Limited hepatitis B immunoglobulin with potent nucleos(t)ide analogue is a cost-effective prophylaxis against hepatitis B virus after liver transplantation.

BACKGROUND: Prophylaxis against hepatitis B virus (HBV) recurrence after orthotopic liver transplantation (OLT) includes lifelong hepatitis B immunoglobulin (HBIG) and oral antiviral agent(s). In the presence of high-genetic-barrier nucleos(t)ide analogues, the need for lifelong HBIG is questioned. We evaluated the safety and cost-effectiveness of a limited HBIG course. METHODS: OLT from 2006 to 2013 were reviewed. Patients with pre-OLT hepatitis B virus surface antigen who received HBV prophylaxis with 2 HBIG doses (anhepatic and first post-operative day; 10,000 units/dose) and potent nucleos(t)ide analogues were included. The primary end point was HBV recurrence (HBV-DNA detection). RESULTS: Thirteen patients (primary transplants) were included, median Model for End-Stage Liver Disease score was 18, and there was no fulminant failure; HBV-DNA was detected in 4 patients at OLT. After OLT, 10 patients received entecavir and/or tenofovir. Median follow-up was 23 months. One recurrence occurred (7.7%) at month 13 (HBV-DNA: 14 IU/mL); the graft maintained excellent function. This minimal viremic expression is related to hepatocellular carcinoma recurrence with neoplastic replication carrying integrated HBV-DNA; thus, there is no defined HBV viral recurrence. No graft loss or patient death was related to HBV recurrence. The 1-year patient and graft survival rate was 84.6%. Cost-savings in the first year was $178,100 per patient when compared with Food and Drug Administration-approved HBIG dosing. CONCLUSIONS: In the era of potent oral nucleos(t)ide analogues, a limited HBIG course appears to be cost-effective in preventing HBV recurrence.

An assessment of treatment history and its association with clinical outcomes and relapse in 155 pemphigus patients with response to a single cycle of rituximab.

BACKGROUND: Studies of pemphigus vulgaris and foliaceus patients treated with rituximab have used several different dosing protocols. Likewise, patients' clinical history varies in the length of the disease prior to initiation of rituximab, previous immunosuppressants used and adjuvants used during rituximab treatment. OBJECTIVE: We sought to assess clinical factors associated with improved outcomes and a greater duration from last dose of rituximab to time of relapse in patients responding to a single cycle of rituximab. METHODS: We retrospectively evaluated published cases of pemphigus patients treated with a single cycle of rituximab. RESULTS: One hundred and fifty-five patients were evaluated. An increased number of months with disease before receiving treatment were associated with failure to achieve complete remission. Patients treated using the low-dose rheumatoid arthritis protocol (2 × 500 mg) experienced a lower rate of complete response and a decrease in the time to relapse. Patients treated using the standard lymphoma protocol (375 mg/m(2) × 4 weeks) demonstrated improved time to relapse. There was no difference seen in the rate of patients reaching complete response in patients treated with the standard lymphoma protocol vs. the standard rheumatoid arthritis protocol (1000 mg × 2). The use of adjuvant plasma exchange or immunoadsorption was associated with an increase in the time to relapse. CONCLUSION: Based on these observations, the low-dose rheumatoid arthritis protocol should not be recommended due to the inferior clinical response and shortened time to relapse.

Outcome of kidney transplantation using expanded criteria donors and donation after cardiac death kidneys: realities and costs.

Expanded criteria donors (ECDs) and donation after cardiac death (DCD) provide more kidneys in the donor pool. However, the financial impact and the long-term benefits of these kidneys have been questioned. From 1998 to 2005, we performed 271 deceased donor kidney transplants into adult recipients. There were 163 (60.1%) SCDs, 44 (16.2%) ECDs, 53 (19.6%) DCDs and 11 (4.1%) ECD/DCDs. The mean follow-up was 50 months. ECD and DCD kidneys had a significantly higher incidence of delayed graft function, longer time to reach serum creatinine below 3 (mg/dL), longer length of stay and more readmissions compared to SCDs. The hospital charge was also higher for ECD, ECD/DCD and DCD kidneys compared to SCDs, primarily due to the longer length of stay and increased requirement for dialysis (70,030 dollars, 72,438 dollars, 72,789 dollars and 47,462 dollars, respectively, p < 0.001). Early graft survival rates were comparable among all groups. However, after a mean follow-up of 50 months, graft survival was significantly less in the ECD group compared to other groups. Although our observations support the utilization of ECD and DCD kidneys, these transplants are associated with increased costs and resource utilization. Revised reimbursement guidelines will be required for centers that utilize these organs.