Cholangiocarcinoma (CCA) is a dreaded complication of primary sclerosing cholangitis (PSC); however, marked variability in the incidence of CCA in PSC is reported. Furthermore, limited information exists on risk factors for the development of CCA in PSC. The aim of this study was to determine the incidence of CCA in patients with PSC and to evaluate baseline risk factors for the later development of CCA. From a previous study of the natural history of PSC, we identified 161 patients with PSC who did not have CCA at study entry. Patients were followed until a diagnosis of CCA was established, liver transplantation was performed, or death occurred. Patients were followed for a median of 11.5 yr (interquartile range 4.0-16.1 yr). Fifty-nine patients (36.6%) died, 50 patients (31.1%) underwent liver transplantation, and 11 patients (6.8%) developed CCA. The rate of CCA developing was approximately 0.6% per year. Compared to the incidence rates of CCA in the general population, the relative risk of CCA in PSC was significantly increased (RR = 1,560; 95%CI = 780, 2,793; p < 0.0001). On univariate analysis, a history of variceal bleeding (p < 0.001), proctocolectomy (p= 0.01), and lack of symptoms (p= 0.02) were significant risk factors for CCA with the Mayo Risk Score being marginally significant (p= 0.051). Multivariate analysis determined only variceal bleeding to be a significant risk factor for CCA (RR 24.2; 95%CI: 3.3-67.1). No association was found between the duration of PSC and the incidence of CCA. In conclusion, approximately 7% of PSC patients later developed CCA over a mean follow-up of 11.5 yr, which is dramatically higher than the rates in the general population. Variceal bleeding is a major risk factor for the later development of CCA.

Recurrence of hepatitis C virus (HCV) infection after liver transplantation (LT) is almost universal. However, variables that hasten the progression of allograft injury have not been fully defined. Cytomegalovirus ( 0 is a common infection post-LT, and its impact on the course of post-LT HCV infection remains unclear. We investigated the impact of CMV infection on patient and graft outcomes in 93 consecutive HCV-infected liver transplant recipients. Data were collected prospectively, with surveillance cultures for CMV and protocol liver biopsies. CMV infection (defined as isolation of CMV fiom blood and treatment with ganciclovir) occurred in 25 patients (26.9%). Graft failure (defined as cirrhosis, relisting for LT, re-LT, or death) was significantly more common in CMV-positive compared with CMV-negative patients (52% v 19.1%; P = .002). Fibrosis stage 2 or greater on the 4-month liver biopsy specimen was more common in CMV-infected patients (45% v 16.4%; P = .01). Patients who underwent LT in more recent years had an increased risk for graft failure. Donor and recipient age, CMV infection, and mycophenolate mofetil use were significantly associated with graft failure in a stepwise multivariate analysis. CMV infection occurs in approximately one quarter of HCV-infected liver transplant recipients and is an independent risk factor for graft failure in these patients. Whether CMV mediates this by inducing increased immunosuppression or directly enhancing HCV replication requires further study. reported in 8% to 28% of HCV-infected liver transplant recipients after the fifth postoperative year.3 Several studies have attempted to define viral, host, and iatrogenic factors that increase the risk for developing cirrhosis. Viral factors, including genotype greater pre-LT viral l0ad,5 and the emergence of quasispecies,6 have been implicated in some studies. Treatment for acute cellular rejection (ACR) and increased levels of immunosuppression also have been associated with more severe recurrence.7-9Cytomegalovirus (CMV) is a DNA virus that commonly causes infection in immunocompromised patients, including liver transplant recipients. lo CMV has been shown to have direct immunosuppressive effects that increase the risk for other opportunistic infections.11.12 This increased degree of immunosuppression could potentially lead to a greater HCV viral load and thereby hasten HCV recurrence. The few studies to date that have examined the impact of CMV infection on post-LT outcomes in HCV-infected patients have included small numbers of patients and reached varied conclusions. Two studies implicated C M V infection as a risk for allograft cirrhosis in HCVpositive liver transplant recipient~.'3.'~ A third study was unable to identify variation in risk for more severe histological recurrence of HCV attributable to post-LT C M V infection.l5Aims of our study are to examine the prevalence of CMV infection in a large series of patients undergoing LT for HCV and determine the impact of CMV infection on post-LT outcomes in these pat...

Frailty is strongly and independently associated with an increased risk of unplanned hospitalization or death in outpatients with cirrhosis. The CFS is a rapid screen that could be easily adopted in liver clinics to identify those at highest risk of adverse events.

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Liver transplant recipients and their infants may have an increased risk of obstetric complications. Our objective was to describe pregnancy outcomes in women with a prior transplant from a population-based perspective. We analyzed the 1993-2005 US Nationwide Inpatient Sample database to identify obstetric hospitalizations among transplant recipients (n ϭ 206) and controls matched by age, hospital, and year (n ϭ 4060). The effect of prior transplantation on maternal and fetal outcomes was evaluated with regression models with adjustments for patient and hospital factors, including admission to a transplant center. Between 1993 and 2005, 146 delivery admissions among liver transplant recipients were identified. Cesarean deliveries were more common among transplant recipients (38% versus 24%; P ϭ 0.0001); however, this difference was not significant after multivariate adjustment [OR (odds ratio) ϭ 0.87; 95% confidence interval (CI) ϭ 0.60-1.27]. Maternal mortality was similar among cases and controls (0% versus 0.02%; P ϭ 1.00), but transplant patients had higher rates of fetal mortality (6.3% versus 2.0%; P ϭ 0.0006), antepartum admission (OR ϭ 2.27; 95% CI ϭ 1.59-3.25), and maternal (OR ϭ 2.63; 95% CI ϭ 1.82-3.80) and fetal complications (OR ϭ 2.49; 95% CI ϭ 1.68-3.70). Gestational hypertension (30% versus 9%; P Ͻ 0.0001) and postpartum hemorrhage (8% versus 3%; P ϭ 0.009) were more common among transplant recipients; their infants had higher rates of prematurity (27% versus 11%; P Ͻ 0.0001), distress (10% versus 5%; P ϭ 0.005), and growth restriction (5% versus 2%; P ϭ 0.05) but not congenital anomalies. Hospitalization in a transplant center (ϳ50%) was associated with similar obstetric outcomes. In conclusion, although most pregnancy outcomes are favorable, liver transplant recipients and their infants have an increased risk of obstetric complications. Additional studies evaluating mechanisms aimed at reducing these complications are necessary. Liver Transpl 16:56-63, 2010.

Rituximab was safe, well tolerated and resulted in biochemical improvement in subjects with refractory AIH. These results support further investigation of rituximab as a treatment for AIH.

The recent epidemiology and outcomes of primary biliary cirrhosis (PBC) in North America are incompletely described, partly due to difficulties in case ascertainment. In light of their availability, broad coverage, and limited expense, administrative databases may facilitate such investigations. We used population-based administrative data (inpatient, ambulatory care, and physician billing databases) and a validated International Classification of Diseases coding algorithm to describe the epidemiology and natural history of PBC in the Calgary Health Region (population Ϸ1.1 million). Between 1996 and 2002, the overall age/sex-adjusted annual incidence of PBC was 30.3 cases per million (48.4 per million in women, 10.4 per million in men). Although the incidence remained stable, the prevalence increased from 100 per million in 1996 to 227 per million in 2002 (P < 0.0005). Among 137 incident cases with a total follow-up of 801 personyears from diagnosis (median 5.8 years), 27 patients (20%) died and six (4.4%) underwent liver transplantation. The estimated 10-year probabilities of survival, liver transplantation, and transplant-free survival were 73% (95% confidence interval [CI] 60%-83%), 6% (95% CI 2.5%-12.6%), and 68% (95% CI 55%-78%), respectively. Survival in PBC patients was significantly lower than that of the age/sex-matched Canadian population (standardized mortality ratio 2.87; 95% CI 1.89-4.17); male sex (hazard ratio [HR] 3.80; 95% CI 1.85-7.82) and an older age at diagnosis (HR per additional year, 1.06; 95% CI 1.03-1.10) were independent predictors of mortality. Conclusion: This population-based study demonstrates that the burden of PBC in Canada is high and growing. Survival of PBC patients is significantly lower than that of the general population, emphasizing the importance of developing new therapies for this condition.

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