Global prevalence, cascade of care, and prophylaxis coverage of hepatitis B in 2022: a modelling study

BACKGROUND

The 2016 World Health Assembly endorsed the elimination of hepatitis B virus (HBV) infection as a public health threat by 2030; existing therapies and prophylaxis measures make such elimination feasible, even in the absence of a virological cure. We aimed to estimate the national, regional, and global prevalence of HBV in the general population and among children aged 5 years and younger, as well as the rates of diagnosis, treatment, prophylaxis, and the future burden globally.

METHODS

In this modelling study, we used a Delphi process with data from literature reviews and interviews with country experts to quantify the prevalence, diagnosis, treatment, and prevention measures for HBV infection. The PRoGReSs Model, a dynamic Markov model, was used to estimate the country, regional, and global prevalence of HBV infection in 2022, and the effects of treatment and prevention on disease burden. The future incidence of morbidity and mortality in the absence of additional interventions was also estimated at the global level.

FINDINGS

We developed models for 170 countries which resulted in an estimated global prevalence of HBV infection in 2022 of 3·2% (95% uncertainty interval 2·7-4·0), corresponding to 257·5 million (216·6-316·4) individuals positive for HBsAg. Of these individuals, 36·0 million were diagnosed, and only 6·8 million of the estimated 83·3 million eligible for treatment were on treatment. The prevalence among children aged 5 years or younger was estimated to be 0·7% (0·6-1·0), corresponding to 5·6 million (4·5-7·8) children with HBV infection. Based on the most recent data, 85% of infants received three-dose HBV vaccination before 1 year of age, 46% had received a timely birth dose of vaccine, and 14% received hepatitis B immunoglobulin along with the full vaccination regimen. 3% of mothers with a high HBV viral load received antiviral treatment to reduce mother-to-child transmission.

INTERPRETATION

As 2030 approaches, the elimination targets remain out of reach for many countries under the current frameworks. Although prevention measures have had the most success, there is a need to increase these efforts and to increase diagnosis and treatment to work towards the elimination goals.

FUNDING

John C Martin Foundation, Gilead Sciences, and EndHep2030.

Redefining fatty liver disease: an international patient perspective

Despite its increased recognition as a major health threat, fatty liver disease associated with metabolic dysfunction remains largely underdiagnosed and undertreated. An international consensus panel has called for the disease to be renamed from non-alcoholic fatty liver disease (NAFLD) to metabolic-associated fatty liver disease (MAFLD) and has suggested how the disease should be diagnosed. This Viewpoint explores the call from the perspective of patient advocacy groups. Patients are well aware of the negative consequences of the NAFLD acronym. This advocacy group enthusiastically endorses the call to reframe the disease, which we believe will ultimately have a positive effect on patient care and quality of life and, through this effect, will reduce the burden on health-care systems. For patients, policy makers, health planners, donors, and non-hepatologists, the new acronym MAFLD is clear, squarely placing the disease as a manifestation of metabolic dysfunction and improving understanding at a public health and patient level. The authors from representative patient groups are supportive of this change, particularly as the new acronym is meaningful to all citizens as well as governments and policy makers, and, above all, is devoid of any stigma.

Deep-sequencing reveals broad subtype-specific HCV resistance mutations associated with treatment failure

A percentage of hepatitis C virus (HCV)-infected patients fail direct acting antiviral (DAA)-based treatment regimens, often because of drug resistance-associated substitutions (RAS). The aim of this study was to characterize the resistance profile of a large cohort of patients failing DAA-based treatments, and investigate the relationship between HCV subtype and failure, as an aid to optimizing management of these patients. A new, standardized HCV-RAS testing protocol based on deep sequencing was designed and applied to 220 previously subtyped samples from patients failing DAA treatment, collected in 39 Spanish hospitals. The majority had received DAA-based interferon (IFN) α-free regimens; 79% had failed sofosbuvir-containing therapy. Genomic regions encoding the nonstructural protein (NS) 3, NS5A, and NS5B (DAA target regions) were analyzed using subtype-specific primers. Viral subtype distribution was as follows: genotype (G) 1, 62.7%; G3a, 21.4%; G4d, 12.3%; G2, 1.8%; and mixed infections 1.8%. Overall, 88.6% of patients carried at least 1 RAS, and 19% carried RAS at frequencies below 20% in the mutant spectrum. There were no differences in RAS selection between treatments with and without ribavirin. Regardless of the treatment received, each HCV subtype showed specific types of RAS. Of note, no RAS were detected in the target proteins of 18.6% of patients failing treatment, and 30.4% of patients had RAS in proteins that were not targets of the inhibitors they received. HCV patients failing DAA therapy showed a high diversity of RAS. Ribavirin use did not influence the type or number of RAS at failure. The subtype-specific pattern of RAS emergence underscores the importance of accurate HCV subtyping. The frequency of "extra-target" RAS suggests the need for RAS screening in all three DAA target regions.

Identifying Improved and Non-improved Aspects of Health-related Quality of Life After Liver Transplantation Based on the Assessment of the Specific Questionnaire Liver Disease Quality of Life

INTRODUCTION

The specific questionnaire Liver Disease Quality of Life (LDQOL) is a valid tool for measuring quality of life (QOL) and has been used to show that liver transplantation (LT), which is an effective treatment for end-stage liver disease, may improve QOL.

OBJECTIVES

This study aims to identify aspects of QOL that improve after LT and those that do not.

PATIENTS AND METHODS

Patients accepted for LT were invited to answer the LDQOL at baseline and after transplantation at 6 and 12 months. LDQOL contains the 36-item Short Form Health Survey (SF-36) and 12 specific dimensions. Responsiveness was assessed using the paired Student t test.

RESULTS

The study included a cohort of 156 patients, 73% males, of an average age of 53 (26-67) years, with the following common indications: tumor (35%), hepatitis C (23%), and alcohol-related (21%) liver disease. Mean scores showed a statistically significant (P < .05) improvement after 1 year in 6 of 8 SF-36 dimensions, in the physical component summary score, and in 7 of 12 disease-specific dimensions. The two dimensions that showed no improvement in the SF-36 dimensions were "social functioning" and "vitality," whereas the specific dimensions to not improve were "sleep problems," "social interaction," "activities of daily living," and "concerns about the future."

CONCLUSION

Findings suggest that perceived QOL after LT improves but could be further enhanced with the use of specific programs for amending sleep disorders and physical aspects.

Everolimus in clinical practice in long-term liver transplantation: an observational study

INTRODUCTION

Everolimus, a mammalian target of rapamycin (mTOR) inhibitor, has been used in acute and chronic treatment of kidney and heart transplants. There is scarce information regarding its use in liver transplant recipients, although everolimus may be a useful alternative for selected cases.

OBJECTIVE

The objective of this study was to study the clinical, biochemical, and pathological features of patients to whom everolimus was added based upon defined clinical profiles.

STUDY DESIGN

This study was prospective observational ongoing study to evaluate the effectiveness and safety of everolimus alone or in combination with low doses of a calcineurin inhibitor (CNI). Chronic liver transplant recipients without contraindications to everolimus were defined based upon 7 profiles of complications. The initial everolimus dose (0.25 mg every 12 hours) was overlapped during conversion, measuring blood levels and evaluating clinical tolerance. Routine monitoring was performed to obtain immunosuppressant blood levels near the lower limit of the therapeutic range.

RESULTS

The 35 patients' including 17 men and 18 women, had an overall mean age of 61 ± 10 years with a mean follow-up of 34 months. The everolimus treatment lasted 20 months (range, 6-60). The indication for everolimus conversion were as follows: renal insufficiency (45.7%), no response to hepatitis C virus (HCV) treatment (42.9%), autoimmune hepatitis associated with interferon (8.5%), de novo autoimmune hepatitis (25.5%), de novo tumor (37.1%), neurotoxicity (14.3%), or side effects to rapamycin treatment (5.7%). Patients may have presented more than one indication. Effectiveness was assessed based upon improved liver (48.6%) or renal function (31.25% with renal insufficiency) or withdrawal of prednisone (100% of 10 patients receiving prednisone). CNI was withdrawn from 48.6% of patients due to de novo tumors or neurotoxicity. The side effect were as follows: anemia, leukopenia, or thrombocytopenia (11.4%) or dyslipidemia (27.3%). The survival rate was 94.3%.

CONCLUSIONS

Administration of everolimus to chronic liver transplants enhanced therapeutic options in the long term recipients when applied for predefined clinical indications and administrated with dose adjustments based on serial monitoring of exposure.

Effectiveness and safety of everolimus in the treatment of autoimmune hepatitis related to anti-hepatitis C virus therapy after liver transplant: three case reports

Treatment of recurrent hepatitis C after liver transplantation is indicated in selected cases. During the combined treatment with pegylated interferon and ribavirin, some patients develop immune-mediated liver dysfunction similar to the previously described "de novo" autoimmune hepatitis. Herein we have presented three liver transplant patients who during or after combined antiviral treatment were diagnosed as autoimmune hepatitis related to interferon based on their clinical, biochemical, and liver histology features. There were two women and one man, of ages 49, 52, and 49 years who were transplanted due to cirrhosis related to hepatitis C virus genotype 1. In two patients, elevated liver enzymes occurred during antiviral therapy and in the third, after the therapy. The diagnosis of autoimmune hepatitis was reached after excluding other possible causes. One patient had a sustained viral response; and two cases were nonresponders. Antinuclear antibodies were present in two subjects and antinuclear antibodies and anti-smooth muscle antibodies in the other case. First-line treatment of autoimmune hepatitis with prednisone and azathioprine stabilized clinical and biochemical parameters'. In order to avoid the long-term use of prednisone, everolimus was introduced in the three patients. Interestingly, hepatitis C did not progress and clinical, biochemical, as well as histological parameters stabilized. In one patient, the liver fibrosis stage as assessed by histology showed improvement. However, one subject experienced repeated cerebral hemorrhage and died. Although this is heterogeneous population with partially known characteristics, with a difficult differential diagnosis, the objectives of preserving liver function and avoiding recurrent progressive hepatitis C seemed to be achieved by adding everolimus. In addition, we totally stopped prednisone therapy. In conclusion, treatment with everolimus in combination with cyclosporine achieved a partial remission in two liver transplan cases of autoimmune hepatitis related to interferon therapy.

Assessing outcomes in liver disease patients: reliability and validity of the Spanish version of the Liver Disease Quality of Life Questionnaire (LDQOL 1.0)

OBJECTIVE

To assess the reliability and validity of a Spanish version of the LDQOL 1.0 (Liver Disease Quality of Life questionnaire).

METHODS

Observational, cross-sectional study in Spanish patients awaiting liver transplantation (LT). Feasibility was assessed by analyzing administration times and missing responses. Ceiling and floor effects were calculated and reliability was tested by examining internal consistency (Cronbach's alpha). Convergent validity was tested by examining correlations between LDQOL disease-specific and Short Form health survey with 36 questions (SF-36) dimensions. Known groups' validity was tested by examining the LDQOL's capacity to discriminate between groups defined by etiology and Child-Turcotte-Pugh (CTP) scores.

RESULTS

A total of 200 patients were included for analysis. Mean age (SD) was 52.6 (9.8) years and 73% of the sample were male. The most common indication for LT was liver cancer (34%). Mean (SD) time to complete the questionnaire was 35.8 minutes (21.2 minutes). Missing responses were highest on the dimensions of sexual functioning and symptoms of liver disease. Ceiling effects were over 20% on 7 of the LDQOL's 12 disease-specific scales. Cronbach's alpha coefficients were over 0.70 on all but 2 dimensions. Correlations between SF-36 and LDQOL disease-specific dimensions generally fulfilled the hypotheses, with 35 of the 40 highest and lowest correlations (87.5%) being in the expected direction. The LDQOL discriminated well between patients in CTP class A and C, and as hypothesized, hepatocarcinoma and alcoholic cirrhosis patients scored better on most dimensions than patients with hepatitis C virus or other etiologies.

CONCLUSIONS

The Spanish version of the LDQOL 1.0 has shown satisfactory reliability and validity.

Health-related Quality of Life before and after a solid organ transplantation (kidney, liver, and lung) of four Catalonia hospitals

INTRODUCTION AND AIMS

It has been described that patients who receive a transplant display a better Health Related Quality of Life (HRQoL). Our objective was to describe the HRQoL before and after a solid organ transplantation, comparing results among various transplantations.

METHODS

This HRQoL study using the SF-36 was implemented before as well as at 3 and 12 months posttransplantation. Posttransplantation were compared with pretransplantation scores as well as with the general population.

RESULTS

One hundred sixty-two renal, 159 liver, and 58 lung candidates were included before transplantation, among whom there were 126 renal, 108 liver, and 22 lung recipients. The median age of all transplant recipients was 53 years with 68% men. The various transplant types began with different HRQoL: lung showed the worst, followed by the liver, and then renal. The scores of the SF-36 before and 3 months posttransplantation showed significant improvements, except for "Pair." At 12 versus 3 months, mental health was somewhat better for renal, and almost all dimensions showed significant improvement for liver and lung patients. All subjects showed clear improvements after transplantation.

CONCLUSION

All patients showed clear improvements after transplantation when mental health was compared with the general population, particularly lung transplant recipients who expressed the greatest improvement. However, they still showed deficits in physical health.

Perceived state of health is worse in kidney recipients younger than 60 years vs older than 60 years

OBJECTIVE

To evaluate the differences in perceived state of health (PSH) according to patient age younger or older than 60 years.

PATIENTS AND METHODS

One hundred sixty-two patients were entered on the waiting list for renal transplantation from July 2003 at 4 hospitals in California and were observed prospectively for 2 years. Data were obtained at baseline and at 3 and 12 months after transplantation. All patients answered a generic Perceived State of Health (PSH) questionnaire, the 36-item Short-Form Health Survey (SF-36), and the EuroQol (EQ-5D) questionnaire. Data were analyzed using the t test for independent variables and the chi(2) test for contingency tables.

RESULTS

Patients aged 60 years or older had higher PSH scores compared with those younger than 60 years on all dimensions of the SF-36 and on the 2 summary scores. Scores for the physical domains were significantly improved at all follow-up visits. After transplantation, scores for the EQ-5D were higher for older patients vs younger patients (mean [SD], 80 [16] vs 67 [14]; P = .01). The PSH score for the older patients was similar to that for the general population (>45 points). The PSH scores for the physical and mental health domains were worse for the younger patients compared with the general population; no differences were noted for clinical variables.

CONCLUSION

Patients older than 60 years have higher PSH scores compared with patients younger than 60 years. However, scores for the younger patients were significantly improved at 1 year after transplantation.

Impact of health related quality of life in Catalonia liver transplant patients

OBJECTIVE

Our aim was to study the changes in the Health Related Quality of Life (HRQoL) during the first year following liver transplantation.

MATERIALS AND METHODS

Among 159 patients awaiting orthotopic liver transplantation (OLT) who were prospectively studied at 4 hospitals in Catalonia, 108 actually obtained an organ. HRQoL over time, namely, before, as well as at 3 and 12 months after transplantation, was recorded using the Short Form-36 (SF-36) and the Liver Disease Quality of Life (LDQOL 1.0). After we searched medical, clinical, and sociodemographic records to examine the studied variables on the HRQoL at each moment, the significance was explored using t tests and one-way analysis of variance (ANOVA).

RESULTS

Comparison of the SF-36 dimensions before and at 3 months after transplantation revealed almost all domains to show significant improvements (P < .01), except bodily pain, role-physical, social functioning, and PCS. Comparisons between 3 and 12 months after transplantation showed only significant improvements in role-physical, physical functioning, and PCS (P < .05). The other dimensions showed similar or slightly better scores, but the differences were not significant. For LDQOL 1.0 before and 3 months after transplantation, the dimensions with significant differences (P < .01) were: effects of liver disease on activities of daily living; concentration; health distress; sleep problems; stigmata of liver disease; and sexual function. Comparing 3 and 12 months posttransplantation, no dimension showed a significant improvement. A negative correlation existed between hypertensive patients and PCS on the SF-36 (P < .001). The clinical diagnosis of alcoholic liver disease showed better scores in some dimensions of the LDQOL than the other diagnoses. Female subjects showed significantly worse HRQoL than men (P < .001). Child-Pugh and Model for End-Stage Liver Disease (MELD) classifications were not associated with the HRQoL either before or after transplantation.

CONCLUSIONS

The most important finding in this study was that all domains showed significant improvements in HRQoL at 3 months after transplantation with only slight improvements at 12 months.

Gastrointestinal complications in liver transplant recipients: MITOS study

INTRODUCTION

Liver transplant recipients frequently suffer gastrointestinal (GI) complications but their prevalence and their influence on quality of life remain unknown.

OBJECTIVE

The objective of this study was to asses the prevalence, impact on quality of life, and management of GI complications in liver transplant recipients.

PATIENTS AND METHODS

This was an epidemiologic, cross-sectional, multicenter study. Four hundred seventeen liver recipients were recruited in 14 centers. A questionnaire was filled for every patient.

RESULTS

The median age of the patients was 55 years. The median time since transplantation was 4.1 +/- 4 years. Whereas 19.2% presented some GI disease before transplantation, 49.4% showed this type of complication after transplantation. Diarrhea was the most prevalent GI complication, and anorexia was the GI disorder that affected patients daily activities the most frequently. GI complications were more frequent among female patients, subjects with pretransplantation hiatal hernia, and those readmitted after transplantation. Of the patients with GI complications, 70.9% received pharmacological treatment (89.7% with gastric protectors). Immunosuppressive therapy was also modified because of GI complications. Immunosuppressive drug dose was reduced in 18.1%, transiently stopped in 3.4%, and definitively stopped in 3.4% of cases. The drug most frequently changed was mycophenolate mofetil: dose reduction, 23.6%; transient withdrawal, 5.7%; and definitive withdrawal, 6.6%.

CONCLUSIONS

The prevalence of GI complications in the liver transplant population was approximately 50%. GI complications showed a significant impact on the quality of life of the patients. They were related to female gender, to pretransplantation GI pathology, and posttransplantation hospital admission. These complications were frequently managed with pharmacological therapy or with changes in immunosuppressive therapy.

[Adefovir dipivoxil compassionate use program in Spain: efficacy and resistance analysis]

BACKGROUND AND OBJECTIVE

The extended treatment with lamivudine in patients with chronic hepatitis B is associated with the emergence of resistances. Patients with resistance to lamivudine show a loss of biochemical and virological responses and a higher progression of their liver disease. Adefovir dipivoxil, an analogue of the nucleotides, is effective for the treatment of patients with resistance to lamivudine. The aim of this study was to evaluate the efficacy, safety and resistance of adefovir dipivoxil in patients with chronic hepatitis B refractory to treatment with lamivudine.

PATIENTS AND METHOD

One hundred and twenty hepatits B virus patients refractory to lamivudine were treated with adefovir dipivoxil. Seventy-four patients were followed up during two years. In all cases, the hepatitis B virus-DNA was determined by polymerase chain reaction, and in those cases without response to treatment, the presence of resistances to adefovir and lavimudine were studied.

RESULTS

At the second year of treatment, we observed a biological response of 54.1%, a biochemical response of 62.2%, while an elimination of hepatitis B e antigen was seen in 21% cases. 20% patients developed resistance to adefovir dipivoxil, and the most frequent detected mutations were: A181V, A181T and N236T. Drug safety was excellent; in fact, only one adverse effect related to the drug was detected.

CONCLUSIONS

Treatment with adefovir dipivoxil for 2 years in mono-therapy in patient who are previously non-responders to lavimudine is associated with a high biochemical and virologycal response with an excellent safety. At the second year of treatment, the adefovir dipivoxil resistance rate is 20%.

Treatment of chronic he1patitis C genotype 1 with peginterferon-alpha2a (40 kDa) plus ribavirin under routine clinical practice in Spain: early prediction of sustained virological response rate

BACKGROUND

Sustained virological response rates of up to 52% have been obtained with peginterferon alpha2a (40 kDa) plus ribavirin in patients suffering from chronic hepatitis C genotype 1 in randomized-controlled trials.

AIM

To assess early virological response and its clinical utility in predicting an sustained virological response in patients suffering from chronic hepatitis C genotype 1 in routine clinical practice in Spain.

METHODS

Treatment-naïve patients received pegylated interferon alpha2a (40 kDa) 180 microg/week plus ribavirin 1000/1200 mg/day for 48 weeks, and were followed for a further 24 weeks. Overall, 475 patients received at least one dose of medication and were included in the efficacy population.

RESULTS

The overall sustained virological response rate was 48%. Of those with week 12 virological data, 83% had an early virological response. The negative predictive value of an early virological response was 93%.

CONCLUSION

If sustained virological response is the goal, a treatment-decision based on a 12-week evaluation during routine clinical practice is feasible.

Treatment of chronic he1patitis C genotype 1 with peginterferon-alpha2a (40 kDa) plus ribavirin under routine clinical practice in Spain: early prediction of sustained virological response rate

BACKGROUND

Sustained virological response rates of up to 52% have been obtained with peginterferon alpha2a (40 kDa) plus ribavirin in patients suffering from chronic hepatitis C genotype 1 in randomized-controlled trials.

AIM

To assess early virological response and its clinical utility in predicting an sustained virological response in patients suffering from chronic hepatitis C genotype 1 in routine clinical practice in Spain.

METHODS

Treatment-naïve patients received pegylated interferon alpha2a (40 kDa) 180 microg/week plus ribavirin 1000/1200 mg/day for 48 weeks, and were followed for a further 24 weeks. Overall, 475 patients received at least one dose of medication and were included in the efficacy population.

RESULTS

The overall sustained virological response rate was 48%. Of those with week 12 virological data, 83% had an early virological response. The negative predictive value of an early virological response was 93%.

CONCLUSION

If sustained virological response is the goal, a treatment-decision based on a 12-week evaluation during routine clinical practice is feasible.

Cofactors associated with liver disease mortality in an HBsAg-positive Mediterranean cohort: 20 years of follow-up

The risk of developing liver cancer in hepatitis B virus (HBV) carriers differs across geographical areas, suggesting that exposure to other risk factors may contribute to HBV-linked cancer risk. Our study estimates the mortality due to liver disease and the role of other risk factors in a Spanish HBV cohort. 2,352 hepatitis B surface antigen (HBsAg)-positive and 15,504 HBsAg-negative subjects were identified among blood donors during 1972-1985 and were followed until December 2000 through the Mortality Registry. Clinical examination and an epidemiological questionnaire were performed on 1,000 HBsAg-positive survivors during 1994-1996. In subjects deceased from liver disease, medical records were revised and relatives were interviewed. A nested case-control analysis was conducted comparing both groups. In HBsAg-positive men, an excess mortality from liver cancer [standardized mortality ratio (SMR): 14.1; 7.7-23.6], cirrhosis (SMR: 10.5; 7.0-15.1), haematological neoplasms (SMR: 3.2; 1.2-6.9) and AIDS was detected (SMR: 5.5; 2.2-11.4). In women, an excess was found for cirrhosis (SMR: 7.2; 1.4-21.1). Progression factors to liver disease were alcohol intake [odds ratio (OR): 6.3; 3.1-12.8], diabetes (OR: 3.6; 1.3-9.6), HBV replication (OR: 50.0; 14.9-167.3) and hepatitis C virus (HCV) infection (OR: 27.4; 7.1-107.7). In conclusion, in Spain after 20 years of follow-up, chronic HBV exposure appears as a major risk factor for liver cancer among men and for cirrhosis in both sexes. The risk of death from liver disease among HBV carriers with the presence of HBV replication, HCV, alcohol consumption and diabetes was significantly increased and suggests synergism among these exposures and HBV. Mortality from haematological neoplasms was detected and could be associated to HIV coinfection. These results support screening and adequate follow-up among HBsAg-positive subjects at high risk to develop liver disease, particularly when these risk cofactors are present.

Clinical and virological effects during two years of ongoing adefovir dipivoxil in the treatment of lamivudine-resistant chronic hepatitis B infection

OBJECTIVE

Our aim was to evaluate the efficacy and safety of adding adefovir to lamivudine therapy for hepatitis B virus (HBV)-infected patients resistant to Ramivudine.

PATIENTS AND METHODS

Among 17 studied patients, 7 had chronic active HBV infection and 10 were posttransplant with HBV infection (9 with de novo HBV). They received lamivudine plus adefovir therapy for 2 years. We assessed reductions in serum HBV-DNA and alanine aminotransferase (ALT) levels, loss of HBeAg (in HBeAg+ cases), and HBsAg clearance.

RESULTS

A virological response, as defined by HBV-DNA below the cut off by hybridization, was observed in 12 (70.6%) patients and loss of HBeAg in 4 (44.4%) of the 9 initially HBeAg-positive cases. A biochemical response, defined as a decreased serum ALT to the normal range, occurred in 4 (26.7%) patients. Median serum creatinine increased in 3 of 15 (20%) patients, excluding those on hemodialysis. There were two noteworthy cases of sustained HBsAg seroconversion with adefovir (11.8%): one patient with de novo HBV infection posttransplantation and positive hepatitis C virus-RNA serology, and one patient with decompensated HBV cirrhosis in whom viral replication ceased, making him eligible for transplantation.

CONCLUSIONS

Currently, adefovir is an effective rescue therapy that broadens the existing range of options for patients with lamivudine-resistant chronic hepatitis B infection, particularly those with decompensated cirrhosis awaiting a liver graft, and those with recurrent posttransplantation HBV. The relatively small biochemical response seen in these patients may be attributable to the high prevalence of concomitant hepatitis C virus infection (41%).

Study on the Efficacy and Safety of Adefovir Dipivoxil Treatment in Post–Liver Transplant Patients With Hepatitis B Virus Infection and Lamivudine-Resistant Hepatitis B Virus

Hepatitis B virus (HBV) recurrence and de novo HBV infection are frequent events in liver transplantation recipients. Treatment with lamivudine is initially efficient in both infections but the incidence of lamivudine-resistant HBV emergence increases over time. Adefovir appears to be promising in post-liver transplantation patients with recurrent HBV infection and lamivudine-resistant HBV. This study analyzed adefovir treatment in 42 post-liver transplantation patients who developed recurrent HBV or de novo HBV infection with lamivudine-resistant HBV (54.8% HCV-coinfected). Patients received 10 mg of oral adefovir once daily for a mean period of time of 21.5 months (range from 12 to 31 months). In 62.9% of patients, ALT levels decreased significantly. Serum HBV-DNA was undetectable in 64% of the cases. Twenty percent of patients lost HBeAg marker and 13.3% of them developed anti-HBe. In 9.5% of recipients, HBsAg became negative. There was no significant change in serum creatinine levels. In only one patient was worsening of the renal function detected, making dose adjustment necessary. No other side effects were reported. Our results confirm the efficacy and safety of adefovir treatment in post-liver transplantation patients with lamivudine-resistant HBV, neither were adefovir-resistant mutations identified in patients after 21 months of therapy, nor were there adverse events, especially renal toxicity.

Validation of the Spanish version of the Liver Disease Quality of Life questionnaire in transplant patients

OBJECTIVE

Our aim was to validate Spanish and Catalan versions of the Liver Disease Quality of Life questionnaire (LDQOL) for use in liver transplant patients.

METHODS

The LDQOL consists of the SF-36 generic measure of health-related quality of life (HRQOL) and 12 disease-specific dimensions for liver disease patients. The Spanish and Catalan versions of the questionnaire were administered to 138 patients with a liver transplant. Cronbach's alpha coefficients (CAC) were used to test the internal consistency of disease-specific scales. Test-retest reliability was calculated using the Intraclass Correlation Coefficient (ICC) in a sub-group of 41 patients who completed the questionnaire on two occasions 1 to 2 weeks apart. Validity was analysed by determining the instrument's capacity to discriminate between patient groups classified according to years since transplant, disease etiology, and symptom severity. Ceiling and floor effects were also calculated.

RESULTS

Internal consistency in the disease-specific dimensions was acceptable or good (CACs 0.60-0.97), as was test-retest reliability in all dimensions (statistically significant CCIs of 0.62-0.89), except the symptoms dimension (CCI=0.46, P<.05). Few differences were found in disease-specific dimension scores between patients classified according to number of years since transplant or etiology, but differences were found in some dimensions according to symptom severity. Moderate to severe ceiling effects were found in several disease-specific dimensions.

CONCLUSIONS

The Spanish and Catalan versions of the LDQOL may be useful for measuring HRQOL in this population, though it will be important to investigate further the instrument's sensitivity to change.

Applicability of liver transplantation in Catalonia at the end of the millennium. A prospective study of adult patient selection for liver transplantation

We prospectively studied the global applicability of liver transplantation in Catalonia, a region with a high rate of organ donation. We followed 232 adult patients assessed as possible candidates for liver transplantation over 12 months in the three hospitals that perform the procedure in this region. The liver disease leading to patient assessment was cirrhosis in most cases, alone (159 patients) or associated with hepatocellular carcinoma (57 patients). After being assessed, 150 patients (65%) were accepted for transplantation and included on the waiting list, and 82 (32%) were excluded. Death during the period of assessment, advanced tumoral disease, early stage of liver disease, and extrahepatic co-morbidities were the most important reasons for exclusion. The median time of assessment of patients accepted for transplantation was 40 days. Of the 150 patients included on the waiting list, 131 (87%) received transplants, 17 (11%) were removed from the list, and two were still waiting for transplantation at the end of the follow-up period. Death and tumor progression were the most important reasons for patients' removal from the waiting list. The median time on the waiting list was 59 days. In conclusion, among liver-transplant candidates the overall applicability of this therapy in Catalonia was relatively low (131 out of 232 transplant candidates finally underwent transplantation, 56%), and inadequate liver-transplant indications and death or tumor progression during the period of assessment or while the patient was on the waiting list were the most frequent reasons why liver transplantations did not proceed.

[Induction therapy with interferon alfa-2a in compensated hepatitis C virus-related cirrhosis. Randomized, multicenter study]

BACKGROUND

Although standard dose interferon (IFN) is successful in only 5% of patients with compensated hepatitis C virus (HCV)-related cirrhosis, it has been suggested that this therapy might decrease the risk of complications or the incidence of hepatocellular carcinoma. Based on HCV kinetics, daily IFN may improve response rates.

PATIENTS AND METHOD

Forty cirrhotic patients were randomised to receive (Group I: 19) or not (Group II: 21) treatment with IFN (4.5 MU/daily for 24 weeks, followed by 4.5 MU/48 hours for a further 24 weeks period, only if ALT was within normal values).

RESULTS

Dose reduction and discontinuation for adverse events was required in 11 (58%) and 6 (31.5%) cases, respectively. End-of-treatment response was not observed in any of the 21 controls but in 4 of the 19 (21%) treated patients (p = 0.04); a sustained response was achieved in only 2 treated patients (10.5%). The 3-year probability of developing any of the following: ascites, hepatocellular carcinoma, transplantation or death was lower in Group I than in Group II (6% vs 27%; p = 0.05).

CONCLUSION

Although induction IFN therapy is associated with common side effects and poor sustained response in compensated HCV-related cirrhosis, it might improve the outcome of patients at the medium-term.

[Surgical treatment of hepatocellular carcinoma. Long term results]

BACKGROUND

Surgical treatment for hepatocellular carcinoma remains controversial due to a lack of prospective randomized studies.

MATERIAL AND METHOD

Between January 1990 and December 2000, 121 liver transplantations (group 1) and 52 hepatectomies (group 2) were performed for hepatocellular carcinoma. Each surgical treatment was carried out depending on patients' and tumor's characteristics.

RESULTS

Patients from group 1 had a more advanced tumoral grade, with higher involvement of two lobes (19 vs 4%; p = 0.015) and higher number of nodules (1.9 DE [2] vs 1.2 [0.6]; p = 0.001); yet the mean tumor size was lower (3 cm [1.5] vs 4.2 [3.2]; p = 0.006). Operative mortality (4% vs 2%; p = 0.66) and 5- and 10-years survival (68% and 42% vs 63% and 45%; p = 0.23) were similar between both groups. Nevertheless, 5- and 10-years recurrence rates (10.6% and 10.6% vs 50% and 65.5%; p < 0.0001) were more favourable in group 1. Prognostic factors of recurrence included microscopic vascular invasion (RR = 12.12; CI, 2.02-75.52) and alpha-fetoprotein levels higher than 300 ng/mL (RR = 7.12; 95% CI, 1.08-47.02) in group 1, and the pT3-4 stage (RR = 3.86; 95% CI, 1.06-14.03) in group 2. Mean time on waiting lists for liver transplantation was 3.06 (2.66) months and it has increased significantly in last years, especially among blood group 0 patients. However, this fact has not been associated with a worsening of survival rates (p = 0.98).

CONCLUSIONS

After a good patient selection, either liver transplantation or hepatectomy achieve excellent long term survival rates in patients with hepatocellular carcinoma, though the former allows a better control of the tumoral disease. The increase of mean time on waiting lists for liver transplantation during the last years has not led to a worsening of survival results.

[Analysis of 500 liver transplantations at Bellvitge Hospital, Spain]

BACKGROUND

We present the experience of the liver transplantation program at the Hospital of Bellvitge with 500 transplantations performed during 15 years, to describe changes in liver transplantation observed throughout the time and to analyze the long term results.

PATIENTS AND METHOD

Five groups each one including 100 consecutive transplantations are studied.

RESULTS

The main indications were hepatocellular carcinoma (23%), alcoholic cirrhosis (22.8%), and post-hepatitis C cirrhosis (18.8%). Sixty-five retransplantations were performed in 59 patients (13%), being the more frequent indications arterial thrombosis (13 patients) and primary nonfunction of graft (10 patients). In 10 patients a hepatorenal transplantation was performed. In group I, the most frequent donor cause of death was cranial traumatism (80%), while in group V it was the vascular pathology (52%). There were other significative differences between these groups of patients (I vs V): patients with stage 2 or 3 from UNOS status (45 vs 19%), blood use (29.6 [26] vs 4.6 [5.3] PRBC), ICU stay (13 [13] vs 7.4 [11] days), hospital stay (40 [52] vs 23.7 [17] days), rejection rate (46 vs 20%) and primary graft nonfunction (9 vs 3%). However, the infection rates (48 vs 54.5%) and biliary tract complications (26 vs 20%) have not shown statistically significant differences. Actuarial one and 5-year survival are 83 and 70% respectively.

CONCLUSIONS

An important and progressive improvement of liver transplantation results has been observed. However, de novo tumours, hepatitis C virus recurrence and chronic rejection can limit long term results.

European collaborative study on factors influencing outcome after liver transplantation for hepatitis C. European Concerted Action on Viral Hepatitis (EUROHEP) Group

BACKGROUND & AIMS

Liver transplantation for hepatitis C virus (HCV)-related liver disease is characterized by frequent graft infection by HCV. The prognosis and risk factors for morbidity and mortality in this condition were determined.

METHODS

A retrospective study of 652 consecutive anti-HCV-positive patients undergoing liver transplantation between 1984 and 1995 in 15 European centers was conducted; 102 patients coinfected with hepatitis B virus (HBV) received immunoglobulin prophylaxis for antibody to hepatitis B surface antigen.

RESULTS

Overall, 5-year survival was 72%. Five-year actuarial rates of hepatitis and cirrhosis were 80% and 10%. Genotypes 1b, 1a, and 2 were detected in 214 (80%), 24 (9%), and 24 (9%) of 268 patients analyzed. The only discriminant factor for patient or graft survival was hepatocellular carcinoma as primary indication. Independent risk factors for recurrent hepatitis included the absence of HBV coinfection before transplantation (relative risk [RR], 1.7; 95% confidence interval [CI], 1.2-2.6; P = 0.005), genotype 1b (RR, 2; 95% CI, 1.3-2.9; P = 0.01), and age > 49 years (RR, 1.4; 95% CI, 1.1-1.8; P = 0.01).

CONCLUSIONS

The results of transplantation for HCV-related disease are compromised by a significant risk of cirrhosis, although 5-year survival is satisfactory. Genotype 1b, age, and absence of pretransplantation coinfection by HBV are risk factors for recurrent HCV.

[Liver retransplantation in adults: clinical course and results of 13 years' experience]

INTRODUCTION

Liver retransplantation is the only alternative to irreversible graft failure. However, it remains a controversial treatment. The aim of this study was to analyze the clinical course and the results of liver retransplantation in our center.

PATIENTS AND METHODS

The actuarial survival in a series of 54 retransplantations in 49 patients between February 1984 and December 1997 was analyzed. The retransplantations were grouped according to period: group A (n = 16) 1984-1992, group B (n = 22) 1993-1995 and group C (n = 16) 1996-1997.

RESULTS

The actuarial survival per group according to year was: 31.25%, 54.55% and 62.50% for groups A, B, and C, respectively, which shows a clear improvement with time, although differences were not statistically significant.

CONCLUSIONS

The results of liver transplantation in our series show a lower actuarial survival rate than those of primary transplantation but these results have improved in recent years.

Outcome of autoimmune hepatitis after liver transplantation

BACKGROUND

Recurrence of autoimmune hepatitis after liver transplantation is not rare, but there is little information about its time of onset, risk factors, response to treatment and prognosis. The aim of this study was to evaluate the rate of recurrence and outcome of autoimmune hepatitis after transplantation.

METHODS

The records of patients transplanted in eight centers in our country between 1984 and 1996 were retrospectively analyzed.

RESULTS

Forty-three of the 2331 (1.8%) recipients fulfilled diagnostic criteria of autoimmune hepatitis at the time of transplantation. Sixteen patients were excluded from evaluation. Nine (33%) of the 27 patients evaluated fulfilled criteria for recurrence of autoimmune hepatitis, with a mean time of recurrence after orthotopic liver transplantation of 2.6+/-1.5 years. Patients with recurrence had a longer follow-up time after transplantation (5.1 vs. 2.5 years, P=0.0012) and were receiving less immunosuppressive treatment. The estimated risk of recurrence of autoimmune hepatitis in the graft increased over time: 8% over the first year and 68% 5 years after transplantation. None of the seven patients with liver-kidney microsomal-positive antibodies recurred (P=0.059). Fifty percent of the patients failed to respond or responded only partially to therapy, although none of the patients have deteriorated clinically after 2.4+/-1.06 years of follow-up after recurrence.

CONCLUSIONS

Recurrence of autoimmune hepatitis in the graft is a common event with an incidence that increases over time as immunosuppression is reduced. Although response to treatment is poor, patient and graft survival do not appear to be decreased.

[Is surgery for portal hypertension a contraindication for liver transplantation?]

INTRODUCTION

Orthotopic liver transplantation (OLT) is the only curative treatment for hepatic cirrhosis and is the most effective in the control of portal hypertension. The aim of this study was to analyze whether greater morbi-mortality is observed in patients undergoing liver transplantation with previous surgery for portal hypertension with respect to patients not having undergone this surgery.

MATERIALS AND METHODS

Different variables were analyzed in 2 groups of transplanted patients: one of 18 patients who had previously undergone surgery for portal hypertension and another group of 54 patients without this previous surgery.

RESULTS

The following factors were studied: mean operative time and length of anahepatic phase, intraoperative consumption of concentrates of erythrocytes, fresh frozen plasma, units of platelets and cryoprecipitates, days of mechanical ventilation, stay in the ICU and total postoperative stay. No significant differences were observed (p < 0.05) in any of these factors or in survival.

DISCUSSION

On analysis of the difficulty of surgical technique, postoperative evolution and survival and based on the variables described it may be concluded that previous surgery for portal hypertension does not only not contraindicate posterior liver transplantation, but rather may be useful in patients with an adequate hepative reserve presenting variceal hemorrhage since posterior transplantation does not present a worsened prognosis.

[Resection as elective treatment of hilar cholangiocarcinoma (Klatskin tumor)]

A retrospective analysis of our experience in the treatment of hiliary cholangiocarcinoma or Klatskin tumor was performed with the aim of evaluating the morbi-mortality and prognosis of its treatment to thereby determine the usefulness of the different therapeutic options. From 1989 to 1997, 51 patients diagnosed with hiliary cholangiocarcinoma were treated in our hospital. Surgery was indicated in 16 with curative aims (group I) while palliative treatment with percutaneous biliary drainage was indicated in 35 (group II). Biliary resection was carried out in 8 patients being associated with hepatic resection in 4 (group IA) and in 8 patients undergoing liver transplantation (group IB). Clinico-epidemiologic data and hospital stay were similar in all the groups. The frequency of complications was similar in groups I and II although the frequency of cholangitis (49%) in group II was noticeable. The percentage of readmissions was also greater in group II (12 vs 46%, respectively; p = 0.03) with prosthesis obstruction being the most frequent cause. Accumulated survival at 1, 2, and 3 years in group I was 84, 64 and 48% with a median survival of 33 months, while in group II the median survival was of 6 months with no patient surviving more than 2 years (p = 0.0001). When groups IA and IB were compared, greater frequency of complications in groups IA (100 vs 37%; p = 0.002), similar frequency of readmissions (87 vs 75%; p = NS), median survival greater in group IB (12.5 months vs 48 months) and significantly higher actuarial survival in group IB (48% in 2 years vs 83% to 2 years; p = 0.02) was observed. In conclusion, surgery is the treatment of choice in hiliary cholangiocarcinoma whenever possible, given the greater survival without a significant increase in morbimortality. Likewise, we consider that liver transplantation is a useful option in the treatment of patients with cholangiocarcinoma type IV of Bismuth.

Myocardial abscess at a distant zone from the active valvular infection

A case of an infective endocarditis with myocardial abscess due to Streptococcus anginosus at a distant location from the active valvular infection is reported. We conclude that local cardiac suppurative complications can appear in the evolution of endocarditis caused by this virulent organism.

Survival after liver transplantation in cirrhotic patients with and without hepatocellular carcinoma: a comparative study

Cumulative recurrence after surgical resection for hepatocellular carcinoma (HCC) is very high. Several retrospective analyses have shown that liver transplantation was more effective than resection for patients with HCC at early tumor stages. Consequently, in January 1990, we decided to prospectively indicate orthotopic liver transplantation (OLT) as the first surgical treatment for small, localized HCC in cirrhotic patients without nodal involvement independently of the degree of liver function. The aim of this prospective cohort study was to analyze prognosis, recurrence rate, and survival after liver transplantation in patients in whom the main indication was HCC with cirrhosis. Thirty-eight patients in whom the main indication for liver transplantation was HCC and hepatic cirrhosis were compared with 136 transplantations because of cirrhosis without tumor, performed in our unit from January 1990 to December 1995. HCC arising in noncirrhotic livers and those incidently discovered after OLT were excluded from the study. Chemoembolization using doxorubicin, lipiodol, and Gelfoam was performed before OLT in 31 patients with good liver function. There were no differences in gender, but HCC patients were older (57 +/- 7 vs. 50 +/- 10 years [P < .001]). Liver function was better in HCC (Child-Pugh score: 6.9 +/- 2 vs. 8.6 +/- 1.8; P < .001), and hepatitis C virus antibody was positive in 31 (82%) vs. 51 (37%) (P < .007). Seven tumors had bilobar involvement (18%). Capsule was present in 22 (58%). The mean size of the tumor was 3.4 +/- 2 cm. Seventeen tumors (45%) were larger than 3 cm, and 4 (11%) were larger than 5 cm. The average number of nodules was 2 +/- 1. The tumor-node-metastasis stage of the tumors was pT1 in 6 patients (16%), 11 were pT2 (29%), 12 were pT3 (31%), and 9 were pT4 (24%). Seven patients were retransplanted in the HCC group (18%) and 19 (14%) in the nontumor group (not significant). Tumor recurrence was detected in three patients (8%). One, 3-, and 5-year survival rates were 82% vs. 79%, 75% vs. 71%, and 63% vs. 68%, respectively, for patients with and without HCC, and no differences were found between the two groups (P = .84). Survival was significantly reduced in patients with a macroscopic vascular invasion and tumors greater than 5 cm in diameter. Recurrence and mortality after liver transplantation in cirrhotic patients with carefully selected HCC are similar to the results in cirrhotic patients without tumor.

[Infectious gastroenteritis in relapses of inflammatory bowel disease. Therapeutic implications]

The incidence and clinical importance of infectious gastroenteritis was studied in 67 consecutive relapses of inflammatory bowel disease (IBD). A stool culture was done in every case before starting treatment. Stool culture was positive in 6 relapses (8.9%): Four were exacerbations of ulcerative colitis and two of Crohn's disease (8.8% in ulcerative colitis vs 9% in Crohn's disease; NS). The microorganisms isolated were Campylobacter jejuni in three cases, Salmonella enteritidis in two and Staphylococcus aureus in one case. There were not clinical differences between patients with positive and negative stool culture. Treated with antibiotics, stool cultures became negative in all of them but only in three the disease was controlled. The other three had to be treated with corticosteroids to achieve remission. We conclude that stool culture should be practised in all relapses of IBD and in case of positivity, antibiotic therapy should be started. With this approach the use of corticosteroids can be avoided in some patients.

Liver transplantation in hepatocellular carcinoma

The initial enthusiasm for orthotopic liver transplantation (OLT) in patients with hepatocellular carcinoma (HCC) soon vanished as early recurrences appeared. OLT in HCC remains a controversial issue. We evaluated the efficacy of preoperative studies to select No-Mo patients and determined whether pT stage and histopathological grade (G) have a prognostic significance. A group of 25 patients, all previously thoroughly studied to rule out extrahepatic disease, underwent OLT for HCC. All patients were pNo after pathological study and none of the six patients who died in the postoperative period showed extrahepatic dissemination at necropsy (pMo). The recurrence rate was 43%. The 2 and 5 years actuarial survival was 62% and 43% respectively. The pT and G were not prognostic factors for long-term survival. We think that HCC is still a good indication for OLT because almost 50% of patients have good survival prospects.

[Gammagraphy with 111In-labelled leukocytes in an acute outbreak of inflammatory intestinal disease. Evaluation of the localization, extension and degree of activity]

We have studied 59 patients suspected of presenting an acute bout of inflammatory bowel disease: 23 had Crohn's disease and 36 had ulcerative colitis. All them underwent scintigraphic examination using 111In labelled leukocytes during the first 72 hours after their admittance and in a period no longer than 30 days, they also underwent barium enema and/or endoscopic study. Scintigraphic examination was more sensitive (100%), specific (100%) and accurate (100%) than endoscopy (72%, 100% and 78%) and barium enema (69%, 80% and 71%) in Crohn's disease. In ulcerative colitis, although endoscopy (100%) was slightly more sensitive than scintigraphy (100% and 94% against 78% and 93%). Reliability of barium enema was always lower to that of scintigraphy. In both conditions, scintigraphic examination detected a higher number of affected segments than barium enema did (40/16 in Crohn's disease and 65/31 in ulcerative colitis). Correlation between the index of scintigraphic activity and Harvey's index of clinical and biologic activity was highly significant (p less than 0.001) in both diseases. We conclude that scintigraphic examination using 111In labelled leukocytes is a reliable examination method for evaluation of localization, extension, and degree of activity of inflammatory bowel disease and that it must be a part of the examination protocol.

[Quality of life after liver transplant]

Hepatic transplant has recently undergone ostensible changes in post operative mortality. The present study investigates whether this improvement in survival is associated with a subjective and objective improvement in quality of life. Nineteen patients were evaluated preoperatively and/or postoperatively with a questionnaire (Nottingham Health Profile). The results showed a remarkable improvement in the quality of life of these patients, which became more marked after three months. The readaptation to work was good, considering the current state of our society. The mean yearly hospital stay was 12 days, distributed in three admissions mainly to perform hepatic biopsy.

111In-oxine-labelled autologous leucocytes in inflammatory bowel disease: new scintigraphic activity index

The usefulness of scintigraphy with 111In-oxine-labelled autologous leucocytes was investigated in 27 patients with inflammatory bowel disease (IBD): 16 with ulcerative colitis and 11 with Crohn's disease. Scans were performed 2-4 h (early scan) and at 24 h (late scan) after leucocyte reinjection. No false-negative results occurred in the early scan; however, in the late scan, 2 patients with Crohn's disease had a normal scintigram. A new index of activity (Il) based on the number and relative activity of abnormal 111In-leucocyte zones was used for scan quantitation. All patients with clinically active IBD had Il greater than or equal to 2. The scintigraphic index showed a significant correlation with the Harvey clinical index, especially in patients with ulcerative colitis. Our results suggest that an early scan (2-4 h) provides useful information in cases of IBD, and that Il greater than or equal to 2 is indicative of the degree of disease activity in such patients.