Management of complications of cirrhosis in liver transplant candidates
1
Average # Days until transplant Largest tumor (mm) Average number of tumors Tumor size post-Rx Tumor necrosis at explant Average change in AFP Treated (7) 482 45.417.1 2.0 28.019.0 75% -400 Untreated (2) 65 24.011.0 1.8 — 2.5% 23 P-Value 0.03 NS NS 0.03 0.0003 NS Conclusions: Small HCC can be effectively treated using local ablation therapy. 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, tumor necrosis, or response to treatment. 262 A META-ANALYSIS OF URSODEOXYCHOLIC ACID FOR THE TREATMENT OF PRIMARY SCLEROSING CHOLANGITIS Steven E. Gruchy, M.D.*, John M. Fardy, M.D. Memorial University of Newfoundland, 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 lethal clinical situations including liver cirrhosis. Ursodeoxycholic acid (UDCA) has been shown to be effective in another cholestatic liver disease, primary biliary cirrhosis. A number of randomized clinical trials using UDCA for the treatment of PSC have been carried out with different results. The main objective of this study was to determine if the literature provides evidence that UDCA is effective at preventing disease progression in patients with PSC. Methods: Meta-analysis was used to evaluate the effect of UDCA on the rate of disease progression in patients with PSC. Only randomized con- trolled trials that compared UDCA to placebo were included. Three fully published randomized controlled trials as well as one published in abstract form were identified in the literature. A combined end point was used to determine disease progression. This end point consisted of liver biochem- istries and liver histology. Results: Pooling of the three fully published randomized controlled trials yielded a standard difference, UDCA compared to placebo, in alkaline phosphatase (ALP) of 18.97 U (95% CI, 8.78, 29.15) favoring UDCA. A standard difference in bilirubin of 15.61 mg/dl (95% CI, 5.200, 26.03) favoring UDCA. Stastitical heterogeneity was not reached when pooling the individual liver biochemistries. An odds ratio of improvement of liver histology 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 liver biochemistries; however, whether this improvement in liver biochemistry can be translated into an actual improvement in liver histology and pre- vention of disease progression can only be determined through further study. 263 MANAGEMENT OF COMPLICATIONS OF CIRRHOSIS IN LIVER TRANSPLANT CANDIDATES Guilherme 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 as it has been recognized that improving biological conditions of liver trans- plant (OLT) candidates has a significative impact in post OLT morbidity and mortality. Methods: We have evaluated in a 8,5 years period, 240 cirrhotics for transplantation. After identification and exclusion of high risk candidates, 164 patients with Child-Pugh 8 were selected for elective OLT; all clinical events before OLT were registered. Results: Mean waiting list time was 11 months, and global mortality was 18%. In 60 patients pharmacological primary prophylaxis was begun and in 84, prevention of recurrent bleedind was achieved, along with propran- olol, with endoscopic sclerotherapy in acute bleeding (39 patients), elective sclerotherapy (36) and banding (9). In 6 patients hypertonic glucose was injected in bleeding gastric varices and TIPS was used in 5 patients. In 85 patients with ascitis, diuretics were efficient in 50, but in 35 repeated paracentesis was needed and in 3 patients TIPS were effective in controling refractory ascitis. In 24 patients, spontaneous bacterial peritonitis was diagnosed, and all were subsequently enrolled in secondary prophylaxis with quinolone. Only 70 of the 84 bleeding cirrhotic patients were sub- mitted to antibiotics during in-hospital management. Encephalopathy was the main feature in 14 patients (excluding post bleeding or post infection episodes). In 6 hepatocellular carcinoma patients, intention to cure surgery was performed; in 10 patients with hemochromatosis, phlebotomies were begun, and in 10 Wilson’s disease patients, oral chelating agents were given. One HCV cirrhotic patient had a spontaneous liver rupture and had angiographic embolization. Only 20 of 32 HCV cirrhotics were able to had interferon plus ribavirin pre OLT, and lamivudine was begun in 15 HBV infected candidates. Conclusions: We conclude that the inclusion of cirrhotics in a OLT list is a dynamic and evolving process, consuming significative clinical and technical resources, but warrants an improved medical assistance to a particularly high risk group of patients. 264 RECOMBINANT ERYTHROPOIETIN FOR TREATMENT OF PEGUILATED INTERFERON-RIBAVIRIN INDUCED ANEMIA Susana 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 accumulation of ribavirin thriphosphate in red blood cells, which promotes extravascular hemolysis in reticuloendothelial system. Sometimes a significant drop of hemoglobin to less than 10 g/dl, implies dose reduction or withdrawal, because of impaired quality of life and higher risk of cardiovascular morbidity. in oncological studies, it has been suggested that recombinant erythropoietin (RhuEpo) particularly in highly symptomatic patients could achieve to mantain recommended ribavirin dosage for hepatitis C therapy. We present the clinical features of a 28 years old male, transfused in childhood 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 mild necroinflammatory activity with no fibrous septa. At the 4 th month of PegINF 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 negative PCR. He was profoundly asthenic, with orthopneia, and begun 40.000 U/week of RhuEpo, with clinical and biochemical follow up every 2 weeks. At the 8 th week of RhuEpo use (6 month PegINF RBV treatment), his Hgb 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 NEW SUBGROUP OF PATIENTS ELIGIBLE FOR ANTIVIRAL TREATMENT Guilherme 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
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Transcript of Management of complications of cirrhosis in liver transplant candidates
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.
262
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
