Impact of new treatment options for hepatitis c virus infection in liver transplantation

Liver transplant candidates and recipients with hepatitis C virus(HCV)-related liver disease greatly benefit from an effective antiviral therapy. The achievement of a sustained virological response before transplantation can prevent the recurrence of post-transplant HCV disease that occurs universally and correlates with enhanced progression to graft cirrhosis. Previous standard-of-care regimens(e.g.,pegylated-interferon plus ribavirin with or without first generation protease inhibitors,boceprevir and telaprevir) displayed suboptimal results and poor tolerance in liver transplant recipients. A new class of potent direct-acting antiviral agents(DAA) characterized by all-oral regimens with minimal side effects has been approved and included in the recent guidelines for the treatment of liver transplant recipients with recurrent HCV disease. Association of sofosbuvir with ribavirin and/or ledipasvir is recommended in liver transplant recipients and patients with decompensated cirrhosis. Other regimens include simeprevir,daclatasvir,and combination of other DAA. Possible interactions should be monitored,especially in coinfected human immunodeficiency virus/HCV patients receiving antiretrovirals.

Pros and cons of liver transplantation in human immunodeficiency virus infected recipients

Before the introduction of combined highly active antiretroviral therapy, a positive human immunodeficiency virus (HIV) serological status represented an absolute contraindication for solid organ transplant (SOT). The advent of highly effective combined antiretroviral therapy in 1996 largely contributed to the increased demand for SOT in HIV-positive individuals due to increased patients’ life expectancy associated with the increasing prevalence of end-stage liver disease (ESLD). Nowadays, liver failure represents a frequent cause of mortality in the HIV-infected population mainly due to coinfection with hepatitis viruses sharing the same way of transmission. Thus, liver transplantation (LT) represents a reasonable approach in HIV patients with stable infection and ESLD. Available data presently supports with good evidence the practice of LT in the HIV-positive population. Thus, the issue is no longer “whether it is correct to transplant HIV-infected patients”, but “who are the patients who can be safely transplanted” and “when is the best time to perform LT”. Indeed, the benefits of LT in HIV-infected patients, especially in terms of mid- and long-term patient and graft survivals, are strictly related to the patients’ selection and to the correct timing for transplantation, especially when hepatitis C virus coinfection is present. Aim of this article is to review the pros and cons of LT in the cohort of HIV infected recipients.

Prevalence and prognostic value of cardiac troponin in elderly patients hospitalized for COVID-19

BACKGROUND Increases in cardiac troponin(cTn)in coronavirus disease 2019(COVID19)have been associated with worse prognosis.Nonetheless,data about the significance of cTn in elderly subjects with COVID19 are lacking.METHODS From a registry of consecutive patients with COVID19 admitted to a hub hospital in Italy from 25/02/2020 to 03/07/2020,we selected those≥60 yearold and with cTnI measured within three days from the molecular diagnosis of SARSCoV2 infection.When available,a second cTnI value within 48 h was also extracted.The relationship between increased cTnI and allcause inhospital mortality was evaluated by a Cox regression model and restricted cubic spline functions with three knots.RESULTS Of 343 included patients(median age:75.0(68.0−83.0)years,34.7%men),88(25.7%)had cTnI above the upperreference limit(0.046μg/L).Patients with increased cTnI had more comorbidities,greater impaired respiratory exchange and higher inflammatory markers on admission than those with normal cTnI.Furthermore,they died more(73.9%vs.37.3%,P<0.001)over 15(6−25)days of hospitalization.The association of elevated cTnI with mortality was confirmed by the adjusted Cox regression model(HR=1.61,95%CI:1.06−2.52,P=0.039)and was linear until 0.3μg/L,with a subsequent plateau.Of 191(55.7%)patients with a second cTnI measurement,49(25.7%)had an increasing trend,which was not associated with mortality(univariate HR=1.39,95%CI:0.87−2.22,P=0.265).CONCLUSIONS In elderly COVID19 patients,an initial increase in cTn is common and predicts a higher risk of death.Serial cTn testing may not confer additional prognostic information.