Management of hepatitis C infection before and after liver transplantation

Chronic hepatitis C(CHC) is the most common indication for liver transplantation(LT). Aggressive treatment of hepatitis C virus(HCV) infection before cirrhosis development or decompensation may reduce LT need and risk of HCV recurrence post-LT. Factors associated with increased HCV risk or severity of recurrence include older age, immunosuppression, HCV genotype 1 and high viral load at LT. HCV recurrence post-LT leads to accelerated liver disease and cirrhosis development with reduced graft and patient survival. Currently, interferon(IFN)-based regimens can be used in dualagent regimens with ribavirin, in triple-agent antiviral strategies with direct-acting antivirals(e.g., protease inhibitors telaprevir or boceprevir), or before transplant in compensated patients to reduce HCV viral load to prevent or reduce the risk of post-LT recurrence and complications; they cannot be used in patients with decompensated cirrhosis. IFN-based regimens are used in less than half of HCV-infected patients waiting for LT due to extremely low efficacy and poor tolerability. However, antiviral therapy is indicated after LT in patients with histologically confirmed CHC despite tolerability issues. Improvements in side effect management have increased survival in patients achieving therapeutic targets. HCV treatment pre- and post-LT results in significant health care costs especially when lack of efficacy leads to disease worsening, although studies have shown sofosbuvir treatment before LT vs conventional post-LT dual antiviral is cost effective. The suboptimal efficacy and tolerability of IFN-based therapies, plus the significant economic burden, means the need for effective and well tolerated IFN-free antiHCV therapy for pre- and post-LT remains high.

A systematic review of the management of acute superior mesenteric vein thrombosis in adults

Background:Acute thrombosis of the superior mesenteric vein(SMV)is a rare but potentially catastrophic condition.Clinically separate from portal venous thrombosis due to a higher proportion of associated thrombophilic disorders and intestinal infarction,SMV thrombosis warrants a distinct approach to management.The aim of this review is to report the evidence for current practice.Methods:A systematic review was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Four clinical trials databases and 4 trial registries were searched.This search was not limited by language or study type,but was limited to an adult population(18 years and above).The search period was between January 1,2000 and February 28,2019.The review was registered in the PROSPERO database:CRD42018116825.Bias was assessed using the ROBINS-I tool.Results:A total of 7989 studies were identified,resulting in 19 observational studies being analyzed.Eighteen studies reported on anti-coagulation,1 reported on anti-coagulation plus endovascular thrombectomy,9 reported on thrombolysis,and 10 reported on the role of surgery.Bias assessment showed that confounding was a significant area of potential bias.This review has reported that the management of SMV thrombosis is centered around a patients’perceived hemodynamic stability.If there is evidence of perforation or peritonism then surgical intervention is advocated.Otherwise,anti-coagulation or thrombolysis is preferred.Conclusions:The data reported were compared with,and added to,that presented by the European Society for Vascular Surgery 2017 guidelines.Overall the source data were heterogenous,with multiple sources of bias and statistical comparison was not achievable.