Background & Aims We investigated the efficacy of entecavir, a cyclopentyl guanosine nucleoside analogue, as monoprophylaxis in patients with chronic hepatitis B who received a liver transplant. ...Methods We studied data from 80 consecutive patients who received a liver transplant (47 from living donors and 33 from deceased donors) for hepatitis B–related disease and entecavir monotherapy as prophylaxis. None of the patients received hepatitis B immunoglobulin. Indications for transplant included decompensation from cirrhosis (27.5%), acute-on-chronic hepatitis B (47.5%), and hepatocellular carcinoma (25%). The median follow-up time was 26 months (range, 5–40 months). Before transplant, 33 patients were not on antiviral therapy and 47 were on oral therapy (18 had received less than 3 months of treatment). Results At the time of transplant, the median log HBV DNA level was 3.5 copies/mL (range, 1.54–8.81); 21 patients (26%) had undetectable levels of HBV DNA. The cumulative rate of hepatitis B surface antigen (HBsAg) loss was 86% and 91% after 1 and 2 years, respectively. Ten patients had reappearance of HBsAg. Eighteen patients (22.5%) were HBsAg positive at the time of their last examination; 17 of these had undetectable levels of HBV DNA, and the remaining patient had a low level of HBV DNA (217 copies/mL). There was no evidence of mutations at sites that confer resistance to entecavir among patients who were HBsAg positive. Conclusions Although only 26% of patients had complete viral suppression at the time of transplant, 91% lost HBsAg, with 98.8% achieving undetectable levels of HBV DNA. A hepatitis B immunoglobulin–free regimen of entecavir monotherapy is effective after liver transplantation for chronic hepatitis B.
The long-term outcomes of oral antiviral therapy without hepatitis B immune globulin (HBIG) in prevention of reinfection with hepatitis B after liver transplantation are not known. We aimed to ...determine the long-term outcomes from a large population of chronic hepatitis B (CHB) liver transplant recipients using oral antiviral therapy alone.
A total of 362 consecutive CHB patients transplanted from January 2003 to May 2011 were included. None of the patients received HBIG. Viral serology, viral load, and liver biochemistry were performed at regular intervals during follow-up.
Of the 362 patients, 176 (49%), 142 (39%), and 44 (12%) were on lamivudine (LAM), entecavir (ETV), and combination therapy (predominantly LAM+adefovir), respectively, at the time of transplant. The median follow-up length was 53 months. The rate of hepatitis B surface antigen seronegativity and hepatitis B virus (HBV) DNA suppression to undetectable levels at 8 years was 88 and 98%, respectively. The virological relapse rates (>1 log increase IU/ml) at 1, 3, 5, and 8 years was 5, 10, 13 and 16%, respectively. The virological relapse rate at 3 years for LAM, ETV, and combination group was 17, 0, and 7%, respectively (P<0.001). Forty-two patients had virological relapse, of which 36 had YMDD mutation (31 in the LAM group and 5 in the combination group). The overall 8-year survival was 83%, with no difference between the three treatment groups (P=0.94). No mortality from HBV recurrence occurred in the 362 patients.
Oral nucleoside/nucleotide analogs without HBIG are effective in preventing graft loss secondary to hepatitis B recurrence after liver transplantation. However, new agents with a high barrier to resistance should be used to minimize drug resistance and to prevent virological rebound.
Liver stiffness measurement (LSM) using transient elastography has recently become available for the assessment of liver fibrosis. Whether LSM can predict the functional liver reserve in patients ...undergoing liver resection is not certain.
To correlate liver stiffness measurement (LSM) with indocyanine green (ICG) clearance test and liver biochemistry, and to determine its usefulness in predicting postoperative outcomes in patients undergoing liver resection.
Transient elastography and ICG clearance test were performed pre-operatively in 44 patients with hepatocellular carcinoma. The LSM and ICG retention rate at 15 minutes (R15) were correlated with pre-operative factors and post-operative outcomes.
There was significant correlation between ICG R15 and LSM. In patients with LSM ≥11 kPa vs <11 kPa, there was significantly higher ICG R15 (17.1% vs 10.0% respectively, p = 0.025). For patients with ICG R15≥10% compared to those <10%, there was significantly higher LSM (12.0 vs 7.6 kPa respectively, p = 0.015). Twenty-eight patients proceeded to resection. There was a significant correlation between LSM and the peak INR after liver resection (r = 0.426, p = 0.024). There was a significant correlation between ICG R15 and the post-operative peak AST level (r = -0.414, p = 0.029) and peak ALT level (r = -0.568, p = 0.002). The operative time was a significant independent factor associated with post-operative complications and peak INR.
LSM correlated well with ICG R15 in patients undergoing liver resection, and predicted early post-operative complications. Addition of LSM to ICG R15 testing may provide better prognostic information for patients undergoing resection.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract Background Cirrhosis has been shown to be associated with left ventricular (LV) myocardial dysfunction, but studies of right ventricular (RV) function in cirrhotic patients compared with ...controls are scarce. Limited studies have prospectively evaluated the progression of myocardial function in patients with cirrhosis and assessed changes in cardiac function following liver transplantation (LTx). So the aim of the study was to evaluate biventricular myocardial function in cirrhotic patients and its alteration with or without liver transplantation. Methods A total of 103 patients with cirrhosis (age 55 ± 7 years, male 75%) were recruited. Conventional and 2-dimensional speckle tracking echocardiography was performed to determine the presence of LV and RV (biventricular) dysfunction. For comparison, 48 matched control subjects were included. Follow-up echocardiography was performed in 41 patients following LTx and in 26 patients who did not undergo LTx. Results Patients with cirrhosis had biventricular dilatation, increased LV mass, impaired LV diastolic function, and biventricular systolic strain compared with controls. Following LTx, cirrhotic patients had reduced biventricular dilatation, a smaller LV mass, and improved biventricular systolic strain after a mean duration of 18.2 ± 6.6 months. Patients who did not undergo LTx had a further increase in LV mass but no significant change in biventricular dimensions or systolic strain (mean duration of 20.4 ± 8.3 months). Conclusions The present study demonstrates that patients with cirrhosis had biventricular dilatation and impaired biventricular systolic strain compared with controls. Following LTx, biventricular dilatation reduced and biventricular systolic strain improved. In contrast, patients who did not undergo LTx experienced a further increase in LV mass.
Liver transplantation (LT) is the most effective treatment for small and unresectable hepatocellular carcinomas (HCCs). With scarcity of deceased donor livers, living donor LT (LDLT) is the ...alternative to deceased donor LT (DDLT). Animal studies have suggested that regeneration of the partial liver graft encourages HCC recurrence. Increased recurrence was observed in a few studies. Thus, there is the belief that the use of small-for-size graft carries the potential risk of disease recurrence. Nevertheless, those studies were retrospective, with sample sizes not large enough for conclusions.Living donor LT can be performed when a suitable donor is available. The fast tracking of patients for transplantation without a period of observation is an issue. Meta-analyses, however, showed no significant increase in HCC recurrence after LDLT. Patients listed for DDLT and without suitable living donors have to endure a long wait, during which the aggressiveness of their HCC is observed. Such observation almost guarantees slow disease progression when they get transplanted. Nevertheless, a long wait has the disadvantage of transplanting patients with more advanced tumors, although still within standard criteria. Judicious use of deceased donor grafts is the responsibility of the transplant community.Living donor LT for HCC should only be performed after careful assessment of the recipient and tumor status. Although tumor size and number are references widely adopted in tumor staging, biological staging of tumors using positron emission tomography could provide additional information of tumor behavior. A high level of serum α-fetoprotein also warns against LT because it is predictive of a high HCC recurrence rate.
Hepatopancreatoduodenectomy (HPD) is the combination of major hepatectomy and pancreatoduodenectomy(PD). The use of this procedure was first reported by Takasaki et al1 in 1980. With the improvements ...of surgical techniques and intensive care, many centers can perform pancreatic resection or partial hepatic resection with a mortality rate of <5%.2-4However, HPD is not a widely applied procedure because of its high mortality rate (14%-50%)5-10 resulting mainly from pancreatic fistula or liver failure related to resected liver volume and operative blood loss. Indications for HPD and the role of this operation have not been adequately analyzed. This study is to review our experience with this complicated procedure.
Hepatitis B is endemic in many regions of Asia, including China, Korea and India. This results in a heavy burden of hepatocellular carcinoma (HCC) because hepatitis B virus is a major risk factor in ...the development of the disease. In addition, the incidence of hepatitis-C-related HCC is on the rise in the United States. HCC patients with poor liver function reserve are not suitable candidates for resection, and liver transplantation (LT) has emerged as the treatment of choice for small unresectable HCCs. To treat more HCC patients with LT, the standard patient selection criteria have been expanded at a number of centers. Careful and well-considered selection of patients is the key to success in LT for HCC. Although tumor size and tumor number are used to predict whether transplantation is likely to be successful, the weighting that should be attached these two parameters has not been determined. In addition to the size and number of lesions, the morphology of HCC is also predictive of its behavior. Well-circumscribed lesions, in general, are less aggressive than those with poorly defined borders. On the waiting list for LT, HCC patients compete with liver failure patients. It is essential that the criteria used for selecting HCC patients for LT should be easily applicable and fair to other transplant candidates. In the face of the scarcity of deceased-donor livers and the inevitable risks for living liver donors, a predictably low rate of recurrence of HCC after LT is mandatory.
PDF
