotype 1, (ii) 58% for genotype 3 and (iii) 75% for genotype 2. SVR was achieved in three (23%) cirrhotic patients. Compliance with the treatment regimen was 98%. Seven per cent of patients were withdrawn from therapy prematurely because of side-effects.

CONCLUSIONS

These 'shared care' clinic results compare well with controlled clinical trials using combination therapy for chronic HCV infection. Outcomes were poorer in genotype 1 patients and in patients with cirrhosis. Compliance with therapy was excellent because of the 'Shared Care Programme' with participation of general practitioners, psychiatrists and hepatitis C nurse practitioners in the management protocol.

Toxicity of non-nucleoside analogue reverse transcriptase inhibitors

The non-nucleoside reverse transcriptase inhibitors (NNRTI) nevirapine (NVP), efavirenz (EFV), and delaviridine (DLV) are increasingly being used to treat HIV infection. Studies have shown excellent tolerance and efficacy and less development of virological resistance with HIV regimens that include NNRTIs. Nevertheless, abnormalities in liver enzymes are common in patients with HIV infection, and there are multiple etiologies for these abnormalities, including drug toxicity, viral hepatitis, opportunistic infections, and substance abuse. In particular, highly active antiretroviral therapy (HAART) can result in hepatotoxicity through a variety of mechanisms, such as mitochondrial toxicity, lipodystrophy syndrome, and steatohepatitis. The NNRTIs have been most frequently implicated in hypersensitivity reactions. NVP-containing HAART regimens may be more hepatotoxic than are those with EFV and DLV, at least for the first 6 weeks, although the data are still contradictory. Coinfection with hepatitis C and B viruses appears to significantly increase the risk of toxicity, and therefore all patients should be screened for viral hepatitis prior to commencing HAART. Close monitoring of transaminases is suggested in all patients commencing HAART, especially those with preexisting liver disease and coinfection with viral hepatitis.

Hepatotoxicity of antiretroviral therapy

Hepatotoxicity is a serious complication in patients taking HAART. Coinfection with hepatitis viruses increases the risk of liver toxicity while taking antiretroviral therapy. Baseline transaminases should be checked before beginning antiretorviral therapy and all patients should be screened for pre-existing liver disease, most notably hepatitis B and C infections. Regular monitoring of transaminases is mandatory when commencing antiretroviral therapy. In patients with normal liver function, transaminases may be checked monthly after commencing HAART for the first 3 months. If stable this can be broadened to 3 month intervals. In patients with pre-existing liver disease monitoring should be performed more frequently (every 2 weeks) when initiating therapy. Once stable liver enzymes should be checked monthly. The less hepatotoxic drugs such as lamivudine and abacavir should be preferred in patients at high risk for hepatotoxicity. Risks include co-infection with hepatitis B and C viruses, a previous record of hepatotoxicity, cirrhosis, obesity and female gender. Minor enzyme elevations (< 5-fold upper normal limit) are generally safe to tolerate and usually resolve. Patients must be closely observed with regular liver function tests and a hypersensitivity type drug reaction should be excluded. The onset of clinical symptoms, elevated serum lactate or evidence of severe hepatic dysfunction (coagulopathy or elevation of ammonia levels) are suggestive of severe toxicity and HAART should be withheld. Treatment of suspected HAART related hepatotoxicity should first involve withdrawal of therapy. Hypersensitivity reactions may be treated with corticosteroids. Nucleoside-induced mitochondrial damage may improve with riboflavin or thiamine therapy.