ABSTRACT
Hepatitis C virus (HCV) infection may be associated with extra-hepatic illness including mixed cryoglobulinemia (MC). Consistent evidence exists on HCV-MC in the non-transplantation setting but information on HCV-related cryoglobulinemia after solid organ transplantation is limited, particularly after liver transplantation (LT). We report on a 48-year-old man who developed HCV-associated cryoglobulinemic vasculitis with recurrent hepatitis after liver transplant. One year after transplant for HCV-positive cirrhosis, he presented severe cutaneous manifestations, and biopsy-proven cryoglobulinemic membrano-proliferative glomerulonephritis (MPGN). HCV RNA clearance occurred within a few weeks of antiviral therapy; sustained viral response (SVR) was obtained by one year of anti-HCV combination therapy (eight months of pegylated IFN/ribavirin and four months of standard IFN/ribavirin). SVR was linked to complete remission of skin, liver, and kidney abnormalities. Tolerance to the pegylated IFN/ribavirin regimen was not excellent due to the occurrence of lobar pneumonia with anemia; thus, peg-IFN was replaced by recombinant IFN, with a favorable outcome. Clinical and viral remission persisted over a 48-month follow-up. HCV-associated mixed cryoglobulinemia flareups following LT were successfully managed with combined antiviral therapy. HCV-related MC is uncommon in developed countries and this clearly hampers randomized controlled clinical trials aimed at evaluating the efficacy and safety of anti-HCV therapy after solid organ transplantation or in the non-transplantation setting.
Subject(s)
Antiviral Agents/therapeutic use , Cryoglobulinemia/drug therapy , Hepatitis C/drug therapy , Liver Transplantation/adverse effects , Cryoglobulinemia/diagnosis , Cryoglobulinemia/virology , Drug Substitution , Drug Therapy, Combination , Glomerulonephritis, Membranoproliferative/diagnosis , Glomerulonephritis, Membranoproliferative/drug therapy , Glomerulonephritis, Membranoproliferative/virology , Hepatitis C/complications , Hepatitis C/diagnosis , Humans , Interferon alpha-2 , Interferon-alpha/therapeutic use , Male , Middle Aged , Polyethylene Glycols/therapeutic use , Recombinant Proteins/therapeutic use , Recurrence , Ribavirin/therapeutic use , Time Factors , Treatment OutcomeABSTRACT
OBJECTIVE: To investigate the rate of immediate persistent bleeding requiring haemostasis and of delayed bleeding after endoscopic sphincterotomy in liver transplanted patients. METHODS: Clinical records of patients who underwent endoscopic sphincterotomy at our Center between January 2003 and December 2009 were reviewed. Platelets count, international normalized ratio, aminosalicylic acid use, presence of cholangitis and use of precut were evaluated as risk factors for bleeding. Crude and adjusted risk ratios (RR) with 95% confidence interval were calculated, using Poisson model. RESULTS: Forty-nine liver transplanted patients and 202 controls were studied. Rate of delayed bleeding, but not need of immediate haemostasis, was increased in liver transplanted patients, RRs of 11.0 (3.0-40.0) and 1.5 (0.7-3.4) respectively. The RR of delayed bleeding remained unchanged once adjusted for the other evaluated variables. CONCLUSION: In liver transplanted patients, the risk of bleeding after endoscopic sphincterotomy is markedly increased. Reasons for this increase still need to be elucidated.
Subject(s)
Liver Transplantation/adverse effects , Postoperative Hemorrhage/etiology , Sphincterotomy, Endoscopic/adverse effects , Adolescent , Adult , Aged , Aged, 80 and over , Cholangiopancreatography, Endoscopic Retrograde/adverse effects , Epidemiologic Methods , Female , Hemostasis, Surgical/methods , Humans , Male , Middle Aged , Platelet Count , Postoperative Care/methods , Postoperative Hemorrhage/therapy , Postoperative Period , Young AdultABSTRACT
BACKGROUND: Estrogen receptor-alpha (ERalpha) is variably expressed in hepatocellular carcinoma (HCC) and is believed to be correlated with prognosis and survival. Recently, another estrogen receptor (ERbeta) has been identified, but its relevance in liver diseases is unknown. METHODS: The expression of ERbeta in the liver of 42 patients with HCC (10 with paired extratumoral tissues) and 26 with chronic liver disease without HCC was studied by a reverse transcriptase-polymerase chain reaction method, and correlated with the expression of ERalpha and severity of the liver disease. RESULTS: Both ERbeta and wild-type ERalpha were found to be expressed more often in patients with chronic liver disease compared with those with HCC (69% vs. 45% [P = 0.046] and 46% vs. 10% [P = 0.0008], respectively). ERs were similarly expressed in HCC and in the paired extratumoral tissue. Wild-type receptors, either alone or together with the deleted mutants ERdelta5, were more often coexpressed in chronic liver disease (58%) than in HCC (29%); in 13 tumors (31%), either ERdelta5 or no receptors at all were detected (P = 0.006). Hepatitis B virus (HBV)-related tumors either did not appear to express ERs or expressed ERdelta5 more often than hepatitis C virus (HCV)-related tumors (67% vs. 15%; P = 0.007). The same was true for multinodular compared with single nodular tumors (50% vs. 19%; P = 0.04). CONCLUSIONS: Both receptors were expressed in chronic liver disease and neoplastic livers demonstrating different patterns in relation to the etiology and clinical presentation of the tumor. These differences might underscore different pathogenetic mechanisms in HBV-related and HCV-related HCC and a different evolutionary course for the tumor.
