Prevalence of resistance-associated substitutions and retreatment of patients failing a glecaprevir/pibrentasvir regimen

OBJECTIVES

To investigate resistance-associated substitutions (RASs) as well as retreatment efficacies in a large cohort of European patients with failure of glecaprevir/pibrentasvir.

METHODS

Patients were identified from three European Resistance Reference centres in Spain, Italy and Germany. Sequencing of NS3, NS5A and NS5B was conducted and substitutions associated with resistance to direct antiviral agents were analysed. Clinical and virological parameters were documented retrospectively and retreatment efficacies were evaluated.

RESULTS

We evaluated 90 glecaprevir/pibrentasvir failures [3a (n = 36), 1a (n = 23), 2a/2c (n = 20), 1b (n = 10) and 4d (n = 1)]. Ten patients were cirrhotic, two had previous exposure to PEG-interferon and seven were coinfected with HIV; 80 had been treated for 8 weeks. Overall, 31 patients (34.4%) failed glecaprevir/pibrentasvir without any NS3 or NS5A RASs, 62.4% (53/85) showed RASs in NS5A, 15.6% (13/83) in NS3 and 10% (9/90) in both NS5A and NS3. Infection with HCV genotypes 1a and 3a was associated with a higher prevalence of NS5A RASs. Patients harbouring two (n = 34) or more (n = 8) RASs in NS5A were frequent. Retreatment was initiated in 56 patients, almost all (n = 52) with sofosbuvir/velpatasvir/voxilaprevir. The overall sustained virological response rate was 97.8% in patients with end-of-follow-up data available.

CONCLUSIONS

One-third of patients failed glecaprevir/pibrentasvir without resistance. RASs in NS5A were more prevalent than in NS3 and were frequently observed as dual and triple combination patterns, with a high impact on NS5A inhibitor activity, particularly in genotypes 1a and 3a. Retreatment of glecaprevir/pibrentasvir failures with sofosbuvir/velpatasvir/voxilaprevir achieved viral suppression across all genotypes.

Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

[Expert recommendations: Hepatitis C and transplantation]

With the approval of new direct acting antiviral agents (DAA), therapeutic options for patients with chronic hepatitis C virus (HCV) infection are now generally available before and after liver transplantation (LT). Interferon-free DAA regimens are highly effective therapies and provide a good safety profile. However, the body of clinical evidence in this patient population is limited and the best treatment strategies for patients on the waiting list with (de)compensated cirrhosis and after LT are not well defined. The following recommendations for antiviral therapy in the context of LT are based on the currently available literature and clinical experience of experts in the field, and have been discussed in an expert meeting. The aim of this article is to guide clinicians in the decision making when treating patients before and after LT with DAAs.

Renal function at two years in liver transplant patients receiving everolimus: results of a randomized, multicenter study

In a 24-month prospective, randomized, multicenter, open-label study, de novo liver transplant patients were randomized at 30 days to everolimus (EVR) + Reduced tacrolimus (TAC; n = 245), TAC Control (n = 243) or TAC Elimination (n = 231). Randomization to TAC Elimination was stopped prematurely due to a significantly higher rate of treated biopsy-proven acute rejection (tBPAR). The incidence of the primary efficacy endpoint, composite efficacy failure rate of tBPAR, graft loss or death postrandomization was similar with EVR + Reduced TAC (10.3%) or TAC Control (12.5%) at month 24 (difference -2.2%, 97.5% confidence interval [CI] -8.8%, 4.4%). BPAR was less frequent in the EVR + Reduced TAC group (6.1% vs. 13.3% in TAC Control, p = 0.010). Adjusted change in estimated glomerular filtration rate (eGFR) from randomization to month 24 was superior with EVR + Reduced TAC versus TAC Control: difference 6.7 mL/min/1.73 m(2) (97.5% CI 1.9, 11.4 mL/min/1.73 m(2), p = 0.002). Among patients who remained on treatment, mean (SD) eGFR at month 24 was 77.6 (26.5) mL/min/1.73 m(2) in the EVR + Reduced TAC group and 66.1 (19.3) mL/min/1.73 m(2) in the TAC Control group (p < 0.001). Study medication was discontinued due to adverse events in 28.6% of EVR + Reduced TAC and 18.2% of TAC Control patients. Early introduction of everolimus with reduced-exposure tacrolimus at 1 month after liver transplantation provided a significant and clinically relevant benefit for renal function at 2 years posttransplant.

Claudin-7 expression in hepatocellular carcinoma

BACKGROUND

The importance of adhesion molecules for local invasion by neoplastic cells and development of metastasis has been confirmed by numerous studies over the past decade. Claudins are integral parts of tight junctions. The aim of the present study was to examine the significance of the expression of claudin-7 messenger RNA (mRNA) as a prognostic factor for hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

We examined liver tumor and nontumor tissues from 20 HCC patients who underwent resection or liver transplantation.

RESULTS

A significant increase in the expression of claudin-7 was observed in tumor versus nontumor tissues. There was no significant correlation between the expression profile of claudin-7 mRNA and patient demographic data, the presence of cirrhosis, or the histological stage of tumor differentiation or vascular invasion. Survival analysis showed a trend toward a better prognosis among patients with overexpression of claudin-7 in tumor tissues.

When the heart kills the liver: acute liver failure in congestive heart failure

Congestive heart failure as a cause of acute liver failure is rarely documented with only a few cases.

Although the pathophysiology is poorly understood, there is rising evidence, that low cardiac output with consecutive reduction in hepatic blood flow is a main causing factor, rather than hypotension. In the setting of acute liver failure due to congestive heart failure, clinical signs of the latter can be absent, which requires an appropriate diagnostic approach.

As a reference center for acute liver failure and liver transplantation we recorded from May 2003 to December 2007 202 admissions with the primary diagnoses acute liver failure. 13/202 was due to congestive heart failure, which was associated with a mortality rate of 54%. Leading cause of death was the underlying heart failure. Asparagine transaminase (AST), bilirubin, and international normalized ratio (INR) did not differ significantly in surviving and deceased patients at admission. Despite both groups had signs of cardiogenic shock, the cardiac index (CI) was significantly higher in the survival group on admission as compared with non-survivors (2.1 L/min/m² vs. 1.6 L/min/m², p = 0.04). Central venous - and pulmonary wedge pressure did not differ significantly. Remarkable improvement of liver function was recorded in the group, who recovered from cardiogenic shock.

In conclusion, patients with acute liver failure require an appropriate diagnostic approach. Congestive heart failure should always be considered as a possible cause of acute liver failure.

Use of paclitaxel-eluting balloons for endotherapy of anastomotic strictures following liver transplantation

Biliary anastomotic strictures after liver transplantation are a major source of morbidity and graft failure; however, repeated endoscopic therapy has shown variable long-term success rates. Thus the aim of this prospective case series was to evaluate the safety and efficacy of using paclitaxel-eluting balloons in 13 patients requiring treatment for symptomatic anastomotic strictures following liver transplantation. Sustained clinical success-defined as no need for further endoscopic intervention for at least 6 months - was achieved in 12 /13 patients (92 %). One, two, and three interventions were required in 9 (69 %), 1, and 2 patients, respectively (mean number of sessions was 1.46). Mean (± SD) bilirubin level dropped from 6.8 (± 4.1) mg/dL to 1.4 (± 0.9) mg/dL. These promising results justify carrying out a randomized comparative trial to confirm this innovative approach.

Everolimus with reduced tacrolimus improves renal function in de novo liver transplant recipients: a randomized controlled trial

In a prospective, multicenter, open-label study, de novo liver transplant patients were randomized at day 30±5 to (i) everolimus initiation with tacrolimus elimination (TAC Elimination) (ii) everolimus initiation with reduced-exposure tacrolimus (EVR+Reduced TAC) or (iii) standard-exposure tacrolimus (TAC Control). Randomization to TAC Elimination was terminated prematurely due to a higher rate of treated biopsy-proven acute rejection (tBPAR). EVR+Reduced TAC was noninferior to TAC Control for the primary efficacy endpoint (tBPAR, graft loss or death at 12 months posttransplantation): 6.7% versus 9.7% (-3.0%; 95% CI -8.7, 2.6%; p<0.001 for noninferiority [12% margin]). tBPAR occurred in 2.9% of EVR+Reduced TAC patients versus 7.0% of TAC Controls (p = 0.035). The change in adjusted estimated GFR from randomization to month 12 was superior with EVR+Reduced TAC versus TAC Control (difference 8.50 mL/min/1.73 m(2) , 97.5% CI 3.74, 13.27 mL/min/1.73 m(2) , p<0.001 for superiority). Drug discontinuation for adverse events occurred in 25.7% of EVR+Reduced TAC and 14.1% of TAC Controls (relative risk 1.82, 95% CI 1.25, 2.66). Relative risk of serious infections between the EVR+Reduced TAC group versus TAC Controls was 1.76 (95% CI 1.03, 3.00). Everolimus facilitates early tacrolimus minimization with comparable efficacy and superior renal function, compared to a standard tacrolimus exposure regimen 12 months after liver transplantation.

A randomized, controlled study to assess the conversion from calcineurin-inhibitors to everolimus after liver transplantation--PROTECT

Posttransplant immunosuppression with calcineurin inhibitors (CNIs) is associated with impaired renal function, while mTor inhibitors such as everolimus may provide a renal-sparing alternative. In this randomized 1-year study in patients with liver transplantation (LTx), we sought to assess the effects of everolimus on glomerular filtration rate (GFR) after conversion from CNIs compared to continued CNI treatment. Eligible study patients received basiliximab induction, CNI with/without corticosteroids for 4 weeks post-LTx, and were then randomized (if GFR > 50 mL/min) to continued CNIs (N = 102) or subsequent conversion to EVR (N = 101). Mean calculated GFR 11 months postrandomization (ITT population) revealed no significant difference between treatments using the Cockcroft-Gault formula (-2.9 mL/min in favor of EVR, 95%-CI: [-10.659; 4.814], p = 0.46), whereas use of the MDRD formula showed superiority for EVR (-7.8 mL/min, 95%-CI: [-14.366; -1.191], p = 0.021). Rates of mortality (EVR: 4.2% vs. CNI: 4.1%), biopsy-proven acute rejection (17.7% vs. 15.3%), and efficacy failure (20.8% vs. 20.4%) were similar. Infections, leukocytopenia, hyperlipidemia and treatment discontinuations occurred more frequently in the EVR group. No hepatic artery thrombosis and no excess of wound healing impairment were noted. Conversion from CNI-based to EVR-based immunosuppression proved to be a safe alternative post-LTx that deserves further investigation in terms of nephroprotection.

Transhilar passage in right graft live donor liver transplantation: intrahilar anatomy and its impact on operative strategy

The passage through the hilar plate during right graft live donor liver transplantation (LDLT) can have dangerous consequences for both donors and recipients. The purpose of our study was to delineate hilar transection and biliary reconstruction strategies in right graft LDLT, with special consideration of central and peripheral hilar anatomical variants. A total of 71 consecutive donors underwent preoperative three-dimensional (3D) CT reconstructions and virtual 3D hepatectomies. A three-modal hilar passage strategy was applied, and its impact on operative strategy analyzed. In 68.4% of cases, type I and II anatomical configurations allowed for an en block hilar transection with simple anastomotic reconstructions. In 23.6% of cases, donors had "difficult" type II and types III/IV hilar bile duct anatomy that required stepwise hilar transections and complex graft biliary reconstructions. Morbidity rates for our early (A) and recent (B) experience periods were 67% and 39%, respectively. (1) Our two-level classification and 3D imaging technique allowed for donor-individualized transhilar passage. (2) A stepwise transhilar passage was favored in types III and IV inside the right-sided hilar corridor. (3) Reconstruction techniques showed no ameliorating effect on early/late biliary morbidity rates.

Long-term outcomes of liver transplant patients with human immunodeficiency virus infection and end-stage-liver-disease: single center experience

Objective

Orthotopic-liver-transplantation (OLT) in patients with Human-Immunodeficiency-Virus infection (HIV) and end-stage-liver-disease (ESDL) is rarely reported. The purpose of this study is to describe our institutional experience on OLT for HIV positive patients.

Material and methods

This is a retrospective study of all HIV-infected patients who underwent OLT at the University Hospital of Essen, from January 1996 to December 2009. Age, sex, HIV transmission-way, CDC-stage, etiology of ESDL, concomitant liver disease, last CD4cell count and HIV-viral load prior to OLT were collected and analysed. Standard calcineurin-inhibitors-based immunosuppression was applied. All patients received anti-fungal and anti-pneumocystis carinii pneumonia prophylaxis post-OLT.

Results

Eight transplanted HIV-infected patients with a median age of 46 years (range 35-61 years) were included. OLT indications were HCV (n = 5), HBV (n = 2), HCV/HBV/HDV-related cirrhosis (n = 1) and acute liver-failure (n = 1). At OLT, CD4 cell-counts ranged from 113-621 cells/μl, and HIV viral-loads from < 50-175,000 copies/ml. Seven of eight patients were exposed to HAART before OLT. Patients were followed-up between 1-145 months. Five died 1, 3, 10, 31 and 34 months after OLT due to sepsis and graftfailure respectively. Graft-failure causes were recurrent hepatic-artery thrombosis, HCV-associated hepatitis, and chemotherapy-induced liver damage due to Hodgkin-disease. One survivor is relisted for OLT due to recurrent chronic HCV-disease but non-progredient HIV-infection 145 months post-OLT. Two other survivors show stable liver function and non-progredient HIV-disease under HAART 21 and 58 months post-OLT.

Conclusions

OLT in HIV-infected patients and ESLD is an acceptable therapeutic option in selected patients. Long-term survival can be achieved without HIV disease-progression under antiretroviral therapy and management of the viral hepatitis co-infection.

Established and emerging therapies for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver with a worldwide increasing incidence. The incidence of HCC is closely related to the epidemiology of the risk factors which are mainly represented by chronic viral hepatitis B and C. Obesity and type II diabetes, often associated with chronic nonalcoholic fatty liver disease, are emerging independent risk factors for HCC development. Although the risk factors for HCC are well characterized, the molecular mechanisms responsible for malignant transformation of hepatocytes are not well understood. HCC diagnosis and therapy follow defined algorithms according to the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases guidelines. Liver transplantation has been shown the best outcome for selected patients with early tumor stage but its application is limited by the shortage of liver grafts. After hepatic resection prognosis remains unsatisfactory due to a high incidence of tumor recurrence. Selective internal radiation therapy is emerging as promising loco-regional treatment for patients with advanced HCC having good performance status and liver reserve but not amenable to surgery. The recently introduced orally active multikinase inhibitor sorafenib has been established as palliative systemic therapy. Further improved understanding of molecular mechanisms underlying HCC development will facilitate the development of new targeted therapeutic strategies.

Current immunosuppressive approaches in liver transplantation

A significant increase of potent immunosuppressive agents over the last two decades has contributed to improved patient and graft survival after liver transplantation (LT). Numerous ongoing studies aim to determine the most effective immunosuppressive protocols while minimizing drug-related side effects. These protocols often combine several drugs with different mechanisms of action and toxicities allowing dosage adjustment. There is also a trend towards tailored immunosuppressive regimens according to the etiology of liver disease and comorbidities such as renal dysfunction and cardiovascular disease. The introduction of antibody induction therapies and antimetabolites resulted in an increasing number of studies with steroid minimization and calcineurin inhibitor (CNI) reduction protocols. Combined mycophenolate mofetil and minimal dose CNI therapy has shown to be safe and to improve kidney function and cardiovascular risk profile in the majority of studies. Sirolimus (SRL) and everolimus constitute a new class of compounds designated as the mammalian target of rapamycin (mTOR) inhibitors, which exhibit immunosuppressive and antiproliferative effects. There are conflicting results with respect to renal improvement upon switch to mTOR inhibitor therapy with concomitant reduction/elimination of CNI. Further trials will determine whether earlier conversion to mTOR inhibitors enable prevention of CNI-related renal dysfunction. Future results from randomized controlled studies will also show whether SRL can improve recurrence-free survival in patients transplanted for hepatocellular carcinoma.

Renal function and cardiovascular risk profile after conversion from ciclosporin to tacrolimus: prospective study in 80 liver transplant recipients

BACKGROUND

Increased risk of cardiovascular and cerebrovascular disease in liver transplant recipients results in particular from the side effects of calcineurin inhibitor-based immunosuppressive therapy. Several studies have demonstrated a more favourable outcome for patients receiving tacrolimus (TAC) as compared with ciclosporin (CS).

AIM

To investigate the effects of conversion from CS to TAC on cardiovascular risk factors and renal function in liver transplant recipients.

METHODS

In a prospective study, all except two patients had chronic kidney disease stages 2-4 (n = 80), according to estimated glomerular filtration rate using the abbreviated Modification of Diet in Renal Disease equation.

RESULTS

Conversion was accompanied with a mean decrease of total cholesterol from 194.6 +/- 54.0 mg/dL to 175.8 +/- 44.2 mg/dL (P < 0.001), low density lipoprotein cholesterol from 106.7 +/- 39.2 mg/dL to 90.9 +/- 28.6 mg/dL (P < 0.001) and mean arterial blood pressure values from 102.2 +/- 13.2 mm Hg to 95.9 +/- 11.7 mm Hg (P < 0.001). Renal function remained stable. No cases of de novo diabetes mellitus were identified. The Framingham risk score was significantly reduced from 5.2 +/- 4.4 at baseline to 4.4 +/- 5.3 after 12 months (P = 0.006).

CONCLUSIONS

Conversion from CS to TAC has been shown to improve the cardiovascular risk profile and may retard further decline of renal function after liver transplantation.

Role of osteopontin and CD44s expression for patients with hepatocellular carcinoma undergoing liver transplantation or resection

BACKGROUND

Detection of new biomarkers for hepatocellular carcinoma (HCC) is needed to estimate prognosis after liver transplantation (OLT) or hepatic resection. Osteopontin (OPN) is a secreted, calcium-binding, phosphorylated, acidic glycoprotein that is overexpressed in various cancers. Cluster differentiation 44 standard isoform (CD44s) is one of the primary receptors of OPN; it may contribute to metastatic tumor spread.

MATERIALS AND METHODS

Tumor tissue and surrounding hepatic parenchyma were obtained from 53 HCC patients who underwent liver resection. Their RNA was extracted from nitrogen-frozen tissues, and OPN mRNA levels were estimated by quantitative reverse transcription-polymerase chain reactions. Formalin-fixed, paraffin-embedded tissues were obtained from the same patients, and additionally from 60 OLT HCC patients to perform expression analysis for OPN and CD44s by standard avidin-biotin immunostaining methods.

RESULTS

Expression of OPN and CD44s was significantly higher among HCC compared with adjacent nontumor tissue. The OPN mRNA expression and protein abundance correlated positively; OPN overexpression was associated with high tumor grade. A positive correlation existed between OPN and CD44s expression; both proteins were significantly overexpressed in HCC lesions with positive lymph nodes. No significant correlation existed between patient survival and OPN and CD44s expression.

CONCLUSION

Expression of both OPN and CD44s in HCC is associated with advanced tumor stage, thus possibly contributing prognostic information when evaluated together with classical clinicopathological parameters.

Incidence of liver retransplantation and its effect on patient survival

PURPOSE

The purpose of this study was to review our institutional experience with re-liver transplantation (OLT) after split and full-size OLT.

PATIENTS AND METHODS

We evaluated data corresponding to retransplanted patients over an 8-year period who underwent deceased donor OLT at our institution. Variables analyzed included indications for primary OLT, and re-OLT, the type of graft used during the initial versus re-OLT, the time from initial to re-OLT, and patient survival after re-OLT.

RESULTS

Sixty-four of 697 first OLT (9.2%) required re-OLT. Forty-nine cases were among 637 (7.6%) full-size OLT, while 15 were among 60 (25%) split OLT (P < .001). Median time to re-OLT was 8 days (range = 1-1885 days). Main indications for re-OLT were primary nonfunction/initial poor function (44%), hepatic artery thrombosis (26%), biliary complications (11%), and hepatitis C recurrence (6%). Forty-eight percent of the re-OLTs were performed within the first posttransplant week. The overall survival for these 64 patients was 55% and 48% at 1 and 3 years after the primary OLT, and 44% at both 1 and 3 years after the re-OLT, respectively.

CONCLUSIONS

The overall incidence of re-OLT remains 9%. Approximately half of all re-OLT occured within the first posttransplant week. Early retransplantation was associated with the best patient survival. Overall survival after re-OLT was about 10% to 20% lower than that after primary OLT.

Liver transplantation as a primary indication for intrahepatic cholangiocarcinoma: a single-center experience

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is not a widely accepted indication for orthotopic liver transplantation (OLT). The present study describes our institutional experience with patients who underwent transplantation for ICC as well as those with ICC who underwent transplantation with the incorrect diagnosis of hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Data corresponding to ICC patients were reviewed for the purposes of this study. Patients with hilar cholangiocarcinoma and incidentally found ICC after OLT for benign diseases were excluded from further consideration.

RESULTS

Among the 10 patients, 6 underwent transplantation before 1996 and 4 after 2001. Those who underwent transplantation in the early period had a preoperative diagnosis of inoperable ICC (n = 4) and ICC in the setting of primary sclerosing cholangitis (n = 2). In the latter period the subjects had a diagnosis of HCC in cirrhosis (n = 3) or recurrent ICC after an extended right hepatectomy (n = 1). Median survival was 25.3 months for the whole series and 32.2 months (range, 18-130 months) when hospital mortality was excluded (n = 3). Four patients are currently alive after 30, 35, 42, and 130 months post-OLT, respectively. Two patients died of tumor recurrence at 18 and 21 months post-OLT, respectively. One-, 3-, and 5-year survival rates were 70%, 50%, and 33%, respectively.

CONCLUSIONS

The role of OLT in the setting of ICC may be re-evaluated in the future under strict selection criteria and with prospective multicenter randomized studies. Potential candidates to be included are those with liver cirrhosis and no hilar involvement who meet the Milan criteria for HCC.

Clinical trial: switch to combined mycophenolate mofetil and minimal dose calcineurin inhibitor in stable liver transplant patients--assessment of renal and allograft function, cardiovascular risk factors and immune monitoring

BACKGROUND

Calcineurin inhibitor (CNI)-related nephrotoxicity significantly contributes to chronic renal failure after liver transplantation.

METHODS

In this prospective study, liver transplantation patients with renal dysfunction were randomized either to receive mycophenolate mofetil (MMF) followed by stepwise reduction of CNI with defined minimal CNI-trough levels (MMF group), or to continue their maintenance CNI dose (control group). Immune monitoring was performed in a subgroup of the patients.

RESULTS

In the MMF group (n = 50), renal function assessed by serum creatinine improved >10% in 62% of patients, was stable in 36% and deteriorated >10% in 2% after 12 months compared with baseline values. Mean serum creatinine levels (+/- s.d.) significantly decreased from 1.90 +/- 0.44 mg/dL to 1.61 +/- 0.39 mg/dL and the corresponding calculated glomerular filtration rate significantly increased from 38.8 +/- 9.6 mL/min/1.73 m(2) to 47.0 +/- 11.8 mL/min/1.73 m(2) over a 12-month follow-up period. Blood pressure and levels of liver enzymes significantly decreased. In the control group (n = 25), there were no significant changes with respect to the investigated parameters. The MMF group had significantly lower numbers of circulating cytotoxic T cells compared with the controls; whereas regulatory T cells significantly increased.

CONCLUSION

Combined MMF and minimal dose CNI therapy after liver transplantation is nephroprotective and may promote allograft tolerance.

Meta-analysis of tumor recurrence after liver transplantation for hepatocellular carcinoma based on 1,198 cases

BACKGROUND

The purpose of this study was to systematically review tumor characteristics leading to recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT).

MATERIAL AND METHODS

A computer search of the Medline database was carried out. Tumor characteristics examined were: 1) no vascular versus vascular invasion, 2) solitary versus multifocal tumors, 3) well differentiated versus not well differentiated HCCs, 4) HCC meeting versus HCC exceeding the Milan criteria, 5) HCC < or =5 cm versus HCC>5 cm.

RESULTS

Of 45 clinical studies screened, 9 fulfilled the study criteria. These studies included from 21 to 316 patients, for a total of 1198 patients. A fixed effects model was applied. A significant correlation between vascular invasion, not well differentiated HCC, tumor size >5 cm, HCC exceeding the Milan criteria, and HCC recurrence post transplant was shown (common odds ratio of 8.727, 2.89, 13.32 and 4.205, respectively). Heterogeneity for the parameter solitary versus multifocal tumor was shown.

CONCLUSION

High risk pathology for HCC recurrence is characterized by not well differentiated tumors and by HCCs that exceed the Milan criteria. A clinical application of these data may be a scoring system which includes the tumor grading in the evaluation and listing of HCC patients to LT.

Single-center experience on liver transplantation for hepatocellular carcinoma arising in alcoholic cirrhosis: results and ethical issues

BACKGROUND

Liver transplantation is currently recognized as the optimal treatment for both early hepatocellular carcinoma in the setting of cirrhosis (HCC) as well as for alcoholic liver disease (ALD). The purpose of this study was to evaluate the outcome of patients with HCC and ALD in the absence of viral hepatitic infections.

METHODS

Twelve recipients were transplanted with a diagnosis of HCC and ALD in the absence of viral hepatitis during a 6-year period. Nine received deceased donor livers, and 3 live donor grafts. Our results were compared to those obtained by a search of the world literature.

RESULTS

The postoperative course was uneventful in all but one patient. All recipients experienced a good quality of life postoperatively. Three-year overall and recurrence-free survival rates were 82 and 73%, respectively. Nine patients are currently alive, after a median follow-up of 29 months.

CONCLUSION

This is the first study to evaluate liver transplantation for HCC in ALD. Although outcomes are excellent, the evaluation of patients with ALD and HCC constitutes a challenging topic in transplantation surgery, especially when live liver donation is considered. An interdisciplinary structured approach is recommended, with special emphasis on ethical considerations.

Ribavirin with either standard or pegylated interferon to treat recurrent hepatitis C after liver transplantation

AIM

To investigate the efficacy of two anti-viral protocols in hepatitis C virus-reinfected liver transplant recipients.

METHODS

In this prospective study, 26 liver transplant patients were treated with standard interferon-alpha2b for 12 months or standard interferon-alpha2b for 3 months followed by pegylated interferon-alpha2b for 9 months. Interferon was combined with ribavirin in all patients. The histological course of the study population was compared with an untreated historic control group (n = 38) with similar baseline characteristics.

RESULTS

The sustained virological response rates in the standard interferon group and in the pegylated interferon group were 27.3% and 26.7%, respectively. Only 29% of patients with sustained virological response had end of treatment histological response, whereas 47% of viral non-responders showed end of treatment histological response. The percentage of patients with histological improvement was significantly higher in the study population when compared to the controls. Univariate analysis indicated that hepatitis C virus genotype non-1, high baseline alanine aminotransferase, the time interval between liver transplant and interferon therapy and the body mass index predicted sustained virological response. In the multivariate model, baseline alanine aminotransferase and the body mass index remained a significant predictor of sustained virological response.

CONCLUSIONS

Both treatment regimens offer similar efficacy profiles. Failure to eradicate hepatitis C virus should not lead to treatment discontinuation if serial liver biopsies demonstrate histological response.

Target range maximum of cyclosporine blood concentration two hours post dose in stable liver transplant patients

Recently, single blood level measurement 2 hours after cyclosporine administration (C2) is taken as a more sensitive indicator of drug exposure in de novo transplant recipients than trough levels (C0). However, few studies focused on the determination of the C2 target range maximum and its associated adverse events in stable liver recipients. This prospective study was designed to assess the relative risk of developing CsA related side effects in patients with high C2-levels. Adverse effects were determined clinically, and by using a specially designed questionnaire. Eventual adverse events as well as C2 levels were determined repeatedly up to 4 times in 3-months intervals (observation period 9 +/- 3 months) in 36 long-term liver recipients (1-13.5 years post-transplant), in addition to conventional C0 levels. Cyclosporine dose was adjusted according to a predefined C0 target level range and clinical status. Totally 103 questionnaires and the corresponding paired CsA blood level records were obtained. C0 levels and C2 levels ranged from 90 to 287 (143 +/- 31) ng/ml and from 212 to 1358 (672 +/- 203) ng/ml respectively. No patient experienced a rejection episode during the observation period, demonstrating the efficiency of the immunosuppressive therapy. However, 33/36 patients (91%) showed symptoms attributable to CsA therapy. C2 levels above 750 ng/ml, determined at least twice in an interval of 3 months, were identified as a relevant risk factor for the presence of multiple adverse effects, which were defined as the combination of hypertension, renal insufficiency and more than two neurological complaints (RR = 3.11, p<0.01). This risk population was not completely identified by determination of C0 level.

Indications for Liver Transplantation

Candidates for OLT must have irreversible acute or chronic end stage liver disease (table 41b.1). Virus or alcohol-induced liver cirrhosis constitute the most common disease indications in adults [1] (fig. 41b.1). In our department 28% of cirrhotic liver transplant recipients are transplanted for hepatitis C virus (HCV)-related liver disease and 26% undergo OLT for alcohol-related liver disease. Other indications include cholestatic liver disorders [primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), biliary atresia], hepatitis B virus (HBV) infection, autoimmune hepatitis, cystic fibrosis, inherited metabolic diseases (Wilson’s disease, hemochromatosis, alpha-1-antitrypsin deficiency), nonalcoholic steatohepatitis, nonmetastatic hepatocellular carcinoma, and acute virally-, toxin-, or drug-induced hepatic failure. The most common indications in children comprise biliary atresia and metabolic liver diseases

Impact of combined mycophenolate mofetil and low-dose calcineurin inhibitor therapy on renal function, cardiovascular risk factors, and graft function in liver transplant patients: preliminary results of an open prospective study

As liver transplantation (LT) is now being performed with excellent 1-year graft survival rates of 85% to 90%, attention has been shifted to reducing long-term complications of calcineurin inhibitors (CNI). We randomized LT patients (2:1) who displayed renal dysfunction under CNI treatment to either mycophenolate mofetil (MMF) (1000 mg twice a day) followed by stepwise reduction of CNI (n = 21; Tac trough levels <4 ng/mL, CsA trough levels <50 ng/mL); or continue their current CNI dose (n = 11; control group). Three months after study entry, we observed significantly decreased mean values in the CNI reduction group of serum creatinine (1.88 +/- 0.36 versus 1.58 +/- 0.33 mg/dL, P < .001) and BUN (39.2 +/- 11.8 versus 29.9 +/- 9.59 mg/dL, P < .001) with a significantly increased GFR (51.4 +/- 10.8 versus 61.6 +/- 14.1 mL/min, P < .001). Improved renal function in these long-term LT recipients (5.6 +/- 3.6 years posttransplant; range, 2 to 13 years) suggests at least a partial reversibility of CNI-induced renal damage. Furthermore, we found an improved lipid profile as well as a significantly decreased mean systolic (140 +/- 19 versus 130 +/- 14 mm Hg, P < .01) and diastolic (82 +/- 9 to 74 +/- 8 mm Hg, P < .001) blood pressure 3 months after introduction of MMF therapy. Additionally, transaminases significantly improved in the CNI reduction group within this time period (ALT 37.9 +/- 25.9 versus 25.2 +/- 13.2, P < .05). MMF and CNI-reduced immunosuppressive regimens may improve long-term patient survival, suggesting a broad application within the liver transplant setting.

[New techniques in liver transplantation]

Due to innovative surgical techniques, improved immunosuppressive regimens and better postoperative management, orthotopic liver transplantation achieved patient and allograft survival rates of 80 to 90% that have expanded both the indications for transplantation as well as the number of potential recipients awaiting liver transplantation. One of the major challenges facing organ transplantation is the current shortage of donors. Despite supportive legislation, media network systems and the attempt to raise public awareness, the actual donor numbers have remained relatively constant and do not meet the growing need for more organs. In 2002 the mortality among patients waiting for a liver organ reached 20%. Among the several measures that can be undertaken to expand the donor pool is the use of previously unused donors, such as marginal livers, domino-, split- or living related liver transplantation.

[Surgical and interventional treatment of liver metastases]

The liver is the most common target organ for metastatic disease. The majority of patients undergoing surgical treatment for liver metastases have colorectal primaries. Endocrine liver metastases, or metastases from other tumors such as mammary carcinoma, sarcomas, renal tumors or gastrointestinal stromal tumors (GIST) are appreciably less common for surgical treatment. The gold standard of treatment is resection of the metastatic lesions. In the meantime, advances in surgical techniques and improved perioperative patient management make it possible to perform extensive resections with acceptable morbidity and mortality rates. In the event of metastases that are not primarily resectable, various downstaging procedures are available, with the aid of which secondary resectability can be achieved. Among the interventional treatment options that should be applied only in palliative intent, radiofrequency ablation is in widespread use.

Combination therapy with peginterferon alpha-2B and ribavirin in liver transplant recipients with recurrent HCV infection: preliminary results of an open prospective study

Allograft reinfection with hepatitis C virus (HCV) in transplant recipients occurs commonly and represents a major concern in the transplant setting. Suppression of viral replication in HCV transplant patients should prevent or delay progression to cirrhosis and graft failure. In this ongoing study, we present preliminary data from a prospective trial of standard interferon (IFN) alpha-2b (2 million units daily) for 3 months and subsequent peginterferon (PEG IFN) alpha-2b (1.5 microg/kg/week) for 9 months. IFN therapy was combined with ribavirin (10 to 12 mg/kg). So far, HCV has become undetectable by qualitative PCR in 33% of patients while 25% had a reduction of HCV RNA to undetectable by the bDNA assay and 42% had no virological response after 6 months of therapy. A biochemical response was detected in 42% of patients. Improvement of inflammatory activity was observed in 42% of patients after 6 months. In three patients anemia necessitated administration of erythropoietin and three patients received granulocyte-colony stimulating factor (G-CSF) due to leucopenia [corrected] In conclusion, we observed that daily IFN alpha-2b and subsequent PEG IFN alpha-2b therapy in combination with ribavirin provides biochemical and virological benefits in transplant recipients with established recurrent HCV infection.

Future directions in immunosuppression

As liver transplantation is now being performed with an excellent 5-year survival rate of approximately 70% at selected centers, attention has been shifted to reduce long-term complications of calcineurin inhibitors including diabetes, hypertension, and hyperlipidemia, which have a major effect on morbidity and mortality within the transplant setting. Cyclosporine (CsA) monitoring has been performed traditionally by measurement of predose "trough" blood concentrations (C0). Recent development of 2 hour postdose CsA (C2) monitoring strategy has emerged as a much more sensitive approach for assessing the pharmacokinetics and providing greater precision in the optimization of Neoral dosing than C0 measurements. Furthermore, a reduction of risk factors for atherosclerotic vascular disease and in the incidence and severity of acute cellular rejection have been associated with the adoption of C2 monitoring. However, further data from multicenter trials are required to evaluate the long-term benefits of this new therapeutic monitoring strategy.

[Advances and limitations of liver transplantation in Germany]

Orthotopic liver transplantation (OLT) is now an established therapy for end stage liver disease as well as acute liver failure. Improvements in surgical techniques, meticolous selection of transplant candidates and advances in immunosuppression have markedly increased patient and graft survial. The demand for organ grafts has continuously increased. Living donor organ transplantation omits the problem of organ shortage with prolonged waiting times for OLT and the likelihood of disease progression especially in tumor patients. Advanced liver disease related to chronic viral hepatitis is one of the primary indications for OLT worldwide. Combination therapy with hepatitis B immunoglobulin and lamivudine has been widely adopted as an effective prophylactic treatment regimen against recurrent HBV infection. Reinfection of the allograft is obligate in viremic post transplant patients with HCV infection. However the use of pegylated interferon in combination with ribavirin holds promise for delaying rapid progression of HCV infection in the allograft and the need for retransplantation. Recurrence of PBC, PSC and autoimmune hepatitis affects between 20 % and 30 % grafts at 10 years but appears to have little impact on long-term graft function and survival. In patients with hepatocellular carcinoma fulfilling strict selection criteria for OLT, 5 year survival rates of approximately 75% have been reported.

CNI-sparing regimens within the liver transplant setting: experiences of a single center

One- and 5-year survival rates after liver transplantation have improved with the development of potent immunosuppressive drugs. Thus, attempts have shifted to reduce long-term complications of CNI and prednisone therapy. Minimization of CNI and concomitant introduction of MMF has resulted in a significant improvement of renal function, blood pressure and triglyceride values in our transplant patients. In recipients who develop recurrent or de novo malignancies, SRL therapy might be recommended. In addition, the flexibility to individualize immunosuppression should be favored in selected patients. However, large prospective randomized trials are required in order to determine if SRL/low dose CNI or SRL monotherapy are reasonable options for prolonging patient survival. Moreover, important questions such as the appropriate SRL target dose for prevention of tumor growth need to be answered. Numerous studies investigating distinct immunosuppressive combination therapies and withdrawal or minimization of CNI are available in the literature; however it is not yet clear which treatment regimens will prove to be the most efficacious and least toxic.

Treatment of hepatitis B reinfection after liver transplantation

Patients with chronic replicative hepatitis B virus (HBV) infection who undergo orthotopic liver transplantation (OLT) in the absence of prophylactic antiviral therapy have a high risk of graft reinfection. Serial monitoring of serum HBV DNA and HBV sequence analysis, especially of the polymerase and the "a" epitope of the surface antigen, may be a requisite diagnostic tool in order to provide optimal therapeutic management for inhibition of viral replication before and after OLT. Combination therapy with hepatitis B immunoglobulin (HBIG) and lamivudine has been widely adopted as an effective prophylactic treatment regimen against recurrent HBV disease. The major issue of concern has been the development of lamivudine resistance due to the emergence of mutations in the YMDD motif of the HBV DNA polymerase gene. Among newer antivirals, adefovir dipivoxil and entecavir have been demonstrated to be effective against both wild-type and lamivudine resistant mutants. Due to the availability of antiviral drugs, outcome of patient and graft survival has dramatically improved and has become similar or even better as compared to patients with non-HBV-related liver diseases.