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      Liver transplantation in a patient with hepatitis B, C and D coinfection associated with hepatocellular carcinoma: a management strategy for a rare condition. Case report : Transplante hepático em paciente com coinfecção pelos vírus B, C e D associada a carcinoma hepatocelular: uma estratégia de tratamento para uma condição rara. Relato de caso

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          Abstract

          CONTEXT:

          Orthotopic liver transplantation (OLT) is the treatment of choice for end-stage liver disease. Cirrhosis due to hepatitis C infection is the leading indication for liver transplantation worldwide. However, patients who are given transplants because of viral liver diseases often present clinical coinfections, including hepatitis B together with hepatitis D. Currently, different strategies exist for patient management before and after liver transplantation, and these are based on different protocols developed by the specialized transplantation centers.

          CASE REPORT:

          We present a rare case of a 58-year-old man with chronic hepatitis B, C and D coinfection. The patient developed cirrhosis and hepatocellular carcinoma. His treatment comprised antiviral therapy for the three viruses and OLT. The patient's outcome was satisfactory.

          CONCLUSION:

          OLT, in association with antiviral therapy using entecavir, which was administered before and after transplantation, was effective for sustained clearance of the hepatitis B and D viruses. A recurrence of hepatitis C infection after transplantation responded successfully to standard treatment comprising peginterferon alfa-2A and ribavirin.

          Translated abstract

          CONTEXTO:

          O transplante ortotópico de fígado (TOF) é o tratamento de escolha em pacientes com doença hepática terminal. A cirrose por hepatite C é a principal indicação de transplante hepático no mundo. No entanto, pacientes transplantados por hepatopatias virais frequentemente apresentam coinfecções, como hepatite B associada a hepatite D. Atualmente, existem diferentes estratégias de manejo em pacientes pré e pós-transplantados conforme diferentes protocolos de conduta de serviços especializados em transplante.

          RELATO DE CASO:

          Apresentamos o raro caso de um homem de 58 anos diagnosticado com as hepatites crônicas B, C e D. O paciente evoluiu com cirrose e carcinoma hepatocelular. O tratamento consistiu de terapia antiviral para os três vírus e de transplante ortotópico de fígado. O desfecho do paciente foi satisfatório.

          CONCLUSÃO:

          O transplante ortotópico de fígado, associado à terapia antiviral com entecavir antes e após o procedimento, foi eficaz na depuração sustentada dos vírus B e D. A recidiva do vírus C após o transplante respondeu com sucesso ao tratamento padrão com alfapeginterferon 2A e ribavirina.

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          Most cited references40

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          Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis.

          The role of orthotopic liver transplantation in the treatment of patients with cirrhosis and hepatocellular carcinoma is controversial, and determining which patients are likely to have a good outcome after liver transplantation is difficult. We studied 48 patients with cirrhosis who had small, unresectable hepatocellular carcinomas and who underwent liver transplantation. In 94 percent of the patients, the cirrhosis was related to infection with hepatitis B virus, hepatitis C virus, or both. The presence of tumor was confirmed by biopsy or serum alpha-fetoprotein assay. The criteria for eligibility for transplantation were the presence of a tumor 5 cm or less in diameter in patients with single hepatocellular carcinomas and no more than three tumor nodules, each 3 cm or less in diameter, in patients with multiple tumors. Thirty-three patients with sufficient hepatic function underwent treatment for the tumor, mainly chemoembolization, before transplantation. After liver transplantation, the patients were followed prospectively for a median of 26 months (range, 9 to 54). No anticancer treatment was given after transplantation. The overall mortality rate was 17 percent. After four years, the actuarial survival rate was 75 percent and the rate of recurrence-free survival was 83 percent. Hepatocellular carcinoma recurred in four patients (8 percent). The overall and recurrence-free survival rates at four years among the 35 patients (73 percent of the total) who met the predetermined criteria for the selection of small hepatocellular carcinomas at pathological review of small hepatocellular carcinomas at pathological review of the explanted liver wer 85 percent and 92 percent, respectively, whereas the rates in the 13 patients (27 percent) whose tumors exceeded these limits were 50 percent and 59 percent, respectively (P=0.01 for overall survival; P=0.002 for recurrence-free survival). In this group of 48 patients with early-stage tumors, tumor-node-metastasis status, the number of tumors, the serum alphafetoprotein concentration, treatment received before transplantation, and 10 other variables were not significantly correlated with survival. Liver transplantation is an effective treatment for small, unresectable hepatocellular carcinomas in patients with cirrhosis.
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            • Record: found
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            Hepatocellular carcinoma.

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              • Record: found
              • Abstract: not found
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              Management of varices and variceal hemorrhage in cirrhosis.

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                Author and article information

                Journal
                Sao Paulo Med J
                Sao Paulo Med J
                Sao Paulo Med J
                São Paulo Medical Journal
                Associação Paulista de Medicina - APM
                1516-3180
                1806-9460
                03 July 2015
                2015
                : 133
                : 6
                : 525-530
                Affiliations
                [I ] originalMD. Physician, Health Sciences Center, Universidade Federal do Acre (UFAC), Rio Branco, Acre, Brazil
                [II ] originalMSc. Physician, Director and Founder, Liver Transplantation Group, Hospital Beneficência Portuguesa, São Paulo, São Paulo, Brazil
                [III ] originalMD. Physician, Liver Transplantation Group, Hospital Beneficência Portuguesa, São Paulo, São Paulo, Brazil.
                [IV ] originalMD, PhD. Physician, General Surgery Unit, Hospital das Clínicas do Acre, Rio Branco, Acre, Brazil
                [V ] originalMD, MSc. Physician, Hepatology and Tropical Diseases Unit, Hospital das Clínicas do Acre, Rio Branco, Acre, Brazil
                [VI ] originalMD, PhD. Physician, Hepatology and Tropical Diseases Unit, Hospital das Clínicas do Acre, Rio Branco, Acre, Brazil
                Author notes
                Address for correspondence: Lucas Carvalho Dantas. Centro de Ciências da Saúde e do Desporto (CCSD). Campus Universitário, Universidade Federal do Acre, BR 364, Km 04, Distrito Industrial - Rio Branco (AC) - Brasil. CEP 69920-900. Tel. (+55 68) 3227-4085. E-mail: lucasdantas00@ 123456hotmail.com

                Conflict of interests: None

                Article
                10.1590/1516-3180.2015.8881501
                10496563
                26176835
                edee1805-e38a-43d5-b432-5d698a801eeb

                This is an open access article distributed under the terms of the Creative Commons license.

                History
                : 03 May 2014
                : 25 September 2014
                : 20 October 2014
                Page count
                Figures: 1, Tables: 1, Equations: 0, References: 30, Pages: 6
                Categories
                Case Report

                hepatitis b,hepatitis c,hepatitis d,carcinoma, hepatocellular,liver transplantation

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