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Hepatitis D virus causes chronic hepatitis D. The virus is defective, meaning it requires simultaneous presence of hepatitis B virus within the hepatocytes to complete its viral cycle. Globally, 15 to 20 millions people are estimated to be chronically co-infected by hepatitis B and D viruses. Current therapy remains limited to pegylated interferon alfa, which has an unsatisfactory success rate, several contraindications and many side effects. Drugs directly targeting the hepatitis D virus life cycle are being developed with promising results. These drugs target viral entry into hepatocytes, virion assembly or secretion from infected hepatocytes. This article provides an overview of the newly developed therapies and their efficacy., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Non-alcoholic fatty liver disease (NAFLD) includes a spectrum of hepatic pathology ranging from non-alcoholic fatty liver, non-alcoholic steatohepatitis (NASH) occasionally complicated with hepatic fibrosis or even cirrhosis. In order to propose a diagnosis with positive criteria, a panel of experts recently proposed the use of an alternative nomenclature, metabolic-dysfunction-associated fatty liver disease (MAFLD) whose use remains debated. In addition, in Switzerland and elsewhere, there is strong epidemiological growth of NAFLD. The next years will probably see the approval of new therapies for NAFLD/NASH but, at present, management remains focused on lifestyle interventions and joint monitoring by the primary care physician and, when necessary, the specialist., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Acute cirrhotic decompensation is characterized by a rapid and sudden deterioration of hepatocellular function. It may be associated with secondary failure of one or more organs. The definition and understanding of a complex cirrhotic decompensation with multi-organ damage, is still poorly defined. This entity is currently called Acute on Chronic Liver Failure (ACLF). Depending on the number of affected organs, decompensation is classified into 4 stages, from 0 to 4. Mortality is proportional to the number of failed organs, with mortality from 50 % to 80 % at 30 days when 3 or more organs are affected. The interest of liver transplantation in the most severe forms, which has been debated for a long time, seems to be a safe alternative with good results in well selected patients., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêt en relation avec cet article.

The population of liver transplant recipients has increased in Switzerland over the last few years. Morbidity and mortality after liver transplantation are due, in the early post-transplant period, to surgical and infectious complications as well as to rejection, whereas cardiovascular, metabolic, renal and oncologic complications are the most frequent complications in the late post-transplant period. The role of the general practitioner in the long-term follow-up of liver transplant recipients is of the highest importance and can represent the first-line care of these patients as soon as 6 to 12 months post-transplantation, while maintaining a close and regular collaboration with the transplant center. Multidisciplinary and structured follow-up, along with some specific screening tests, is warranted in order to refine patient management in a timely manner and to optimize outcomes., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Paracentesis is a frequent procedure, especially in patients with cirrhosis. In these patients, given the fears of severe bleeding associated with coagulation disorders as well as thrombocytopenia, we were interested to review the literature on this subject. Few studies are available and, for the moment, recommendations are of a low level of evidence. Paracentesis seems to be a safe procedure without severe haemorrhagic complications (< 1%), regardless of coagulation disorders and platelet count. Renal insufficiency, Child-Pugh C cirrhosis, thrombocytes < 50 G/L and cirrhosis of alcoholic origin may however increase the risk of bleeding. Caution should be observed in these patients., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Portal vein thrombosis is frequently encountered in patients with cirrhosis. Increased indication for non-invasive imaging in patients with cirrhosis has dramatically increased the recognition of PVT. This has led to a large amount of studies on pathogenesis as well as the prognostic impact of portal vein thrombosis on natural history of cirrhosis. However, in clinical practice, several aspects of the management of portal vein thrombosis remain unclear. This practical review discusses the most recent data toward the management of portal vein thrombosis in cirrhosis, especially regarding : a) the value of etiological workup ; b) the impact of portal vein thrombosis on the natural history of cirrhosis, and c) the indications and modalities of anticoagulation therapy., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Refractory ascites affects 10% of patients with advanced cirrhosis. Recurrent ascites is commonly managed by repeat large volume paracentesis with volume expansion, and in selected patients, by the implantation of a transjugular intrahepatic portosystemic shunt (TIPS). Both approaches are associated with potential complications, including vascular traumatic injuries in the setting of paracentesis. A new automatic pump has been developed to mechanically remove ascites from the peritoneal cavity to the bladder. The benefit of this pump in terms of reduced frequency of paracentesis should be balanced by the risk of adverse events that include infection, catheter dysfunction, and renal insufficiency. The place of this new device in the management of ascites due either to portal hypertension or to cancer remains to be determined.

Liver tests abnormalities during pregnancy should encourage the clinician to seek liver diseases of pregnancy. The liver diseases of pregnancy are those proper to pregnancy including hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, all the "hypertensive" related diseases and acute fatty liver of pregnancy. These pathologies can involve the vital prognosis of the mother and the child. An adequate management reduces maternal-fetal complications. Close monitoring of pregnancy with sometimes induction of labour and verification of the normalization of liver tests after childbirth are essential.

Long-term treatment with proton pump inhibitors (PPI) is becoming more prevalent. Although they are well tolerated in the short term, serious concerns about long-term use have arisen. Recent data suggest that the latter is associated with an increased risk for osteoporotic fracture (especially vertebral), Clostridium difficile infection and rebound acid hypersecretion after treatment discontinuation. Acute interstitial nephritis is rare but may progress to chronic renal failure. An increased risk of community-acquired pneumonia has not been established in the general population and seems limited to the most vulnerable patients. Consistent data are still missing to correctly assess the risk of iron deficiency, vitamin B12 deficiency or hypomagnesaemia and the risk of digestive malignant diseases, despite the pathophysiological basis that exists concerning gastric malignancy. Many drug interactions can occur on long-term treatment, including some that imply the cytochrome P450 enzymes. Finally, the risk-benefit balance for a chronic PPI use in children seems unfavorable in most cases., (Copyright © 2012 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Hepatocellular carcinoma (HCC) is one of the most frequent malignant tumors worldwide and its incidence has increased over the last years in most developed countries. The majority of HCCs occur in the context of liver cirrhosis. Therefore, patients with cirrhosis and those with hepatitis B virus infection should enter a surveillance program. Detection of a focal liver lesion by ultrasound should be followed by further investigations to confirm the diagnosis and to permit staging. A number of curative and palliative treatment options are available today. The choice of treatment will depend on the tumor stage, liver function and the presence of portal hypertension as well as the general condition of the patient. A multidisciplinary approach is mandatory to offer to each patient the best treatment.

This article describes the new organ allocation system for liver transplantation introduced in Switzerland on July 1, 2007. In its newly adopted transplantation law, Switzerland chose the MELD score (Model for end-stage liver disease), based on three laboratory values: total bilirubin, serum creatinine and INR. Advantages and limitations of the MELD score are discussed. Finally the West Switzerland joint liver transplantation program is briefly introduced.

Due to obesity epidemics, nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are becoming the main causes of chronic liver disease in western countries. Nonalcoholic steatohepatitis is a potentially progressive disease that may cause cirrhosis. We analysed liver histology in 505 patients at the time of gastric by-pass surgery. Steatosis was present in 92% of these patients, mild (< 30% of hepatocytes) in 46%, moderate (30-60% of hepatocytes) in 30%, and severe in 23%. Insulin resistance, diabetes, elevated ferritin and elevated liver tests were independent predictors of NASH in the liver these obese patients. Early identification of these factors might help to select patients at risk of NASH in whom liver biopsy should be considered.

The success of liver transplantation essentially depends on the prevention and treatment of long term complications, which may be due to surgery, opportunistic infections, organ rejection and relapse of the initial liver disease. The side effects of immunosuppressive drugs--arterial hypertension, glucose intolerance and diabetes, dyslipidemia and obesity, renal failure, osteoporosis, malignancy, and anaemia--should be regularly screened and treated without delay. Surgical procedures in transplanted patients are safe and rarely followed by complications. Although pregnancy in this setting is considered at risk, because of prematurity and low birth weight, overall outcomes are favourable. The yearly influenza vaccination is strongly recommended. The survival and the quality of life of liver transplant patients also depend on a good communication between the general practitioner and the transplantation centre.

Wilson's disease is a rare genetic condition, transmitted on a recessive autosomal mode, which involves a disturbance of copper metabolism. Its prevalence is 1: 30000. It is treatable but may be lethal if not managed early and treated adequately. It is caused by the loss of function of an adenosine triphosphatase (ATP 7B), which is due to a mutation in the ATP 7B gene on chromosome 13. This leads to a decrease or absence of copper transport to the bile and its accumulation within certain organs, particularly the liver and the brain. In this article we present two cases of Wilson's disease in two young male patients. We also briefly review the pathophysiology of the illness, discuss the latest guidelines for diagnosis and treatment and outline the recent genetic discoveries.

The pegylated interferon is now the first choice of treatment for patients without a counter-indication. The association of this treatment with lamivudine does not increase the effectiveness. For patients non-responders to the PEG-IFN or presenting counter-indications, the long-term administration of lamivudine is limited by the frequent appearance of mutations, so that escape from the treatment requires the use of other antivirals. Adefovir is currently the treatment of choice in the event of resistance to lamivudine. Its effectiveness is confirmed by many studies and the risk of emergence of resistance is very low. Entecavir is a selective inhibitor of polymerase HBV and shows a better efficacy than lamivudine. It is well tolerated and is associated only with a weak risk of resistance, even after a prolonged treatment.

The shortage of cadaver organs has prompted transplant centres to seek new sources of grafts. While living-donor left lobe transplantation (segments II and III) is an established procedure for children, living donor right liver transplantation (segments V, VI, VII, VIII), which can provide adequate liver mass for an average-sized adult patient, is technically more demanding and potentially associated with higher risks for the donor. In view of the permanent shortage of organs in Switzerland, we started an adult living donor liver transplantation programme in 1999 with the approval of the Clinical Ethics Committee of Geneva University Hospitals. Donor evaluation was performed only after the recipient had been officially registered for transplantation in the national waiting list. Preoperative evaluation consisted of a preliminary information phase with blood tests and Doppler ultrasonography, a second phase with radiological non invasive investigations (CT scan with volume measurements, magnetic resonance cholangiography) and a third phase including liver biopsy and angiography. A formal psychiatric evaluation was performed in all cases and detailed consent was required. Eight potential donors were investigated, 5 were not retained because of too small right liver or steatosis, and 3 were accepted (wife, son, sister). Living-donor hepatectomy was performed without interrupting the vascular blood flow. The liver graft was perfused ex-situ with University of Wisconsin solution. The grafts were anastomosed to the preserved vena cava of the recipient and the portal and arterial anastomoses were performed without interposition grafts, with short cold ischaemic times in the 3 cases. The graft-to-recipient weight ratio ranged from 1.04 to 1.12%. The grafts worked immediately; the post-operative course in the 3 recipients was unremarkable and no rejection episode occurred. Significant complications were observed in one donor (percutaneously drained bilioma and spontaneously resolved popliteal sensory palsy). Living-donor right liver transplantation is a potentially valuable solution to the increasing shortage of donor organs. The procedure can be performed safely provided stringent criteria for donor selection, for donor-recipient coupling (> 1% graft to body weight ratio) and for centre selection (experience in liver surgery, reduced and split liver transplantation) are applied.

Between July 1987 and August 1998, 173 orthotopic liver transplantations (OLT) were performed in Geneva. We studied a homogeneous group of 114 OLT performed during the 6 years between 1992 and 1997 on 107 patients (89 adults and 18 children; 7 retransplantations). Although Geneva has the largest transplantation programme in Switzerland and is the only centre performing paediatric liver transplantation, the mean number of procedures per year was 19, corresponding to only a small transplantation programme in Europe. It could be reasonably questioned, therefore, whether Swiss patients are not at a disadvantage as compared with patients from European countries with larger liver transplantation centres. Although the perioperative morbidity was still considerable, the results of this series -90% of actuarial patient survival at 1 and 2 years and 84% at 5 years-compare favourably with the results of the European Liver Transplantation Registry: 76% of actuarial patient survival at 1 year and 65% at 5 years. In this series, 95 patients (89%) were alive on January 1, 1998. As no patient was refused on the severity of the liver disease and as more than 10% of OLT were performed as emergencies, a bias due to the selection of the best cases cannot explain the good results. This series demonstrates that a small liver transplantation centre may obtain results that compare favourably with the results of large European centres, and that Swiss patients are not at a disadvantage as compared with patients of other European countries.

Small bowel transplantation is theoretically the best treatment for patients with short bowel syndrome and receiving total parenteral nutrition (TPN). The aim of our study was to determine the number of potential candidates for small bowel transplantation in Switzerland. We analyzed the clinical parameters of patients treated by TPN for short bowel syndrome obtained from university pediatric clinics, the SVK (Schweizerischer Verband für Gemeinschaftsaufgaben der Krankenkassen) and referring physicians. In 1995, 7 adults and 2 children were under TPN for short bowel syndrome. In the adult group (mean age 57), the causes of short bowel syndrome were 3 cases of mesenteric infarct, 2 cases of mechanical ileus, one Gardner syndrome and one inflammatory bowel disease. In the pediatric group, the causes of intestinal insufficiency were in one chronic enteropathy with malabsorption and in one congenital malformation. The average duration of TPN was 4.4 (1-10) years for the adults and 13 months for the children. The various complications related to TPN were repeated catheter sepsis in 5 patients, 2 cases of catheter thrombotic occlusion and 3 cases of cholestatic hepatopathy. The contraindications to small bowel transplantation were age, a history of malignant tumor, pulmonary hypertension and a psychiatric disorder. 4 patients were considered potential candidates for transplantation: 2 adults and 2 children, corresponding to an incidence of 0.5/million inhabitants. Considering that the prevalence and incidence of short bowel syndrome in Switzerland are comparable to those in other western countries, we think it should be possible to initiate a small bowel transplantation program in Switzerland.

Type I familial amyloid polyneuropathy (FAP), or Andrade's disease, is an inherited autosomal dominant disease, always fatal, involving mixed progressive polyneuropathy associated with systemic amyloid deposits. The disease is secondary to mutations of a gene (located on chromosome 18) which encodes for a serum protein, transthyretin. This variant protein is essentially (> 90%) produced in the liver and constitutes the biological marker of the disease. Many surgical teams have established a liver transplantation program for this non-cirrhotic pathology. Between January and August 1994, we performed three orthotopic liver transplantations (OLT) in patients with FAP. The patients were men aged between 30 and 33 years and the mean duration of symptoms was 3 years. The diagnosis of FAP was confirmed by rectal biopsy and detection of the genetic mutation (PCR analysis). All patients presented a severe sensory, motor and autonomic neuropathy with major digestive and urologic dysfunction. Two other patients were not accepted for OLT because of advanced disease with ulcerous lesions of the inferior limbs and cardiopathy. All patients survived with excellent post-operative hepatic function. One month after OLT, one patient had hepatocellular rejection which responded favorably to steroids. Another patient developed post-transfusional B hepatitis 10 months after the graft, but without major hepatic lesions. In the three cases, we observed stabilization of the peripheral neuropathy and an objective improvement of the autonomic affection (neurogenic bladder, diarrhea). The patients who did not undergo transplantation died within a year. Thus, in patients suffering from familial amyloid polyneuropathy OLT must be performed, especially in the early stage of the disease and especially in young patients before serious neurological complications set in.

A retrospective study over the last 5 years on drug-induced liver injury was performed in the Internal Medicine Department of the University Hospital of Geneva. According to WHO and Council for International Organizations of Medical Sciences (CIOMS) criteria for drug-induced liver adverse events, 142 cases were identified, with 255 drugs fulfilling causality criteria of certain, probable or possible. 63 patients (44%) suffered severe consequences of liver injury, including 9 deaths. Drugs reported belonged to the therapeutic classes of antibiotics (43%), cardiovascular (20%), analgesics (10%), gastrointestinal (9%), psychotropic (7%), and others (11%). Despite bias inherent to the retrospective methodology, only 10% of the side effects were spontaneously reported to the pharmaco-vigilance board. This is in accordance with the known reporting rate. It can be concluded that spontaneous reports are to be regarded only as signals.

Surgery is the only treatment which can achieve long-term survival of patients with colorectal liver secondaries. This study reports the results in 71 patients with liver metastases who underwent hepatic resection from January 1980 to December 1994. The mean age was 60 years (range 37 and 80 years). Operations included 33 right hepatectomies, 5 extended right hepatectomies, 6 left hepatectomies, 11 left lobectomies,. Surgery was macroscopically and microscopically curative in 61 patients. Information was not available in 2 patients. Significant morbidity was observed in 37% of patients. Actuarial survival at 1, 3 and 5 years was 83%, 27% and 20% respectively. At the end of the follow-up, 50 patients had died and 6 were lost to follow-up. Techniques of hepatic resection for secondaries are well established and postoperative mortality is low. Pending advances in chemotherapy, we recommend surgery as being the only way of improving long-term survival in patients with colorectal hepatic metastases.

From January 1986 to September 1995, 4 patients were hospitalized in our ward for gastrointestinal bleeding from ectopic varices. The patients were all female, aged 30 to 65 years. The etiology of portal hypertension in these patients was alcoholic cirrhosis, cirrhosis in Wilson's disease and previous alveolar echinococcosis treated by right hepatectomy, complicated by post-operative portal thrombosis. Clinical presentation in all 4 cases was lower gastrointestinal bleeding. Diagnosis was by emergency arteriography in 3 cases; no source was found in one case with recurrent hemorrhage. The 4 patients had a history of abdominal surgery. The location of the ectopic varices was small bowel and cecum. 3 patients were treated surgically: right colectomy, partial small bowel resection and porto-caval shunt with complete lysis of adhesions. One patient was treated conservatively with emergency placement of a TIPS (transjugular intrahepatic porto-systemic shunt), with simultaneous embolization of cecal varices. Upon laparotomy, all 3 surgical cases presented ectopic varices in post-operative adhesions. In conclusion, in a patient with portal hypertension presenting with lower gastrointestinal bleeding, hemorrhage from ectopic varices should be kept in mind and investigated by arteriography. A history of abdominal surgery seems to be a predisposing factor in development of ectopic varices by adhesion formation.

Primary biliary cirrhosis is regarded as one of the optimal indications for orthotopic liver transplantation in adults. With the decrease in the operative mortality, the analysis of the potential long-term complications including disease recurrence is becoming increasingly relevant. The purpose of this study was to evaluate the long-term results of liver transplantation for primary biliary cirrhosis in our center. From 1988, 14 patients were transplanted for this indication and all of them were alive with a mean follow-up of 43 months by the end of June 1995. At that time, all complications related to chronic liver disease were reversed by the transplant except for osteopenia. Lumbar column fractures and overweight were the major inconveniences encountered. Hypertension and diabetes related to antirejection therapy disappeared during the first year of follow-up in all but one patient. Recurrence of the disease was not encountered in this series where a triple association of immunosuppressive therapy was maintained in each patient. At long-term, the frequency of disease recurrence in the liver allograft seems quite low and even in this situation immunosuppressive agents may alter the evolution of the disease. All patients (n - 12) who had at least 1 year of follow-up had a normal level of bilirubin and their quality of life was good to excellent. These results, confirmed by the international experience, support the notion that patients suffering from primary biliary cirrhosis should be transplanted as early as complications from this chronic liver disease occur.

Up to now, liver resections have been the initial treatment of almost all cancers and benign tumors limited to a liver lobe. This retrospective review assesses the results of a consecutive series of 113 major elective hepatic resections during a ten-year period. Major hepatectomy was defined by the resection of at least 3 Couinaud segments. Mean age was 52 years (20 to 79 years). There were 62 women and 51 men. 35 resections were performed for colorectal metastases, 22 for a benign tumor, 20 for non-colorectal metastases, 11 for hydatid disease, 10 for hepatocarcinoma, 7 for cholangiocarcinoma and 8 for other indications. The resections performed were 86 right hepatectomies with 18 extended right hepatectomies, 24 left hepatectomies with 4 extended left hepatectomies and 3 trisegmentectomies. Total vascular exclusion was used in 22 patients (19%). Mortality rate was zero. Significant morbidity was encountered in 24 patients (21%). These results suggest that the mortality rate may be independent of the extent of liver resection, provided that hepatic function is normal and preoperative selection adequate. With improving surgical management and techniques, and the use of intra-operative sonography, extensive liver surgery can now be performed with a very low mortality rate.

Between 1 january 1992 and 31 december 1993, 32 liver transplantations were performed in 29 patients (5 transplants in 3 children and 27 transplants in 26 adults) at Geneva University Hospital. Despite 5 super-urgent transplantations (3 fulminant hepatitis, 1 end-stage Wilson disease and 1 primary nonfunction), all patients are still alive and all have lived more than 10 months. On 1 october 1994, all patients were at home and 93% were in good general condition. No patient of this series had been transplanted for cancer and all patients positive for hepatitis B surface antigen receive long-term administration of anti-HBs immune globulin: in this respect, the long-term mortality risk of the present series of patients seems to be very low. Although these results highlight that liver transplantation can be performed safely by a competent medico-surgical team, two significant difficulties have to be outlined. First, patients are likely to die on the waiting list due to unavailable grafts, especially in emergency cases. Second, the postoperative period of patients with decompensated end-stage liver disease at the time of liver transplantation is still one of high morbidity. These facts underline that chronic liver disease patient should be evaluated for liver transplantation prior to the terminal decompensated stage of the disease, when the candidate's invariably poor general condition precludes successful liver transplantation.

The incidence of recurrence of hepatitis B virus (HBV) following orthotopic liver transplantation (OLT) is as high as 80% when no attempt at prevention has been considered. HBV reinfection is associated with the reappearance of hepatitis B surface antigen (HBsAg) and HBV DNA in serum and, in most cases, with rapid severe graft damage. Immunoprophylaxis using polyclonal anti-HBs immunoglobulins reduces the risk of recurrence but this long-term therapy remains highly expensive. In this report, we use fresh frozen plasma (FFP) with high titers of anti-HBs immunoglobulins in an attempt to reduce HBV recurrence. From July 1987 to September 1993, 11 patients underwent OLT for HBV-related liver disease (18% of our OLT patients). FFP were administered to 6 patients continually for 7 to 46 months. Only one patient, under long-term immunosuppressive treatment before OLT, was reinfected 7 months after OLT. Rapid development of graft failure was observed with histologic manifestations of a fibrosing cholestatic hepatitis, leading to patient death after 12.5 months with concomitant bacterial infection. In this protocol, the rate of reappearance of HBsAg was 17%, a figure which can be favorably compared with other reports. All patients were subsequently tested for HCV and HIV and remained negative. In conclusion, FFP with high titers of anti-HBs immunoglobulins is at least as effective as polyclonal anti-HBs immunoglobulins in reducing the rate of HBV recurrence following OLT. The estimated cost of this new immunoprophylaxis method is less than 10% of the classical prophylaxis based on purified human polyclonal anti-HBs immunoglobulins.

Cytomegalovirus (CMV) belongs to the family of Herpes viridae and has become the single most important viral pathogen in clinical transplantation. This is an endemic and ubiquitous virus. After transplantation it is necessary to distinguish CMV infection (positive seroconversion and/or isolation of the virus in the blood, urine, sputum or tissues in the absence of clinical symptoms) from CMV disease, which is a clinical expression of viremia in association with a documented CMV infection. The overall incidence of CMV infection in transplant recipients is about 50% and the incidence of CMV disease ranges from 15 to 25% whatever the transplanted organ. In this study (52 liver transplantations in 48 patients), 12 patients had CMV infection and 10 patients developed CMV disease (24%). The onset of CMV disease was 33 +/- 7 days after transplantation. Cytomegalovirus hepatitis was observed 7 times, CMV pneumonia once and 2 CMV infections characterized by oscillating fever in association with a hematological syndrome. 8 patients were treated with intravenous gancyclovir (DHPG, 9-[1,3-dihydroxy-2-propoxymethyl]-guanine) for 15 days and 2 patients by reduction of their immunosuppressive therapy only. There were significantly more (p < 0.05) opportunistic infections and/or bacteremia in patients with CMV disease. The association of CMV IgG negative recipients and CMV IgG positive donors appeared to be a significant factor (p < 0.05) for CMV disease. The number of transfusions, the level of immunosuppression and the absence of prophylaxis did not influence the incidence of CMV disease. Despite prolonged hospitalization and increased morbidity, there were no deaths in patients who developed CMV disease, which is good evidence of the efficacy of gancyclovir.(ABSTRACT TRUNCATED AT 250 WORDS)