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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The success of direct-acting antivirals &#40;DAA&#41; against hepatitis C virus &#40;HCV&#41; was a major breakthrough in medicine&#46; Many studies showed that DAA are safe and effective for chronic HCV infection treatment after kidney transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> In 2018 KDIGO updated the Guidelines on chronic HCV in chronic kidney disease &#40;CKD&#41; including the recommendation that all infected kidney transplant recipients &#40;KTR&#41; should be evaluated for treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">About KTR treated in our kidney transplantation unit<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> we would like to report two fatal cases&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The first was a 71-year-old male with IgA nephropathy with prior HCV infection &#40;genotype 1b&#41;&#44; who underwent kidney transplantation in 1991&#46; In 2016 hepatic fibrosis &#40;fibroscan F3&#41; was documented and HCV treatment with ledipasvir&#47;sofosbuvir was prescribed reaching sustained viral response &#40;SVR&#41; at 12 weeks&#46; One year after therapy&#44; elevation of alpha-fetoprotein &#40;AFP&#41; from 2&#46;9 to 10&#46;9<span class="elsevierStyleHsp" style=""></span>ng&#47;ml &#40;reference value &#60;8&#46;8<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41; was noticed&#44; despite undetectable HCV viral load&#46; Hepatic ultrasound found no abnormalities but computed tomography showed extensive hepatic nodular involvement and partial portal vein thrombosis&#44; suggestive of hepatocellular carcinoma &#40;HCC&#41;&#46; The patient died four months after HCC diagnosis&#44; before treatment with sorafenib was started&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The second patient was a 72-year-old female with CKD due to chronic pyelonephritis who underwent renal transplantation in 2003&#46; She had prior chronic HCV infection &#40;genotype 1a&#41; and had documented hepatic cirrhosis &#40;fibroscan F4&#41;&#46; Treatment with sofosbuvir&#47;ledipasvir&#47;ribavirin was given 13 years after transplantation&#44; reaching SVR at 24 weeks&#46; Eleven months later&#44; AFP increased &#40;7&#46;2&#8211;2864<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41;&#46; Despite normal hepatic ultrasound&#44; magnetic resonance imaging showed a nodular lesion compatible with HCC&#46; The lesion was successfully embolized&#46; Ten months later&#44; bone metastasis was evident as she suffered a fracture on her left hip&#46; Bone biopsy confirmed metastatic HCC&#46; Although HCV viral load remained undetectable&#44; the patient died 14 months after the diagnosis&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Even after HCV eradication by DAA&#44; the risk of progression to HCC remains a threat&#46; As illustrated in these two cases&#44; the suspicion was raised by an increasingly AFP despite an unsuspected ultrasound&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In patients with chronic HCV infection and cirrhosis&#44; the risk of developing HCC remains uncertain&#46; However this risk is significantly reduced compared to untreated patients or in the ones who did not achieve SVR&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The European Association for the Study of the Liver recommends that patients with advanced fibrosis or cirrhosis with SVR should undergo surveillance for HCC every 6 months by means of ultrasound&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> However&#44; in these two KTR cases&#44; ultrasound was ineffective for detection of HCC&#44; which occurred less than one year after apparently successful DAA therapy&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The purpose of reporting these two cases is fourfold&#58; &#40;1&#41; to alert for the need to fully evaluate patients who display an increase of AFP levels&#59; &#40;2&#41; ultrasound may not be a sensitive method to HCC diagnosis&#59; &#40;3&#41; to raise the possibility that immunosuppression may eventually increase the oncogenic potential of previous HCV infection&#59; &#40;4&#41; as HCV infection lasted for many years and HCC developed shortly after DAA a causal relation cannot be discarded&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors disclose no conflicts of interest&#46;</p></span></span>"
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Letter to the Editor
Hepatocellular carcinoma after direct-acting antiviral therapy in kidney transplant recipients infected with hepatitis C virus
Carcinoma hepatocelular después del tratamiento con antivirales de acción directa en pacientes trasplantados renales infectados con el virus de la hepatitis C
Rita Calçaa,
Autor para correspondencia
arrcalca@gmail.com

Corresponding author.
, Cristina Jorgea, Luís Lebreb, Eunice Cacheiraa, Sara Queridoa, Célia Nascimentoa, Teresa Adragãoa, Margarida Brugesa, André Weigerta, Domingos Machadoa
a Department of Nephrology, Hospital Santa Cruz – Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
b Department of Gastroenterology, Hospital Egas Moniz – Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
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who underwent kidney transplantation in 1991&#46; In 2016 hepatic fibrosis &#40;fibroscan F3&#41; was documented and HCV treatment with ledipasvir&#47;sofosbuvir was prescribed reaching sustained viral response &#40;SVR&#41; at 12 weeks&#46; One year after therapy&#44; elevation of alpha-fetoprotein &#40;AFP&#41; from 2&#46;9 to 10&#46;9<span class="elsevierStyleHsp" style=""></span>ng&#47;ml &#40;reference value &#60;8&#46;8<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41; was noticed&#44; despite undetectable HCV viral load&#46; Hepatic ultrasound found no abnormalities but computed tomography showed extensive hepatic nodular involvement and partial portal vein thrombosis&#44; suggestive of hepatocellular carcinoma &#40;HCC&#41;&#46; The patient died four months after HCC diagnosis&#44; before treatment with sorafenib was started&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The second patient was a 72-year-old female with CKD due to chronic pyelonephritis who underwent renal transplantation in 2003&#46; She had prior chronic HCV infection &#40;genotype 1a&#41; and had documented hepatic cirrhosis &#40;fibroscan F4&#41;&#46; Treatment with sofosbuvir&#47;ledipasvir&#47;ribavirin was given 13 years after transplantation&#44; reaching SVR at 24 weeks&#46; Eleven months later&#44; AFP increased &#40;7&#46;2&#8211;2864<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41;&#46; Despite normal hepatic ultrasound&#44; magnetic resonance imaging showed a nodular lesion compatible with HCC&#46; The lesion was successfully embolized&#46; Ten months later&#44; bone metastasis was evident as she suffered a fracture on her left hip&#46; Bone biopsy confirmed metastatic HCC&#46; Although HCV viral load remained undetectable&#44; the patient died 14 months after the diagnosis&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Even after HCV eradication by DAA&#44; the risk of progression to HCC remains a threat&#46; As illustrated in these two cases&#44; the suspicion was raised by an increasingly AFP despite an unsuspected ultrasound&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In patients with chronic HCV infection and cirrhosis&#44; the risk of developing HCC remains uncertain&#46; However this risk is significantly reduced compared to untreated patients or in the ones who did not achieve SVR&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The European Association for the Study of the Liver recommends that patients with advanced fibrosis or cirrhosis with SVR should undergo surveillance for HCC every 6 months by means of ultrasound&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> However&#44; in these two KTR cases&#44; ultrasound was ineffective for detection of HCC&#44; which occurred less than one year after apparently successful DAA therapy&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The purpose of reporting these two cases is fourfold&#58; &#40;1&#41; to alert for the need to fully evaluate patients who display an increase of AFP levels&#59; &#40;2&#41; ultrasound may not be a sensitive method to HCC diagnosis&#59; &#40;3&#41; to raise the possibility that immunosuppression may eventually increase the oncogenic potential of previous HCV infection&#59; &#40;4&#41; as HCV infection lasted for many years and HCC developed shortly after DAA a causal relation cannot be discarded&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors disclose no conflicts of interest&#46;</p></span></span>"
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