Background Chronic hepatitis C virus (HCV) infection causes substantial health and economic burden in the United States (US). With the availability of direct-acting antiviral agents (DAAs), recently approved and other therapies under development and 1-time birth-cohort screening, the burden of HCV disease is expected to decrease. Objective To predict the impact of new therapies and screening on chronic HCV cases and associated disease outcomes. Design Individual-level state-transition model. Setting Existing and anticipated HCV therapies and screening in the US. Patients Total HCV-infected population in the US. Measurements Chronic HCV cases and advanced-stage HCV outcomes. Results The number of chronic HCV cases decreased from 3.2 million in 2001 to 2.3 million in 2013. One-time birth-cohort screening beginning in 2013 is expected to identify 487 000 HCV cases in the next 10 years. In contrast, 1-time universal screening could identify 933 700 HCV cases. With the availability of highly effective therapies, HCV could become a rare disease in the next 22 years. The adoption of recently approved HCV therapies and one-time birth-cohort screening can prevent approximately 124 200 cases of decompensated cirrhosis, 78 800 cases of hepatocellular carcinoma, 126 500 liver-related deaths and 9900 liver transplants by 2050. Increasing the treatment capacity would further reduce the burden of HCV-related disease. Limitations Empirical data on the effectiveness of the future HCV therapies, on the future annual incidence of HCV, and on HCV treatment capacity are lacking. Conclusions New HCV therapies along with widespread implementation of screening and treatment will play an important role in reducing the burden of HCV disease. More aggressive screening recommendations are needed to identify a large pool of infected patients. Funding source National Institutes of Health.

The hepatitis C virus (HCV) is a major cause of liver disease worldwide. The understanding of the viral life cycle has been hampered by the lack of a satisfactory cell culture system. The development of the HCV replicon system has been a major advance, but the system does not produce virions. In this study, we constructed an infectious HCV genotype 1b cDNA between two ribozymes that are designed to generate the exact 5 and 3 ends of HCV. A second construct with a mutation in the active site of the viral RNA-dependent RNA polymerase (RdRp) was generated as a control. The HCV-ribozyme expression construct was transfected into Huh7 cells. Both HCV structural and nonstructural proteins were detected by immunofluorescence and Western blot. RNase protection assays showed positive-and negative-strand HCV RNA. Sequence analysis of the 5 and 3 ends provided further evidence of viral replication. Sucrose density gradient centrifugation of the culture medium revealed colocalization of HCV RNA and structural proteins in a fraction with the density of 1.16 g͞ml, the putative density of HCV virions. Electron microscopy showed viral particles of Ϸ50 nm in diameter. The level of HCV RNA in the culture medium was as high as 10 million copies per milliliter. The HCV-ribozyme construct with the inactivating mutation in the RdRp did not show evidence of viral replication, assembly, and release. This system supports the production and secretion of high-level HCV virions and extends the repertoire of tools available for the study of HCV biology.assembly ͉ cell culture ͉ infection ͉ ribozyme ͉ viral replication T he hepatitis C virus (HCV) is an important cause of human illness worldwide (1). Although it has proven to be a difficult public health problem, it has been no easier to study in the laboratory. A major impediment has been the lack of robust model systems to study the complete viral life cycle. HCV is a member of the Flaviviridae family of Ϸ9.6 kb, and it has a central ORF flanked by the 5Ј and 3Ј noncoding regions. The ORF is divided into the coding sequences for the structural proteins at the 5Ј end and the nonstructural proteins at the 3Ј end. Study of the biology of hepatitis C at a molecular level focused initially on expression and manipulation of individual viral proteins in tissue culture.The development of the subgenomic and genomic replicons is a major breakthrough to understanding viral replication and viral-cell interactions and provides a means to test therapeutic targets (2, 3). However, as yet, none of these systems produce viral particles, nor do they produce infectious virions. Although some infectious tissue culture systems have been described; in general, these systems have not been robust enough to study the complete viral life cycle (4, 5).Why virion production has been such an elusive goal remains unclear; however, the promise of a system that produces authentic virions is clear. Not only would more of the biology of the virus become accessible for study, but also such a system would provide a means to s...

Depression after liver transplantation has been associated with decreased survival, but the effects of pre-transplant depression on early and late post-transplant outcomes remain incompletely evaluated. We assessed all patients who had undergone single-organ liver transplantation at a single center over the prior 10 years. A diagnosis of pre-transplant depression, covariates, and the outcomes of interest were extracted from the electronic medical record. Potential covariates included demographics, etiology and severity of liver disease, comorbidities, donor age, graft type, immunosuppression, and ischemic times. In multivariable models adjusting for these factors, we evaluated the effect of pre-transplant depression on transplant length of stay (LOS), discharge disposition (home vs. facility) and long-term survival. Among 1115 transplant recipients with a median follow-up time of 5 years, the average age was 56±11 and MELD was 12±9. Nineteen percent of the study population had a history of pre-transplant depression. Pre-transplant depression was associated with longer LOS (median = 19 vs. 14 days, IRR = 1.25, CI = 1.13,1.39), discharge to a facility (36% vs. 25%, OR 1.70,CI = 1.18,2.45), and decreased survival (HR = 1.54,CI = 1.14,2.08) in this cohort, accounting for other potential confounders. In conclusion, pre-transplant depression was significantly associated with longer transplant length of stay, discharge to a facility, and mortality in this cohort.

Objectives The treatment of choice for HCC with cirrhosis is liver transplantation (LT). We assessed if patients evaluated for hepatocellular carcinoma are being diagnosed by surveillance, the proportion of patients meeting Milan criteria at diagnosis, and rates of liver transplantation. Methods All HCC cases in cirrhotic patients at Duke University Medical Center in the MELD era (Feb 2002–Oct 2008) were identified. Surveillance was defined as an imaging exam for detection of HCC in the 12 months prior to diagnosis of HCC. Logistic regression was used to examine predictors of LT. Results There were 319 cases meeting diagnostic criteria for HCC. Only 30.7% were diagnosed by surveillance and 43.7% met Milan criteria at diagnosis. Patients diagnosed by surveillance were more likely to meet Milan criteria and to receive LT (p <0.0001 for both outcomes). Surveillance was associated with higher rates of LT with an OR 2.6 (95% CI 1.2–5.7, p = 0.02). Patients managed by a hepatologist were more likely to be diagnosed by surveillance (65.9 vs. 19.0%, p <0.0001). Patients meeting Milan criteria managed by a hepatologist were more likely to receive LT than those referred from other providers (26.4 vs. 8%, p = 0.009). Conclusions A minority of HCC cases in cirrhotic patients were diagnosed by surveillance, and only 12.5% underwent LT. Patients diagnosed by surveillance were more likely to meet Milan criteria and to undergo LT. These findings highlight the need for increased identification of patients with chronic liver disease and for subsequent referral to hepatologists for enrollment in HCC surveillance programs.

SUMMARY Cytokeratin-18 (CK-18) is a major intermediate filament protein in liver cells. The M30 fragment of CK-18 has been identified as a useful marker of apoptosis associated with fibrosis and steatosis in nonalcoholic steatohepatitis (NASH). We sought to assess the relationship of this marker and steatosis in a cohort of adult patients with chronic hepatitis C. The study cohort included sera from 267 treatment-naïve chronic hepatitis C (CHC) patients and 100 healthy controls with normal alanine aminotransferase (ALT). Biopsies from CHC patients were assessed for METAVIR fibrosis stage, Histology Activity Index (HAI) inflammation score and steatosis grade by expert histopathologists. The M30 fragment of CK-18 was quantified by ELISA. Wilcoxon Rank Sum, Spearman Correlation and Linear Regression tests were performed for statistical analysis. Median CK-18 levels were higher in CHC patients compared to controls (411 vs 196 U/L, P < 0.0001). Fibrosis stage was associated with increasing serum CK-18 levels (P = 0.015) and CK-18 levels were higher for F2–F4 vs F0–F1 (500 vs 344 U/L; P = 0.001). There was no association between CK-18 and increasing steatosis grade 1, 2 or 3 (460.7 vs 416.8 vs 508.3 U/L; P = 0.35) and presence or absence of steatosis (445.3 vs 365.8 U/L; P = 0.075). Fibrosis stage was independently associated with serum M30 in a multivariable linear regression model (P = 0.03). CK-18 levels were higher in CHC compared to healthy controls and associated with hepatic fibrosis. There was no difference in CK-18 M30 levels between CHC patients with and without steatosis. Although apoptosis may still contribute to hepatitis C virus (HCV)-mediated steatosis, our results suggest that serum CK-18 will not be a clinically useful test for identifying significant steatosis in CHC.

Pharmacogenomic (PG) testing is important in developing individualized therapeutic approaches. In the phase 3 IDEAL clinical trial, a subset of patients receiving peginterferon and ribavirin for treatment of chronic hepatitis C agreed to provide blood samples for genetic testing. Genome-wide association studies subsequently identified associations between IL28B polymorphism and sustained virologic response, and ITPA polymorphism and ribavirin-associated anemia. Objective To characterize the groups of patients who accepted or declined PG testing in the IDEAL study. Methods Clinical and demographic factors and treatment outcomes were compared at all sites that had approved PG testing. Differences between patients who consented to and declined PG testing were analyzed using Student t and chi-square tests. Results In total, 109 of 118 sites participated in the PG sub-study, and 1674 of 2949 (57%) patients enrolled at these sites consented to PG testing. More patients treated in academic medical centers than in community centers (60% vs. 52%, P < 0.001) provided consent. More males than females (58% vs. 54%, P = 0.04) consented to PG testing. There was no significant difference in PG participation between patients from different racial groups, including whites and African Americans (58% vs. 54%, P = 0.07). Treatment outcomes were also similar according to PG participation. Conclusions In the IDEAL study, patient consent to PG testing did not introduce selection bias. Treatment at an academic center and male gender were associated with higher rates of PG testing consent. Efficacy and safety outcomes were similar in patients who accepted and declined PG testing.

The aim of this study was to assess the independent association between pre-transplant prescription opioid use and readmission following liver transplantation. We reviewed the medical records of all patients at a single medical center undergoing primary, single-organ, liver transplantation from 2004 to 2014. We assessed factors associated with hospital readmission 30 days and 1 year after hospital discharge using multivariable competing risk regression models. Among 1056 transplant recipients, 49 (4.6%) were prescribed pre-transplant prescription opioids. Readmission occurred in 421 (40%) patients within 30 days and 689 (65%) within 1 year. Patients with pre-transplant opioid use had a significantly higher risk of readmission at 30 days (HR 1.7; 95% CI 1.1-2.5) and a non-significantly elevated risk at 1 year (HR 1.4; 95% CI 1.0-1.9) when controlling for other potential confounders. Although pain was the major reason for readmission in only 12 (3%) patients at 30 days and 33 (6%) patients at 1 year, pre-transplant opioid use was significantly associated with pain-related readmission at both time points. In conclusion, prescription opioid use pre-transplantation was significantly associated with all-cause 30-day readmissions and pain-related readmissions at 30 days and 1 year.

Immune reconstitution syndrome (IRS) is an increasingly common condition that has been described in immunosuppressed individuals once immune function is restored. In this case, we describe a patient who had a renal transplant and subsequently developed pulmonary histoplasmosis. His course was also complicated by the development of a clinical syndrome that was originally attributed to thrombocytopenic thrombotic purpura (TTP). When he did not improve with plasmapheresis and high dose prednisone, a bone marrow biopsy revealed disseminated histoplasmosis and administration of prednisone was rapidly tapered. While on 5 mg of prednisone, he developed an inflammatory syndrome characterised by haemoptysis and respiratory distress, full work-up with pathology was consistent with immune reconstitution syndrome. Treatment for IRS consists of continuing treatment for the underlying infection and consideration of administering anti-inflammatory medication for supportive care. This syndrome should be considered in patients who develop worsening inflammatory symptoms while receiving appropriate treatment for their fungal infection in the setting of restoration of immune function.