Review of Medical Management of Primary Biliary Cholangitis.

Primary biliary cholangitis (PBC) is a chronic cholestatic liver disease with presumed autoimmune etiology. Current treatment options include ursodeoxycholic acid, obeticholic acid, and fibrate, which target mainly cholestasis. There is no effective therapy against autoimmune or hepatic fibrosis components. We can still achieve adequate biochemical response with monotherapy or a combination of medications in non-cirrhotic and compensated cirrhotic PBC patients. Several criteria are available for risk stratification and assess treatment response. Liver stiffness measurement by transient elastography is also a useful tool for evaluating disease progression. Lack of treatment or inadequate response are predictors of poor outcome. There is a strong need for additional therapies for PBC.

Castleman's Disease and Posttransplant Lymphoproliferative Disorder after Liver Transplant: 3-Year Follow-Up.

A 59-year-old male with a history of hepatitis C cirrhosis and history of hepatitis B exposure presented 8 months after orthotopic liver transplant (LT) with fever, fatigue, myalgia, night sweats, nonproductive cough, and shortness of breath. Bone marrow biopsy for pancytopenia was positive for Epstein-Barr virus (EBV) DNA. Lymph node biopsy for lymphadenopathy on imaging showed human herpes virus 8 (HHV8) associated Castleman's disease. Treatment included valganciclovir, rituximab, and prednisone taper with eventual discontinuation. Quantitative HHV8 DNA was initially 611,000 DNA copies/mL and was later undetectable at 6 months following treatment and remained undetectable at 3-year follow-up.

Impact of anti-thymocyte globulin during immunosuppression induction in patients with hepatitis C after liver transplantation.

BACKGROUND: Induction immunosuppression with anti-thymocyte globulin (ATG) provides potential benefits after liver transplantation (LT). However, its use in patients with LT and hepatitis C (HCV) is controversial. AIM: To evaluate the 1- and 2-year patient survival and HCV recurrence rate in patients receiving ATG during the induction phase of immunosuppression (IPI) after LT. METHODS: A total of 49 patients undergoing their first LT for HCV were randomized to receive ATG during IPI. Patient survival and HCV recurrence were determined at 1 and 2 years. The frequency of acute cellular rejection (ACR), infections, and neoplasms was also evaluated. RESULTS: Twenty-six patients were randomized to receive ATG (Arm-1) and 23 to standard induction therapy (Arm-2). Those given ATG had lower HCV recurrence (26.9 vs 73.9 %, p = 0.001). The 1- and 2-year patient survival rates were similar for both arms (p = 0.33). Infections occurred in 46.1 % subjects in Arm-1 and 34.7 % in Arm-2 (p = 0.562). There was a greater proportion of fungal infections in Arm-1 (19.2 vs 0 %, p = 0.032). CONCLUSIONS: ATG during the IPI was associated with lower frequency of recurrence of HCV in patients undergoing LT. This, however, did not affect the 1- and 2-year survival and the frequency of ACR, infections, or neoplasms.

[Post-transplant hepatitis C. Immunosuppression and antiviral treatment]. / Hepatitis C postrasplante. Inmunosupresión y tratamiento antiviral.

There is always a second infection with HCV during the post-transplant period. Recurrence of the disease is one of the main present therapeutic challenges because there are still many questions to answer. Some transplant groups suggest that recurrence is earlier in certain circumstances, especially in face of repetitive episodes of acute rejection in the early post-transplant period. Different transplant centers have various approaches to minimize the risk of recurrence secondary to excessive immunosuppression. They go from absolute avoidance of steroids to single therapy with inhibitors of calcineurin. Some investigators advocate for a fast reduction in the dose of corticosteroids (in less than 3 months), elimination of steroids from the therapy or administration of a single steroid dose in the immediate post-transplant period. Some are trying to establish a regime based on a single inhibitor of calcineurin and supported with mofetil micofenolate if it's effective. There are other inhibitors being studied, like anti-CD25 antibodies. The goals of the treatment for HCV recurrence must be aimed at obtaining an effective therapy that may be able to prevent the damage and to inhibit the viral replication and subsequent inflammation on long term basis. Recently there have been reports about different schemes with IFN and ribavirin, either as single therapy or in combination, that showed modest advances in early viral elimination and delaying the recurrence of the disease. One of the risks of therapy with interferon that has immunomodulation properties, is organ rejection. Ribavirin administration as single therapy is contraindicated. There are still some unanswered questions, since nobody knows for sure how long therapy for HCV should be continued.