Average #Days untiltransplant

Largesttumor(mm)

Averagenumber of

tumors

Tumorsize

post-Rx

Tumornecrosis

at explant

Averagechangein AFP

Treated (7) 482 45.4�17.1 2.0 28.0�19.0 75% -400Untreated (2) 65 24.0�11.0 1.8 — 2.5% �23P-Value 0.03 NS NS 0.03 0.0003 NS

Conclusions: Small HCC can be effectively treated using local ablationtherapy. The tumor size can be reduced significantly using chemoemboli-zation, alcohol injection, acetic acid injection, or radio-frequency ablation.Tumor ablation significantly prolongs patient survival on the liver trans-plant list. Tumor necrosis is significantly greater in the treatment group.Serial measurements of AFP do not correlate with tumor size, tumornecrosis, or response to treatment.

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A META-ANALYSIS OF URSODEOXYCHOLIC ACID FOR THETREATMENT OF PRIMARY SCLEROSING CHOLANGITISSteven E. Gruchy, M.D.*, John M. Fardy, M.D. Memorial University ofNewfoundland, St. John’s, NF, Canada.

Purpose: Primary sclerosing cholangitis (PSC) is a progressive liver dis-ease of unknown etiology. This disease can lead to many potential lethalclinical situations including liver cirrhosis. Ursodeoxycholic acid (UDCA)has been shown to be effective in another cholestatic liver disease, primarybiliary cirrhosis. A number of randomized clinical trials using UDCA forthe treatment of PSC have been carried out with different results. The mainobjective of this study was to determine if the literature provides evidencethat UDCA is effective at preventing disease progression in patients withPSC.Methods: Meta-analysis was used to evaluate the effect of UDCA on therate of disease progression in patients with PSC. Only randomized con-trolled trials that compared UDCA to placebo were included. Three fullypublished randomized controlled trials as well as one published in abstractform were identified in the literature. A combined end point was used todetermine disease progression. This end point consisted of liver biochem-istries and liver histology.Results: Pooling of the three fully published randomized controlled trialsyielded a standard difference, UDCA compared to placebo, in alkalinephosphatase (ALP) of 18.97 U (95% CI, 8.78, 29.15) favoring UDCA. Astandard difference in bilirubin of 15.61 mg/dl (95% CI, 5.200, 26.03)favoring UDCA. Stastitical heterogeneity was not reached when poolingthe individual liver biochemistries. An odds ratio of improvement of liverhistology in the UDCA group compared to the placebo group was 2.980(95% CI, 0.823–10.79), which was not significant.Conclusions: These results may indicate that UDCA can improve liverbiochemistries; however, whether this improvement in liver biochemistrycan be translated into an actual improvement in liver histology and pre-vention of disease progression can only be determined through furtherstudy.

263

MANAGEMENT OF COMPLICATIONS OF CIRRHOSIS INLIVER TRANSPLANT CANDIDATESGuilherme Macedo, Ph.D.*, Susana Lopes, M.D.,Fernando Araujo, M.D., Sonia Barroso, M.D., Jose Costa Maia, M.D.,Tavarela Veloso, Ph.D. H.S.Joao, Porto, Portugal.

Purpose: Treating complications of cirrhosis became an important issue asit has been recognized that improving biological conditions of liver trans-plant (OLT) candidates has a significative impact in post OLT morbidityand mortality.Methods: We have evaluated in a 8,5 years period, 240 cirrhotics fortransplantation. After identification and exclusion of high risk candidates,

164 patients with Child-Pugh �8 were selected for elective OLT; allclinical events before OLT were registered.Results: Mean waiting list time was 11 months, and global mortality was18%. In 60 patients pharmacological primary prophylaxis was begun andin 84, prevention of recurrent bleedind was achieved, along with propran-olol, with endoscopic sclerotherapy in acute bleeding (39 patients), electivesclerotherapy (36) and banding (9). In 6 patients hypertonic glucose wasinjected in bleeding gastric varices and TIPS was used in 5 patients. In 85patients with ascitis, diuretics were efficient in 50, but in 35 repeatedparacentesis was needed and in 3 patients TIPS were effective in controlingrefractory ascitis. In 24 patients, spontaneous bacterial peritonitis wasdiagnosed, and all were subsequently enrolled in secondary prophylaxiswith quinolone. Only 70 of the 84 bleeding cirrhotic patients were sub-mitted to antibiotics during in-hospital management. Encephalopathy wasthe main feature in 14 patients (excluding post bleeding or post infectionepisodes). In 6 hepatocellular carcinoma patients, intention to cure surgerywas performed; in 10 patients with hemochromatosis, phlebotomies werebegun, and in 10 Wilson’s disease patients, oral chelating agents weregiven. One HCV cirrhotic patient had a spontaneous liver rupture and hadangiographic embolization. Only 20 of 32 HCV cirrhotics were able to hadinterferon plus ribavirin pre OLT, and lamivudine was begun in 15 HBVinfected candidates.Conclusions: We conclude that the inclusion of cirrhotics in a OLT list isa dynamic and evolving process, consuming significative clinical andtechnical resources, but warrants an improved medical assistance to aparticularly high risk group of patients.

264

RECOMBINANT ERYTHROPOIETIN FOR TREATMENT OFPEGUILATED INTERFERON-RIBAVIRIN INDUCED ANEMIASusana Lopes, M.D., Guilherme Macedo, Ph.D.*, Berta Carvalho, M.D.,Tavarela Veloso, Ph.D. H.S.Joao, Porto, Portugal.

Purpose: Hemolysis is an universal phenomenon in ribavirin treatment,with interferon, in HCV infected patients. It occurs after the accumulationof ribavirin thriphosphate in red blood cells, which promotes extravascularhemolysis in reticuloendothelial system. Sometimes a significant drop ofhemoglobin to less than 10 g/dl, implies dose reduction or withdrawal,because of impaired quality of life and higher risk of cardiovascularmorbidity. in oncological studies, it has been suggested that recombinanterythropoietin (RhuEpo) particularly in highly symptomatic patients couldachieve to mantain recommended ribavirin dosage for hepatitis C therapy.We present the clinical features of a 28 years old male, transfused inchildhood in a right nephrectomy, and recognized to be infected with HCV,genotype 1b (5,98 log) in 2002. Before treatment Hgb was 13,5 g/dl,normal renal function and ALT 152 / AST 102. Histology showed mildnecroinflammatory activity with no fibrous septa. At the 4th month ofPegINF � RBV therapy, with adjusted dose to BMI (80 �g w PegINF �800 mg qd RBV), Hgb dropped to 9,2 g/dl, with normal ALT and negativePCR. He was profoundly asthenic, with orthopneia, and begun 40.000U/week of RhuEpo, with clinical and biochemical follow up every 2 weeks.At the 8th week of RhuEpo use (6 month PegINF � RBV treatment), hisHgb was 12,8 g/dl, assymptomatic with normal blood pressure, and reas-sumed the antiviral treatment schedule as from the beginning.

265

HEPATITIS B VIRUS INFECTION : DEFINITION OF A NEWSUBGROUP OF PATIENTS ELIGIBLE FOR ANTIVIRALTREATMENTGuilherme Macedo, Ph.D.*, Susana Lopes, M.D.,Fernando Araujo, M.D., Fatima Carneiro, Ph.D.,Tavarela Veloso, Ph.D. H.S.Joao, Porto, Portugal.

Purpose: The group of HBsAg positive patients with permanent or inter-mittent viral replication inhibition, is highly heterogeneous and includes :coinfected patients (with HCV or HDV), inactive carriers and patients with

S90 Abstracts AJG – Vol. 98, No. 9, Suppl., 2003

slight variations of viral load only detected with sensitive HBV DNAassays. The relative strength of this group is relatively unknown, but couldbe a very important to treatment with new and safe antivirals, given the wellknown risk of hepatocellular carcinoma and progression to cirrhosis, beinggenerally excluded from regular trials because of normal transaminases(ALT).Methods: We prospectively evaluated 148 HBsAg positive patients during54 months. HBV DNA was assessed every 6–9 months by PCR. Histologyand immunohistochemmistry was available in all patients.Results: Positive HBV DNA was detected in 115/148, with normal ALTin 26% (39). All positive DNA with normal ALT were AntiHBe�(HBeAg-). Only 22% of HBsAg � patients had minimal lesions, withvariable degrees of hepatitis and cirrhosis in all others. Only 23% areproperly defined as inactive carriers, as 77% had DNA persistently ortemporarily detected by PCR. Cirrhosis was diagnosed in 12% of inactivecarriers, 8% of normal ALT patients with � DNA, and in 35% of abnormalALT patients.Conclusions: We conclude that beyond the classical candidates for anti-viral treatment (51%), in our population of patients, a significative group(26%) could be enrolled in therapeutic trials if the treatment goal is toerradicate HBV DNA.

266

THE NEED OF VACCINATION AGAINST HEPATITIS A INPATIENTS WITH CHRONIC LIVER DISEASE : FACT ORFANCY?Guilherme Macedo, Ph.D.* Susana Lopes, M.D. Fernando Araujo, M.D.Tavarela Veloso, Ph.D. H S Joao, Porto, Portugal.

Purpose: It has been suggested that there is an ongoing change in recentyears, in the prevalence of anti HAV antibody among portuguese popula-tion, particularly related to overall improvement in sanitary conditions,both in urban and rural areas in the last 3 decades. This lower prevalencewould be related with the lower infection rate in children, adolescents andyoung adults.Methods: Given the recommendations for anti HAV vaccination in chronicliver disease patients, we analysed the prevalence of anti HAV antibody in320 patients from the Hepatology out-patient clinic with mean age of 48years (18-75). Seroconversion was assessed at the 7th month (1 month afterbooster dose).Results: Only in 13 patients (4%) with chronic liver disease, the anti HAVwas not detected. Their mean age is 25 (18–40) years old. Anti HAVprevalence was 87% in � 40 years old patients (85/98) and 100% in � 40years old patients (222/222). Their clinical features are presented (5 withHCV chronic hepatitis, 6 with HBV chronic hepatitis, 1 with AlagilleSyndrome and one post liver transplantation for fulminant hepatitis) andtheir seroconversion rate was 100% .Conclusions: We conclude that, even if among out-patient population thereis a lower prevalence of anti HAV antibody, pre vaccination testing ismandatory, and its use is expected to be exceptional in chronic liver diseasepatients older than 40.

267

CORRELATION OF SERUM HEPATITIS C VIRUS RNA LOADAND ITS ASSOCIATION WITH ALANINEAMINOTRANSFERASE IN PATIENTS REPORTING TOGASTROENTEROLOGY AND LIVER CLINIC OF HOLYFAMILY, RAWALPINDI, PAKISTANMohammad Umar, F.C.P.S., Faiz Anwar, F.C.P.S.,Hamama Tul Bushra, F.C.P.S.*, Atifa Shoaib, F.C.P.S.,Amir Chohan, M.B.B.S. Rawalpindi Medical College, Rawalpindi,Punjab, Pakistan.

Purpose: Serum Hepatitis C virus RNA load is among the importantfactors in determining the response to anti-viral therapy in chronic HepatitisC patients. This study was conducted to see pattern of viral load in patients

with chronic hepatitis C in local population and its association with alanineAminotransferase.Methods: We have studied viral load in 50 patients. These are divided into4 categories according to age. We also calculated the relationship betweenviral load and alanine Aminotransferase (ALT). Patients were tested forALT and viral load with Amplicor HCV RNA essay for qualitative detec-tion and DNA essay for quantitative estimation.Results: Total patients are 50, with age ranging from 22 to 56 years. Meanage is 38.94 � 8.52 SD. Females are 21 (42%), Males are 29 (58%); agebetween 20 to 30 years are 8 (16%), between 31 to 40 years are 25 (50%),between 41 to 50 are 12 (24%), 5 (10%) have age greater than 50 years.Mean viral load is 20.44 MEq/ml. 19 (38%) patients have viral load lessthan 3 MEq/ml and 31 (62%) patients have greater than 3 MEq/ml. MeanALT is 112 IU/L.Conclusions: Most patients have viral load � 3 MEq/ml (3 million copies/ml). Mean viral load in patients more than 50 years was significantly (p �0.01) higher than other patients. No positive correlation was found betweenALT and HCV RNA viral load (p � 0.05).

268

A CASE OF HEPATIC AMYLOIDOSIS WITH A RAPIDLYPROGRESSIVE COURSEGeorgios I. Papachristou, M.D.*, Shelly S. Lo, M.D.,Toby O. Graham, M.D. University of Pittsburgh Medical Center,Pittsburgh, PA.

Background: Amyloidosis is a rare disorder of protein metabolism thatleads to extracellular tissue deposition of insoluble proteinaceous material.Although hepatic involvement is common in systemic amyloidosis, clini-cally significant liver failure is very rare. We report a case of primaryamyloidosis, AL type, with massive hepatomegaly complicated by swiftlyprogressive liver failure.Case: A 58 year-old African American female visited her primary physi-cian with a 10 day history of epigastric fullness and fatigue. She reportedhaving dark urine, pale stools, and pruritus. On examination she had scleralicterus and a vertical liver span of 20 cm. Laboratory findings weresignificant for abnormal liver tests (AST 91 IU/liter , ALP 1887 IU/liter ,total bilirubin 8.9 mg/dl with a direct of 5.2 mg/dl), hypoalbuminemia (1.8g/dl), and mild coagulopathy (INR 1.4). CT scan showed hepatomegalywith diffusely homogenous low attenuated hepatic parenchyma suggestiveof an infiltrative process. Liver biopsy revealed diffuse parenchymal infil-tration by acellular material with hepatocyte compression and loss. Theimmunostain for amyloid protein P was positive. The M spike (IgG kappa)on electrophoresis confirmed a diagnosis of primary amyloidosis, AL type.One month following diagnosis, she developed liver failure, complicatedby S. viridans sepsis, renal and respiratory failure, and expired.Discussion: Primary systemic amyloidosis (AL) is a plasma cell dyscrasiaassociated with a monoclonal protein derived from immunoglobulin lightchain fragments. The liver is commonly involved in all forms of systemicamyloidosis, especially in AL. Hepatomegaly, modest elevations in ALP,and hypoalbuminemia are the most common features. The presence ofhyperbilirubinemia suggests an ominous prognosis and most deaths arerelated to renal or cardiac complications. Treatment of AL focuses onsuppressing the underlying B cell monoclonal proliferative disorder. Treat-ment options include chemotherapy alone, or chemotherapy followed byautologous stem-cell transplantation in patients with a high performancestatus. In individuals with isolated advanced hepatic amyloidosis, ortho-tropic liver transplantation followed by autologous stem-cell transplanta-tion has been recommended. In the above case, a question remains whetherinitiation of chemotherapy or liver transplantation at the time of presenta-tion, would have altered the patient’s rapid downhill course.

S91AJG – September, Suppl., 2003 Abstracts