Journal of Hepatology - Articles in Press

TACE treatment in hepatocellular carcinoma: what should we do now? - Accepted Manuscript

2012-01-27

Genetic testing for hepatocellular carcinoma: an ambitious goal still to achieve - Accepted Manuscript

Enrico Galmozzi, Massimo Colombo — 2012-01-27

Liver transplantation for severe alcoholic hepatitis saves lives - Accepted Manuscript

Andrew K. Burroughs — 2012-01-27

At the cancer steering wheel: Defining key genomic drivers of liver cancer with next generation sequencing - Accepted Manuscript

Anuradha Budhu, Xin Wei Wang — 2012-01-27

Post-liver transplantantion graft biopsies should not be used to assess the IL28B donor genotype in HCV recipients - Accepted Manuscript

Maria Francesca Donato, Enrico Galmozzi, Cristina Rigamonti, Alessio Aghemo — 2012-01-27

Molecular epidemiology in HCV-related hepatocellular carcinoma: first steps - Accepted Manuscript

Augusto Villanueva, Xavier Forns, Josep M. Llovet — 2012-01-25

Abstract: Chronic viral hepatitis is the most important risk factor for progression to hepatocellular carcinoma (HCC). To identify genetic risk factors for progression to HCC in individuals with chronic hepatitis C virus (HCV), we analyzed 467,538 SNPs in 212 Japanese individuals with chronic HCV with HCC and 765 individuals with chronic HCV without HCC. We identified one intronic SNP in the DEPDC5 locus on chromosome 22 associated with HCC risk and confirmed the association using an independent case-control population (710 cases and 1,625 controls). The association was highly significant when we analyzed the stages separately as well as together (rs1012068, P(combined) = 1.27 × 10(-13), odds ratio = 1.75). The significance level of the association further increased after adjustment for gender, age and platelet count (P = 1.35 × 10(-14), odds ratio = 1.96). Our findings suggest that common variants within the DEPDC5 locus affect susceptibility to HCC in Japanese individuals with chronic HCV infection.

The Option of HBIG-Free Prophylaxis Against Recurrent HBV - Accepted Manuscript

Alyson N. Fox, Norah A. Terrault — 2012-01-23

Abstract: Since the early 1990’s, hepatitis B immune globulin (HBIG) has been central to the prevention of hepatitis B virus (HBV) recurrence after liver transplantation. When used in combination with oral nucleos(t)ide analogues, HBIG prevents reinfection with HBV in ⩾90% of transplant recipients. While HBIG is highly efficacious, its use is undermined by its high cost. Because of this limitation, there have been many studies of alternative regimens seeking to minimize the dose or duration of HBIG without sacrificing low HBV recurrence rates. Toward that goal, lower dose intramuscular HBIG in combination with oral nucleos(t)ide analogues has been shown to be highly efficacious in preventing disease recurrence and represents a significant cost savings when compared with high dose intravenous administration. The withdrawal of HBIG after a defined course of combination HBIG and oral antivirals has also been shown to be effective, particularly if combination antiviral therapy is used. The ability to achieve undetectable HBV DNA levels pre-transplantation in the majority of patients may contribute to the high efficacy of these HBIG “light” regimens. Additionally, the success of antiviral rescue therapy for those patients who fail prophylaxis and develop recurrent HBV infection post-transplant has provided the impetus to move increasingly towards HBIG-free approaches. New techniques to detect occult HBV in hepatic and extrahepatic sites may allow clinicians to define a subgroup of patients in whom withdrawal of HBIG or all prophylaxis may be applicable.

Prevention of Acute Kidney Injury in a rodent model of cirrhosis following selective gut decontamination is associated with reduced renal TLR4 expression - Accepted Manuscript

2012-01-18

Abstract: Background and aims: Superimposed infection and/or inflammation precipitates renal failure in cirrhosis. This study aimed to test the hypothesis that increased gut bacterial translocation in cirrhosis primes the kidney to the effect of superimposed inflammation by upregulating expression of, toll-like receptor-4 (TLR4), NFkB and cytokines. A well-characterized bile-duct ligated (BDL) model of cirrhosis which develops renal failure following superimposed inflammatory insult with LPS was used and selective gut decontamination was performed using Norfloxacin.Methods: Sprague-Dawley rats were studied: Sham, Sham+LPS; BDL, BDL+LPS; an additional BDL and BDL+LPS groups were selectively decontaminated with Norfloxacin. Plasma biochemistry, plasma renin activity (PRA) and cytokines and, protein expression of TLR4, NFkB and cytokines were measured in the kidney homogenate. The kidneys were stained for TLR4, TLR2, and caspase-3. Endotoxemia was measured using neutrophil burst and LAL assays.Results: The groups treated with Norfloxacin showed significant attenuation in the increase in plasma creatinine, plasma and renal TNFa and renal tubular injury on histology. The increased renal protein expression of TLR4, NFkB and caspase-3 in the untreated animals was significantly attenuated in the Norfloxacin treated animals. PRA was reduced in the treated animals and severity of endotoxemia was reduced.Conclusions: The results show for the first time that the kidneys in cirrhosis show an increased expression of TLR4, NFkB and the pro-inflammatory cytokine, TNFa which makes them susceptible to a further inflammatory insult. This increased susceptibility to LPS can be prevented with selective decontamination, providing novel insights into the pathophysiology of renal failure in cirrhosis.

A novel biliary stent loaded with 125I seeds in patients with malignant biliary obstruction: preliminary results versus a conventional biliary stent - Accepted Manuscript

2012-01-18

Abstract: Background & aims: Stenting is a palliative therapy method for relieving malignant biliary obstruction. The aim was to evaluate the safety and effectiveness of a irradiation stent when compared to a conventional biliary stent in patients with biliary obstruction caused by both primary and metastatic adenocarcinomas.Methods: Participants were randomly assigned to receive treatment with a biliary irradiation stent (irradiation stent group) or a conventional biliary stent (control group). After stent implantation, the outcomes were measured in terms of relief of obstructive jaundice, survival time, complications related to the procedure. A p-value of less than 0.05 was considered to indicate a significant difference.Results: The stents were successfully placed in all 23 patients. The obstructive jaundice was relived in all patients except three in the control group. The median and mean overall survival in the irradiation stent group were longer than that in the control group (7.40 months vs. 2.50 months, 8.03 months vs. 3.36 months, p=0.006). The number of patients with stent patent at 3, 6, and 12 months in the irradiation stent group were 11(91.7%), 7(58.3%), and 1(8.3%), respectively. While in the control group, 4(36.4%), 1(9.1%), and 0(0%), respectively. There were no significant differences in the complications related to stent insertion between two groups.Conclusions: This interim analysis shows that treatment with the biliary intraluminal irradiation stent in patients with biliary obstruction caused by adenocarcinomas appears safe and technical feasible and has benefits in relieving jaundice, and seems to extend survival when compared to a conventional biliary stent.

Molecular forms of HMGB1 and Keratin-18 as mechanistic biomarkers for mode of cell death and prognosis during clinical acetaminophen hepatotoxicity - Accepted Manuscript

2012-01-18

Abstract: Background & Aims: Full length keratin-18 (FL-K18) and High Mobility Group Box-1 (HMGB1) represent circulating indicators of necrosis during acetaminophen (APAP) hepatotoxicity in vivo. In addition, the caspase-cleaved fragment of K18 (cK18) and hyper-acetylated HMGB1 represent serum indicators of apoptosis and immune cell activation respectively. The study aim was to assess their mechanistic utility to establish the balance between apoptosis, necrosis and immune cell activation throughout the time course of clinical APAP hepatotoxicity.Methods: HMGB1 (total, acetylated) and K18 (apoptotic, necrotic) were identified and quantified by novel LC-MS/MS assays in APAP overdose patients (n=78).Results: HMGB1 (total; 15.4±1.9ng/ml, p<0.01, acetylated; 5.4±2.6ng/ml, p<0.001), cK18 (5649.8±721.0U/l, p<0.01) and FL-K18 (54770.2±6717.0U/l, p<0.005) were elevated in the sera of APAP overdose patients with liver injury compared to overdose patients without liver injury and healthy volunteers. HMGB1 and FL-K18 correlated with alanine aminotransferase (ALT) activity (R2=0.60 and 0.58 respectively, p<0.0001) and prothrombin time (R2=0.62 and 0.71 respectively, p<0.0001). Increased total and acetylated HMGB1 and FL-K18 were associated with worse prognosis (King’s College Criteria) or patients that died/required liver transplant compared to spontaneous survivors (all p<0.05-0.001), a finding not reflected by ALT and supported by ROC analysis. Acetylated HMGB1 was a better predictor of outcome than the other markers of cell death.Conclusion: K18 and HMGB1 represent blood-based tools to investigate the cell death balance clinical APAP hepatotoxicity. Activation of the immune response was seen later in the time course as shown by the distinct profile of acetylated HMGB1 and was associated with worse outcome.

A Randomized Trial of 48 versus 24 Weeks of Combination Pegylated Interferon and Ribavirin Therapy in Genotype 6 Chronic Hepatitis C - Accepted Manuscript

Pham Thi Thu Thuy, Chalermrat Bunchorntavakul, Ho Tan Dat, K. Rajender Reddy — 2012-01-18

Abstract: Background and Aims: Genotype 6 chronic hepatitis C is encountered predominantly in Southeast Asia and data on optimal treatment strategy is limited. This study was aimed to assess the rate and predictors of sustained virological response (SVR) in genotype 6 chronic HCV following 48 and 24 weeks of pegylated interferon and ribavirin therapy.Methods: This investigator-initiated, open-label randomized trial was conducted in Vietnam between 2008 and 2010. One hundred and five treatment-naïve HCV genotype 6 patients were randomized to either 48-week (N=70) or 24-week (N=35) duration of pegylated interferon (PEG-IFN) alfa-2a 180 mcg/week and ribavirin (RBV) 15 mg/kg/day; 92 patients completed the study (63 in 48-week and 29 in 24-week group). Primary outcome was sustained virological response (SVR) as intention-to-treat analysis.Results: There was no statistical difference in SVR between 48-week and 24-week treated groups (71% vs. 60%, respectively; p=0.24). In the 48-week and 24-week treatment groups, 81% and 80% achieved rapid virological response (RVR) (p=0.86) and 86% and 80% achieved complete early virological response (p=0.45). Among those with RVR, SVR was in 86% (48-weeks) and 75% (24-weeks), whereas following non-RVR, only 8% had an SVR with 48-week treatment duration.Conclusion: Overall, RVR was achieved in the majority of genotype 6 patients and, in them, similar and high rates of SVR were noted following 24 weeks and 48 weeks therapy. This observation however needs validation in a larger study to demonstrate non-inferiority of the shorter duration therapy. In non-RVR patients, even 48 weeks therapy achieved low SVR rates.

Efficacy of non-selective β-blockers as adjunct to endoscopic prophylactic treatment for gastric variceal bleeding: A randomized controlled trial - Accepted Manuscript

2012-01-18

Abstract: Background and aims: Gastric variceal obturation (GVO) therapy is the current treatment of choice for gastric variceal bleeding (GVB). However, the efficacy of non-selective ß-blockers (NSBB) in the secondary prevention of GVB is still debatable. This study aimed to evaluate the efficacy of additional NSBB to repeated GVO in the secondary prevention of GVB.Methods: From April 2007 to March 2011, 95 patients with GVB after primary hemostasis using GVO were enrolled. Repeated GVO were performed until GV eradication. Forty-eight and 47 patients were randomized into the GVO alone group (Group A) and the GVO+NSBB group (Group B), respectively. Primary outcomes in terms of re-bleeding and overall survival were analyzed by multivariate analysis.Results: After a mean follow-up of 18.10 months in group A, 26 patients bled and 20 died. In group B, 22 patients bled and 22 died after a mean follow-up of 20.29 months. The overall re-bleeding and survival rates analyzed by the Kaplan-Meier method were not different between the two groups (p=0.336 and 0.936, respectively). The model of end-stage liver disease (MELD) score and main portal vein thrombosis (MPT) were independent determinants of re-bleeding while MPT and re-bleeding were independent factors of mortality by time-dependent Cox-regression model. Asthenia was the most common adverse event and was higher in group B (p<0.001).Conclusion: Adding NSBB therapy to repeated GVO provides no benefit for the secondary prevention of bleeding and mortality in patients with GVB.

Development Of The Bile Ducts: Essentials For The Clinical Hepatologist - Accepted Manuscript

Mario Strazzabosco, Luca Fabris — 2012-01-16

Abstract: Several cholangiopathies result from a perturbation of developmental processes. Most of these cholangiopathies are characterised by the persistence of biliary structures with foetal configuration. Developmental processes are also relevant in acquired liver diseases, as liver repair mechanisms exploit a range of autocrine and paracrine signals transiently expressed in embryonic life. We briefly review the ontogenesis of the intra and extrahepatic biliary tree, highlighting the morphogens, growth factors and transcription factors that regulate biliary development, and the relationships between developing bile ducts and other branching biliary structures. Then we discuss the ontogenetic mechanisms involved in liver repair, and how these mechanisms are recapitulated in ductular reaction, a common reparative response to many forms of biliary and hepatocellular damage. Finally, we discuss the pathogenic aspects of the most important primary cholangiopathies related to altered biliary development i.e. polycystic and fibropolycystic liver diseases, Alagille syndrome.

Histamine regulation of biliary proliferation - Accepted Manuscript

Heather Francis, Fanyin Meng, Gianfranco Alpini — 2012-01-16

Alpha-fetoprotein Response Correlates with EASL Response and Survival in Solitary Hepatocellular Carcinoma Treated with Trans-arterial Therapies: A Subgroup Analysis - Accepted Manuscript

2012-01-16

Abstract: Background and Aims: Alpha-fetoprotein (AFP) is a universally recognized tumor marker in hepatocellular carcinoma (HCC). Its utility in assessing response to treatment remains controversial. We sought to study the: a) correlation between AFP response and imaging response, and b) ability of AFP, EASL and WHO response to predict survival outcomes in patients with solitary HCC.Methods: 629 HCC patients were treated with transarterial locoregional therapies over an 11-year period. To eliminate confounding factors, we included patients with single tumors, baseline AFP⩾200 ng/mL, and no extrahepatic disease; this identified our study cohort of 51 patients. AFP response was defined as >50% decrease from baseline; this was correlated to EASL and WHO response criteria by Kappa agreement, Pearson correlation and receiver operating curves. Survival analyses were performed by Landmark, risk-of-death and Mantel-Byar methodologies. None of the patients received sorafenib.Results: Three months post-treatment, AFP and EASL response correlated well (Kappa: 0.83; Pearson: 0.84); the sensitivity, specificity, positive and negative predictive values of AFP in predicting EASL response at 3 months were 96.6%, 85.7%, 92.3% and 93.3% respectively. Correlation with WHO response was low. From the 3-month landmark, WHO, EASL and AFP responders survived longer than nonresponders (P=0.006, 0.0001 and <0.0001 respectively). The risk of death was lower for EASL and AFP responders by both risk-of-death and Mantel-Byar methodologies (P<0.05).Conclusion: Response by AFP and EASL are predictors of survival outcome in patients with solitary HCC. AFP correlates with imaging response assessment by EASL guidelines. Achieving AFP response should be one of the therapeutic intents of locoregional therapies.

4-phenylbutyrate modulates ubiquitination of hepatocanalicular MRP2 and reduces serum total bilirubin concentration - Accepted Manuscript

2012-01-16

Abstract: Background& aims: Multidrug resistance-associated protein 2 (in humans, MRP2; in rodents, Mrp2) mediates biliary excretion of bilirubin glucuronides. Therefore, upregulation of MRP2/Mrp2 expression may improve hyperbilirubinemia. We investigated the effects of 4-phenylbutyrate (4PBA), a drug used to treat ornithine transcarbamylase deficiency (OTCD), on the cell surface expression and transport function of MRP2/Mrp2 and serum T-Bil concentration.Methods: MRP2-expressing MDCKII (MRP2-MDCKII) cells and rats were studied to explore the change induced by 4PBA treatment in the cell surface expression and transport function of MRP2/Mrp2 and its underlying mechanism. Serum and liver specimens from OTCD patients were analyzed to examine the effect of 4PBA on hepatic MRP2 expression and serum T-Bil concentration in humans.Results: In MRP2-MDCKII cells and rat liver, 4PBA increased the cell surface expression and transport function of MRP2/Mrp2. In patients with OTCD, hepatic MRP2 expression increased and serum T-Bil concentration decreased significantly after 4PBA treatment. In vitro studies designed to explore the mechanism underlying this drug action suggested that cell surface-resident MRP2/Mrp2 is degraded via ubiquitination-mediated targeting to the endosomal/lysosomal degradation pathway and that 4PBA inhibits the degradation of cell surface-resident MRP2/Mrp2 by reducing its susceptibility to ubiquitination.Conclusions: 4PBA activates MRP2/Mrp2 function through increased expression of MRP2/Mrp2 at the hepatocanalicular membrane by modulating its ubiquitination, and thereby decreases serum T-Bil concentration. 4PBA has thus therapeutic potential for improving hyperbilirubinemia.

Cost-effectiveness of semiannual surveillance for hepatocellular carcinoma in cirrhotic patients of the Italian Liver Cancer population - Accepted Manuscript

2012-01-16

Abstract: Background & aims: It was recently shown that semiannual surveillance for hepatocellular carcinoma (HCC) in cirrhotic patients provides a prognostic advantage over the annual program; however, its cost-effectiveness (CE) in the general cirrhotic population still needs to be defined.Methods: A Markov model was built to compare CE of these two strategies, considering literature results and treatment modalities of 918 cirrhotic patients from the Italian Liver Cancer (ITA.LI.CA) database.Results: Results from the Markov model suggest that, compared to annual surveillance, semiannual surveillance lead to a gain in quality-adjusted life expectancy, in an unselected cirrhotic population, of 1.35 quality-adjusted life-months (QALMs) over 10 years since surveillance start, in compensated patients, and of 0.73 QALMs in decompensated patients. Semiannual surveillance was more cost-effective in compensated than in decompensated cirrhosis, with an incremental CE ratio (ICER) of 1,997 and 3,814 €/QALM, respectively. In compensated cirrhosis, semiannual surveillance was more cost-effective than the annual program, when the annual HCC incidence was ⩾3.2% and the relative survival gain after cancer diagnosis was ⩾20% with respect to the annual program. In decompensated cirrhosis, semiannual surveillance was cost-effective in patients amenable to liver transplantation. In both groups, CE of semiannual surveillance improved with the increase of annual incidence and the survival benefit obtainable with HCC treatment.Conclusions: Both surveillance strategies for HCC in cirrhotic patients can be recommended, according to the individual risk profile for HCC occurrence and the expected survival gain obtainable after tumor diagnosis and therapy.

Renal failure and hyponatremia in patients with cirrhosis and skin and soft tissue infection. A retrospective study - Uncorrected Proof

2012-01-16

Background & Aims: Skin and soft tissue infection in cirrhosis is considered a non-severe infection, but specific information is lacking. This study aimed at assessing the characteristics, occurrence of renal failure, and outcome of cirrhotic patients with skin and soft tissue infection.Methods: Ninety-two patients with cirrhosis and skin and soft tissue infection admitted to hospital within a 6-year period were retrospectively analyzed. A control group matched by severity of liver disease, admitted for reasons other than infection, was also studied.Results: Resolution of the infection was achieved in 96% of patients. Twenty (21.7%) patients with skin and soft tissue infection developed renal failure, compared to only five patients (5.4%) of the control group (p=0.001). Renal failure was persistent despite infection resolution in 10 of the 20 patients vs. none of the control group. Renal failure was associated with poor prognosis. Hyponatremia developed in 40% and 25% of the infection and control group, respectively (p=0.028). Within a 3-month follow-up period, 25 patients (23%) with skin and soft tissue infection died or were transplanted compared to only four patients (4%) of the control group (p<0.001). Factors independently associated with mortality in the infection group were: site of acquisition of the infection and MELD–sodium score at diagnosis.Conclusions: Skin and soft tissue infection is a severe complication of cirrhosis with high frequency of renal failure and hyponatremia that may persist despite resolution of the infection. MELD–sodium score is useful to assess 3-month mortality in these patients.

Epidemiology of primary sclerosing cholangitis and primary biliary cirrhosis: a systematic review - Accepted Manuscript

Kirsten Boonstra, Ulrich Beuers, Cyriel Y. Ponsioen — 2012-01-16

Abstract: Objective: Studies on the epidemiology of primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC) show variable outcome. We aimed to systematically review the incidence and prevalence rates, as well as geographical distribution and temporal trends of PSC and PBC.Data sources: A systematic search of literature was performed in Medline and EMBASE (search last conducted January 10th 2011).Study selection: Population based epidemiological studies reporting incidence and/or prevalence rates for PSC or PBC in a defined geographical area of at least 100,000 adult inhabitants were considered relevant.Data extraction: Study area, study period, number of patients, number of inhabitants, incidence per 100,000 inhabitants per year, prevalence per 100,000 inhabitants, method of case-finding, method of case-ascertainment, male/female ratio and in case of PSC, occurrence of inflammatory bowel diseases (IBD) were extracted from retrieved articles.Results: The literature search yielded 2286 abstracts of which 31 articles fulfilled all inclusion criteria. Studies varied in size from 10 to 770 patients in catchment areas from 100,312 to 19,230,000 inhabitants. The incidence and prevalence rates for PSC range from 0 - 1.3 per 100,000 inhabitants/year and 0 – 16.2 per 100,000 inhabitants respectively. PBC incidence rates range from 0.33 – 5.8 per 100,000 inhabitants/year and prevalence rates range from 1.91 – 40.2 per 100,000 inhabitants; prevalence rates are increasing in time.Conclusion: Incidence and prevalence rates of both PSC and PBC vary widely and seem to be increasing. True population-based studies are scarce and therefore large population-based studies combining meticulous case-finding and case-ascertainment strategies are necessary.

Clinical evidence for the regression of liver fibrosis - Corrected Proof

Elizabeth L. Ellis, Derek A. Mann — 2012-01-16

Summary: Fibrosis is a common pathological process for the majority of liver diseases which in a significant minority of patients leads to end-stage cirrhosis and/or hepatocellular carcinoma. Data emerging from small rodent models of chronic liver disease have demonstrated that fibrotic extracellular matrix can be remodelled and near-normal hepatic architecture regenerated upon cessation of injury. Moreover, regression of liver fibrosis in these model systems can be stimulated with drugs that target the activities of fibrogenic hepatic stellate cells. These findings are exciting as they suggest that established fibrosis is susceptible to regression and possibly even reversion. Alongside these experimental studies is a growing body of clinical data that suggest regression of fibrosis may also occur in liver disease patients for whom an effective treatment is available for their underlying liver injury. This paper provides an up-to-date review of the currently available clinical data and also considers technical caveats that highlight the need for caution in establishing a new dogma that human liver fibrosis is reversible.

Validation of A Stopping Rule at Week 12 Using HBsAg and HBV DNA for HBeAg-Negative Patients Treated with Peginterferon Alfa-2a - Accepted Manuscript

2012-01-16

Abstract: Background &Aims: It was recently demonstrated that none of the hepatitis B e antigen (HBeAg-)negative patients without any serum hepatitis B surface antigen (HBsAg) decline and with <2 log hepatitis B virus (HBV) DNA decline at week 12 of a 48-week peginterferon alfa-2a (PEG-IFN) treatment course achieved a sustained response (SR). We aimed to validate this stopping rule in two independent trials.Methods: HBeAg-negative patients receiving 48 or 96 weeks of PEG-IFN in the phase III registration trial (N=85) and PegBeLiver study (N=75) were stratified according to the presence of any HBsAg decline and/or ⩾2 log HBV DNA decline at week 12. SR was defined as HBV DNA <2,000 IU/mL and normal alanine aminotransferase 24 weeks after treatment.Results: The original PARC trial included 102 patients (genotype A/D/other: 14/81/7), 25 (25%) had a SR. The validation dataset consisted of 160 patients (genotype A/B/C/D/other: 10/18/34/91/7), 57 (36%) achieved a SR. The stopping rule performed well across the two studies (p=0.001) and its negative predictive value [NPV] was 95% in the validation dataset harbouring genotypes A-D. Its performance was best for genotype D. Also among the 34 patients treated for 96 weeks, none of the 7 (21%) without HBsAg decline and with <2 log HBV DNA decline at week 12 achieved a SR (NPV 100%).Conclusions: We confirmed in two independent studies that a combination of HBsAg and HBV DNA levels at week 12 identifies HBeAg-negative patients with a very low chance of SR to either 48 or 96 weeks of PEG-IFN therapy.

PPARα Activation Improves Endothelial Dysfunction And Reduces Fibrosis And Portal Pressure In Cirrhotic Rats - Accepted Manuscript

2012-01-16

Abstract: Background & aims: Peroxisome proliferator-activated receptor α (PPARα) is a transcription factor activated by ligands that regulates genes related to vascular tone, oxidative stress and fibrogenesis, pathways implicated in the development of cirrhosis and portal hypertension. This study is aimed at evaluating the effects of PPARα activation with fenofibrate on hepatic and systemic hemodynamics, hepatic endothelial dysfunction and hepatic fibrosis in CCl4-cirrhotic rats.Methods: Cirrhotic rats treated with oral fenofibrate (25 mg/kg/day, n=10) or its vehicle (n=12) for 7 days had measurements of mean arterial pressure (MAP), portal pressure (PP) and portal blood flow (PBF). Then, the liver was perfused and dose-relaxation curves to acetylcholine (Ach) were performed. We also evaluated Sirius Red staining of liver sections, collagen-I mRNA expression and smooth muscle actin (α-SMA) protein expression, cyclooxygenase 1 (COX-1) protein expression, and cGMP levels in liver homogenates and TXB2 production in perfusates. Nitric oxide (NO) bioavailability and eNOS activation were measured in hepatic endothelial cells (HEC) isolated from cirrhotic rat livers.Results: CCl4 cirrhotic rats treated with fenofibrate had a significantly lower PP (-29%) and higher MAP than those treated with vehicle. These effects were associated with a significant reduction in hepatic fibrosis and improved vasodilatory response to acetylcholine. Moreover, a reduction in COX-1 expression and TXB2 production in rats receiving fenofibrate and a significant increase in NO bioavailability in HEC with fenofibrate were observed.Conclusions: PPARα activation markedly reduced PP and liver fibrosis and improved hepatic endothelial dysfunction in cirrhotic rats, suggesting it may represent a new therapeutic strategy for portal hypertension in cirrhosis.

Relationship between baseline hepatic status and outcome, and effect of sorafenib on liver function: SHARP trial subanalyses - Accepted Manuscript

2012-01-16

Abstract: Background & aims: Hepatic markers are utilized in many classification systems of patients with hepatocellular carcinoma and, by measuring organ damage and tumor stage, can influence treatment. Moreover, elevated serum concentrations of aminotransferases and alpha-fetoprotein are indicators of poor prognosis in patients with hepatocellular carcinoma. We examined the effects of sorafenib on hepatic markers by performing exploratory subset analyses of the Sorafenib HCC Assessment Randomized Protocol (SHARP) trial in patients categorized by baseline concentrations of alanine aminotransferase/aspartate aminotransferase, alpha-fetoprotein, and bilirubin; and by evaluating the effects of sorafenib on bilirubin concentrations during treatment.Methods: Patients (N=602) were grouped by baseline concentrations of alanine aminotransferase/aspartate aminotransferase (not significantly elevated, mildly elevated, or moderately elevated), alpha-fetoprotein (normal or elevated), and bilirubin (normal or elevated). Bilirubin was measured at baseline and on day 1 of each cycle.Results: Patients with elevated baseline concentrations of alanine aminotransferase/aspartate aminotransferase, alpha-fetoprotein, or bilirubin had shorter OS than those with normal baseline concentrations, irrespective of treatment group. No notable differences in safety profiles were observed between patients with normal vs elevated alanine aminotransferase/aspartate aminotransferase, alpha-fetoprotein, or bilirubin. Median changes from baseline in bilirubin concentration at the last cycle of treatment were +0.17 and +0.19 mg/dL in the sorafenib and placebo groups, respectively.Conclusions: These subset analyses suggest that sorafenib is safe and effective for hepatocellular carcinoma, irrespective of baseline alanine aminotransferase/aspartate aminotransferase, alpha-fetoprotein, or bilirubin concentration and that hepatic function remains stable over the course of sorafenib therapy.

Assessment of pathology reports on hilar cholangiocarcinoma: The results of a nationwide, multicenter survey performed by the AFC-HC-2009 study group - Corrected Proof

2012-01-16

Background & Aims: To assess the accuracy of pathology reports in patients operated on for hilar cholangiocarcinoma.Methods: Pathology reports for 263 patients operated on in 22 tertiary hepatobiliary centers were reviewed. The report format, turnaround time, tissue specimens, intraoperative consultations, macroscopic and microscopic descriptions, and conclusions were assessed.Results: Surgeons provided pathologists with pertinent clinical and imaging data in only 14% of cases and gave information on specimen orientation in only 24% of cases. The reports frequently failed to give information on prognostic histological factors: tumor differentiation (missing in 27% of cases), vascular invasion (45%), tumor thickness (99%), and infiltration of the bile duct surgical margins (4%). Distances between the tumor and the vessel margin, liver margin and the periductal soft tissue circumferential margin were not specified in 87%, 79%, and 89% of cases, respectively. Only 21% of the reports gave the pTNM stage in the conclusion section. A lack of information prevented retrospective pTNM staging in 48% of cases. Three percent of the reports had discrepancies in their conclusion section.Conclusions: Our French, nationwide study revealed that pathology reports on hilar cholangiocarcinoma frequently lack important information on the main prognostic histological factors and pTNM staging. We recommend the use of a standardized pathology report in this context.

Predictors for Incidence and Remission of NAFLD in the General Population During a Seven-Year Prospective Follow-Up - Accepted Manuscript

2012-01-16

Abstract: Background & aims: Data on the incidence and remission rates of Non-alcoholic fatty liver disease (NAFLD) as well as predictive factors are scant. This study aims to evaluate NAFLD’s epidemiology in prospective follow-up of individuals sampled from the general population.Methods: Evaluation of metabolic parameters and ultrasonographic evidence of NAFLD was performed in 213 subjects, with no known liver disease or history of alcohol abuse. The evaluation was performed at baseline and after a 7-year period by identical protocols.Results: Of the 147 patients who did not have NAFLD at baseline, 28 (19%) were found to have NAFLD at a 7-year follow-up. Baseline BMI, HOMA score, blood cholesterol, triglycerides, leptin levels and weight gain (5.8±6.1 vs. 1.4±5.5 kg P<0.001) were significantly higher and adiponectin was lower among those who developed NAFLD at 7 years follow-up, compared with those who remained NAFLD free. However, only weight gain and baseline HOMA were independent predictors for the development of NAFLD. Of the 66 patients who were found to have NAFLD at baseline, as many as 24 patients (36.4%) had no evidence of NAFLD at 7 years. Weight loss of 2.7±5.0 kg was significantly associated with NAFLD remission. Moreover, there was a 75% remission rate among NAFLD patients who lost 5 percent or more from their baseline weight.Conclusions: Among the general population, weight gain and baseline insulin resistance are predictors for NAFLD incidence. One third of NAFLD patients may have remission of disease within a 7-year follow-up, mostly depending on modest weight reduction.

Understanding silibinin’s modes of action against HCV using viral kinetic modeling - Accepted Manuscript

Jeremie Guedj, Harel Dahari, Ralf T. Pohl, Peter Ferenci, Alan S. Perelson — 2012-01-16

Abstract: Background &aims: Legalon® SIL (SIL) is a chemically hydrophilized version of silibinin that has exhibited high antiviral effectiveness against hepatitis C virus (HCV). Its main mode of action (MOA) remains unclear, with contradicting in-vitro studies supporting either suppression of entry and cell-to-cell spread or suppression of viral RNA synthesis as the main MOA. We sought to provide new insight into SIL’s MOA in genotype-1/4 patients receiving intravenous SIL monotherapy for 7 days via mathematical modeling.Methods: Changes in HCV RNA in 25 patients receiving 10, 15 or 20 mg/kg/day of SIL were analyzed and modeled using viral kinetic methods.Results: In 15 patients virus declined in a biphasic manner, in which a sharp drop between days 0 and 2 was followed by a slower second phase of decline. In 10 patients the initial decline was weaker and virus declined in a single phase over the 7 day period. The blocking production effectiveness, ε, was dose dependent with mean ε=0.49 and 0.89 in the 10 or 15 mg/kg/day and 20 mg/kg/day dosing groups, respectively (P=0.020). The effectiveness of blocking viral infection, ηwas estimated as 0.60 with no significant differences across dosing groups. For all patients the mean rate of viral-load decline measured between days 2 and 7 was high (0.3 logIU/mL/day), i.e., 4 fold higher than typically observed during the 2nd phase of (pegylated)-interferon-α±ribavirin treatment.Conclusions: Modeling HCV kinetics in vivo suggests that SIL may block both viral infection and viral production/release with its main dose-dependent effect being blocking viral production/release.

Vandetanib in patients with inoperable hepatocellular carcinoma: a phase II, randomized, double-blind, placebo-controlled study - Accepted Manuscript

2012-01-16

Abstract: Background and Aims: Inhibitors of vascular endothelial growth factor receptor (VEGFR) and epidermal growth factor receptor (EGFR) have shown anti-tumor activities in advanced hepatocellular carcinoma (HCC). The present study evaluated the efficacy and safety of vandetanib, an oral inhibitor of both VEGFR and EGFR, in patients with unresectable advanced HCC.Methods: Eligible patients were randomized 1:1:1 to receive vandetanib 300 mg/day, vandetanib 100 mg/day, or placebo. Upon disease progression, all patients had the option to receive open-label vandetanib 300 mg/day. The primary objective was to evaluate tumor stabilization rate (complete response + partial response + stable disease ⩾ 4 months). Secondary assessments included progression-free survival (PFS), overall survival (OS) and safety. Biomarker studies included circulating pro-angiogenic factors and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).Results: Sixty-seven patients were randomized to vandetanib 300 mg (n=19), vandetanib 100 mg (n=25) or placebo (n=23) groups. Twenty-nine patients entered open-label treatment. Vandetanib induced a significant increase in circulating VEGF and decrease in circulating VEGFR levels. In both vandetanib arms, tumor stabilization rate was not significantly different from placebo: 5.3% (vandetanib 300 mg), 16.0% (vandetanib 100 mg) and 8.7% (placebo). DCE-MRI did not detect significant vascular change after vandetanib treatment. Although trends of improved PFS and OS after vandetanib treatment were found, they were statistically insignificant. The most common adverse events were diarrhea and rash, whose incidence did not differ significantly between treatment groups.Conclusion: Vandetanib has limited clinical activity in HCC. The safety profile was consistent with previous studies.

The impact of organ dysfunction in cirrhosis: Survival at a cost? - Uncorrected Proof

2012-01-16

Background & Aims: The incidence of cirrhosis and subsequent development of organ dysfunction (OD) requiring intensive care unit (ICU) support is rising. Historically, critically ill cirrhotics are perceived as having poor prognosis and substantial cost of care.Methods: The aim was to prospectively analyse resource utilisation and cost of a large cohort of patients (n=660) admitted to a Liver ICU from 2000–2007 with cirrhosis and OD. Child Pugh, MELD, SOFA, APACHE II, and organ support requirements were collected. The Therapeutic Intervention Scoring System (TISS) score, a validated tool for estimating cost in ICU, was calculated daily. Logistic regression was used to determine independent predictors of increased cost.Results: Alcohol was the most common etiology (47%) and variceal bleeding (VB) the most common reason for admission (35%). Invasive ventilatory support was required in 74% of cases, vasopressors in 49%, and 50% required renal replacement therapy. Forty-nine per cent of non-transplanted patients survived to ICU discharge. Median TISS score and ICU cost per patient were 261 and €14,139, respectively. VB patients had the highest survival rates (53% vs. 24%; p<0.001) and lower associated cost. A combination of VB (OR 0.48), need for ventilation (OR 2.81), low PO2/FiO2 on admission (OR 0.97), and lactate (OR 0.93) improved cost prediction on multivariate analysis (AUROC 0.7; p<0.001) but organ failure scores per se were poor predictors of cost.Conclusions: Patients with cirrhosis and OD result in considerable resource expenditure but have acceptable hospital survival. Further health economic assessment and outcome prediction tools are required to appropriately target resource utilisation.

Structural and inflammatory heterogeneity in subcutaneous adipose tissue: relation with liver histopathology in morbid obesity - Accepted Manuscript

2012-01-16

Abstract: Background//Aim: In addition to total body fat, the regional distribution and inflammatory status of enlarged adipose tissue are strongly associated with metabolic co-morbidities of obesity. We recently showed that the severity of histological liver lesions related to obesity increases with the amounts of macrophage accumulation in visceral adipose tissue (VAT), while no association was found with the subcutaneous adipose tissue (SAT). In the abdominal region, SAT is anatomically divided in two layers, i.e. superficial (sSAT) and deep (dSAT) SAT. The aim of the present study was to test the hypothesis that these distinct compartments differentially contribute to hepatic alterations in obesity.Methods: Biopsies of liver, sSAT, dSAT and VAT were collected in 45 subjects with morbid obesity (Age 43.7 ± 1.6 years; BMI 48.5 ± 1.2 kg/m2) during bariatric surgery. Large scale gene expression analysis was performed to identify the pathways that discriminate sSAT from dSAT. Adipose tissue macrophages were quantified by immunohistochemistry using HAM56 antibody in subjects scored for liver histopathology.Results: An inflammatory gene pattern discriminates between sSAT and dSAT. dSAT displayed an intermediate level of macrophage accumulation between sSAT and VAT. The abundance of macrophages in dSAT, but not in sSAT, was significantly increased in patients with non-alcoholic steatohepatitis (NASH) and/or fibroinflammatory hepatic lesions.Conclusion: These data show distinct gene signature and macrophage abundance in the two compartments of SAT, with dSAT more closely related to VAT than to sSAT in terms of inflammation and relation with the severity of liver diseases in morbid obesity.

Tumor progression-related transmembrane protein aspartate-β-hydroxylase is a target for immunotherapy of hepatocellular carcinoma - Uncorrected Proof

2012-01-16

Background & Aims: Hepatocellular carcinoma (HCC) has a poor survival rate due to recurrent intrahepatic metastases and lack of effective adjuvant therapy. Aspartate-β-hydroxylase (ASPH) is an attractive cellular target since it is a highly conserved transmembrane protein overexpressed in both murine and human HCC tumors, and promotes a malignant phenotype as characterized by enhanced tumor cell migration and invasion.Methods: Dendritic cells (DCs), expanded and isolated from the spleen, were incubated with a cytokine cocktail to optimize IL-12 secretion and co-stimulatory molecule expression, then subsequently loaded with ASPH protein for immunization. Mice were injected with syngeneic BNL HCC tumor cells followed by subcutaneous inoculation with 5–10×105 ASPH loaded DCs using a prophylactic and therapeutic experimental approach. Tumor infiltrating lymphocytes (TILs) were characterized, and their role in producing anti-tumor effects determined. The immunogenicity of ASPH protein with respect to activating antigen specific CD4+ T cells derived from human peripheral blood mononuclear cells (PBMCs) was also explored.Results: We found that immunotherapy with ASPH-loaded DCs suppressed and delayed established HCC and tumor growth when administered prophylactically. Ex-vivo re-stimulation experiments and in vivo depletion studies demonstrated that both CD4+ and CD8+ cells contributed to anti-tumor effects. Using PBMCs derived from healthy volunteers and HCC patients, we showed that ASPH stimulation led to significant development of antigen-specific CD4+ T-cells.Conclusions: Immunization with ASPH-loaded DCs has substantial anti-tumor effects which could reduce the risk of HCC recurrence.

High intrahepatic HHV-6 virus loads but neither CMV nor EBV are associated with decreased graft survival after diagnosis of graft hepatitis - Corrected Proof

2012-01-16

Background & Aims: In liver transplant recipients with graft hepatitis, the relevance of herpesviruses is not well defined.Methods: Viral loads of CMV, EBV, and HHV-6 were determined in blood and liver biopsies of 170 liver transplant recipients with graft hepatitis by quantitative PCR.Results: HHV-6-, CMV-, and EBV-DNA were detected in 58%, 14%, and 44% of the biopsies, respectively, with coinfections in 34%. High intrahepatic HHV-6 DNA levels (>75th percentile, 11.27copies/1000cells) and detection of HHV-6 DNAemia were significantly associated with decreased graft survival after diagnosis of graft hepatitis (p=0.014 and p=0.003, respectively, median follow-up was 23.8months). Multivariate analysis confirmed high intrahepatic HHV-6 loads as an independent factor associated with reduced graft survival (adjusted hazard ratio 2.61, 95%confidence interval 1.16–5.87). Low concentrations of HHV6 DNA in the liver, indicating latent infection, did not influence graft survival. Neither CMV nor EBV (qualitative detection and high virus loads) nor acute rejection (according to the BANFF score) affected graft survival. However, patients had been treated for CMV reactivations and acute rejections in this retrospective study.High age and high bilirubin levels were the other independent factors associated with reduced graft survival (adjusted hazard ratio 3.56CI 1.52–8.34 and 3.23CI 1.50–6.96, respectively).Conclusions: High intrahepatic HHV-6-DNA levels are associated with decreased graft survival in liver transplant recipients with graft hepatitis. The significance of HHV-6 as potential etiology of graft hepatitis needs further evaluation.

Focus - Corrected Proof

Daniel Shouval — 2012-01-13

Almost three decades have passed since the historical NIH consensus conference which paved the road for introduction of liver transplantation (LT) into routine clinical practice worldwide. Progress in technical and medical skills as well as development of potent anti-rejection agents led to a progressively improved long-term survival of patients who underwent LT, 20 and even 30 years ago. In the early years of liver transplantation, guideline driven protocol liver biopsies were used extensively to study the natural history, response to anti-rejection treatment, recurrence of the original liver disease and complications of LT. The cumulative experience gained through these investigations led to a number of conclusions : (1) Histo-pathologic abnormalities in relatively old grafts followed up to 15years, did not necessarily correlate with disturbed standard liver function tests which may remain intact. (2) Routine liver function tests have a low specificity and sensitivity for diagnosis of rejection and remain an inaccurate mean for assessment of graft dysfunction. (3) Protocol liver biopsies performed several years after LT, at a time of normal liver function tests and in the absence of clinical signs, may unmask significant occult morbidities such as recurrence of autoimmune liver disease, including PBC and PSC, hepatitis C and advanced fibrosis, chronic rejection (i.e. central venulitis, bile duct loss and fibrosis) or non-alcoholic fatty liver disease. (4) Early recognition of histologic graft abnormalities may contribute to better control and improve survival in patients with overt or occult liver disease. (5) Unexplained idiopathic post-transplant chronic hepatitis (IPTH), nodular regenerative hyperplasia and hepatic structural changes including, hepatocyte disarray, perisinusoidal fibrosis, sinusoidal dilatation and peliosis hepatis have been reported in up to 30% of protocol liver biopsies performed ⩾5years after transplantation.

Deregulation of microRNAs expression occurs in stages of multistep hepatocarcinogenesis: why is it different? - Accepted Manuscript

Cai Guohong, Liu Ya, Yin Wen — 2012-01-09

Reply to: “Interaction between IL28B and PNPLA3 genotypes in the pathogenesis of steatosis in chronic hepatitis C non genotype-3 patients” - Corrected Proof

Eric Trépo, Pierre Pradat, Jeanette J. McCarthy, Hans L. Tillmann — 2012-01-09

We thank Dr. Valenti et al. for raising an additional point that PNPLA3 might be associated with steatosis in the setting of HCV infection after controlling for IL28B . They demonstrate in their cohort of 567 treatment naïve patients that both IL28B (rs12979860) and PNPLA3 (rs738409) may contribute to steatosis. Furthermore, in their study the beneficial effect of IL28B was limited to the patients without the PNPLA3 risk allele “G” as rs738409. A role of PNPLA3 GG genotype for steatosis in HCV infected patients has been observed in several studies, especially when excluding genotype 3 patients . In the Duke cohort, we did not find a significant difference for steatosis in relation to PNPLA3, (25/52 vs. 67/127, p=0.623). However, in the European cohort, the rs738409 SNP was used instead of SNP rs2281135. The SNP rs2281135 is considered a tagging SNP (rs2281135) for the likely causal SNP (rs738409) within the PNPLA3 region. Thus, as we had a tagging SNP (rs2281135) for the likely causal SNP (rs738409) within the PNPLA3 region only for the Duke cohort, we cannot rule out that the lack of a significant difference is due to the lack of accuracy of a surrogate SNP. Interestingly though, when grouped according to PNPLA3 rs2281135 GG vs. non-GG, the role of IL28B remained significant in the PNPLA3 rs2281135 GG patients only (p=0.002), while it was only a trend in the non-GG patients (p=0.46).

Bacterial resistance in cirrhotic patients: An emerging reality - Corrected Proof

Manuela Merli, Cristina Lucidi — 2012-01-09

Bacterial infections are frequent and represent a relevant issue in cirrhotic patients. Susceptibility to bacterial infections is increased in cirrhotic patients for multiple reasons. These patients show immunological dysfunctions, due to the so called “immune paralysis”, and an impairment in the reticuloendothelial system function resulting in a reduced ability of the liver to contrast the bacterial load from the intestine . Moreover, they are predisposed to an increase in the rate and severity of “gut bacterial translocation” (GBT), defined as the migration of viable microorganisms and microbial products from the gut to mesenteric lymph nodes and other extra intestinal sites. GBT appears to be related mainly to three pathophysiological mechanisms: intestinal bacterial overgrowth, due to decreased small bowel motility, increased intestinal permeability, proportional to the degree of portal hypertension, and impaired local and systemic immunity . All these factors are particularly evident in decompensated patients and GBT is reported to occur in 30–40% of patients with ascites.

Interaction between IL28B and PNPLA3 genotypes in the pathogenesis of steatosis in chronic hepatitis C non genotype-3 patients - Corrected Proof

Luca Valenti, Alessio Aghemo, Albert Friedrich Stättermayer — 2012-01-09

Steatosis is frequently observed in patients with chronic hepatitis C (CHC), and is associated with fibrosis progression and treatment failure . Tillmann et al. recently reported a negative association between the interleukin 28B (IL28B) rs12979860 CC genotype, predicting sustained virological response , and steatosis in genotype-1 CHC . However, whether this association was independent of other genetic factors was not evaluated.

Reply to: “Deregulation of microRNAs expression occurs in stages of multistep hepatocarcinogenesis: why is it different?” - Accepted Manuscript

Chun-Ming Wong, Irene Oi-Lin Ng — 2012-01-09

Uncover the immune biomarkers underlying hepatitis B e antigen (HBeAg) seroconversion: A need for more translational study - Uncorrected Proof

George K.K. Lau, Fu-Sheng Wang — 2012-01-09

The Hepatitis B e antigen (HBeAg) is a non-particulate secretory protein, which is not essential for viral assembly or replication but is important for the establishment of persistent infection in vivo. A recent study suggested that it down-regulates the innate immune response to infection and function as a T cell tolerogen . For patients with chronic HBeAg positive chronic hepatitis B infection (CHB), HBeAg seroconversion, defined as loss of HBeAg with the appearance of anti-HBe, is often associated with clinical remission and a transition to inactive liver disease . Accompanying HBeAg seroconversion, there is a reduction in liver fibrosis, a lower incidence of cirrhosis and hepatocellular carcinoma. HBeAg seroconversion, whether spontaneous or treatment-induced, is also associated with a higher probability of hepatitis B surface antigen (HBsAg) loss and seroconversion, which is considered to be a more permanent clinical remission of liver disease. Thus, the achievement and maintenance of HBeAg seroconversion, in association with polymerase chain reaction-undetectable hepatitis B virus (HBV) DNA levels, is an important goal in the management of patients with HBeAg-positive CHB. Based on evidence demonstrating HBeAg seroconversion as an important hallmark event of a durable clinical remission of liver disease, major liver societies treatment guidelines have adopted HBeAg seroconversion with sustained suppression of HBV DNA as an end point for treatment in patients with HBeAg-positive CHB who do not have cirrhosis or decompensated liver disease.

Identification of molecular pathways involved in oxaliplatin-associated sinusoidal dilatation - Corrected Proof

2011-12-26

Background & Aims: Oxaliplatin-based chemotherapy for colorectal liver metastases (CRLM) can result in vascular liver lesions such as sinusoidal dilatations. Physiopathology remains unclear and variability between patients suggests that there is individual susceptibility. A better understanding of the molecular mechanisms of oxaliplatin liver toxicity may allow the identification of biomarkers and adaptation of chemotherapy delivery.Methods: Between 1998 and 2009, 83 non-tumor frozen liver samples were obtained from patients operated on for CRLM after an exclusive oxaliplatin-based chemotherapy. Gene-expression profiles were first analyzed by microarray on a selected population of 19 patients: 9 patients with severe sinusoidal dilatation after a short period of chemotherapy and 10 patients without any sinusoidal dilatation after a long period of chemotherapy. These were compared with a control group of 5 patients without any chemotherapy and lesions. Twenty-two differentially-expressed (at least 1.5-fold difference in expression) genes were selected. These were validated using microfluidic quantitative RT-PCR in an independent set of 58 patients (28 with sinusoidal dilatation and 30 without sinusoidal dilatation).Results: Among the 22 selected genes, 12 were validated as being up-regulated in samples from patients with sinusoidal dilatation compared to patients without sinusoidal dilatation. Genes involved in angiogenesis (VEGFD, THY-1, GPNMB) and cellular adhesion (VWF, CDH13, THBS2), and extracellular matrix components (COL1A1, COL4A1, SLCO1A2) were over-represented in patients with sinusoidal dilatation.Conclusions: This molecular signature confirms the involvement of angiogenesis and coagulation in sinusoidal injuries induced by oxaliplatin and reinforces a potential protective role of bevacizumab and aspirin, as suggested in retrospective clinical studies.

A dual role for hypoxia inducible factor-1α in the hepatitis C virus lifecycle and hepatoma migration - Corrected Proof

2011-12-19

Background & Aims: Hepatitis C virus (HCV) causes progressive liver disease and is a major risk factor for the development of hepatocellular carcinoma (HCC). However, the role of infection in HCC pathogenesis is poorly understood. We investigated the effect(s) of HCV infection and viral glycoprotein expression on hepatoma biology to gain insights into the development of HCV associated HCC.Methods: We assessed the effect(s) of HCV and viral glycoprotein expression on hepatoma polarity, migration and invasion.Results: HCV glycoproteins perturb tight and adherens junction protein expression, and increase hepatoma migration and expression of epithelial to mesenchymal transition markers Snail and Twist via stabilizing hypoxia inducible factor-1α (HIF-1α). HIF-1α regulates many genes involved in tumor growth and metastasis, including vascular endothelial growth factor (VEGF) and transforming growth factor-beta (TGF-β). Neutralization of both growth factors shows different roles for VEGF and TGFβ in regulating hepatoma polarity and migration, respectively. Importantly, we confirmed these observations in virus infected hepatoma and primary human hepatocytes. Inhibition of HIF-1α reversed the effect(s) of infection and glycoprotein expression on hepatoma permeability and migration and significantly reduced HCV replication, demonstrating a dual role for HIF-1α in the cellular processes that are deregulated in many human cancers and in the viral life cycle.Conclusions: These data provide new insights into the cancer-promoting effects of HCV infection on HCC migration and offer new approaches for treatment.

Short course adjuvant terlipressin in acute variceal bleeding: A randomized double blind dummy controlled trial - Corrected Proof

2011-12-19

Background & Aims: Terlipressin is recommended for 3–5days as adjuvant to endoscopic variceal band ligation (EVBL) in esophageal variceal bleeding (EVB). We assessed whether terlipressin can be administered for a shorter period of time to patients with EVB.Methods: All eligible EVB patients received 24h of open label terlipressin at presentation. After successful EVBL, patients were randomized to receive active or dummy terlipressin for the next 48h. We excluded patients with failure to achieve initial hemostasis, bleeding gastric varices, known hepatoma, and/or portal vein thrombosis, advanced cirrhosis (Child-Pugh score ⩾12), and patients on a ventilator. The primary outcome was failure to control EVB. The secondary outcomes were 30-day mortality; re-bleeding and composite outcome of failure to control EVB.Results: A total of 130 eligible patients were randomized to receive terlipressin for a total of 24 (short course or SC) or 72h (usual course or UC). Baseline patient characteristics were comparable; the majority of patients were HCV-infected and male. There was one failure to control EVB (1.5%) in UC and none in SC terlipressin (p=0.50). The 30-day re-bleeding rate was 1.5% and 3.1% in UC, and SC terlipressin, respectively (p=0.50). The 30-day mortality was 12, 6 (9.2%) patients in each group (p=0.50). The 30-day failure to control bleeding was observed in 14 patients; seven in each group (p=0.494).Conclusions: In patients with esophageal variceal bleeding, a 24-h course of terlipressin is as effective as a 72-h course when used as an adjunctive therapy to successful EVBL.

Transcriptional regulation of miR-224 upregulated in human HCCs by NFκB inflammatory pathways - Corrected Proof

2011-12-16

Background & Aims: miR-224 is up-regulated in human HCCs as compared to both paired peri-tumoral cirrhotic tissues and cirrhotic livers without HCC. Here, we have cloned the miR-224 regulatory region and characterized its transcriptional regulation by the NFκB-dependent inflammatory pathways.Methods: Mature miRNA expression was evaluated by a 2 step stem–loop real-time RT-PCR. The recruitment of polymerase II and transcription factors on the pre-miR-224 promoter has been assessed by ChIPSeq and ChIP.Results: We found miR-224 levels strongly up-regulated in both peri-tumoral cirrhotic livers and HCC samples as compared to normal livers. In silico analysis of the putative miR-224 promoter revealed multiple NFκB sites. We showed that LTα and TNFα activate transcription from the miR-224 promoter and of endogenous miR-224 expression in HCC cell lines, whereas the expression of miR-224 target API5 was reduced. Exogenously expressed p65/RelA activates the miR-224 promoter and a dominant negative form of IκBα (IκBSR) represses it. ChIP analysis showed that p65/NFκB is recruited on the miR-224 promoter and that its binding sharply increases after exposure to LPS, TNFα, and LTα. Altogether these findings link the inflammatory signals to NFκB-mediated activation of miR-224 expression. An antago-miR specific for miR-224 blocked LPS and LTα stimulated HCC cells migration and invasion. Conversely, the IKK inhibitor BMS-345541 blocks pre-miR-224-induced cellular migration and invasion.Conclusions: Our results identify p65/NFκB as a direct transcriptional regulator of miR-224 expression and link miR-224 up-regulation with the activation of the LPS, LTα, and TNFα inflammatory pathways and cell migration/invasion in HCC.

13C-Aminopyrine breath test accurately predicts long-term outcome of chronic hepatitis C - Corrected Proof

2011-12-14

Background & Aims: Although numerous non-invasive tests are currently available to explore liver function and disease activity in patients with HCV-related chronic diseases, none of these indicate the likelihood of disease progression in the individual patient.We aimed at assessing the prognostic ability of 13C2-aminopyrine breath test (13C-ABT) in the prediction of liver fibrosis progression in patients with HCV chronic hepatitis who prospectively entered a long-term follow-up.Methods: Fifty patients with HCV-related chronic disease who underwent paired liver biopsy (at baseline and after a mean period of 86months) were included in the study. 13C-ABT was carried out at baseline and every 3years. Histological progression was defined as increase of at least 2 fibrosis units according to Ishak score.Results: Fourteen patients progressed of at least 2 fibrosis units during the follow-up. These patients were more frequently infected with a HCV-1b genotype and had, at baseline, a significantly older age, higher BMI, AST levels, and AST to platelet ratio index (APRI). 13C-ABT was altered in 57% of cases at baseline and in 100% of the cases at 3-year follow-up. In the univariate analysis, age (p=0.005), BMI (p=0.006), platelet count (p=0.03), AST (p=0.012) and ALT (p=0.04) levels, APRI (p=0.03), and baseline 13C-ABT results (p<0.0001) were all independently associated with progression of liver fibrosis. By Cox’s multiple regression analysis, the 13C-ABT was the only covariate that significantly predicted liver fibrosis progression (HR 6.7; 95% CI 2.3–20.1; p<0.001).Conclusions: 13C-ABT accurately predicts the risk of disease progression in patients with HCV-related chronic hepatitis.

The phenotypic fate and functional role for bone marrow-derived stem cells in liver fibrosis - Corrected Proof

Tatiana Kisseleva, David A. Brenner — 2011-12-14

Summary: Liver fibrosis is an outcome of chronic liver injury of any etiology. It is manifested by extensive deposition of extracellular matrix (ECM) proteins that produce a fibrous scar in the injured liver. Bone marrow (BM) cells may play an important role in pathogenesis and resolution of liver fibrosis. BM cells contribute to the inflammatory response by TGF-β1 secretion and activation of liver resident myofibroblasts. Moreover, BM itself can serve as a source of collagen expressing cells, e.g. BM-derived fibrocytes and mesenchymal progenitors, which in turn, have a potential to in situ differentiate into fibrogenic myofibroblasts and facilitate fibrosis. Finally, BM cells play an active part in resolution of liver fibrosis after cessation of fibrogenic stimuli. While natural killer (NK) cells are implicated in apoptosis of activated hepatic stellate cells/myofibroblasts, cells of myelo-monocitic lineage secrete matrix metalloproteinases to actively degrade the fibrous scar. The focus of this review is on the current understanding of the role of different subsets of BM cells in the onset, development and resolution of liver fibrosis.

Snapshot liver transcriptome in hepatocellular carcinoma - Corrected Proof

Andreas Teufel, Jens U. Marquardt, Frank Staib, Peter R. Galle — 2011-12-14

Hepatocellular carcinoma ranks among the most common cancers worldwide. However, besides surgery, therapeutic strategies remain limited and a detailed analysis and characterization of the tumor biology will be essential in order to identify (novel) therapeutic targets . With the development of sorafenib, a first step of successful targeting molecular changes in HCC has been made but many more will have to follow in order to establish a potent arsenal of specific therapeutic options .

The interaction of hepatic lipid and glucose metabolism in liver diseases - Corrected Proof

2011-12-14

Summary: It is widely known that the liver is a central organ in lipogenesis, gluconeogenesis and cholesterol metabolism. However, over the last decades, a variety of pathological conditions highlighted the importance of metabolic functions within the diseased liver. As observed in Western societies, an increase in the prevalence of obesity and the metabolic syndrome promotes pathophysiological changes that cause non-alcoholic fatty liver disease (NAFLD). NAFLD increases the susceptibility of the liver to acute liver injury and may lead to cirrhosis and hepatocellular cancer. Alterations in insulin response, β-oxidation, lipid storage and transport, autophagy and an imbalance in chemokines and nuclear receptor signaling are held accountable for these changes. Furthermore, recent studies revealed a role for lipid accumulation in inflammation and ER stress in the clinical context of liver regeneration and hepatic carcinogenesis. This review focuses on novel findings related to nuclear receptor signaling – including the vitamin D receptor and the liver receptor homolog 1 – in hepatic lipid and glucose uptake, storage and metabolism in the clinical context of NAFLD, liver regeneration, and cancer.

Renal failure and cirrhosis: A systematic review of mortality and prognosis - Corrected Proof

2011-12-14

Background & Aims: To evaluate renal failure (RF) in cirrhosis to determine and quantify its prognostic significance.Methods: Studies were identified by MEDLINE, EMBASE, Cochrane, ISI Web of Science (1977–2010); search terms included renal failure, mortality, and cirrhosis. Included studies (n=74) reported >10 patients and mortality data (8088 patients). Mortality at 1, 3, and 12months was evaluated with respect to Child-Pugh score, serum creatinine, ascites, ICU status or sepsis, prospective study design, and publication year. Pooled odds ratio (POR) for death was compared for RF vs. non-RF (5668 patients).Results: Overall median mortality for RF patients was 67%: 58% at 1month and 63% (IQR 54–79) at 12months. POR for death RF vs. non-RF patients was 7.6 (95%CI 5.4–10.8). Overall mortality before 2005 (1264 patients) was 74% and after 2005 (2833 patients) was 63% with a marked reduction only at 30days (71% vs. 52%).Conclusions: This study provides a measure of the increased risk of death in cirrhosis with renal failure. RF increases mortality 7-fold, with 50% of patients dying within one month. Preventative strategies for RF are needed.

Diagnosis of liver fibrosis and cirrhosis using liver stiffness measurement: Comparison between M and XL probe of FibroScan® - Corrected Proof

2011-12-14

Background & Aims: Unreliable results of liver stiffness measurement are obtained in 16% of cases and are independently associated with body mass index (BMI) greater than 30kg/m2. A new FibroScan® probe (XL probe) was designed specifically for obese patients. The aim of this study was to evaluate the accuracy of liver stiffness measurement using M and XL probes of Fibroscan® for the diagnosis of fibrosis and cirrhosis in a large cohort of patients.Methods: Consecutive patients undergoing liver biopsies for chronic liver disease were prospectively recruited. Liver stiffness measurement was performed within 1week before liver biopsy using both M and XL probes of FibroScan®.Results: A total of 286 patients were evaluated. A reliable liver stiffness measurement using M probe was obtained in 79.7% of cases. In the other 21.3%, liver stiffness measurement using XL probe was obtained in 56.9% of patients. A strong correlation was found between M and XL values, regardless of BMI. In all groups, median liver stiffness measurement using the XL probe was significantly lower than liver stiffness measurement using the M probe. By multivariate analysis, unsuccessful liver stiffness examination with M probe was independently associated with age >50years and BMI >30kg/m2. By univariate analysis, only BMI >30kg/m2 was associated with unsuccessful liver stiffness measurement with XL probe. No significant difference was observed between the M and XL probes for the diagnosis of liver fibrosis.Conclusions: Liver stiffness measurement with either M or XL probe is possible in 91.2% of patients with comparable diagnostic accuracy. In clinical practice, the M probe could be used as first step for liver stiffness measurement. In case of no valid shot or unreliable measurement, the XL probe could be used. This result could be useful for the assessment of liver fibrosis in NAFLD and/or obese patients.

Accumulation of endoplasmic reticulum stress and lipogenesis in the liver through generational effects of high fat diets - Corrected Proof

Jiong Li, Jin Huang, Jian-Shuang Li, Hong Chen, Kun Huang, Ling Zheng — 2011-12-14

Background & Aims: The dramatic rise of nonalcoholic fatty liver disease (NAFLD) among children in the past decade cannot be solely explained by the increased high fat diet (HFD) intake in kids. Recent studies suggest that the offspring of HFD-fed mothers develop a worse form of NAFLD when weaned on the HFD than when weaned on the normal chow (NC), indicating that a feed-forward circle may exacerbate the syndromes throughout multiple generations. In the present study, the aforementioned feed-forward circle was investigated in mice by employing continuous HFD feeding for three generations.Methods: C57BL/6 mice were fed with either a HFD or NC for three consecutive generations (F0, F1, and F2). Body weight, food intake, hepatic histology; levels of insulin, leptin, and triglycerides; expression of factors involved in lipogenesis and endoplasmic reticulum (ER) stress pathways; and histone methylation status were investigated in male offspring.Results: Obesity occurred earlier, became more severe through generations (F2>F1>F0), and was accompanied by a gradual increase of histological scoring of steatosis in male mice with transgenerational HFD feeding. The highest degree of steatosis occurred in HFD-treated F2 mice and was associated with the highest levels of insulin and leptin. The latter mice were characterized by enhanced lipogenesis and ER stress with a trend of transgenerational changes was detected for LXRα, ERO1-α, histone methylations, and H3K9 histone methyltransferase. Furthermore, chromatin immunoprecipitation (CHIP) assay demonstrated a significantly reduced accumulation of methylated histones in LXRα and ERO1-α gene promoters.Conclusions: Under HFD feeding stress, the male offspring of the F2 generation (derived from both grand-maternal and maternal obesity) are extremely susceptible to developing obesity and hepatic steatosis. This is presumably a consequence of transgenerational accumulation of epigenetic modifications leading to up-regulation of lipogenesis and ER stress pathways in the liver.

The CXCL1 rs4074 A allele is associated with enhanced CXCL1 responses to TLR2 ligands and predisposes to cirrhosis in HCV genotype 1-infected Caucasian patients - Corrected Proof

2011-12-14

Background & Aims: CXCL1 is a ligand for CXC chemokine-receptor 2 expressed on hepatic stellate cells (HSC). Thus, CXCL1 might contribute to HSC activation and fibrogenesis. Here, we investigated whether the CXCL1 rs4074 polymorphism affects CXCL1 expression and progression of chronic hepatitis C virus (HCV) infection towards cirrhosis.Methods: The study involved 237 patients with chronic HCV genotype 1 infection (75 with cirrhosis) and 342 healthy controls. The CXCL1 rs4074 polymorphism was determined by a LightSNiP assay on the LightCycler system. CXCL1 serum levels and induction in response to HCV proteins were studied by ELISA.Results: Distributions of CXCL1 genotypes (GG/GA/AA) matched the Hardy–Weinberg equilibrium in all subgroups (HCV-associated cirrhosis: 29.3%/54.7%/16.0%; non-cirrhotic HCV infection: 45.1%/44.4%/10.5%, healthy controls: 46.2%/40.9%/12.9%). HCV-infected cirrhotic patients had a significantly greater CXCL1 rs4074 A allele frequency (43.3%) than patients without cirrhosis (32.7%, OR=1.573, p=0.03) and healthy controls (33.3%, OR=1.529, p=0.02). In vitro carriers of the A allele produced greater amounts of CXCL1 in response to TLR2-ligands including HCV core and NS3, and HCV-infected carriers of the CXCL1 rs4074 A allele had higher CXCL1 serum levels than those with the G/G genotype. Moreover, multivariate Cox-regression analysis confirmed age and the presence of a CXCL1 rs4074 A allele as risk factors for cirrhosis.Conclusions: Enhanced production of CXCL1 in response to HCV antigens in carriers of the rs4074 A allele together with its increased frequency in cirrhotic patients with hepatitis C suggest the CXCL1 rs4074 A allele as a genetic risk factor for cirrhosis progression in hepatitis C.