The utility of gadoxetic acid-enhanced magnetic resonance imaging in the surveillance for postoperative recurrence of hepatocellular carcinoma.

This study aimed to investigate the utility of gadoxetic acid-enhanced magnetic resonance imaging (Gd-MRI) in surveillance for recurrent hepatocellular carcinoma (HCC) after hepatectomy.This retrospective study analyzed 147 patients who underwent surveillance with alternating multidetector computed tomography (MDCT) and Gd-MRI after hepatectomy for HCC. The patients were followed-up every 3 months during the first 2 years, and every 6 months thereafter. At each visit, MDCT was performed but once a year (every 12 months), Gd-MRI was performed instead of MDCT. Each HCC recurrence detection rate of MDCT and Gd-MRI was evaluated, and recurrent HCC characteristics were compared according to the detection test.A total of 63 patients had recurrent HCC. Among them, 9 were detected with Gd-MRI and 29 with MDCT. The baseline characteristics of patients with recurrent HCC showed no significant differences according to the detection test. The HCC recurrence detection rate of Gd-MRI and MDCT was 4.8% (9/180) and 4.3% (29/580), respectively, on the per test basis (P = 0.764). However, in the population with a follow-up period of ≥12 months, the detection rate of Gd-MRI and MDCT was 4.3% (7/150) and 1.5% (19/400), respectively (P = 0.035). Recurrent HCCs detected with Gd-MRI were smaller than those detected with MDCT (tumor size < 2 cm, 100% vs 65.5%, P = 0.040).Our data suggest that Gd-MRI has advantages in detecting recurrent HCC after hepatectomy. Surveillance with alternating MDCT and Gd-MRI may identify more recurrent HCC in an early stage than with MDCT alone in patients who received hepatectomy for HCC.

Impact of EGF, IL28B, and PNPLA3 polymorphisms on the outcome of allograft hepatitis C: a multicenter study.

Hepatitis C virus (HCV) infection is accelerated following liver transplantation (LT). Single nucleotide polymorphisms (SNPs) near the epidermal growth factor (EGF) (rs4444903), IL28B (rs12979860), and PNPLA3 (rs738409) loci are associated with treatment response, fibrosis, and hepatocellular carcinoma in non-transplant hepatitis C, but allograft population data are limited. We sought to determine the role of these SNPs in 264 patients with HCV who underwent LT between 1990 and 2008. Genotypes were determined from donor wedge/allograft biopsies and recipient explants. Cox proportional hazards model was used to assess time to cirrhosis, liver-related death, and retransplantation, adjusting for donor age and sustained virological response (SVR). Over a median follow-up of 6.3 yr, a trend toward increased progression to graft cirrhosis was observed among recipients of an EGF non-AA vs. AA donor liver (adjusted HR 2.01; 95% CI 0.93-4.34; p = 0.08). No other genotypes predicted cirrhosis development or graft survival. The CC IL28B variant in both recipients and donors was associated with increased rate of SVR (R-CC/D-CC 8/12[67%], R-non-CC/D-CC or R-CC/D-non-CC 23/52[44%], R-non-CC/D-non-CC 12/45[27%], p linear trend = 0.009). Recipient EGF, IL28B, and PNPLA3, and donor IL28B and PNPLA3 genotypes do not predict adverse outcomes in HCV LT recipients. A potential association exists between donor EGF genotype and cirrhosis.

Feasibility of α-fetoprotein as a diagnostic tool for hepatocellular carcinoma in Korea.

BACKGROUND/AIMS: The aim of this study was to evaluate the feasibility of α-fetoprotein (AFP) as a diagnostic tool for hepatocellular carcinoma (HCC) in Korean patients. METHODS: We retrospectively reviewed the medical records of HCC and cirrhosis patients at three hospitals. For each HCC patient, a cirrhosis patient matched for age, sex, etiology, and Child-Pugh classification was selected by simple random sampling. The performance of AFP in the diagnosis of HCC was determined using receiver operating characteristic curve analysis. RESULTS: A total of 732 patients with HCC or cirrhosis were selected for each case and the control groups. The mean age was 54 years, and 72.4% of patients were male. The mean serum AFP levels in the HCC group and cirrhosis group were 3,315.6 and 117.2 ng/mL, respectively (p < 0.001). The area under the receiver operating characteristic curve for all HCC patients was 0.757. The sensitivity, specificity, and positive predictive value of AFP was 50.55%, 87.70%, and 80.43%, respectively, at a cut-off of 20 ng/mL; 37.70%, 95.90%, and 90.20%, respectively, at a cut-off of 100 ng/mL, and 30.05%, 97.27%, and 91.67%, respectively, at a cut-off of 200 ng/mL. A cut-off of 100 ng/mL was more sensitive than one of 200 ng/mL with equivalent specificity and positive predictive value. CONCLUSIONS: The cut-off AFP value for early-stage HCC was 17.4 ng/mL. Our study cautiously suggests that AFP has a role in the diagnosis of HCC, and that the appropriate value of AFP for the diagnosis of HCC may be 100 ng/mL rather than 200 ng/mL.

A prediction model for liver abscess developing after transarterial chemoembolization in patients with hepatocellular carcinoma.

BACKGROUND: Liver abscess is a rare but potentially fatal complication of transarterial chemoembolization. Other than for biliary abnormalities, risk factors for liver abscess formation after transarterial chemoembolization have rarely been discussed. AIMS: To identify other risk factors of liver abscess after transarterial chemoembolization in patients with hepatocellular carcinoma. METHODS: Data for 5299 patients with hepatocellular carcinoma who underwent transarterial chemoembolization from July 1999 to December 2009 were retrospectively reviewed. 72 patients who experienced liver abscess after transarterial chemoembolization were enrolled as a case group, which was compared with a randomly selected control group (n=1009) of patients who did not develop liver abscess after transarterial chemoembolization. RESULTS: Pneumobilia, type 2 biliary abnormality, type 1 biliary abnormality, diabetes mellitus, tumour number (≥3), tumour size (≥3cm), and tumour necrosis on the pre-transarterial chemoembolization computed tomography, and gelfoam embolization and vessel injury during transarterial chemoembolization were all significant predisposing factors for liver abscess after transarterial chemoembolization. A prediction model for postembolization liver abscess was developed from these risk factors. CONCLUSION: The group of patients with risk scores greater than 71 showed a significantly increased risk of liver abscess after transarterial chemoembolization. These high-risk patients should be monitored carefully after transarterial chemoembolization.

Long-term survival after surgical resection for huge hepatocellular carcinoma: comparison with transarterial chemoembolization after propensity score matching.

BACKGROUND AND AIMS: Surgical resection (SR) and transarterial chemoembolization (TACE) have been commonly applied for patients with huge hepatocellular carcinoma (HCC). However, optimal treatment has not been established. METHODS: Between 2000 and 2009, 267 patients with huge HCC (≥ 10 cm) underwent TACE and 84 underwent SR as the first treatment. Propensity score matching generated a matched cohort composed of 152 patients. We investigated overall survival and possible prognostic factors. RESULTS: At baseline, the surgery group showed a tendency to have solitary tumor (72.6% vs 39.3%, P < 0.001), less vessel invasion (29.8% vs 51.3%, P < 0.001), and unilobar tumor extent (77.4% vs 50.9%, P < 0.001) than TACE group. During median follow up of 10 months (range: 0-103), the surgery group showed higher 1-, 3-, and 5-year overall survival rates than TACE group (73.8%, 54.8%, and 39.8% vs 37.8%, 16.3%, and 9.7%, respectively, P < 0.001). In the propensity score-matched cohort, baseline characteristics did not differ between the two groups. Surgery group showed higher 1-, 2-, and 3-year overall survival rates than TACE group (69.7%, 58.6%, and 51.7% vs 40.2%, 33.9%, and 18.5%, respectively, P < 0.001) during median follow up of 14.5 months (range: 0-103). Multivariate analysis revealed that male (HR 1.90; 95% CI, 1.01-3.58; P = 0.048), albumin (HR 0.54; 95% CI, 0.34-0.85; P = 0.008), ascites (HR 1.77; 95% CI, 1.02-3.08; P = 0.044), and SR (HR 0.44; 95% CI, 0.28-0.70; P = 0.001) were the independent prognostic factors associated with survival. CONCLUSION: Comparing survival after SR and TACE, we showed that SR would be associated with better outcomes than TACE as the first treatment of huge HCC.

Clinical features, image findings, and prognosis of inflammatory pseudotumor of the liver: a multicenter experience of 45 cases.

BACKGROUND/AIMS: Inflammatory pseudotumor (IPT) of the liver is a rare disease characterized by chronic infiltration of inflammatory cells. However, the clinical characteristics and outcomes of IPT remain uncertain. METHODS: Clinical features, image findings, and outcomes of 55 patients with histologically proven IPT were evaluated. RESULTS: They consisted of 26 men and 19 women with median age of 65 years. Serum carcinoembryonal antigen and carbohydrate antigen 19-9 levels were normal in 42 patients (93.3%). Enhanced CT scans indicated poorly defined peripheral enhancement (82.5%) at the arterial phase and poorly defined hyperattenuating lesions with internal hypoattenuating areas at the equilibrium phase (77.0%). Gadolinium-enhancement MRI revealed poorly defined peripheral rim-like enhancement (77.8%). Ten patients underwent surgical resection and 35 were treated conservatively with or without antibiotics. No recurrence was noted after surgical resection during follow-up (1 to 48 months). In all patients who received conservative treatment, complete resolution or size reduction was noted during follow-up (1 to 192 months). CONCLUSIONS: CT and MRI provide clues to the diagnosis of IPT in patients with liver masses and normal tumor markers. However, due to the lack of pathognomonic findings, the clinician's suspicion and histological diagnosis are necessary to make an accurate diagnosis of IPT.

A nationwide seroepidemiology of hepatitis C virus infection in South Korea.

BACKGROUND & AIMS: The aim of this study was to reveal nationwide seroprevalence of HCV infection in South Korea by a large-scale survey. METHODS: From January to December 2009, a total of 291 314 adults underwent health check-up in 29 centres nationwide. The data concerning anti-HCV antibody and biochemical tests were obtained from all participants. Among subjects with positive anti-HCV, such data as HCV RNA, genotypes and treatment detail were additionally analysed. RESULTS: Using an estimated 2009 population of Korea, the age, sex and area-adjusted anti-HCV positive rate was 0.78%. Anti-HCV prevalence in female patients (0.83%) was higher than that in male patients (0.75%). Gradual increase in anti-HCV positivity was observed, from 0.34% in those aged 20-29 years to 2.31% in those >70 years. The age- and sex-adjusted anti-HCV prevalence varied in different areas, being higher in Busan and Jeonnam (1.53-2.07%), mid-level in Seoul and surrounding districts (0.50-0.61%) and lower in Jeju (0.23%). The comparative analysis of laboratory variables between anti-HCV (+) and anti-HCV (-) group revealed significantly higher levels of alanine aminotransferase and lower levels of serum lipids in anti-HCV (+) group. Among 1 718 anti-HCV positive subjects, serum HCV RNA was measured only in 478 people, of whom 268 (56.1%) patients had detectable HCV RNA in serum. Among 50 patients for whom assessment of response to antiviral therapy was feasible, overall sustained virological response was achieved in 84% of patients. CONCLUSION: The prevalence of HCV infection is low in South Korea. Studies to analyse risk factors are warranted to reduce HCV infection.

Photodynamic therapy for bile duct invasion of hepatocellular carcinoma.

The prognosis of patients with obstructive jaundice caused by hepatocellular carcinoma (HCC) is dismal, because effective biliary drainage is difficult due to frequent malfunction of the drainage tube caused by hemobilia and/or tumor emboli. Photodynamic therapy (PDT) improves biliary patency and prolongs survival in hilar cholangiocarcinoma. The aim of this study was to assess the safety and efficacy of PDT in unresectable HCC with bile duct invasion. Between January 2009 and September 2010, eleven patients with bile duct invasion of unresectable HCC were enrolled at Samsung Medical Center. PDT was performed with 180 J cm(-1) light activation 48 hours after administration of the photosensitizer at a dose of 2 mg kg(-1) body weight. Biliary drainages were performed in all patients. The safety and efficacy of PDT were prospectively evaluated. Eleven patients had successful PDT and biliary drainage. Jaundice improved in seven out of ten patients who had jaundice before PDT. Hemobilia, which had developed in six cases, was controlled by PDT. There were no complications from the photosensitizer. There was no 30-day mortality, and the mean survival was 140.5 days. PDT controlled hemobilia associated with bile duct invasion of HCC and could be an effective treatment option in these patients.

A comparison of clevudine and entecavir for treatment-naïve patients with chronic hepatitis B: results after 2 years of treatment.

BACKGROUND: This study was undertaken to compare the efficacy, safety, and resistance profile of clevudine (CLV) and entecavir (ETV) following a 2-year treatment period. METHODS: One hundred and eight Korean patients from the prior 48-week study were followed with continuous therapy for up to 2 years and monitored for hepatitis B virus (HBV) DNA levels, HBeAg seroconversion, serum ALT, emergence of drug-resistant mutant HBV, and drug-related adverse events. RESULTS: A complete virological response during the 2-year treatment period occurred in 68.0 % in the CLV group and in 84.5 % in the ETV group (p = 0.043). The cumulative percentage of patients with sustained virological responses at 2 years was 54.0 and 77.6 % in the CLV and ETV group, respectively (p = 0.010). Virological breakthrough occurred in 12 patients in the CLV group; however, there were none in the ETV group (p < 0.001). HBeAg seroconversion rates were not different between the two groups. In patients who maintained sustained virological responses at 2 years, the mean reduction in HBsAg titer was -0.24 and -0.06 log IU/ml in the CLV and ETV group, respectively (p > 0.05). Clinical myopathy occurred in seven patients in the CLV group; however, this was not observed in the ETV group (p = 0.004). CONCLUSIONS: ETV was associated with a significantly higher virological response rate than CLV at 2 years. ETV was superior to CLV in terms of the drug resistance profile and the development of clinical myopathy. Further studies to see whether the unique characteristic of CLV to reduce HBsAg titer is associated with the removal of ccc-DNA from hepatocytes and the remission of the disease are needed.

A clinical predictor of varices and portal hypertensive gastropathy in patients with chronic liver disease.

BACKGROUND/AIMS: The aim of this study was to identify the parameters that could noninvasively predict the presence of esophageal/gastric varices and portal hypertensive gastropathy (PHG) in patients with chronic liver disease (CLD), and to determine the accuracy of those parameters. METHODS: We retrospectively analyzed 232 patients with CLD who underwent both upper endoscopy and liver CT within an interval of 3 months. The multidimensional index (M-Index) for spleen volume was obtained from the multiplication of splenic length, width, and thickness, as measured by computer tomography. RESULTS: The multivariate analysis revealed that platelet, albumin, and M-Index were independently associated with the presence of varices and PHG. We combined three independent parameters, and developed a varices and portal hypertensive gastropathy (VAP) scoring system (=[platelet count (/mm(3))×albumin (g/dL)]/[M-Index (cm(3))]). The area under the receiver operating characteristic curve of the VAP score was 0.850 (95% confidence interval, 0.801-0.899). The VAP cut-off value of 861 had a sensitivity of 85.3%, a positive likelihood ratio of 3.17, and a negative predictive value of 86.4%. For predicting high-risk lesions for bleeding, with a cut-off value of 861 the sensitivity was 92.0%, the positive likelihood ratio was 2.20, and the negative predictive value was 96.4%. CONCLUSIONS: The VAP score can predict the presence of varices and PHG in patients with CLD and may increase the cost-benefit of screening endoscopy in the clinical practice setting. A prospective validation study is necessary in the future.

Comparison of usefulness of clinical diagnostic criteria for hepatocellular carcinoma in a hepatitis B endemic area.

BACKGROUND/AIMS: We compared the accuracy and usefulness of clinical diagnostic criteria for hepatocellular carcinoma in a hepatitis B virus (HBV)-endemic area. METHODS: We reviewed the medical records of 355 patients who had undergone liver resection or biopsy at our institution between January 2008 and December 2009. These patients were reevaluated using four noninvasive diagnostic criteria for hepatocellular carcinoma proposed by the European Association for the Study of the Liver (EASL), the American Association for the Study of Liver Diseases (AASLD), the Korean Liver Cancer Study Group and the National Cancer Center (KLCSG/NCC), and National Comprehensive Cancer Network (NCCN) guidelines. RESULTS: The overall sensitivity was highest using the KLCSG/NCC criteria (79.8%), followed by the AASLD (51.5%), EASL (38.4%), and NCCN (10.1%; P<0.001) criteria, whereas the specificity (84.5-98.3%) and positive predictive value (96.2-98.3%) were similar for all of the criteria. The KLCSG/NCC criteria had an acceptable false-positive rate and the highest sensitivity among all of the patients, including those positive for HBsAg, those without liver cancer, and those with a tumor of at least 2 cm. CONCLUSIONS: The KLCSG/NCC and AASLD criteria exhibited the highest sensitivity, and all four guidelines had a high specificity among all of the patients. Based on the sensitivity and false-positive rate, the KLCSG/NCC criteria was the most useful in the majority of patients. Inclusion of HBV infection in the clinical diagnostic criteria for hepatocellular carcinoma would be reasonable and may lead to an improvement in the sensitivity, with acceptable false-positive rates, in HBV-endemic areas.

Clinical course of sub-centimeter-sized nodules detected during surveillance for hepatocellular carcinoma.

AIM: To evaluate the outcome of sub-centimeter-sized nodules (SCSNs) detected during surveillance for hepatocellular carcinoma (HCC) in patients at risk. METHODS: We retrospectively analyzed a total of 142 patients with liver cirrhosis or chronic hepatitis B or C without a prior history of HCC in whom a SCSN was detected during HCC surveillance. We calculated the rate of HCC development from SCSNs in the study population and analyzed the differences in the baseline clinical characteristics and imaging features between the patients with SCSNs that eventually developed into HCC and patients with SCSNs that did not develop into HCC. RESULTS: During 667 person-years of follow-up, HCC developed in 33 patients. The calculated HCC development rate was 4.9% per year. The cumulative one-, two-, three- and five-year HCC development rates were 5.6%, 10.6%, 14.1% and 20.4%, respectively. Upon baseline comparison, the HCC group was older (54.4 ± 8.3 years vs 48.9 ± 9.4 years; P = 0.003) and had lower albumin levels (3.56 ± 0.58 g/dL vs 3.84 ± 0.55 g/dL; P = 0.012) and higher baseline alpha-fetoprotein (AFP) levels (8.5 ng/mL vs 5.4 ng/mL; P = 0.035) compared to the non-HCC group. Nodule pattern and initial radiologic diagnosis also differed between the two groups. Multivariate analysis revealed that age [P = 0.012, odds ratio (OR) =1.075, 95% confidence interval (CI) =1.016-1.137], sex (P = 0.009, OR = 3.969, 95% CI: 1.403-11.226), and baseline AFP level (P = 0.024, OR = 1.039, 95% CI: 1.005-1.073) were independent risk factors for developing HCC. CONCLUSION: The overall risk of HCC development in patients with SCSNs is similar to that in liver cirrhosis patients. Patients with these risk factors need to be closely monitored during follow-up.

Salvage treatment with hypofractionated radiotherapy in patients with recurrent small hepatocellular carcinoma.

PURPOSE: To investigate the rates of tumor response and local control in patients with recurrent small hepatocellular carcinoma (HCC) treated with hypofractionated radiotherapy (RT) as a salvage treatment and to evaluate treatment-related toxicities. METHODS AND MATERIALS: Between 2006 and 2009, a total of 20 patients with recurrent small HCC were treated with hypofractionated RT after the failure of previous treatment. The eligibility criteria for hypofractionated RT were as follows: 1) HCC less than 5 cm, 2) HCC not adjacent to critical organs, 3) HCC without portal vein tumor thrombosis, and 4) less than 15% of normal liver volume that would be irradiated with 50% of prescribed dose. The RT dose was 50 Gy in 10 fractions. The tumor response was determined by CT scans performed 3 months after the end of RT. RESULTS: The median follow-up period after RT was 22 months. The overall survival rates at 1 and 2 years were 100% and 87.9%, respectively. Complete response (CR) was achieved in seven of 20 lesions (35%) evaluated by CT scans performed 3 months after the end of RT. In-field local control was achieved in 85% of patients. Fourteen patients (70%) developed intra-hepatic metastases. Six patients developed grade 1 nausea or anorexia during RT, and two patients had progression of ascites after RT. There was no grade 3 or greater treatment-related toxicities. CONCLUSIONS: The current study showed a favorable outcome with respect to hypofractionated RT for small HCC. Partial liver irradiation with 50 Gy in 10 fractions is considered tolerable without severe complications.

Virologic response to therapy increases health-related quality of life for patients with chronic hepatitis B.

BACKGROUND & AIMS: We evaluated changes in health-related quality of life (HRQoL) in a longitudinal study of patients given antiviral therapy for chronic hepatitis B (CHB). METHODS: We analyzed changes in HRQoL reported by 2856 Korean patients with CHB who started first-line or rescue antiviral therapy from January 2007 to June 2007; the mean age of the study subjects was 43.3 years, 72% were male, 80% were positive for hepatitis B e antigen, 20% had cirrhosis, and 13% had concomitant disease. These subjects all completed the translated version of the Chronic Liver Disease Questionnaire (CLDQ) and the EuroQol-5 Dimension (EQ5D) when the study began (baseline), and at the end of a 24-week follow-up period. We analyzed changes in utility scores from baseline to 24 weeks of antiviral treatment. RESULTS: After 24 weeks of antiviral therapy, patients had significant improvements in liver function and reduced mean levels of hepatitis B virus DNA (from 6.3 to 3.9 log(10) copies/mL). Utility scores from the visual analogue scale and EQ5D improved after 24 weeks of antiviral therapy (from 0.84 ± 0.19 to 0.94 ± 0.14; P < .0001). Improved CLDQ scores were associated with virologic response (level of hepatitis B virus DNA, <4 log(10) copies/mL); scores increased from 5.21 ± 0.99 at baseline to 6.09 ± 0.72 after 24 weeks of antiviral therapy in responders, but from 5.31 ± 0.94 at baseline to 6.06 ± 0.66 in nonresponders (P = .003). CONCLUSIONS: Patients with CHB who have a virologic response to 24 weeks of antiviral therapy also have significant improvements in HRQoL, measured by EQ5D and CLDQ.

Antiviral therapy in patients after treatment for hepatitis C-related hepatocellular carcinoma.

BACKGROUND/AIMS: Despite great progress, antiviral treatment for chronic hepatitis C in patients with prior hepatocellular carcinoma (HCC) has been rarely investigated. We evaluated the efficacy and safety of antiviral therapy following treatment for hepatitis C-related HCC. METHODS: Thirteen patients (age 34 to 60 years) who were treated with peginterferon plus ribavirin after treatment for HCC were reviewed. RESULTS: There were 6 patients with genotype 1 and 7 patients with genotype 2. All patients showed advanced fibrosis (≥F3) but belonged to the Child-Pugh class A. Treatment was stopped in 2 patients because of recurrent HCC and in 1 patient due to a lack of early virologic response. Seven patients achieved sustained virologic response and three patients relapsed. The sustained virologic response rate was 54% overall, 17% in genotype 1, and 86% in genotype 2. No significant adverse events were reported. CONCLUSIONS: Antiviral therapy should not be excluded in patients who were previously treated with HCC with genotype 2 chronic hepatitis C, in which an efficacious antiviral treatment for chronic hepatitis C was feasible. Additional study is needed to prove the validity of antiviral therapy in patients with genotype 1 hepatitis C-related HCC.

A comparison of 48-week treatment efficacy between clevudine and entecavir in treatment-naïve patients with chronic hepatitis B.

PURPOSE: Clevudine and entecavir are currently available in Korea as antiviral drugs against chronic hepatitis B (CHB). We aimed to compare the efficacy of clevudine and entecavir therapy. METHODS: Treatment-naïve CHB patients who received 30 mg of clevudine or 0.5 mg of entecavir a day were analyzed. Mean reduction of hepatitis B virus (HBV) DNA levels, complete virological response (cVR, undetectable HBV DNA by real-time PCR), biochemical response (recovery to normal ALT level), and hepatitis B e antigen (HBeAg) seroconversion rate at the 48th week of treatment were assessed. RESULTS: A number of 59 patients in clevudine group and 61 patients in entecavir group were included. Mean HBV DNA reductions from baseline were similar in the clevudine and entecavir groups, -6.4 versus -6.8 log(10) copies/mL in HBeAg-positive (p = 0.417) and -6.9 versus -7.0 log(10) copies/mL in HBeAg-negative patients (p = 0.640). The proportion of patients who achieved cVR was not different between the two groups, 53 versus 55% in HBeAg-positive (p = 1.000) and 100 versus 95% in HBeAg-negative patients (p = 0.452). Biochemical response rates and HBeAg seroconversion rates were also similar in both the groups. Two (3.4%) patients in clevudine group showed virologic breakthrough with rtM204I mutation using direct sequencing analysis. Clinical myopathy occurred in two (3.4%) patients in clevudine group. CONCLUSION: Mean reduction of viral loads was similar between clevudine and entecavir groups during 48 weeks. However, virologic breakthrough and significant myopathy were noted only in clevudine-treated patients. Therefore, more attention should be paid to patients receiving clevudine.

[Clinical features and predictive factors of acute hepatitis A complicated with acute kidney injury].

BACKGROUND/AIMS: we assessed the clinical features and prognosis of acute viral hepatitis A (AHA) complicated with acute kidney injury (AKI) and elucidated predictive factors for AKI in patients with AHA. METHODS: we reviewed medical record of 391 patients with AHA admitted at our institution since 2000. RESULTS: AKI was present in 45 patients (11.5%). The proportion of the AKI group increased since 2008 (5.4% before 2008 vs. 15.9% since 2008, p=0.001). The AKI group was older than the non-AKI group (35.7+/-8.7 years vs. 31.3+/-7.8 years, p=0.002). Other baseline clinical characteristics were similar between two groups. Initial hemoglobin, platelet, and serum albumin were significantly low and prothrombin time, serum bilirubin, creatinine, AST, and ALT were significantly high in the AKI group. Hepatic encephalopathy, ascites, gastrointestinal bleeding, and sepsis were more frequently observed in the AKI group. While six patients (13%) in the AKI group received liver transplantation (LT) but three patients died within one month, one patient in the non-AKI group receiving LT is alive. Multivariate analysis showed that older age (OR 1.07, 95% CI 1.02-1.12), initial thrombocytopenia <150,000/mm2 (OR 2.85, 95% CI 1.24-6.57), prothrombin time (PT) prolongation (OR 5.34, 95% CI 2.55-11.19), and hypoalbuminemia (OR 8.24, 95% CI 2.53-26.86) were independently associated with the occurrence of AKI. CONCLUSIONS: AHA with AKI is an increasing problem showing significant morbidity and mortality in Korea. AKI is highly associated with older age, initial thrombocytopenia, PT prolongation, or low serum albumin, and has bad prognostic effect.

Risk factors for relapse in chronic hepatitis C patients who have achieved end of treatment response.

BACKGROUND AND AIM: Some patients with chronic hepatitis C experience virologic relapse even after achieving an end of treatment response. Prolonged therapy can be effective for helping such high-risk patients to avoid relapse. We aimed to identify factors predictive of virologic relapse in chronic hepatitis C patients who have achieved end of treatment response. METHODS: We analyzed data from 242 chronic hepatitis C patients who achieved end of treatment response with peginterferon plus ribavirin therapy from 2003 to 2007. RESULTS: Virologic relapse was identified in 32 patients (13.2%). We considered age, sex, body mass index, presence of diabetes, hemoglobin, platelet, alanine aminotransferase, stage of fibrosis, baseline hepatitis C virus RNA level, rapid virologic response, and adherence to drugs. For genotype 1 patients, older age (> or = 50 years) and higher baseline RNA level (> or = 2,000,000 IU/mL) were significantly correlated with occurrence of relapse. For genotypes 2 and 3, lower adherence to peginterferon (< 80%) was an independent risk factor for relapse. CONCLUSIONS: In chronic hepatitis C patients who had achieved end of treatment response, risk factors for relapse were older age and higher baseline hepatitis C virus RNA level in genotype 1, and lower adherence to peginterferon in genotypes 2 and 3, which may be valuable to individualize duration of therapy.

Early three-dimensional conformal radiotherapy for patients with unresectable hepatocellular carcinoma after incomplete transcatheter arterial chemoembolization: a prospective evaluation of efficacy and toxicity.

PURPOSE: We prospectively evaluated the efficacy and toxicity of early 3-dimensional conformal radiotherapy (3D-CRT) for patients with unresectable hepatocellular carcinoma (HCC) after incomplete transcatheter arterial chemoembolization (TACE). METHODS: Patients with unresectable HCC who failed 1 or 2 courses of TACE were eligible for this study. Three dimensional-CRT was added for HCC with incomplete uptake of iodized oil. Between January 2006 and February 2007, 40 patients (43 lesions) were enrolled. TACE was performed by using Lipiodol and adriamycin, followed by Gelfoam embolization. Two cycles of TACE were performed in 24 patients (60%), whereas 16 patients (40%) underwent one cycle. The median dose of 54 Gy (3 Gy daily) was delivered with 3D-CRT. Tumor response was evaluated by changes in tumor size on serial computed tomography scans and toxicity was evaluated by the Common Terminology Criteria for Adverse Events v3.0. RESULTS: An objective response was achieved in 27 of 43 lesions (62.8%), with a complete response in 9 lesions (20.9%) and partial response in 18 lesions (41.9%). The overall survival rate was 72.0% at 1 year and 45.6% at 2 years. There was no grade 3 or greater acute toxicity. Nine patients (22.5%) showed progression of the disease within the irradiated field during the follow-up and intrahepatic metastases developed in 16 patients (40.0%). CONCLUSION: Early 3D-CRT for HCC unresponsive to 1 or 2 cycles of TACE resulted in a 62.8% tumor response rate and relatively high complete response rates (20.9%) with acceptable toxicity. This study shows that the application of 3D-CRT could be considered for patients with incomplete TACE.

Long-term treatment outcomes for autoimmune hepatitis in Korea.

Immunosuppressive therapy can improve clinical, biochemical and histological features and considerably prolong survival in patients with autoimmune hepatitis. Although ethnicity may affect disease severity and presentation, the long-term outcome of immunosuppression in Korean populations is unknown. This study was aimed to assess the efficacy of immunosuppressive therapy and determine the prognosis of autoimmune hepatitis in Korean populations. We reviewed the medical records of 86 patients diagnosed as having autoimmune hepatitis at the Samsung Medical Center between 1994 and 2008. Seventy-two (83.7%) patients reached remission after a median treatment duration of 3.5 months (range 1 to 44 months). Attempts to withdraw medications were made in 24 cases after the median treatment duration of 36 months (median 6 to 125 months). Thirteen of 24 (54.1%) patients relapsed after treatment withdrawal. Of the 86 patients, 6 (7.2%) experienced disease progression and the overall 5-and 10-yr progression-free survival rates were 91.2% and 85.5%, respectively. In conclusion, immunosuppressive therapy for autoimmune hepatitis results in a favorable rate of remission and excellent progression-free survival, but the relapse rate after treatment withdrawal is high. This suggests that long-term immunosuppressive therapy may be particularly important for treatment of Korean patients.