Trends in treatment for hepatocellular carcinoma in Japan

Hepatocellular carcinoma (HCC) is the fifth leading cause of cancer deaths in Japan, and it has gradually decreased in the last quarter century. The reason for the decrease in HCC patients is the decrease of patients with hepatitis C virus due to avoiding unnecessary blood transfusions and development of direct-acting antiviral agents (DAAs), which have been available since 2014, along with interferon and oral antiviral agents in Japan. On the other hand, the numbers of HCC patients with non-alcoholic steatohepatitis (NASH) and non-alcoholic fatty liver disease (NAFLD) are increasing. In the treatment strategy for HCC in the Japanese guideline, the algorithm involves five clinicopathological factors: liver function (assessed using the Child-Pugh classification, liver damage score, and the ICG-R15 value), presence of extrahepatic metastases, presence of vascular invasion, number of tumors (within 3 or more than 4), and tumor size (within 3 cm or over 3 cm). Surgical resection is sometimes indicated for extrahepatic metastases in patients with well-controlled intrahepatic HCC, and for advanced HCC with vascular invasion, hepatectomy is also recommended as one of the treatment options according to the results of a nationwide survey in Japan. In the latest Japanese guideline, the recommended chemotherapy for advanced HCC is lenvatinib or sorafenib as first-line and regorafenib as second-line therapy. Currently, based on the results of various clinical trials for advanced HCC, the therapeutic options for advanced HCC have increased, such as combination therapy of atezolizumab and bevacizumab, ramucirumab, and cabozantinib. Reports of conversion surgery after chemotherapy have also increased, and the development of multidisciplinary treatment for advanced HCC will be of further interest in the future.

P1648CLINICAL OUTCOMES OF LIVING DONOR KIDNEY TRANSPLANTATION FROM MARGINAL DONORS

Background and Aims Evidence demonstrating the outcomes of living donor kidney transplantation (LDKT) from marginal donors (MDs) is limited. We retrospectively investigated the clinical outcomes of LDKT from MDs in both recipients and donors. Method Clinical data on patients who received LDKT in Jichi Medical University Hospital between 2006 and 2019 were extracted from the medical records. Based on the Japanese guideline for preoperative conditions of donors, they were classified as standard donors (SDs) or MDs, the latter including the elderly and patients with obesity, hypertension, diabetes mellitus, and reduced renal function. Multivariate Cox proportional hazard regression analysis for graft survival was performed using explanatory variables of the donor conditions (MD vs SD) and recipient conditions, including age, gender, duration of dialysis, ABO compatibility, and presence of donor specific antibodies. The estimated glomerular filtration rates (eGFRs) of the donors were compared using an unpaired t-test. Results Of the 293 donors, 195 were SDs and 98 were MDs. Demographics and baseline characteristics of recipients and donors Recipients of kidney transplants from MDs were associated with a higher incidence of death-censored graft loss than recipients of kidney transplants from SDs. Kaplan-Meier plots for overall and death-censored graft survival. Multivariate Cox proportional hazard regression analyses for overall and death-censored graft survival The eGFRs of MDs before transplantation were significantly lower than those of SDs, while no significant differences were observed between the two groups 3- and 5-years after transplantation. Comparison of estimated glomerular filtration rates of donors Conclusion While the renal prognosis of recipients of kidneys from MDs is poorer than that of recipients from SDs, donating a kidney has no adverse effects on the renal health of MDs. The present study is the most comprehensive study that examined that the outcomes of LDKT from MDs according to the Japanese guideline.

P6005Incidence and clinical characteristics of coronary artery spasm in patients with out-of-hospital cardiac arrest

Background Substantial cases of out-of-hospital cardiac arrest (OHCA) due to acute coronary syndrome have been recognized thus far, but there have been few reports about the aetiology of patients with OHCA without the organic heart disease. Especially, coronary artery spasm would be one of the causes of OHCA. Purpose This study aimed to investigate causes of OHCA without the organic heart disease and to investigate the characteristics and angiographic findings of OHCA patients with vasospastic angina (VSA). Methods Between January 2010 and April 2018, 920 patients with OHCA caused by probable or definite cardiovascular disease were transferred to our hospital. Return of spontaneous contraction was successfully achieved in 151 patients, among whom diagnosis was made in 130 patients. First, we analysed the causes of OHCA in these patients. Second, we compared clinical and angiographic characteristics between the VSA group with OHCA (OHCA-VSA) and the VSA group without OHCA (stable VSA; n=72) from our database. Results Among the 130 patients, 95 (73%) had the organic heart disease; 72, acute coronary syndrome; 19, myocardial disease; 2, valvular heart disease; and 1, congenital heart disease. There were 35 patients (27%) without the organic heart disease. Nineteen patients had primary (i.e., Brugada syndrome, QT prolongation) or secondary arrhythmia (i.e. drug adverse effect). Electrocardiogram, coronary angiogram, and LV structure and function were normal in 35 patients. However, there were 16 patients (11%) with VSA defined by Japanese guideline. The OHCA-VSA group was significantly younger (50±14) than the stable VSA group (64±11, P=0.003). The incidence of diffuse-type spasm in the OHCA-VSA group (100%) was significantly higher than that in the stable VSA group (100% vs. 69%, P<0.05). In addition, the incidence of triple-vessel coronary spasm in the OHCA-VSA group was significantly higher than that in the stable VSA group (86% vs. 25%, P=0.003). Conclusion OHCA patients without the organic heart disease had considerable cases of VSA, in addition to primary or secondary arrhythmia. Furthermore, the severity of spasm in the OHCA-VSA group was more serious and extensive than in comparison with the stable VSA group.

P986Future risk of bradyarrhythmias in patients with hypertrophic cardiomyopathy and implantable cardioverter defibrillator indication

Background Subcutaneous-implantable cardioverter defibrillator (S-ICD) has been shown to be effective for prevention of sudden cardiac death. Patients with hypertrophic cardiomyopathy (HCM) having ICD indication are considered to introduce either S-ICD or transvenous-ICD, however it is uncertain which is better since S-ICD is not suitable for patients who need pacing and data on the necessity for pacing in HCM patients are limited. Purpose The purpose of this study was to investigate the risk factors associated with the future risk of bradyarrhythmias needed to be paced in patients with HCM and ICD indication. Methods This is a retrospective, single-center cohort study. Of 169 HCM patients diagnosed in our institution, 80 with ICD indication in accordance with the Japanese guideline in 2011 were enrolled as study subjects (31 females, mean age 63±15 years). They were divided into two groups – patients who progressed to bradyarrhythmias which needed pacing during the follow-up period (Brady group) and those who not (Non-brady group). Baseline characteristics at the time of diagnosis of HCM including demographic information, the results of clinical examination such as blood test, echocardiography and electrocardiography (ECG) were compared between the Brady and Non-brady group. Results During a mean follow-up period of 6.8±5.4 years, 9 patients (11%) progressed bradyarrhtyhmias which needed pacing. Symptomatic sick sinus syndrome (SSS) was the primary cause (7 SSS, 1 atrial fibrillation [AF] with bradycardia, 1 after atrioventricular nodal ablation). Comparing between the Brady and Non-brady group, there was no significant difference in clinical variables such as age, heart rate, PR interval and QRS duration in ECG, EF levels, BNP levels, beta-blocker usage rate, prevalence of hypertension or diabetes mellitus. On the other hand, women were more in Brady group than in Non-brady group (7/9, 78% vs. 24/71, 34%; p=0.01). Furthermore, more patients in Brady group had documented AF at the beginning and during follow-up period (7/9, 78% vs. 25/71, 36%; p=0.02) and took anti-arrhythmic drugs (AAD) (8/9, 89% vs. 19/71, 27%; p<0.001) including amiodarone than those in Non-brady group. Conclusion In HCM patients with ICD indication, around 10% of patients have a potential risk of bradyarrhythmias needed to be paced, especially in female, those with AF and/or AAD usage.