HEPATOLOGY WATCHTM
Timely Information for Practicing Physicians
MARCH 1999
Transjugular intrahepatic portosystemic shunt (TIPS) vs endoscopic sclerotherapy (ES) for variceal rebleeding. Luis Garcia-Villarreal and colleagues randomized 46 cirrhotic patients with variceal bleeding to receive either a TIPS procedure (22 patients) or ES (24 patients) 24 hours after control of bleeding to investigate which treatment more effectively prevents rebleeding. Both overall and early (within 6 weeks) variceal rebleeding occurred more frequently (P<0.001 and <0.05, respectively) in the ES group than in the TIPS group. Moreover, the actuarial probability of survival was greater for the TIPS patients (P<0.05). These data indicate that TIPS is more effective than ES for the prevention of variceal rebleeding, and for the first time, an improvement in survival is projected with TIPS. (Garcia-Villarreal L, et al. Hepatology 1999; 29: 27-32)
Natural history of untreated nonsurgical hepatocellular carcinoma (HCC). Llovet and coworkers retrospectively analyzed the natural history of a cohort of 102 cirrhotic patients with nonsurgical HCC who had been randomized to "no treatment" arms in two previously published randomized trials. Multivariate analysis identified poor performance status, constitutional symptoms, vascular invasion, and extrahepatic spread to be independent predictors of mortality. Patients who had at least one of these factors had 1-, 2-, and 3-year survival rates of 29%, 16%, and 8% versus 80%, 65%, and 50% in patients without adverse factors. The authors conclude that the unresectable HCC patient population is heterogenous and not always grim. (Llovet JM, et al. Hepatology 1999; 29: 62-67)
Pretreatment evaluation of chronic hepatitis C (CHC). Wong et al. evaluated the cost-effectiveness of alternative pretreatment management strategies for a hypothetical population of patients with CHC by utilizing a Markov decision analysis model to estimate prognosis over time for each strategy. They found that pretreatment HCV RNA testing or liver biopsy strategies would result in denying therapy in up to 36% and 6%, respectively, of patients who will obtain a sustained response to interferon therapy and could cause these missed patients to forego an increase in life expectancy of 4 to 11 years. In contrast, an empirical 24-week trial of interferon therapy strategy would provide treatment for all potential sustained responders with a marginal cost-effectiveness ratio of $12,400 per discounted quality-adjusted life-year gained. The authors conclude that the empiric interferon strategy has a marginal cost-effectiveness ratio that compares favorably with that of successful conventional therapies of other diseases and provides treatment for all potential sustained responders. (Wong JB, et al. JAMA 1998; 280: 2088-2093)
Natural history and prognosis of asymptomatic primary biliary cirrhosis (PBC). Springer and associates at The Toronto Hospital conducted a retrospective chart review of all asymptomatic patients who had been referred to the hepatology service between the years 1983 and 1994 with biochemical, serologic, and biopsy findings compatible with PBC to identify features that predict the development of symptomatic disease. A total of 91 patients were included; median follow-up was 61.2 months (range 7-206 months); and patient survival was less than that for an age and gender matched population (P<0.05). Although 33 patients (36%) became symptomatic, multivariate analysis failed to reveal any clinical features that predicted prognosis. These data indicate that asymptomatic PBC patients have a shorter survival than the general population and there are no known prognostic features that identify those patients who will develop symptoms. (Springer J, et al. Am J Gastroenterol 1999; 94: 47-53).
The impact of hepatitis B virus (HBV) and C virus (HCV) infection on kidney transplantation. Mathurin and colleagues screened pretreatment serum samples from 834 patients who underwent kidney transplantation from 1977 to 1996 at the Hopital Pitie-Salpetriere (Paris, France) to investigate the impact of HBV and HCV infection on the survival of kidney transplantation patients. There were 128 HBsAg-positive patients, 216 patients with detectable anti-HCV antibodies, and 490 patients without anti-HCV or HBsAg. Ten-year patient survival and graft survival were lower (P<0.001) in the HBV and HCV infected patients, and multivariate analysis revealed four variables, including biopsy-proven cirrhosis, to be independent prognostic factors for survival. Thus, long-term follow-up data (10 years) shows that HBV and HCV infection has a deleterious impact on the clinical course of kidney transplantation patients. (Mathurin P, et al. Hepatology 1999; 29: 257-263)
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