K.W. Ma

Long‐term outcomes of entecavir monotherapy for chronic hepatitis B after liver transplantation: Results up to 8 years

Long‐term antiviral prophylaxis is required to prevent hepatitis B recurrence for patients with chronic hepatitis B after liver transplantation. We determined the long‐term outcome of 265 consecutive chronic hepatitis B liver transplant recipients treated with entecavir monotherapy without hepatitis B immune globulin. Viral serology, viral load, and liver biochemistry were performed at regular intervals during follow‐up. The median duration of follow‐up was 59 months. The cumulative rates of hepatitis B surface antigen (HBsAg) seroclearance were 90% and 95% at 1 and 5 years, respectively. At 1, 3, 5, and 8 years, 85%, 88%, 87.0%, and 92% were negative for HBsAg, respectively, and 95%, 99%, 100%, and 100% had undetectable hepatitis B virus (HBV) DNA, respectively. Fourteen patients remained persistently positive for HBsAg, all of whom had undetectable HBV DNA. There was no significant difference in liver stiffness for those who remained HBsAg‐positive compared to those who achieved HBsAg seroclearance (5.5 versus 5.2 kPa, respectively; P = 0.52). The overall 9‐year survival was 85%. There were 37 deaths during the follow‐up period, of which none were due to hepatitis B recurrence. Conclusion: Long‐term entecavir monotherapy is highly effective at preventing HBV reactivation after liver transplantation for chronic hepatitis B, with a durable HBsAg seroclearance rate of 92%, an undetectable HBV DNA rate of 100% at 8 years, and excellent long‐term survival of 85% at 9 years. (Hepatology 2017;66:1036‐1044).

Left hepatectomy in a patient with a Fontan circulation

Patients with a Fontan circulation face the long term risk of cardiac cirrhosis and the subsequent development of hepatocellular carcinoma (HCC). A hepatectomy operation imposes significant risk on such patients as the Fontan circulation can be severely compromised. Here we present a 24-year-old woman post-Fontan operation who successfully underwent a left hepatectomy, and discuss the anaesthetic and surgical management.

Liver transplantation: a life-saving procedure following amatoxin mushroom poisoning

In April 2013, a 48-year-old man and his wife picked wild mushrooms near Shing Mun Reservoir. After eating the cooked mushrooms, they developed symptoms resembling gastroenteritis and attended accident and emergency department (A&E) around 12 hours later. The husband was alert with normal blood test results at 18 hours following ingestion. Thirty hours later, his total bilirubin increased to 54 μmol/L (reference range, 4-23 μmol/L), serum alanine transaminase (ALT) to 2928 IU/L (reference range, 8-58 IU/L), serum creatinine to 229 μmol/L (reference range, 67-109 μmol/L), and international normalised ratio (INR) to 1.56 (reference level, <1.1). Mushroom poisoning was suspected and the Hong Kong Poison Information Centre was contacted. He was given N-acetylcysteine (NAC), silibinin, and penicillin G in the intensive care unit. Subsequent blood tests showed no improvement and around 48 hours after ingestion, his serum ALT climbed to 4856 IU/L and INR to 2.25. He was transferred to the intensive care unit of Queen Mary Hospital (QMH) for further care. At QMH, computed tomography of the abdomen revealed hypo-enhancement of the liver parenchyma. Liver transplant workup was initiated in view of impending liver failure. Fortunately his liver function started to stabilise 8 hours after admission to QMH, with a serum ALT peak at 3856 IU/L and INR at 3.5. He then made progressive recovery and was discharged 10 days after admission.