Further, they reached MELD of 25 marginally faster, despite similar HIV viral load and CD4 counts. Although it is not possible to establish the mechanism for these differences, it is useful to note the major differences between these groups. Specifically, the age at HCV acquisition and the route of HCV transmission differ between these groups. Whether the poorer pretransplant outcomes among haemophilic

subjects are related to the presumed longer duration of HCV infection among individuals in this group, (conservative median estimate of 40 years vs. 32 years in non-haemophilic subjects) remains unknown. Further, whether difference in rates of end-stage liver disease (ESLD) progression impacted pretransplant RG7204 cell line outcome remains unknown, but was not substantiated by any difference in classification,

listing, MELD grading or transplantation criteria. Alternatively, the disease may progress more rapidly in individuals with haemophilia, although recent data from a large observational cohort study of co-infected haemophilic men suggest the rates of fibrosis are similar to those in other co-infected groups [18]. It is also possible individuals with haemophilia, because of their co-morbidity (bleeding), present to liver transplantation clinics later in the course of their ESLD, a possibility not supported by the baseline data in this observational study. Future studies that model ESLD progression by age of first HCV exposure may be helpful in that regard. On the basis of the findings of this study, careful consideration 上海皓元 http://www.selleckchem.com/products/MG132.html should be given to earlier, more aggressive monitoring of co-infected individuals, especially those with haemophilia, to avoid pretransplant demise while awaiting liver transplantation. The MELD score, an established predictor of medical urgency for liver transplantation and ESLD survival [19], has been shown also in recent studies to be an independent marker of pretransplant mortality in co-infected transplant

candidates [20-22]. Thus, more frequent determination of MELD scores and/or liver ultrasound in co-infected transplant candidates during the pretransplant period, or in individuals with co-infection even before signs or symptoms of ESLD, e.g at the time of routine quarterly HIV labs [20], might afford better follow-up, earlier detection of ESLD progression and clearer evidence regarding whether the rate of MELD score increase predicts pretransplant mortality in haemophilic candidates. Further, if the effects of age of HCV exposure on ESLD progression can be quantitatively modelled, additional MELD points might be assigned on the basis of duration of HCV infection or the trajectory of MELD increase, similar to the priority MELD system in use for hepatocellular carcinoma. The latter assigns additional MELD points based on tumour stage, thereby equalizing risk, and successfully alleviating the higher mortality experienced by such individuals [23].