Journal of Hepatology

Editorial Board

2010-03-01

Many Ways One Aim

2010-03-01

Clinical School Course 14: Metabolic Liver Diseases

2010-03-01

The International Liver Congress 2010

2010-03-01

Hepatocellular Carcinoma: from Genomics to Treatment

2010-03-01

Focus

Daniel Shouval — 2009-12-24

The majority of acutely infected HCV patients develop persistent viral infection with variable necro-inflammatory activity and fibrosis. It is not fully understood why a subset of patients will follow a benign course which may last for decades, and that is characterized by minimal hepatocellular injury and fibrosis while others follow a progressive pass with repeated cycles of hepatocyte injury and fibrosis.

Ablation for hepatocellular carcinoma: Is there need to have a winning technique?

Alejandro Forner, Jordi Bruix — 2010-01-06

Screening for hepatocellular carcinoma (HCC) in the population at risk (namely patients with liver cirrhosis) is now an established practice . It aims to detect tumors at an early stage so that treatments that may provide a cure for the cancer can be implemented. Years ago, this was seen as an impossible goal and the efforts of those working in the field of clinical liver cancer were seen as unfruitful. However at present, liver resection, transplantation, and ablation are conventional treatments in clinical practice and the current debate centers around which treatments should be given as a priority to patients diagnosed with early HCC. The controversy affects only those individuals who stand to benefit from all treatments. It is clear that patients with early HCC in decompensated cirrhosis will be better served by transplantation if there are no contraindications for it because of age and/or co-morbidities. A commonly held belief is that the depicted uncertainty is easily solved by developing a large, prospective, randomized clinical trial comparing the three options or at least two of them. There are a small number of trials with limited sample sizes and heterogeneous patient populations which have not solved the debate in a robust manner. For a trial to be fully informative it needs to recruit patients whose profile makes them suitable candidates for all three options, as it would not be appropriate to compare suboptimal candidates for surgery with the best candidates for ablation. Since the outcome of liver transplantation is not affected by liver function or by tumor burden if it is still within the Milan criteria , the key would be to define the optimal candidates for resection and ablation, and then select as the target population for the trial the profile that is shared as optimal for both options and stratify them according to the most relevant. Several studies have shown that nodule size is the major parameter that predicts the success of ablation (the cut-off is around 3cm in size) , while presence of more than one nodule also affects efficacy, recurrence, and ultimately, survival . Hence, a valid trial should be restricted to this size and if aiming for optimal candidates, should only include solitary HCC. Data for selection of the best candidates for resection are also known: absence of clinically significant portal hypertension reflected by a hepatic vein pressure gradient <10mmHg and solitary HCC define the optimal population both in the West and the East . Following these comments, a trial comparing resection vs. ablation should optimally include patients without clinically significant portal hypertension diagnosed with solitary HCC<3cm. The end-point of the trial should be survival, and available data in cohort studies indicate that we could have a 70% survival at five years in both arms. Accordingly, the trial could be designed as a non-inferiority trial, with the expectation of providing a basis for suggesting that ablation should be the first choice and leave resection for failures. Since the results for ablation are significantly better in HCC⩽2cm it would be advisable to stratify patients according to this size limit. Now that the trial design is defined, should we ask if such a trial feasible? The answer is clearly negative. The sample size for such a trial would exceed 1000 patients and the study duration would surely last at least 5years. Liver cancer is not as prevalent as colorectal, breast, or lung cancer and the stratum of patients targeted is very narrow. In the BCLC group, this type of patient profile involves less than 1% of the global HCC population and the proportion should be almost the same in most western referral centers where state of the art surgical and ablative skills are available. Hence, the study should be multi-centric and international and thus requires that a vast monitoring effort be in place for several years. As a whole, the budget projection for such a study would be extremely expensive and any assessment would classify the study as unfeasible and/or not robust enough to reach an unequivocal answer to the hypothesis posed.

Harmony in liver fibrosis…

Pierre Bedossa — 2010-01-06

The recent controversy on the respective place of liver biopsy and non-invasive tools in chronic liver diseases has focused attention on the quantitative evaluation of fibrosis. As a basis for further discussion that liver biopsy is the best available standard for assessment of liver fibrosis, the article of Gailhouste et al. in the present issue of the Journal of Hepatology shows that biopsy can tell us much more than a score, providing additional useful information on the texture of fibrosis which might have clinical relevance. Liver fibrosis is the accumulation of newly synthesized extracellular matrix (ECM) molecules within the liver. Several ECM molecules have been characterized and fibrillar collagen (mainly isotype I and III) are among the most important . These molecules auto-assemble into a characteristic triple helical pattern that organize into highly stable fibrillar units. These fibrillar structures serve as a scaffold for the deposition and organization of other ECM molecules and are therefore of major physiopathological importance in the process of liver fibrosis development .

Abundant numbers of regulatory T cells localize to the liver of chronic hepatitis C infected patients and limit the extent of fibrosis

2009-12-24

Background & Aims: Weak hepatitis C virus (HCV) specific immunity in peripheral blood has been shown to be partially controlled by regulatory T cells (Treg). However, little is known about Treg present in livers of HCV-infected patients, their association with clinical parameters, and immunopathology resulting in disease progression.Methods: The frequency and phenotype of CD4+FoxP3+ Treg, conventional CD4+ T cells, and the distribution of lymphocytes and leukocytes were studied by multi-color flowcytometry in liver and peripheral blood of 43 chronic HCV patients at different phases of liver disease. Comparisons between healthy blood and liver and correlations with disease parameters were made.Results: An extensive lymphocyte infiltration containing abundant numbers of CD4+FoxP3+ Treg was present in HCV-infected livers, while absent from healthy liver. Moreover, in all patients, intrahepatic CD4+FoxP3+ Treg showed a fully differentiated and highly activated phenotype on the basis of the surface markers CD45RO, CCR7, CTLA-4 and HLA-DR. These Treg were more numerous in those HCV-infected livers showing only limited fibrosis. However, HCV RNA loads or alanine transaminase levels did not correlate with CD4+FoxP3+ Treg frequencies.Conclusions: Our data demonstrate that large numbers of highly activated and differentiated CD4+FoxP3+ Treg localize to the infiltrated chronic HCV-infected liver and may result in limiting the extent of fibrosis. This suggests that CD4+FoxP3+ Treg play a pivotal role in limiting collateral damage by suppressing excessive HCV-induced immune activation.

T cell immunoglobulin- and mucin-domain-containing molecule-3 (Tim-3) mediates natural killer cell suppression in chronic hepatitis B

2010-01-06

Background & Aims: T cell immunoglobulin- and mucin-domain-containing molecule-3 (Tim-3) has been shown to influence autoimmune diseases; however, its function in viral infection has not been well-defined. We therefore investigated the expression and regulatory function of Tim-3 in natural killer (NK) cells in chronic Hepatitis B (CHB) infection.Methods: Seventy-six CHB patients, 38 healthy controls, and 18 patients with fatty liver disease (FLD) were tested for Tim-3 expression on peripheral blood mononuclear cells (PBMCs) and in the liver tissue by flow cytometry and immunohistochemical stainning. The effects of HBV infection on Tim-3 expression in NK cells and the roles of Tim-3 in regulation of NK-cell function were also studied.Results: There was a significant increase of Tim-3 expression in PBMCs, circulating NK cells and liver infiltrating lymphocytes (LILs) from CHB patients compared to that of healthy controls and FLD patients. Increased Tim-3 expression was also detected in NK92 cells that had been transfected with a HBV expression vector and NK cells isolated from the liver of HBV transgenic mice. Importantly, blockage of Tim-3 signaling with anti-Tim-3 antibodies or Tim-3-Fc fusion proteins resulted in an increased cytotoxicity for NK92 cells compared to HepG2 and HepG2.2.15 cells, as well as an elevated interferon-gamma (IFN-γ) production. Similarly, enhanced cytotoxicity was also observed in PBMCs or NK cells from CHB patients treated with the Tim-3 blockade ex vivo.Conclusion: HBV infection can up-regulate Tim-3 expression in NK cells, which may in turn suppress NK-cell functions in CHB patients.

A longitudinal analysis of innate and adaptive immune profile during hepatic flares in chronic hepatitis B

2010-01-13

Background & Aims: The pathogenesis of hepatic flares (HF) in patients chronically infected with hepatitis B virus (HBV) is controversial. Therefore, we studied the kinetics of innate and adaptive immune activation during HF in chronic hepatitis B.Methods: Soluble (IFN-α, IL-1β, TNF-α, IL-6, IL-8, IL-10, CCL-2, CCL-3, CXCL-9, CXCL-10) and cellular (HBV-specific T cells, NK, Treg) immunological parameters were measured longitudinally (10month–4week intervals) in patients (n=5) who developed HF after therapy withdrawal and cross-sectionally in chronic (n=29) and acute hepatitis B patients (n=5). Hepatic expression of different chemokines was studied by co-incubating cytokines (IFN-α, IFN-γ, TNF-α) and activated T, NK and monocytes with hepatocytes and hepatocyte-like cells.Results: A progressive increase of HBV replication precedes HF but occurs without detection of innate immune activation, with the exception of increased serum CXCL-8. Despite the absence of increased circulatory HBV-specific T or activated NK cells, HF were temporally associated with high serum levels of IFN-γ inducible chemokines CXCL-9 and CXCL-10 (but not CCL-2 or CCL-3). CXCL-9 and CXCL-10 displayed different in vitro requirements for activation and are differentially produced in liver injury present in acute or chronic patients.Conclusions: CXCL-9 and CXCL-10 play a major role in the development of HF. Their differential expression in acute versus chronic patients suggests the presence of different mechanisms that govern liver injury during acute and chronic hepatitis B.

The use of β-adrenergic drugs improves hepatic oxygen metabolism in cirrhotic patients undergoing liver resection

2009-12-30

Background & Aims: Hepatic resection is associated with hemodynamic and oxygen metabolism disturbances of the residual liver resulting from liver regeneration. In underlying liver disease, the remnant liver responds inadequately to increased energy demands leading to a less efficient recovery process. The aim of this study was to assess the effect of vasoactive drugs on hepatic oxygen metabolism and hemodynamics in cirrhotic patients that have undergone liver resection.Methods: Thirty patients were randomly allocated to receive peri-operatively low doses (4μg/kg/min) of dopamine (DaG, n=10), dobutamine (DbG, n=10) or saline (CG, n=10). Hepatic hemodynamics, hepatic oxygen metabolism and lactate uptakes were evaluated before drug administration and at the time of abdominal closure. Post-operative liver function and outcome were recorded.Results: The peri-operative use of vasoactive drugs preserved total hepatic blood flow and hepatic compliance, even increasing in patients who received Db, whereas those parameters decreased in CG after liver resection. At this time, oxygen delivery and consumption decreased in CG patients, but were unchanged when vasoactive drugs were used. In all groups, lactate uptake decreased sharply and only DbG showed positive lactate extraction capacity. The peak of post-operative bilirubin, which resumed baseline values more quickly in DbG, inversely correlated with intra-operative hepatic compliance and hepatic oxygen extraction.Conclusion: Low doses of vasoactive drugs, especially dobutamine, improved hepatic oxygen supply and uptake preserving immediate function of the remnant cirrhotic liver.

Encephalopathy assessment in children with extra-hepatic portal vein obstruction with MR, psychometry and critical flicker frequency

2010-01-06

Background & Aims: Mild cognitive and psychomotor deficit has been reported in patients with extra-hepatic portal vein obstruction. This prospective study was done to ascertain the presence of minimal hepatic encephalopathy by neuropsychological testing and its correlation with diffusion tensor imaging derived metrics, T1 signal intensity, brain metabolites in 1H magnetic resonance spectroscopy, blood ammonia and critical flicker frequency in patients with extra-hepatic portal vein obstruction.Methods: Neuropsychological tests, critical flicker frequency, blood ammonia, diffusion tensor imaging, T1 signal intensity and 1H magnetic resonance spectroscopy were determined in 22 extra-hepatic portal vein obstruction and 17 healthy children. Bonferroni multiple comparison post hoc analysis was done to compare controls with patient groups.Results: Based on neuropsychological tests, 7/22 patients had minimal hepatic encephalopathy, and significantly increased Glx/Cr ratio, blood ammonia, mean diffusivity and globus pallidus T1 signal intensity with decreased critical flicker frequency in comparison to controls and in those without minimal hepatic encephalopathy. Cho/Cr, mI/Cr ratio and fractional anisotropy were unchanged in patient groups compared to controls. A significant inverse correlation of neuropsychological test with mean diffusivity, Glx/Cr ratio and blood ammonia and a positive correlation among mean diffusivity, blood ammonia and Glx/Cr ratio was seen.Conclusions: Extra-hepatic portal vein obstruction is a true hyperammonia model with porto-systemic shunting and normal liver functions that results in minimal hepatic encephalopathy in one-third of these children. Hyperammonia results in generalized low grade cerebral edema and cognitive decline as evidenced by increased Glx/Cr ratio, mean diffusivity values and abnormal neuropsychological tests.

Normal to increased thrombin generation in patients undergoing liver transplantation despite prolonged conventional coagulation tests

2009-12-24

Background & Aims: Patients with liver disease often show substantial changes in their hemostatic system, which may aggravate further during liver transplantation. Recently, thrombin generation in patients with stable disease was shown to be indistinguishable from controls provided thrombomodulin, the natural activator of the anticoagulant protein C system, was added to the plasma. These results indicated that the hemostatic balance is preserved in patients with liver disease, despite conventional coagulation tests suggest otherwise.Methods: Here we examined thrombin generation profiles in serial plasma samples taken from ten consecutive patients undergoing liver transplantation.Results: At all time points, the endogenous thrombin potential (ETP) was slightly lower compared to healthy volunteers, despite substantially prolonged PT and APTT values. However, when thrombin generation was tested in the presence of thrombomodulin, the ETP was equal to or even higher than that in healthy subjects. In fact, thrombin generation was hardly affected by thrombomodulin, while thrombin generation in healthy subjects decreased profoundly upon the addition of thrombomodulin. In patients undergoing liver transplantation, efficient thrombin generation in the presence of thrombomodulin may be explained by decreased levels of protein C, S, and antithrombin, and by elevated levels of FVIII.Conclusions: Thrombin generation in patients undergoing liver transplantation is equal or even superior to thrombin generation in healthy volunteers when tested in the presence of exogenous thrombomodulin. These results support the recently advocated restrictive use of plasma during liver transplantation and warrants further study of the prophylactic use of anticoagulants to reduce thromboembolic complications after transplantation.

The αvβ6 integrin is a highly specific immunohistochemical marker for cholangiocarcinoma

2010-01-13

Background & Aims: Hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC) are common primary hepatic malignancies. Their immunohistological differentiation using specific markers is pivotal for treatment and prognosis. We found αvβ6 integrin strongly upregulated in biliary fibrosis, but its expression in primary and secondary liver tumours is unknown. Here, we aimed to evaluate the diagnostic applicability of αvβ6 integrin in differentiating primary liver cancers.Methods: Expression of αvβ6 integrin was evaluated in liver tissues from patients with CC, HCC, fibrolamellar HCC, combined CC/HCC, hepatic metastases of colorectal and pancreatic carcinomas, primary sclerosing cholangitis (PSC), and in human primary and tumour-derived liver cell lines by immunohisto- and cytochemistry, and by TaqMan PCR. Diagnostic performance of the β6 subunit was compared with CK7, CK20, and HepPar 1.Results: In CC cells β6 mRNA levels were induced 125-fold compared to primary cholangiocytes, while it was completely absent in hepatoma cells. In human tissues, β6 transcripts were more than 100-fold upregulated in CC compared to normal liver. By immunohistochemistry, 88% of CC, 50% of PSC, 13% of colorectal carcinoma metastases, and 80% of pancreatic carcinoma metastases presented αvβ6, whereas all HCC, combined CC/HCC and fibrolamellar HCC stained negative. Specificity of β6 immunohistochemistry for CC (100%) surpassed all other tested markers and sensitivity was equal to CK7 (86% vs. 90%).Conclusion: The αvβ6 integrin is strongly expressed in human CC but not in HCC and therefore can be considered as a specific immunohistochemical marker in the differential diagnosis of primary liver tumours.

Inflammatory tumour microenvironment is associated with superior survival in hepatocellular carcinoma patients

2009-08-03

Background & Aims: Hepatocellular carcinoma (HCC) is an aggressive malignancy with few treatment options. As the status of the tumour immune microenvironment can affect progression of established tumours, we evaluated potential immune mechanisms associated with survival in HCC.Methods: Immune gene expression profiles were analyzed in tumour and non-tumour liver tissues from resected HCC patients using quantitative PCR and immunohistochemistry. Tumour-infiltrating leukocytes (TILs) were isolated to verify the expression of immune genes and to identify proliferating TILs. These parameters were analyzed statistically in relation with patient survival and tumour phenotype (apoptosis and proliferation).Results: The immune microenvironment within tumours was found to be heterogeneous, although globally more inert compared to the adjacent non-tumour liver tissue. Univariate analysis in 61 patients identified a group of innate immune genes whose expression within tumours is positively associated with patient survival. TNF, IL6 and CCL2 are the most significant genes, with TNF being an independent predictor of survival in multivariate analysis. The gene set includes macrophage and NK-associated molecules such as TLR4, TLR3, CCR2, NCR3. Most of these molecules are expressed by TILs. Importantly, proliferating immune cells, predominantly NK and T cells, are present in tumours of patients with longer survival, and exclusively in areas devoid of proliferating tumour cells. NK and CD8+ T cell densities are correlated positively with tumour apoptosis, and negatively with tumour proliferation.Conclusions: Hence, an inflammatory immune microenvironment within HCC tumours could be an important means to control tumour progression via TIL activation and proliferation.

Clinical outcomes of radiofrequency ablation, percutaneous alcohol and acetic acid injection for hepatocelullar carcinoma: A meta-analysis

2010-01-18

Background & Aims: Radiofrequency ablation (RFA) is often the preferred local ablation therapy for hepatocellular carcinoma (HCC). Percutaneous ethanol injection (PEI) is less frequently used, and percutaneous acetic acid injection (PAI) has been mostly abandoned. Robust evidence showing benefit of one therapy versus another is lacking. Our aim was to evaluate the evidence comparing RFA, PEI and PAI using meta-analytical techniques.Methods: Literature search was undertaken until December 2008 to identify comparative studies evaluating survival, recurrence, complete necrosis of tumour and complications. Only randomized clinical trials and quasi-randomized studies were included. Adjusted indirect comparisons were made when direct comparative studies were insufficient.Results: Eight studies were identified: RFA vs. PEI (n=5), PAI vs. PEI (n=2) and RFA vs. PAI vs. PEI (n=1) including 1035 patients with nine comparisons. RFA was superior to PEI for survival (OR 0.52; 95% CI 0.35–0.78; p=0.001), complete necrosis of tumour and local recurrence. For tumours ⩽2cm RFA was not significantly better than PEI. PAI did not differ significantly from PEI for survival (OR 0.55; 95% CI 0.23–1.33; p=0.18), and local recurrence but required less sessions. PAI had similar outcomes, except local recurrence, to RFA in the direct and indirect comparison.Conclusions: RFA seems to be a superior ablative therapy than PEI for HCC, particularly for tumours >2cm. PAI did not differ significantly from PEI for all the outcomes evaluated. RFA and PAI have similar survival rates. For tumours ⩽2cm outcome benefits comparing RFA and PEI are similar. PAI needs re-evaluation versus both PEI and RFA for tumours ⩽2cm.

Advanced glycation end products induce production of reactive oxygen species via the activation of NADPH oxidase in murine hepatic stellate cells

Eduardo L.M. Guimarães, Christophe Empsen, Albert Geerts, Leo A. van Grunsven — 2009-12-24

Background & Aims: Advanced glycation end products are known to play an important role in the metabolic syndrome and were recently suggested to contribute to liver fibrosis development. However, little is known about the effect of advanced glycation end products on hepatic stellate cells, the major contributors to liver fibrosis development. We therefore studied the effect of advanced glycation end products on reactive oxygen species generation, a main feature for the activation hepatic stellate cells.Methods: Three different types of advanced glycation end products were generated by BSA incubation with different substrates. The presence of advanced glycation end product receptors was examined by RTq-PCR, immunofluorescence and western blotting. Reactive oxygen species production was measured using DCFH-DA.Results: Hepatic stellate cells express five advanced glycation end product receptors: Galectin-3, CD36, SR-AI, SR-BI and RAGE. All receptors, except SR-BI, showed up-regulation during HSC activation. All three advanced glycation end product types induced reactive oxygen species generation. DPI and NSC, a NADPH oxidase and a Rac1 inhibitor respectively, inhibited reactive oxygen species production. Rottlerin, a molecule often used as a PKCδ inhibitor, also abrogated reactive oxygen species production. SiRNA mediated knockdown of p47phox, Rac1 and PKCδ decreased reactive oxygen species production induced by advanced glycation end products, establishing a role for these proteins in reactive oxygen species induction.Conclusions: The demonstration of advanced glycation end product-induced reactive oxygen species generation in hepatic stellate cells unveils a potential new route through which advanced glycation end products induce liver fibrosis in the metabolic syndrome.

Fibrillar collagen scoring by second harmonic microscopy: A new tool in the assessment of liver fibrosis

2010-01-18

Background & Aims: Imaging of supramolecular structures by multiphoton microscopy offers significant advantages for studying specific fibrillar compounds in biological tissues. In this study, we aimed to demonstrate the relevance of Second Harmonic Generation (SHG) for assessing and quantifying, without staining, fibrillar collagen in liver fibrosis.Methods: We first showed the relationship between SHG signal and collagen forms over-produced and accumulated during fibrosis progression. Taking this property into consideration, we developed an innovative method to precisely quantify the fibrosis area in histological slices by scoring of fibrillar collagen deposits (Fibrosis-SHG index).Results: The scoring method was routinely applied to 119 biopsies from patients with chronic liver disease allowing a fast and accurate measurement of fibrosis correlated with the Fibrosis-Metavir score (rho=0.75, p<0.0001). The technique allowed discriminating patients with advanced (moderate to severe) fibrosis (AUROC=0.88, p<0.0001) and cirrhosis (AUROC=0.89, p<0.0001). Taking advantage of its continuous gradation, the Fibrosis-SHG index also allowed the discrimination of several levels of fibrosis within the same F-Metavir stage. The SHG process presented several advantages such as a high reliability and sensitivity that lead to a standardized evaluation of hepatic fibrosis in liver biopsies without staining and pathological examination.Conclusions: Second harmonic microscopy emerges as an original and powerful tool in the assessment of liver fibrosis and offers new possibilities for the evaluation of experimental protocols. We expect that this technology could easily be applicable in the study of other fibro-proliferative pathologies.

TGF-β enhances alcohol dependent hepatocyte damage via down-regulation of alcohol dehydrogenase I

2010-01-06

Background & Aims: Adverse alcohol effects in the liver involve oxidative metabolism, fat deposition and release of fibrogenic mediators, including TGF-β. The work presents an assessment of liver damaging cross-talk between ethanol and TGF-β in hepatocytes.Methods: To investigate TGF-β effects on hepatocytes, microarray analyses were performed and validated by qRT-PCR, Western blot analysis and immunohistochemistry. The cellular state was determined by assessing lactate dehydrogenase, cellular glutathione, reactive oxygen species, lipid peroxidation and neutral lipid deposition. RNA interference was used for gene silencing in vitro.Results: TGF-β is induced in mouse livers after chronic ethanol insult, enhances ethanol induced oxidative stress and toxicity towards cultured hepatocytes plus induces lipid-, oxidative stress metabolism- and fibrogenesis-gene expression signatures. Interestingly, TGF-β down-regulates alcohol metabolizing enzyme Adh1 mRNA in cultured hepatocytes and liver tissue from TGF-β transgenic mice via the ALK5/Smad2/3 signalling branch, with Smad7 as a potent negative regulator. ADH1 deficiency is a determining factor for the increased lipid accumulation and Cyp2E1 dependent toxicity in liver cells upon alcohol challenge. Further, ADH1 expression was decreased during liver damage in an intragastric ethanol infusion mouse model.Conclusion: In the presence of ethanol, TGF-β displays pro-steatotic action in hepatocytes via decreasing ADH1 expression. Low ADH1 levels are correlated with enhanced hepatocyte damage upon chronic alcohol consumption by favoring secondary metabolic pathways.

Porphobilinogen deaminase over-expression in hepatocytes, but not in erythrocytes, prevents accumulation of toxic porphyrin precursors in a mouse model of acute intermittent porphyria

2009-09-23

Background & Aims: Acute intermittent porphyria (AIP) is characterized by hepatic porphobilinogen deaminase (PBGD) deficiency resulting in a marked overproduction of presumably toxic porphyrin precursors. Our study aimed to assess the protective effects of bone marrow transplantation or PBGD gene transfer into the liver against phenotypic manifestations of acute porphyria attack induced in an AIP murine model.Methods: Lethally irradiated AIP mice were intravenously injected with 5×106 nucleated bone marrow cells from wild type or AIP donor mice. To achieve liver gene transfer, AIP mice received via hydrodynamic injection plasmids expressing human PBGD or luciferase, driven by a liver-specific promoter.Results: Erythrocyte PBGD activity increased 2.4-fold in AIP mice receiving bone marrow cells from normal animals. Nevertheless, phenobarbital administration in these mice reproduced key features of acute attacks, such as massively increased urinary porphyrin precursor excretion and decreased motor coordination. Hepatic PBGD activity increased 2.2-fold after hydrodynamic injection of therapeutic plasmid. Mice injected with the luciferase control plasmid showed a high excretion of porphyrin precursors after phenobarbital administration whereas just a small increase was observed in AIP mice injected with the PBGD plasmid. Furthermore, motor disturbance was almost completely abolished in AIP mice treated with the therapeutic plasmid.Conclusions: PBGD deficiency in erythroid tissue is not associated with phenotypic manifestations of acute porphyria. In contrast, PBGD over-expression in hepatocytes, albeit in a low proportion, reduced precursor accumulation, which is the hallmark of acute porphyric attacks. Liver-directed gene therapy might offer an alternative to liver transplantation applicable in patients with severe and recurrent manifestations.

Iron uptake from plasma transferrin by a transferrin receptor 2 mutant mouse model of haemochromatosis

2010-01-06

Background & Aims: Hereditary haemochromatosis type 3 is caused by mutations in transferrin receptor (TFR) 2. TFR2 has been shown to mediate iron transport in vitro and regulate iron homeostasis. The aim of this study was to determine the role of Tfr2 in iron transport in vivo using a Tfr2 mutant mouse.Methods: Tfr2 mutant and wild-type mice were injected intravenously with 59Fe-transferrin and tissue 59Fe uptake was measured. Tfr1, Tfr2 and ferroportin expression was measured by real-time PCR and Western blot. Cellular localisation of ferroportin was determined by immunohistochemistry.Results: Transferrin-bound iron uptake by the liver and spleen in Tfr2 mutant mice was reduced by 20% and 65%, respectively, whilst duodenal and renal uptake was unchanged compared with iron-loaded wild-type mice. In Tfr2 mutant mice, liver Tfr2 protein was absent, whilst ferroportin protein was increased in non-parenchymal cells and there was a low level of expression in hepatocytes. Tfr1 expression was unchanged compared with iron-loaded wild-type mice. Splenic Tfr2 protein expression was absent whilst Tfr1 and ferroportin protein expression was increased in Tfr2 mutant mice compared with iron-loaded wild-type mice.Conclusions: A small reduction in hepatic transferrin-bound iron uptake in Tfr2 mutant mice suggests that Tfr2 plays a minor role in liver iron transport and its primary role is to regulate iron metabolism. Increased ferroportin expression due to decreased hepcidin mRNA levels is likely to be responsible for impaired splenic iron uptake in Tfr2 mutant mice.

Congenital disorders of glycosylation in hepatology: The example of polycystic liver disease

2009-12-24

Autosomal dominant polycystic liver disease (PCLD) is a rare progressive disorder characterized by an increased liver volume due to many (>20) fluid-filled cysts of biliary origin. Disease causing mutations in PRKCSH or SEC63 are found in ∼25% of the PCLD patients. Both gene products function in the endoplasmic reticulum, however, the molecular mechanism behind cyst formation remains to be elucidated. As part of the translocon complex, SEC63 plays a role in protein import into the ER and is implicated in the export of unfolded proteins to the cytoplasm during ER-associated degradation (ERAD). PRKCSH codes for the β-subunit of glucosidase II (hepatocystin), which cleaves two glucose residues of Glc3Man9GlcNAc2 N-glycans on proteins. Hepatocystin is thereby directly involved in the protein folding process by regulating protein binding to calnexin/calreticulin in the ER. A separate group of genetic diseases affecting protein N-glycosylation in the ER is formed by the congenital disorders of glycosylation (CDG). In distinct subtypes of this autosomal recessive multisystem disease specific liver symptoms have been reported that overlap with PCLD. Recent research revealed novel insights in PCLD disease pathology such as the absence of hepatocystin from cyst epithelia indicating a two-hit model for PCLD cystogenesis. This opens the way to speculate about a recessive mechanism for PCLD pathophysiology and shared molecular pathways between CDG and PCLD. In this review we will discuss the clinical-genetic features of PCLD and CDG as well as their biochemical pathways with the aim to identify novel directions of research into cystogenesis.

Is response to antiviral treatment influenced by hepatitis B virus genotype?

Sara Raimondi, Patrick Maisonneuve, Savino Bruno, Mario U. Mondelli — 2010-01-06

Recently released clinical practice guidelines and consensus conference statements point to the importance of hepatitis B virus (HBV) genotyping in therapeutic algorithms for the treatment of chronic hepatitis B. This information usually comes from post hoc analyses of clinical trials which were not designed to study associations with the HBV genotype. We have performed a literature search through to April 2009 and have selected randomized clinical trials of currently approved anti-HBV drugs providing information on HBV genotypes and (i) baseline characteristics of study subjects, (ii) any response to antiviral therapy, (iii) interaction between HBV genotypes and the type of therapy. There were several intrinsic features and weaknesses in the majority of clinical trials conducted so far which make it difficult to reach firm conclusions about the role of HBV genotypes in response to antiviral therapy. Indeed, most trials were necessarily multicenter in order to reach a sufficient statistical power, but pooling together patients of different ethnicities may have revealed false-positive associations between response to antiviral therapy and HBV genotype. Moreover, endpoint definitions, especially for the composite ones, varied substantially among studies, leading to lack of homogeneity. Finally, possible interactions between the type of therapy and the HBV genotype were only seldom analysed. The present review highlights several caveats regarding current indications proposed by the major clinical practice guidelines and consensus conference statements published thus far and emphasise the need for further long term studies in the field.

International Hepatology

Shannon S. Glaser, Gianfranco Alpini — 2010-01-06

COMMENTARY ON: Tbx3 promotes liver bud expansion during mouse development by suppression of cholangiocyte differentiation.Lüdtke TH, Christoffels VM, Petry M, Kispert A. Hepatology 2009 Mar;49:969–78, PMID: 19140222. Reprinted with permission of John Wiley & Sons, Inc. Copyright Hepatology, 2009.Abstract: After specification of the hepatic endoderm, mammalian liver organogenesis progresses through a series of morphological stages that culminate in the migration of hepatocytes into the underlying mesenchyme to populate the hepatic lobes. Here, we show that in the mouse the transcriptional repressor Tbx3, a member of the Tbox protein family, is required for the transition from a hepatic diverticulum with a pseudo-stratified epithelium to a cell-emergent liver bud. In Tbx3-deficient embryos, proliferation in the hepatic epithelium is severely reduced, hepatoblasts fail to delaminate, and cholangiocyte rather than hepatocyte differentiation occurs. Molecular analyses suggest that the primary function of Tbx3 is to maintain expression of hepatocyte transcription factors, including hepatic nuclear factor 4a (Hnf4a) and CCAAT/enhancer binding protein (C/EBP), alpha (Cebpa), and to repress expression of cholangiocyte transcriptionfactors such as Onecut1 (Hnf6) and Hnf1b.Conclusion: Tbx3 controls liver bud expansion by suppressing cholangiocyte and favoring hepatocyte differentiation in the liver bud.

Genetic polymorphism and response to treatment in chronic hepatitis C: The future of personalized medicine

Tarik Asselah — 2010-01-07

COMMENTARY ON: Genetic variation in IL28B predicts hepatitis C treatment-induced viral clearance. Dongliang Ge, Jacques Fellay, Alexander J. Thompson, Jason S. Simon, Kevin V. Shianna, Thomas J. Urban, Erin L. Heinzen, Ping Qiu, Arthur H. Bertelsen, Andrew J. Muir, Mark Sulkowski, John G. McHutchison, David B. Goldstei. Abstract reprinted by permission from Macmillan Publishers Ltd: Nature 200;461(7262):399–401. copyright 2009Abstract: Chronic infection with hepatitis C virus (HCV) affects 170 million people worldwide and is the leading cause of cirrhosis in North America. Although the recommended treatment for chronic infection involves a 48-week course of peginterferon-2b (PegIFN-2b) or -2a (PegIFN-2a) combined with ribavirin (RBV), it is well known that many patients will not be cured by treatment, and that patients of European ancestry have a significantly higher probability of being cured than patients of African ancestry. In addition to limited efficacy, treatment is often poorly tolerated because of side effects that prevent some patients from completing therapy. For these reasons, identification of the determinants of response to treatment is a high priority. Here we report that a genetic polymorphism near the IL28B gene, encoding interferon-3 (IFN-3), is associated with an approximately twofold change in response to treatment, both among patients of European ancestry (P=1.06 10–25) and African-Americans (P=2.06 10–30). Because the genotype leading to better response is in substantially greater frequency in European than African populations, this genetic polymorphism also explains approximately half of the difference in response rates between African-Americans and patients of European ancestry.

The new therapeutic frontier – Nuclear receptors and the liver

Saul J. Karpen, Michael Trauner — 2009-12-24

A joint EASL/AASLD Monothematic Conference on ‘Nuclear Receptors and Liver Disease’ was held from February 27th to March 1st, 2009, in Vienna, Austria, to discuss the latest advances at the forefront of basic and clinical nuclear receptor research and its potential implications for liver diseases. This article reports the highlights of the conference and summarizes the main conclusions emphasizing the relevance for clinical and experimental hepatology. The confluence of nuclear receptors as central transcriptional regulators, acting as sensors and adaptors to many of the small molecules present in the intracellular milieu of all the cells of the liver, provides a current framework to address a broader physiological understanding of the liver. The next stage will be the design and testing of safe and effective therapeutics.

Reactivation of hepatitis B virus after transarterial chemo-embolization for hepatocellular carcinoma in one patient with negative hepatitis B surface antigen

Hung-Hsu Hung, Chien-Wei Su, Jaw-Ching Wu, Shou-Dong Lee — 2009-12-24

We read with interest the excellent paper by Sanchez et al., demonstrating successful entecavir treatment of a patient who developed severe reactivation of hepatitis B virus (HBV) due to potent chemotherapy containing rituximab . The reactivation of HBV following treatment with chemotherapy is well recognized and the incidence can be substantially decreased by pre-emptive anti-viral therapy . It occurs in two clinical settings: (1) in chronic carriers with positive hepatitis B surface antigen (HBsAg) and (2) in those with prior HBV infection who are HBsAg-negative and have antibodies against hepatitis B core antigen (anti-HBc) . For HBsAg-positive patients with hepatocellular carcinoma (HCC), transarterial chemo-embolization (TACE) can also lead to the reactivation of HBV replication . Nevertheless, whether TACE causes severe reactivation of the virus for patients with resolved HBV infection is still unknown. Herein, we report a case with negative HBsAg presenting with reactivation of HBV after the application of TACE for HCC (see ).

Corrigendum to “Acute hepatitis caused by a natural lipid-lowering product: When “alternative” medicine is no “alternative” at all” [J Hepatol 50 (2009) 1273–1277]

2010-01-06

(1) The following section should be read as the following: “In June 2007, her total cholesterol remained high (240mg/dlL), and a metabolic consultant prescribed complementary therapy with a natural product, Equisterol (Istituto Farmacoterapico Italiano S.p.A., Rome, Italy), one 1.17g tablet once a day. According to the manufacturer, Equisterol contains guggulsterol (from the Ayurvedic medicinal plant Commiphora mukul); sistosterol; chlorogenic acid; policosanol; vitamins C, E, and B6; niacin; coenzyme Q; and red yeast rice (roughly containing 1.5% of monacolin K). The manufacturer warned about the possible side effects in subjects with known hypersensitivity to these components”.(2) P1274, Figure 1

Journal of Hepatology

Editorial Board

Many Ways One Aim

Clinical School Course 14: Metabolic Liver Diseases

The International Liver Congress 2010

Hepatocellular Carcinoma: from Genomics to Treatment

Contents

Focus

Ablation for hepatocellular carcinoma: Is there need to have a winning technique?

Harmony in liver fibrosis…

Abundant numbers of regulatory T cells localize to the liver of chronic hepatitis C infected patients and limit the extent of fibrosis

T cell immunoglobulin- and mucin-domain-containing molecule-3 (Tim-3) mediates natural killer cell suppression in chronic hepatitis B

A longitudinal analysis of innate and adaptive immune profile during hepatic flares in chronic hepatitis B

The use of β-adrenergic drugs improves hepatic oxygen metabolism in cirrhotic patients undergoing liver resection

Encephalopathy assessment in children with extra-hepatic portal vein obstruction with MR, psychometry and critical flicker frequency

Normal to increased thrombin generation in patients undergoing liver transplantation despite prolonged conventional coagulation tests

The αvβ6 integrin is a highly specific immunohistochemical marker for cholangiocarcinoma

Inflammatory tumour microenvironment is associated with superior survival in hepatocellular carcinoma patients

Clinical outcomes of radiofrequency ablation, percutaneous alcohol and acetic acid injection for hepatocelullar carcinoma: A meta-analysis

Advanced glycation end products induce production of reactive oxygen species via the activation of NADPH oxidase in murine hepatic stellate cells

Fibrillar collagen scoring by second harmonic microscopy: A new tool in the assessment of liver fibrosis

TGF-β enhances alcohol dependent hepatocyte damage via down-regulation of alcohol dehydrogenase I

Porphobilinogen deaminase over-expression in hepatocytes, but not in erythrocytes, prevents accumulation of toxic porphyrin precursors in a mouse model of acute intermittent porphyria

Iron uptake from plasma transferrin by a transferrin receptor 2 mutant mouse model of haemochromatosis

Congenital disorders of glycosylation in hepatology: The example of polycystic liver disease

Is response to antiviral treatment influenced by hepatitis B virus genotype?

International Hepatology

Genetic polymorphism and response to treatment in chronic hepatitis C: The future of personalized medicine

The new therapeutic frontier – Nuclear receptors and the liver

Reactivation of hepatitis B virus after transarterial chemo-embolization for hepatocellular carcinoma in one patient with negative hepatitis B surface antigen

Corrigendum to “Acute hepatitis caused by a natural lipid-lowering product: When “alternative” medicine is no “alternative” at all” [J Hepatol 50 (2009) 1273–1277]