Journal of Hepatology - Articles in Press

Single nucleotide polymorphisms and risk of hepatocellular carcinoma in cirrhosis - Accepted Manuscript

Pierre Nahon, Jessica Zucman-Rossi — 2012-05-18

Summary: Liver carcinogenesis is a complex and multi-factorial process, in which both environmental and genetic features interfere and contribute to malignant transformation. Patients with cirrhosis are particularly exposed and justify periodical screening in order to detect the early development of hepatocellular carcinoma (HCC). The risk of HCC is, however, not identical from one patient to another. The identification of host factors that may also play an important role in HCC development may improve our understanding of the implications of the various biological pathways involved in liver carcinogenesis; such progress may as well help to refine the selection of patients who could benefit from specific preventative measures or could be given adapted screening policies. Numerous candidate-gene studies have reported associations between single nucleotide polymorphisms (SNPs) and the presence of HCC. Some of these publications unfortunately suffer from major methodological drawbacks because of their case-control, retrospective and mono-centric aspect. Prospective cohort studies conducted in large homogeneous populations and comprising a sufficient number of events during follow-up may overcome these pitfalls, but require a long time to be conducted and are still scarce. More recently, the first Genome Wide Association studies (GWAs) have enabled the identification of unsuspected loci that may be involved in various steps implicated in liver tumourigenesis. Taken together, these studies highlight variants that modulate oxidative stress, iron metabolism, inflammatory and immune responses, DNA-repair mechanisms or systems involved in cell-cycle regulation as genetic traits susceptible to modify the natural history of cirrhotic patients and partly explain the observed differences in the risk of HCC occurrence. However, large genetic epidemiology studies in the field of cancer diseases have suggested the limited ability of polymorphic traits, alone, to refine individual prognosis. The integration of various panels of genes into clinical scores may in the near future define a “genomic risk prediction” specific to liver cancer developed in cirrhotic patients.

EVOLUTION OF INDICATIONS AND RESULTS OF LIVER TRANSPLANTATION IN EUROPE. A Report from the European Liver Transplant Registry (ELTR) - Accepted Manuscript

2012-05-18

Gap junctions and non-neoplastic liver disease - Accepted Manuscript

Mathieu Vinken — 2012-05-18

Abstract: Because of their critical role as goalkeepers of hepatic homeostasis, gap junctions are frequent targets in liver disease. This concept has been demonstrated on many occasions in the light of hepatocarcinogenesis. Relatively little focus has been put on the fate of gap junctions in other liver pathologies, including hepatitis, liver fibrosis and cirrhosis, cholestasis and hepatic ischemia and reperfusion injury. This actually defines the scope of the present paper, whereby an in-depth description of the multiple changes in the expression, localization and function of connexins, the molecular constituents of gap junctions, is provided. The exploitation of connexins as biomarkers and therapeutic targets in liver disease is also illustrated.

Successful mutation-specific chaperone therapy with 4-phenylbutyrate in a child with progressive familial intrahepatic cholestasis type 2 - Accepted Manuscript

2012-05-18

Summary: Background & aims: Progressive familial intrahepatic cholestasis type 2 (PFIC2) is due to mutations in ABCB11 encoding the canalicular bile salt export pump (BSEP) of hepatocyte. Liver transplantation is usually required. 4-phenylbutyrate (4-PB) has been shown in vitro to retarget some selected mutated apical transporters. After an in vitro study in a hepatocellular polarized line, we tested 4-PB treatment in a child with a homozygous p.T1210P BSEP mutation.Methods: Can 10 cells were transfected with plasmids encoding wild type Bsep (Bsepwt) and mutated p.T1210P Bsep (BsepT1210P), both tagged with GFP. Then, cells were treated with 4PB at 37°C or 27°C, immunostained and analyzed using confocal microscopy. The child received 4-PB orally in two divided doses and BSEP liver immunostaining was performed before and after 4-PB as well as bile analysis.Results: In Can 10 cells, in contrast to Bsepwt-GFP, BsepT1210P-GFP was not detected at the canalicular membrane but in the endoplasmic reticulum. 4-PB as well as incubation at 27°C partially corrected BsepT1210P-GFP targeting to the canalicular membrane while combined treatments resulted in normal canalicular localization. In the child, we showed that 4-PB improved clinical and biological parameters of cholestasis and liver function. Also, canalicular expression of p.T1210P BSEP mutant was partially corrected as was biliary bile acid excretion.Conclusions: The results illustrate for the first time the therapeutic potential of a clinically approved chaperone drug in a selected patient with PFIC2 and support that bile secretion improvement might be due to the ability of 4-PB to retarget mutated BSEP.

Liver transplantation for hepatocellular carcinoma in non-cirrhotic livers regardless of the number and size of tumours? - Accepted Manuscript

Thomas Decaens, Alexis Laurent, Alain Luciani — 2012-05-14

EASL Recognition Awardee 2012 Prof. Helmer Ring-Larsen - Accepted Manuscript

Carlo Merkel — 2012-05-11

Hepatocyte-like cells differentiated from human induced pluripotent stem cells (iHLCs) are permissive to hepatitis C virus (HCV) infection: HCV study gets personal - Accepted Manuscript

Karim Si-Tayeb, Jean-Charles Duclos-Vallée, Marie-Anne Petit — 2012-05-07

Two lymph nodes draining the mouse liver are the preferential site of DC migration and T cell activation - Uncorrected Proof

2012-04-27

Background & Aims: Lymph nodes (LNs) play a critical role in host defence against pathogens. In rodents, lymphatic anatomy and drainage have been characterized for many different organs. Surprisingly, the LNs draining the mouse liver have not been clearly identified. This knowledge is of central importance to allow accurate characterization of immune responses to pathogens infecting the liver. It is also important for exploring immune responses in hepatic tumour models, and mechanisms underlying the relative tolerogenic properties of the liver. In this study, we used both anatomical and immunological approaches to identify the LN(s) draining the mouse liver.Methods: Evans Blue and purified dendritic cells were directly injected into the hepatic parenchyma.Results: Using Evans Blue, we identified three LNs adjacent to the liver that stained with the dye within the first 5min, which we termed portal, coeliac, and first mesenteric LNs. We also provide evidence that dendritic cells (DCs) injected under the liver capsule preferentially migrate to the coeliac and portal nodes, leading to local activation of antigen-specific naïve CD8 and CD4 T cells, suggesting this is a route of lymphatic drainage from the liver. Consistent with this result, cell-associated antigen injected under the liver capsule was also cross-presented to CD8 T cells in these nodes.Conclusions: These results suggest for the first time that the coeliac and portal nodes are the main LNs draining the liver, and that DCs exiting the liver can elicit primary T cell activation within these lymph nodes; first mesenteric nodes play a secondary role. We propose this nomenclature to be used as common designations for the observed structures.

Mouse organic solute transporter alpha deficiency alters FGF15 expression and bile acid metabolism - Accepted Manuscript

Tian Lan, Anuradha Rao, Jamie Haywood, Nancy D. Kock, Paul A. Dawson — 2012-04-27

Abstract: Background & aims: Blocking intestinal bile acid (BA) absorption by inhibiting or inactivating the apical sodium-dependent BA transporter (Asbt) classically induces hepatic BA synthesis. In contrast, blocking intestinal BA absorption by inactivation of the basolateral BA transporter, Organic solute transporter alpha-beta (Ostα-Ostβ is associated with an altered homeostatic response and decreased hepatic BA synthesis. The aim of this study was to determine the mechanisms underlying this phenotype, including the role of the farnesoid X receptor (FXR) and fibroblast growth factor 15 (FGF15).Methods: BA and cholesterol metabolism, the intestinal phenotype, expression of genes important for BA metabolism, and intestinal FGF15 expression were examined in wild type, Ostα-/-, Fxr-/-, and Ostα-/-Fxr-/- mice.Results: Inactivation of Ostα was associated with decreases in hepatic cholesterol 7α-hydroxylase (Cyp7a1) expression, BA pool size, and intestinal cholesterol absorption. Ostα-/- mice exhibited significant small intestinal changes, including altered ileal villus morphology, and increases in intestinal length and mass. Total ileal FGF15 expression was elevated almost 20-fold in Ostα-/- mice as a result of increased villus epithelial cell number and ileocyte FGF15 protein expression. Ostα-/-Fxr-/- mice exhibited decreased ileal FGF15 expression, restoration of intestinal cholesterol absorption, and increases in hepatic Cyp7a1 expression, fecal BA excretion, and BA pool size. FXR deficiency did not reverse the intestinal morphological changes or compensatory decrease for ileal Asbt expression in Ostα-/- mice.Conclusions: These results indicate that signaling via FXR is required for the paradoxical repression of hepatic BA synthesis but not the complex intestinal adaptive changes in Ostα-/- mice.

IBD is associated with an increase in carcinoma in PSC irrespective of the presence of dominant bile duct stenosis - Uncorrected Proof

Marcel Janse, Laetitia E. Lamberts, Robert C. Verdonk, Rinse K. Weersma — 2012-04-24

We have read with great interest the paper by Rudolph et al. . The authors have prospectively studied a large cohort of Primary Sclerosing Cholangitis (PSC) patients for up to two decades and identified that only patients with a dominant biliary stenosis with additional IBD had an increased rate in both biliary and colorectal carcinomas (CRC) compared to patients with no dominant stenosis or patients with a dominant stenosis without concomitant IBD. Their findings suggest that the occurrence of additional IBD in PSC patients has a carcinogenic potential and also results in reduced survival free of liver transplantation. The authors recommend that these patients should be carefully screened for bile duct, gallbladder and colorectal carcinomas. We would here like to present our data on an equally large cohort of PSC patients, with a similar follow-up, which does not substantiate their findings.

Regulatory T cells and autoimmune hepatitis: Defective cells or a hostile environment? - Corrected Proof

Ye H. Oo, David H. Adams — 2012-04-23

Autoimmunity occurs when genetically predisposed individuals are exposed to environmental factors that trigger immune responses to self-antigens. The immune system protects the host by recognising and removing invading pathogens and damaged cells and to do this efficiently it must be able to discriminate between infected or damaged cells and healthy self-tissue. This tolerance of self involves both central, thymic mechanisms and peripheral pathways involving regulatory T cells (Treg) () . Regulatory T cells are a subpopulation of T cells which downregulate immune responses, maintain tolerance to self-antigens and prevent the development of autoimmunity. CD4 Treg, defined by high levels of CD25, low levels of CD127, and expression of the transcription factor FOXP3, comprise 1–5% of circulating T cells in humans . FOXP3, which regulates their development, is required for suppressive function and mice and human lacking functional FOXP3 develop multiorgan autoimmunity which in humans takes the form of the IPEX syndrome . It is thus logical to look for defective Treg function in autoimmune hepatitis, an archetypal autoimmune disease . Although previous studies reported reduced numbers and defective Treg function in AIH , Peiseler et al. now report normal frequencies and function of Treg in patients with type 1 AIH; indeed they found higher Treg frequencies in blood and liver tissue during active disease compared with remission. How can these different reports be reconciled?

Focus - Corrected Proof

Scott L. Friedman — 2012-04-23

Ilya Metchnikoff is widely hailed as the father of modern immunology based on his prescient characterization in the late 19th Century of the macrophage’s roles in phagocytic clearance of infections, tissue development and wound repair . In the ensuing ∼120years, his paradigm of macrophage function has remained largely intact, albeit with a greater appreciation for their functional complexity. In addition to those classical functions identified by Metchnikoff, macrophages can also regulate hematopoiesis, reproduction, vasoregulation, apoptosis, cancer metastasis and lipid metabolism . Moreover, there is a growing understanding of macrophage specialization, with their classification into two major subtypes, M1 and M2, which are distinguished primarily by the type of inflammation they elicit. M1 macrophages drive Th1 lymphocyte responses characterized by secretion of interleukin-1, interleukin-6 and tumor necrosis factor alpha, whereas M2 macrophages primarily drive allergic responses with killing and encapsulation of parasites typical of Th2 responses, with secretion of interleukin-4 and interleukin-13 . In reality, there is a continuum of macrophage phenotypes between these two ends of the spectrum, featuring evolving patterns of secretion of interleukins, chemokines, reactive oxygen species, and expression of membrane receptors . Indeed, flow cytometry can be used to characterize and isolate macrophage subtypes based on their cell surface receptor expression . Macrophage heterogeneity can also be tracked by their patterns of transcriptional regulation, with sequence-specific transcription factors and epigenetic changes driving macrophage identity and polarization .

Reply to “IBD is associated with an increase in carcinoma in PSC irrespective of the presence of dominant bile duct stenosis” - Uncorrected Proof

Daniel N. Gotthardt, Adolf Stiehl — 2012-04-23

In a retrospective cohort, Janse et al. analyzed the association of malignancies with the presence of inflammatory bowel disease (IBD) and dominant stenosis (DS) in patients with primary sclerosing cholangitis (PSC). We have analyzed and published on these associations in our prospective cohort, previously . The present study of Janse et al. essentially confirms our data in a retrospective evaluation.

Liver transplantation for acute liver failure in Europe: Outcomes over 20years from the ELTR database - Uncorrected Proof

2012-04-19

Background & Aims: Liver transplantation for acute liver failure (ALF) still has a high early mortality. We evaluated changes during 20years, and identified risk factors for poor outcome.Methods: Donor, graft, and recipient variables from the European Liver Transplant Registry database (January 1988–June 2009), were analysed. Aetiologies and time periods were compared. Three and 12-month survival models were generated from separate training data sets, which were validated. A sub-analysis was performed for recipient older than 50years.Results: Four thousand nine hundred and three patients were evaluated. One, 5- and 10-year patient, and graft survival rates were 74%, 68%, 63%, and 63%, 57%, 50%, respectively. Survival was better in 2004–2009 compared to previous quinquennia (p<0.001), despite donors >60years increased from 1.8% to 21%. A higher incidence of suicide or non-adherence occurred in paracetamol-related ALF (p<0.001). Death or graft loss were independently associated with male recipients (adjusted OR 1.25), recipient >50years (1.26), incompatible ABO matching (1.93), donors >60years (1.21), and reduced size graft (1.54). For both 3- and 12-month models, incompatible ABO matching, non-viral aetiology, reduced size graft, and non-UW preservation fluid were associated with increased mortality/graft loss, whereas male recipients and age >50years were associated only at 12months. Both models had reasonable discriminative ability with good calibration at 3-months. Recipients >50years, combined with donors >60years resulted in 57% mortality/graft loss within first year.Conclusions: Survival after liver transplantation has improved despite increases in donor/recipient age. Recipients >50years paired with donors >60years had a very high mortality/graft loss within the first year.

Liver transplantation for unresectable hepatocellular carcinoma in normal livers - Uncorrected Proof

2012-04-19

Background & Aims: The role of liver transplantation in the treatment of hepatocellular carcinoma in livers without fibrosis/cirrhosis (NC-HCC) is unclear. We aimed to determine selection criteria for liver transplantation in patients with NC-HCC.Methods: Using the European Liver Transplant Registry, we identified 105 patients who underwent liver transplantation for unresectable NC-HCC. Detailed information about patient, tumor characteristics, and survival was obtained from the transplant centers. Variables associated with survival were identified using univariate and multivariate statistical analyses.Results: Liver transplantation was primary treatment in 62 patients and rescue therapy for intrahepatic recurrences after liver resection in 43. Median number of tumors was 3 (range 1–7) and median tumor size 8cm (range 0.5–30). One- and 5-year overall and tumor-free survival rates were 84% and 49% and 76% and 43%, respectively. Macrovascular invasion (HR 2.55, 95% CI 1.34 to 4.86), lymph node involvement (HR 2.60, 95% CI 1.28 to 5.28), and time interval between liver resection and transplantation <12months (HR 2.12, 95% CI 0.96 to 4.67) were independently associated with survival. Five-year survival in patients without macrovascular invasion or lymph node involvement was 59% (95% CI 47–70%). Tumor size was not associated with survival.Conclusions: This is the largest reported series of patients transplanted for NC-HCC. Selection of patients without macrovascular invasion or lymph node involvement, or patients ⩾12months after previous liver resection, can result in 5-year survival rates of 59%. In contrast to HCC in cirrhosis, tumor size is not a predictor of post-transplant survival in NC-HCC.

Alpha-fetoprotein acts as a novel signal molecule and mediates transcription of Fn14 in human hepatocellular carcinoma - Uncorrected Proof

2012-04-19

Background & Aims: The function of cytoplasmic AFP as a regulatory factor in the growth of tumor cells has been well defined. However, its precise mechanism of action and its clinical significance remain to be worked out.Methods: Specimens from HCC patients were analyzed by using immunohistochemistry, co-immunoprecipitation (CoIP), and chromatin immunoprecipitation (ChIP) assays to evaluate the role of AFP in RAR signaling-mediated carcinogenesis. Quantitative real-time reverse transcription PCR, Western blotting, confocal microscopy, CoIP, GST pull-down, siRNA, gene transfection, and ChIP assays were also used for analysis of cell lines.Results: RAR is able to interact with cytoplasmic AFP and binds to the element of the regulatory region of the Fn14 gene in neoplastic tissue of HCC patients. An assay of hepatocyte cell lines of differing AFP expression showed that cytoplasmic AFP is able to block ATRA-induced nuclear translocation of RAR and expression of the Fn14 gene. Knockdown of AFP in siRNA-transfected HepG2 and Bel7402 cells led to greater binding of RAR to its response element. The expression of the Fn14 gene was therefore up-regulated as reflected by increases in mRNA and protein levels. Conversely, transfection of HLE and L02 cells (AFP negative) with the afp gene resulted in apparent reduction of RAR binding to DNA and Fn14 protein.Conclusions: Demonstration of the involvement of cytoplasmic AFP in RAR-mediated expression of the Fn14 gene strongly indicates AFP plays a signal molecule-like role in the regulation of hepatocellular carcinoma growth.

Extended analysis of a genome-wide association study in primary sclerosing cholangitis detects multiple novel risk loci - Uncorrected Proof

2012-04-19

Background & Aims: A limited number of genetic risk factors have been reported in primary sclerosing cholangitis (PSC). To discover further genetic susceptibility factors for PSC, we followed up on a second tier of single nucleotide polymorphisms (SNPs) from a genome-wide association study (GWAS).Methods: We analyzed 45 SNPs in 1221 PSC cases and 3508 controls. The association results from the replication analysis and the original GWAS (715 PSC cases and 2962 controls) were combined in a meta-analysis comprising 1936 PSC cases and 6470 controls. We performed an analysis of bile microbial community composition in 39 PSC patients by 16S rRNA sequencing.Results: Seventeen SNPs representing 12 distinct genetic loci achieved nominal significance (preplication <0.05) in the replication. The most robust novel association was detected at chromosome 1p36 (rs3748816; pcombined=2.1×10−8) where the MMEL1 and TNFRSF14 genes represent potential disease genes. Eight additional novel loci showed suggestive evidence of association (prepl <0.05). FUT2 at chromosome 19q13 (rs602662; pcomb=1.9×10−6, rs281377; pcomb=2.1×10−6 and rs601338; pcomb=2.7× 10−6) is notable due to its implication in altered susceptibility to infectious agents. We found that FUT2 secretor status and genotype defined by rs601338 significantly influence biliary microbial community composition in PSC patients.Conclusions: We identify multiple new PSC risk loci by extended analysis of a PSC GWAS. FUT2 genotype needs to be taken into account when assessing the influence of microbiota on biliary pathology in PSC.

Increased activity of serum mitochondrial isoenzyme of creatine kinase in hepatocellular carcinoma patients predominantly with recurrence - Corrected Proof

2012-04-18

Background & Aims: Mitochondrial isoenzyme of creatine kinase (MtCK) is reportedly highly expressed in hepatocellular carcinoma (HCC). Clinical relevance of serum MtCK activity in patients with HCC was assessed using a novel immuno-inhibition method.Methods: Among patients with cirrhosis caused by hepatitis B or C virus, 147 patients with HCC (12 with the first occurrence and 135 with recurrence) and 92 patients without HCC were enrolled.Results: Serum MtCK activity was higher in cirrhotic patients with HCC than in those without HCC or healthy subjects. Elevated serum MtCK activity in HCC patients decreased after radiofrequency ablation. In case of prediction of HCC, MtCK had a sensitivity of 62.6% and a specificity of 70.7% at a cut-off point of 8.0U/L, with an area under the receiver operating curve of 0.722 vs. 0.713 for alpha-fetoprotein (AFP) and 0.764 for des-gamma-carboxy prothrombin (DCP). Among the HCC patients, serum MtCK activity was elevated in 52.9% individuals with serum AFP level <20ng/ml and 63.2% individuals with serum DCP level <40mAu/ml. Even in patients with a single HCC ⩽2cm, the sensitivity of serum MtCK activity for the prediction of HCC was 64.4%, which was comparable to the overall sensitivity. This increased activity was due to an increase in ubiquitous MtCK, not sarcomeric MtCK, and the enhanced mRNA expression of ubiquitous MtCK was observed in cell lines originating from HCCs in contrast to healthy liver tissues.Conclusions: Serum MtCK activity merits consideration as a novel marker for HCC to be further tested as for its diagnostic and prognostic power.

Visceral adiposity index is not a predictor of liver histology in patients with non-alcoholic fatty liver disease - Corrected Proof

Roslyn Vongsuvanh, Jacob George, Duncan McLeod, David van der Poorten — 2012-04-18

Background & Aims: Visceral adiposity is associated with hepatic steatosis, inflammation, and fibrosis in non-alcoholic fatty liver disease (NAFLD). The visceral adiposity index (VAI), a novel marker of visceral fat distribution and dysfunction, has been correlated with histology in hepatitis C. We assessed the ability of VAI to predict disease severity in NAFLD and hence its role as a non-invasive marker of liver damage.Methods: We examined 190 adults with biopsy-proven NAFLD and 129 controls. All had anthropometric and metabolic profiling. VAI was calculated using waist circumference (WC), body mass index, triglycerides, and HDL-cholesterol. Abdominal fat was quantified by magnetic resonance imaging (MRI) in 38 patients.Results: On multivariate analysis, NAFLD diagnosis and fasting glucose were independently associated with VAI (p <0.05). VAI increased across control, steatosis, and NASH groups (1.5, 2.3, and 3.2, respectively; p=0.000), however, this association was no stronger than the increase in WC across groups (r=0.452 vs. 0.540 respectively, p <0.001). VAI was not associated with steatosis, lobular inflammation or fibrosis, but WC was associated with fibrosis (p=0.01). VAI and WC correlated with an increasing number of metabolic syndrome components (r=0.623 vs. 0.614, p <0.001) and with metabolic syndrome diagnosis (r=0.559 vs. 0.509, p <0.001). VAI only modestly correlated with visceral fat on MRI (r=0.39, p <0.05) compared to WC (r=0.52, p <0.01).Conclusions: In NAFLD, VAI is not associated with steatosis, inflammation or fibrosis. VAI is no more powerful than WC in discriminating steatosis from steatohepatitis, reflecting limitations of the formula with what is known about the pathogenesis of NAFLD.

Excessive alcohol consumption after liver transplantation impacts on long-term survival, whatever the primary indication - Uncorrected Proof

2012-04-18

Background & Aims: Beyond 5years, poorer survival, related to alcohol relapse, is observed in patients with liver transplant for alcohol-related liver disease (ALD). However, alcohol consumption has been significantly understudied in non-ALD transplant recipients. We aimed at analyzing the impact of alcohol consumption on long-term survival irrespective of the indication for transplantation.Methods: This observational study included consecutive adult recipients of a primary liver graft between 1991 and 2007 in our hospital, who survived >6months. Patients without ALD as primary indication, but with a history of excessive alcohol consumption before transplantation, were classified as secondary indication ALD. We studied the impact on survival of excessive consumption of alcohol after transplantation and several other variables.Results: The 441 patients had mean follow-up of 81.7months. Among the 281 patients with excessive alcohol consumption before transplantation, 206 had ALD as primary indication. After transplantation, alcohol consumption was reported by 32.3% of the study population, 43.7% in primary indication ALD, and 24.3% in non-ALD patients. Survival was 82% at 5years and 49% at 10years for patients with excessive alcohol relapse, compared with 86% and 75%, respectively, for patients without persistent excessive alcohol relapse.By multivariable analysis, the independent risk factors of death were: excessive alcohol relapse, age >51years, post-transplantation diabetes mellitus, cyclosporine-based immunosuppression, and non-hepatic cancer.Conclusions: Excessive alcohol consumption has a negative impact on long-term survival after liver transplant, irrespective of the primary indication. Death is mainly due to recurrence of liver disease and non-hepatic cancer.

Urinary neutrophil gelatinase-associated lipocalin as biomarker in the differential diagnosis of impairment of kidney function in cirrhosis - Corrected Proof

2012-04-18

Background & Aims: Impairment of kidney function is common in cirrhosis but differential diagnosis remains a challenge. We aimed at assessing the usefulness of neutrophil gelatinase-associated lipocalin (NGAL), a biomarker of tubular damage, in the differential diagnosis of impairment of kidney function in cirrhosis.Methods: Two-hundred and forty-one patients with cirrhosis, 72 without ascites, 85 with ascites, and 84 with impaired kidney function, were studied. Urinary levels of NGAL were measured by ELISA.Results: Patients with impaired kidney function had higher urinary NGAL levels compared to patients with and without ascites. Patients with urinary tract infection (n=25) had higher uNGAL values than non-infected patients. Patients with acute tubular necrosis (ATN) had uNGAL levels markedly higher (417μg/g creatinine (239–2242) median and IQ range) compared to those of patients with pre-renal azotemia due to volume depletion 30 (20–59), chronic kidney disease (CKD) 82 (34–152), and hepatorenal syndrome (HRS) 76 (43–263) μg/g creatinine (p<0.001 for all). Among HRS patients, the highest values were found in HRS-associated with infections, followed by classical (non-associated with active infections) type-1 and type-2 HRS (391 (72–523), 147 (83–263), and 43 (31–74) μg/g creatinine, respectively; p<0.001). Differences in uNGAL levels between classical type 1 HRS and ATN on the one hand and classical type 1 HRS and CKD and pre-renal azotemia on the other were statistically significant (p<0.05).Conclusions: uNGAL levels may be useful in the differential diagnosis of impairment of kidney function in cirrhosis. Urinary tract infections should be ruled out because they may increase uNGAL excretion.

ARFI, FibroScan, ELF, and their combinations in the assessment of liver fibrosis: A prospective study - Uncorrected Proof

2012-04-18

Background & Aims: Our aim was to evaluate a serologic marker (ELF) and two ultrasound-based methods (FibroScan and ARFI), as well as their combinations, in the assessment of liver fibrosis.Methods: One-hundred and forty-six patients (87 liver transplant recipients, 59 non-transplant patients), who underwent liver biopsy, were prospectively included. We evaluated the diagnostic accuracy of FibroScan, ARFI, ELF and the combination of ELF with either ARFI or FibroScan. After analysis in separate transplant and non-transplant patients, the whole cohort was divided into a training set and a validation set.Results: ARFI imaging was successfully performed across the whole cohort, while FibroScan failed in 16 (11%) patients. The three methods showed similar AUROCs and best cut-off values in transplant and non-transplant patients. In the training set, differences between the AUROCs of ARFI, FibroScan and ELF to diagnose F⩾2 (0.879, 0.861, and 0.764, respectively) and cirrhosis (0.936, 0.918, and 0.841) were not statistically significant, although both ultrasound-based methods showed higher accuracy than ELF. The combination of ELF with ARFI or FibroScan increased the negative and positive predictive values of single tests for the diagnosis of F⩾2 and cirrhosis. Similar results were obtained when the methods were tested in the validation set.Conclusions: ARFI is as effective as either FibroScan or ELF in the non-invasive assessment of liver fibrosis, and its inclusion in an ultrasound device could facilitate its incorporation into routine clinical practice. The combination of ARFI or FibroScan with ELF may help better identify patients with or without significant fibrosis or cirrhosis.

Severe hyponatremia is a better predictor of mortality than MELDNa in patients with cirrhosis and refractory ascites - Corrected Proof

2012-04-18

Background & Aims: The MELDNa score was developed to improve the prognostic value of the MELD score in cirrhosis and was built for serum sodium concentrations numerically capped between 125 and 140mmol/L. This model is not validated in a well-defined population of patients with cirrhosis and refractory ascites in whom severe hyponatremia (⩽125mmol/L) is frequent. This study assessed the prognostic value of severe hyponatremia and the MELDNa score in these patients.Methods: A consecutive, single-centre, observational, prospective study was performed in patients with cirrhosis and refractory ascites defined according to the International Ascites Club criteria. The prevalence of low serum sodium was assessed in this population. Predictive factors of mortality were analyzed and compared.Results: One hundred seventy-four patients were included. Sixty-six (37.9%) had low serum sodium (<130mmol/L). Sixty-one (35.1%) had diuretic-intractable ascites due to severe hyponatremia (⩽125mmol/L). The median MELDNa score was 23 (10–33). The 1-year cumulative incidence of death was 55% (95% CI: 55–56%). The best predictive factors of mortality were the following: severe hyponatremia (⩽125mmol/L) as an underlying cause of refractory ascites, a higher Child–Pugh score, beta-blocker therapy, and a high frequency of large-volume paracentesis. The Child–Pugh score had a higher area under receiver operating curve to predict mortality than MELDNa.Conclusions: In patients with cirrhosis and refractory ascites, severe hyponatremia and Child–Pugh score are better predictors of mortality than MELDNa.

A survey of patterns of practice and perception of NAFLD in a large sample of practicing gastroenterologists in France - Uncorrected Proof

2012-04-18

Background & Aims: Most studies on non-alcoholic fatty-liver disease (NAFLD) originate from tertiary care centers with an academic interest. How this emerging entity is accepted and managed by a wider body of gastroenterologists is unknown, despite significant implications for the diagnosis of at-risk subjects and the utilization of healthcare resources.Methods: We conducted a survey among 352 French, board-certified gastroenterologists from a large variety of practices to understand the clinical burden, perceived severity, and management patterns of NAFLD.Results: Half of participants saw >30 new cases (equal to HCV) of NAFLD and 40% >5 new cases of NASH-cirrhosis yearly. Only 20% of patients were referred by endocrinologists; conversely, gastroenterologists overwhelmingly referred NAFLD patients for assessment of metabolic co-morbidities. In patients with metabolic risk factors, a majority of physicians considered the diagnosis of NAFLD, even if other liver diseases co-existed. The diagnosis heavily relies on aminotransferases, hence patients with normal ALT are usually not diagnosed. Liver biopsy is performed for fibrosis staging but not for the diagnosis/grading of steatohepatitis, and mainly decided based on non-invasive fibrosis procedures. Pharmacological treatment is used despite a lack of clear evidence of efficacy. Physicians monitor patients themselves, usually twice a year.Conclusions: NAFLD is recognized and accepted as a disease in itself with potentially severe outcomes. Most at-risk patients are currently missed because of non-referral by endocrinologists and no exploration of those with normal aminotransferases. The medical need for the diagnosis and treatment of NAFLD is real in the community of gastroenterologists at large.

Immediate vs. delayed treatment in patients with acute hepatitis C based on IL28B polymorphism: A model-based analysis - Uncorrected Proof

2012-04-18

Background & Aims: Timing of treatment initiation in acute hepatitis C (AHC) patients is unclear. Spontaneous viral clearance argues for a “watch-and-wait” strategy. However, early initiation of treatment could increase the sustained virological response (SVR) rate. We compared three different HCV treatment initiation strategies in patients with AHC according to presence of clinical symptoms and IL28B polymorphism: (1) within 2months after transmission (immediate initiation), (2) at 3months (early initiation), and (3) at 4/5months (delayed initiation).Methods: We calculated spontaneous HCV clearance probability based on the symptomatic (sAHC) and asymptomatic (aAHC) nature of disease and C/C or non-C/C genotype. We used different SVR probabilities according to delay between transmission and treatment. We estimated the probability of developing chronic hepatitis C (CHC).Results: The probability of developing CHC was lower for immediate treatment initiation (7.1% in C/C and 7.3% in non-C/C patients with sAHC; 6.6% in C/C and 7.1% in non-C/C patients with aAHC) than for delayed initiation (13.5% in C/C and 18.0% in non-C/C patients with sAHC; 14.6% in C/C and 18.5% in non-C/C patients with aAHC) regardless of the presence of symptoms or IL28B genotype.Conclusions: In patients such as health care workers, in whom HCV is detected ⩽2months following transmission, treatment should be immediately initiated regardless of clinical symptoms and IL28B polymorphism. In those in whom HCV is detected>2months after transmission, treatment 4/5months after may be preferable because of a higher rate of spontaneous HCV clearance after 2months and poor HCV treatment efficacy’s differential between months 3 and 4/5.

National patterns and predictors of liver biopsy use for management of hepatitis C - Uncorrected Proof

2012-04-18

Background & Aims: Liver biopsy remains the standard, recommended method for assessing liver damage associated with chronic hepatitis C (HCV) infection. However, there is considerable debate about how liver biopsy should best be used, especially with the advent of more efficacious antiviral therapies. To identify the factors that influence the use of liver biopsy for HCV patients, we describe variations in liver biopsy use at the delivery system and patient level in a national VA sample.Methods: We analyzed VA HCV registry data for 171,893 VA patients with confirmed chronic HCV. Delivery system characteristics included geographic region and specialist time. Patient characteristics included antiviral treatment indicators, contraindications, volume of healthcare visits, and demographic variables. Logistic regression was used to explore correlates of biopsy use.Results: Liver biopsy use in the VA system increased from 1997 to 2003 but began declining in 2004. Rates of liver biopsy from 2004 to 2006 varied by VA region, ranging from 5% to 18%. Treatment contraindications and laboratory tests were significantly associated with more biopsies. Demographic variables (higher age, lower BMI, race/ethnicity, and less% service connected disability) were associated with fewer biopsies. Regional variability remained significant independent of volume of care and specialist time.Conclusions: Liver biopsy rates in the VA system have variability that seems unrelated to clinical need. New antiviral therapies and non-invasive assessment techniques may create additional uncertainty for the role of liver biopsy, perhaps explaining its decline in recent years. The availability of more effective antiviral therapies may also affect biopsy rates in the future.

Modest alcohol consumption is associated with decreased prevalence of steatohepatitis in patients with non-alcoholic fatty liver disease (NAFLD) - Corrected Proof

2012-04-18

Background & Aims: Non-alcoholic fatty liver disease (NAFLD) is a cardiovascular risk factor. Although modest alcohol consumption may reduce the risk for cardiovascular mortality, whether patients with NAFLD should be allowed modest alcohol consumption remains an important unaddressed issue. We aimed to evaluate the association between modest alcohol drinking and non-alcoholic steatohepatitis (NASH), among subjects with NAFLD.Methods: In a cross-sectional analysis of adult participants in the NIH NASH Clinical Research Network, only modest or non-drinkers were included: participants identified as (1) drinking >20g/day, (2) binge drinkers, or (3) non-drinkers with previous alcohol consumption were excluded. The odds of having a histological diagnosis of NASH and other histological features of NAFLD were analyzed using multiple ordinal logistic regression.Results: The analysis included 251 lifetime non-drinkers and 331 modest drinkers. Modest drinkers compared to non-drinkers had lower odds of having a diagnosis of NASH (summary odds ratio 0.56, 95% CI 0.39–0.84, p=0.002). The odds of NASH decreased as the frequency of alcohol consumption increased within the range of modest consumption. Modest drinkers also had significantly lower odds for fibrosis (OR 0.56 95% CI 0.41–0.77) and ballooning hepatocellular injury (OR 0.66 95% CI 0.48–0.92) than lifetime non-drinkers.Conclusions: In a large, well-characterized population with biopsy-proven NAFLD, modest alcohol consumption was associated with lesser degree of severity as determined by lower odds of the key features that comprise a diagnosis of steatohepatitis, as well as fibrosis. These findings demonstrate the need for prospective studies and a coordinated consensus on alcohol consumption recommendations in NAFLD.

M6P/IGF2R modulates the invasiveness of liver cells via its capacity to bind mannose 6-phosphate residues - Uncorrected Proof

2012-04-18

Background & Aims: The mannose 6-phosphate/insulin-like growth factor II receptor (M6P/IGF2R), a multifunctional protein, plays a central role in intracellular targeting of lysosomal enzymes and control of insulin-like growth factor II (IGF-II) bioactivity. Importantly, the gene encoding this receptor is frequently inactivated in a wide range of malignant tumors including hepatocellular carcinomas. Thus, M6P/IGF2R is considered a putative liver tumor suppressor. The aim of this study was to establish the impact of the receptor on the invasive properties of liver cells.Methods: Reconstitution experiments were performed by expression of wild type and mutant M6P/IGF2R in receptor-deficient FRL14 fetal rat liver cells. RNA interference was used to induce M6P/IGF2R downregulation in receptor-positive MIM-1–4 mouse hepatocytes.Results: We show that the M6P/IGF2R status exerts a strong impact on the invasiveness of tumorigenic rodent liver cells. M6P/IGF2R-deficient fetal rat liver cells hypersecrete lysosomal cathepsins and penetrate extracellular matrix barriers in a cathepsin-dependent manner. Forced expression of M6P/IGF2R restores intracellular transport of cathepsins to lysosomes and concomitantly reduces the tumorigenicity and invasive potential of these cells. Conversely, M6P/IGF2R knock-down in receptor-positive mouse hepatocytes causes increased cathepsin secretion as well as enhanced cell motility and invasiveness. We also demonstrate that functional M6P-binding sites are important for the anti-invasive properties of M6P/IGF2R, whereas the capacity to bind IGF-II is dispensable for the anti-invasive activity of the receptor in liver cells.Conclusions: M6P/IGF2R restricts liver cell invasion by preventing the pericellular action of M6P-modified proteins.

An in situ molecular signature to predict early recurrence in hepatitis B virus-related hepatocellular carcinoma - Uncorrected Proof

2012-04-18

Background & Aims: To develop an in situ molecular signature to predict postsurgical recurrence in hepatocellular carcinoma (HCC) patients.Methods: Immunohistochemistry was performed using tissue microarrays containing both tumoral and peri-tumoral regions of the advancing tumor edge from 336 HCC patients (289 were positive for hepatitis B virus) who underwent curative resection. Forty-nine variables were analyzed in the training set (n=151) using support vector machine and stepwise algorithms to develop a classifier to predict recurrence within 1year which was mainly caused by invasion or metastasis from the primary tumors. The classifier was further validated in an independent cohort of 185 patients (71 internal and 114 external).Results: The final signature was composed of eight IHC features: CD80T, B7-DCT, HLA-DRP, FasLP, Bcl-2T, Ki-67T, cyclin D1T, and CK19T. In the independent test set, this classifier reliably predicted recurrence within 1year (sensitivity, 69.1%; specificity, 65.0%) with an odds ratio of 4.149 (95% CI, 2.189–7.864). Based on a multivariate logistic model, the in situ molecular signature provided significant predictive power independent of tumor number, tumor size, vascular invasion and BCLC classification (p=0.001). The highest potential clinical impact of the classifier was observed in early-stage (BCLC classification 0–A) patients (p<0.0001), and the classifier was also predictive of the time-to-recurrence and overall survival (both p<0.0001).Conclusions: This in situ molecular classifier could provide a novel approach to identify patients who are at greatest risk for postsurgical recurrence of HCC and may benefit from intensive clinical follow-up or chemopreventive strategies.

Methyl donor deficiency impairs fatty acid oxidation through PGC-1α hypomethylation and decreased ER-α, ERR-α and HNF-4α in rat liver - Accepted Manuscript

2012-04-18

Abstract: Background: Folate and cobalamin are methyl donors needed for synthesizing methionine, which is the precursor of S-adenosylmethionine, the substrate of methylation in epigenetic and epigenomic pathways. Methyl donor deficiency produces liver steatosis and predisposes to metabolic syndrome. Whether impaired fatty acid oxidation contributes to this steatosis remains unknown.Methods: We evaluated the consequences of methyl donor deficient diet in liver of pups from dams subjected to deficiency during gestation and lactation.Results: The deprived rats had microvesicular steatosis, with increased triglycerides, decreased methionine synthase activity, S-adenosylmethionine and S-adenosylmethionine/S-adenosylhomocysteine ratio. We observed no change in apoptosis markers, oxidant and reticulum stresses, and carnityl-palmitoyl transferase1 activity and a decreased expression of SREBP-1c. Impaired beta-oxidation of fatty acids and carnitine deficit were the predominant changes, with decreased free and total carnitines, increased C14:1/C16 acylcarnitine ratio, decrease of oxidation rate of palmitoyl-CoA and palmitoyl-L-carnitine and decrease of expression of novel organic cation transporter 1, acylCoA-dehydrogenase and trifunctional enzyme subunit alpha and decreased activity of complexes I and II. These changes were related to lower protein expression of ER-α, ERR-α and HNF-4α and hypomethylation of PGC-1α co-activator that reduced its binding with PPAR-α, ERR-α and HNF-4α.Conclusion: The liver steatosis resulted predominantly from hypomethylation of PGC1-α, decreased binding with its partners and subsequent impaired mitochondrial fatty acid oxidation. This link between methyl donor deficiency and epigenomic deregulations of energy metabolism opens new insights on pathogenesis of fatty liver disease, in particular in relation with the foetal programming hypothesis. (250 words)

Interferon responses and spontaneous HCV clearance: Is it all a matter of fat? - Corrected Proof

Jordan J. Feld — 2012-04-18

Shortly after the discovery of the hepatitis C virus (HCV), it was recognized that the virus interacts intimately with the lipid machinery of the cell. Lipids are involved in almost all stages of the HCV lifecycle beginning with viral entry and including RNA replication, virion assembly and secretion of mature infectious viral particles . The HCV core protein associates directly with cellular lipid droplets leading to recruitment of the non-structural (NS) proteins NS5A and NS3 to form the replicase complex, which serves as a scaffold for the RNA-dependent-RNA polymerase (NS5B) to begin replication of the viral genome . Viral assembly then takes place and seems to parallel the processing of endogenous very low density lipoproteins (VLDL) with transfer of apolipoprotein B (apoB) and then apoE to form infectious low-density viral particles termed lipoviral particles (LVP) . Impaired lipidation of viral particles results in production of non-infectious high-density virions, whereas increased abundance of LVP is associated with increased HCV infectivity . The presence of increased apoE on the surface of LVP is associated with increased infectivity, possibly by facilitating interaction with lipoprotein receptors on hepatocytes . ApoE may be important for more than infectivity. ApoE expression influences immune responses targeting lipid antigens and therefore its presence on HCV viral particles may be important for virus–host interactions .

Human pluripotent stem cell derived hepatocytes support complete replication of hepatitis C virus - Uncorrected Proof

2012-04-18

Background & Aims: Worldwide, about 180million people are chronically infected with the hepatitis C virus (HCV). Current in vitro culture systems for HCV depend chiefly on human hepatoma cell lines. Although primary human hepatocytes support HCV infection in vitro, and immunodeficient mice repopulated with human hepatocytes support HCV infection in vivo, these models are limited because of shortage of human livers to isolate hepatocytes. Therefore, there is significant interest in the establishment of a HCV culture system in human stem cell-derived hepatocyte-like cells.Methods: Human embryonic stem cell (hESC)-derived hepatocytes were infected with HCV in the presence or absence of direct acting antivirals. After inoculation, replication of HCV was analyzed extensively.Results: We demonstrate that human embryonic stem cell (hESC)-derived hepatocytes can be infected with the HCV JFH1 genotype 2a, resulting in the production of viral RNA in the stem cell progeny. Viral replication is inhibited by a non-nucleoside HCV polymerase-inhibitor (HCV-796), a cyclophilin binding molecule (Debio 025-Alisporivir) and the protease inhibitor VX-950 (Telaprevir). Stem cell-derived hepatocytes produced, for more than 10days, HCV core protein as well as virions that were capable of re-infecting hepatoma cells.Conclusions: Hepatocytes derived from hESC support the complete HCV replication cycle (including the production of infectious virus), and viral replication in these cells is efficiently inhibited by selective inhibitors of HCV replication.

The myth of statin hepatotoxicity revisited - Accepted Manuscript

Ted Bader — 2012-04-16

Which is the real efficacy of pegylated interferon alpha 2a or 2b plus ribavirin in HCV infected patients with advanced fibrosis ? - Accepted Manuscript

Adriano M. Pellicelli, Mario Romano, Paolo Guarascio, Pascal Vignally — 2012-04-16

Does ethnicity matter? - Accepted Manuscript

Cyriel Y. Ponsioen, Kirsten Boonstra — 2012-04-16

Reply to “Gaps in the achievement of effectiveness of HCV treatment in national VA practice” - Accepted Manuscript

Bennet Cecil — 2012-04-16

Statin hepatotoxicity and the dilemma of causality in rare hepatic adverse drug reactions - Accepted Manuscript

Johannes Schulze, Xaver Glass — 2012-04-16

Biliary atresia: does ethnicity matter? - Accepted Manuscript

2012-04-16

STAT proteins – Key regulators of anti-viral responses, inflammation, and tumorigenesis in the liver - Uncorrected Proof

Bin Gao, Hua Wang, Fouad Lafdil, Dechun Feng — 2012-04-13

Since its discovery in the early 1990s, the Janus kinase (JAK)-signal transducer and activator of transcription (STAT) signaling pathway has been found to play key roles in regulating many key cellular processes such as survival, proliferation, and differentiation. There are seven known mammalian STAT family members: STAT1, 2, 3, 4, 5a, 5b, and 6. In the liver, activation of these STAT proteins is critical for anti-viral defense against hepatitis viral infection and for controlling injury, repair, inflammation, and tumorigenesis. The identification of functions for these STAT proteins has increased our understanding of liver disease pathophysiology and treatments, while also suggesting new therapeutic modalities for managing liver disease.

MicroRNA silencing and the development of novel therapies for liver disease - Corrected Proof

Gyongyi Szabo, Peter Sarnow, Shashi Bala — 2012-04-13

Summary: In recent years microRNAs have emerged as crucial small non-coding RNA molecules with diverse roles in various diseases including diseases of the liver. In this review, we highlight the latest advances in the field of microRNA biology and their potential as emerging therapeutic targets in liver disease.

Primovist, Eovist: What to expect? - Uncorrected Proof

Bernard E. Van Beers, Catherine M. Pastor, Hero K. Hussain — 2012-04-13

Gadolinium ethoxybenzyl dimeglumine (Gd-EOB-DTPA, Primovist® in Europe and Eovist® in the USA) is a liver-specific magnetic resonance imaging contrast agent that has up to 50% hepatobiliary excretion in the normal liver. After intravenous injection, Gd-EOB-DTPA distributes into the vascular and extravascular spaces during the arterial, portal venous and late dynamic phases, and progressively into the hepatocytes and bile ducts during the hepatobiliary phase. The hepatocyte uptake of Gd-EOB-DTPA mainly occurs via the organic anion transporter polypeptides OATP1B1 and B3 located at the sinusoidal membrane and biliary excretion via the multidrug resistance-associated proteins MRP2 at the canalicular membrane. Because of these characteristics, Gd-EOB-DTPA behaves similarly to non-specific gadolinium chelates during the dynamic phases, and adds substantial information during the hepatobiliary phase, improving the detection and characterization of focal liver lesions and diffuse liver disease. This information is particularly relevant for the detection of metastases, and for the detection and characterization of nodular lesions in liver cirrhosis, including early hepatocellular carcinomas. Finally, GD-EOB-DTPA-enhanced magnetic resonance imaging may provide quantitative assessment regarding liver perfusion and hepatocyte function in diffuse liver diseases. The full potential of GD-EOB-DTPA-enhanced magnetic resonance imaging has to be established further. It is already clear that GD-EOB-DTPA-enhanced magnetic resonance imaging provides anatomic and functional information in the setting of focal and diffuse liver disease that is unattainable with magnetic resonance imaging enhanced with non-specific contrast agents.

Functional aspects on the pathophysiology of portal hypertension in cirrhosis - Uncorrected Proof

Juan-Carlos García-Pagán, Jorge Gracia-Sancho, Jaume Bosch — 2012-04-13

Portal hypertension is a severe and frequent complication of chronic liver disease. Its consequences, bleeding from gastro-esophageal varices and portal hypertensive gastropathy, ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, hepatopulmonary/portopulmonary syndromes, and hepatic encephalopathy, represent the first cause of death and liver transplantation in patients with cirrhosis. The primary factor in the development of portal hypertension is a marked increase in hepatic vascular resistance (IVR) to portal blood flow, which was classically attributed to distortion of the liver architecture inherent to cirrhosis. However, over the past 20years, a better understanding of the liver microcirculation has demonstrated that a dynamic component due to an increased hepatic vascular tone further contributes to augment IVR. Secondarily to the increased IVR, there is a progressive splanchnic vasodilatation that increments portal blood flow, which aggravates and perpetuates the portal hypertension syndrome ().

Hepatitis B virus-related decompensated liver disease: Benefits of antiviral therapy - Uncorrected Proof

Cheng-Yuan Peng, Rong-Nan Chien, Yun-Fan Liaw — 2012-04-13

Following development of liver cirrhosis in patients with chronic hepatitis B, liver disease may continue to progress and decompensation or hepatocellular carcinoma (HCC) may occur, especially in those with active viral replication. Decompensation may manifest with jaundice, ascites, variceal bleeding or hepatic encephalopathy. Earlier studies have shown that the prognosis of decompensated cirrhosis is usually poor with a 5-year survival rate at 14–35% under conventional standard of care. The approval of oral antiviral agents has greatly improved the prognosis, as demonstrated in several cohort studies and randomized clinical trials involving therapy with lamivudine, adefovir dipivoxil, entecavir, telbivudine, or tenofovir disoproxil fumarate. Oral antiviral agents are effective in restoring liver function and improving survival in patients with decompensated cirrhosis especially if therapy is initiated early enough. These agents are generally well tolerated without significant side effects. However, their preventive effect in HCC development has yet to be convincingly demonstrated. Given their known resistance profiles, entecavir, and tenofovir should be considered as the first-line therapy for patients with HBV-related decompensated cirrhosis.

A revolution in HCV treatment with direct-acting antivirals: From non-response to eradication - Corrected Proof

Tarik Asselah — 2012-03-28

COMMENTARY ON: Preliminary study of two antiviral agents for hepatitis C genotype 1. Lok AS, Gardiner DF, Lawitz E, Martorell C, Everson GT, Ghalib R, Reindollar R, Rustgi V, McPhee F, Wind-Rotolo M, Persson A, Zhu K, Dimitrova DI, Eley T, Guo T, Grasela DM, Pasquinelli C. N Engl J Med 2012 January 19;366(3):216–24. Copyrigth (2012). Abstract reprinted with permission from the Massachusetts Medical Society.

Follow-up and indications for liver biopsy in HBeAg-negative chronic hepatitis B virus infection with persistently normal ALT: A systematic review - Corrected Proof

George V. Papatheodoridis, Spilios Manolakopoulos, Yun-Fan Liaw, Anna Lok — 2012-03-26

Background & Aims: The adequacy of monitoring HBeAg-negative patients based on ALT activity is controversial and current guidelines favor liver biopsy in HBeAg-negative cases with normal ALT and HBV DNA>2000IU/ml. We systematically reviewed all the available histological data on HBeAg-negative patients with persistently normal ALT (PNALT) to determine the prevalence of significant liver disease and its associating factors.Methods: Literature search to identify studies with adult HBeAg-negative patients who had PNALT as defined by the authors, a minimum follow-up of 1 year and histological data. Traditional cut-off values of normal ALT were used in all studies. The definitions of PNALT were considered as acceptable or good if there were ⩾3 ALT determinations at unspecified intervals during 6–12months or predefined intervals during ⩾12-month periods, respectively.Results: Six studies including 335 patients met our inclusion criteria. Of these, four studies with 246 patients had good or acceptable definitions of PNALT. In the latter four studies, more than minimal (usually mild) necro-inflammatory activity was observed in 10% and more than mild fibrosis in 8% of all patients (moderate fibrosis: 7%, severe fibrosis: 1%, cirrhosis: 0%), and in 3% and 5% of patients with HBV DNA ⩽20,000IU/ml, respectively.Conclusions: Histologically significant liver disease is rare in HBeAg-negative patients with PNALT based on stringent criteria and serum HBV DNA ⩽20,000IU/ml. Such cases can be considered as true inactive HBV carriers, who require neither liver biopsy nor immediate therapy but continued follow-up.

Portal vein thrombosis, cirrhosis, and liver transplantation - Corrected Proof

Claire Francoz, Dominique Valla, François Durand — 2012-03-23

Summary: Portal vein thrombosis is not uncommon in candidates for transplantation. Partial thrombosis is more common than complete thrombosis. Despite careful screening at evaluation, a number of patients are still found with previously unrecognized thrombosis per-operatively. The objective is to recanalize the portal vein or, if recanalization is not achievable, to prevent the extension of the thrombus so that a splanchnic vein can be used as the inflow vessel to restore physiological blood flow to the allograft. Anticoagulation during waiting time and transjugular intrahepatic portosystemic shunt (TIPS) are two options to achieve these goals. TIPS may achieve recanalization in patients with complete portal vein thrombosis. However, a marked impairment in liver function, which is a characteristic feature of most candidates for transplantation, may be a contraindication for TIPS. Importantly, the MELD score is artificially increased by the administration of vitamin K antagonists due to prolonged INR. When patency of the portal vein and/or superior mesenteric vein is not achieved, only non-anatomical techniques (renoportal anastomosis or cavoportal hemitransposition) can be performed. These techniques, which do not fully reverse portal hypertension, are associated with higher morbidity and mortality risks. Multivisceral transplantation including the liver and small bowel needs to be evaluated. In the absence of prothrombotic states that may persist after transplantation, there is no evidence that pre-transplant portal vein thrombosis justifies long term anticoagulation post-transplantation, provided portal flow has been restored through conventional end-to-end portal anastomosis.

Migration of lymphocytes into hepatic sinusoids - Corrected Proof

Ian N. Crispe — 2012-03-23

. (A) Receptor–ligand pairs directing cells to the liver. Vascular Adhesion Protein-1 (VAP-1) is an adhesion molecule, prominent on hepatic endothelium, that promotes the liver localization of NK cells, CD8+ T cells and CD4+ T cells of the Th2 subset . VAP-1 binds to Sialic Acid-binding Immunoglobulin-like Lectin (Siglec) molecules; T cell and NK cell adhesion acts via Siglec-10, while granulocyte adhesion to VAP-1 is mediated by Siglec-9 , as well as the interaction of CD44 with hyaluronan . Integrin-mediated adhesion receptors also play an important role in the localization of lymphocytes to the liver. Vascular Cell Adhesion Molecule-1 (VCAM-1) binds to Very Late Antigen-4 (VLA-4; also known as α4β1-integrin) and this interaction is important in the hepatic localization of activated CD8+ T cells, and Th1-type CD4+ T cells . These adhesion molecules are involved in antigen-independent homing to the liver, but when T cells recognize an antigen, Intercellular Adhesion Molecule-1 (ICAM-1) assumes greater significance. This is the case both for naïve, and for already-activated CD8+ T cells . When the hepatic vasculature is inflamed, additional adhesion molecules are expressed. Of particular interest is Mucosal Addressin Cell Adhesion Molecule-1 (MAdCAM-1), which is upregulated by both IL-1β and TNF-α , and engages the α4β7 integrin that is prominently expressed on intestinal lymphocytes. This interaction might account for the hepatic trapping of activated gut-derived T cells in inflammatory bowel diseases .

Transcriptional regulators in hepatocarcinogenesis – Key integrators of malignant transformation - Corrected Proof

Mona Malz, Federico Pinna, Peter Schirmacher, Kai Breuhahn — 2012-03-22

Summary: Hepatocellular carcinoma (HCC) is one of the most frequent human malignancies with poor prognosis and increasing incidence in the Western world. Only for a minority of HCC patients, surgical treatment options offer potential cure and therapeutic success of pharmacological approaches is limited. Highly specific approaches (e.g., kinase inhibitors) did not significantly improve the situation so far, possibly due to functional compensation, genetic heterogeneity of HCC, and development of resistance under selective pressure. In contrast, transcriptional regulators (especially transcription factors and co-factors) may integrate and process input signals of different (oncogenic) pathways and therefore represent cellular bottlenecks that regulate tumor cell biology. In this review, we want to summarize the current knowledge about central transcriptional regulators in human hepatocarcinogenesis and their potential as therapeutic target structures. Genomic and transcriptomic data of primary human HCC revealed that many of these factors showed up in subgroups of HCCs with a more aggressive phenotype, suggesting that aberrant activity of transcriptional regulators collect input information to promote tumor initiation and progression. Therefore, expression and dysfunction of transcription factors and co-factors may gain relevance for diagnostics and therapy of HCC.

EASL Clinical Practice Guidelines: Management of chronic hepatitis B virus infection - Corrected Proof

European Association for the Study of the Liver — 2012-03-20

Our understanding of the natural history of hepatitis B virus (HBV) infection and the potential for therapy of the resultant disease is continuously improving. New data have become available since the previous EASL Clinical Practice Guidelines (CPGs) prepared in 2008 and published in early 2009 . The objective of this manuscript is to update the recommendations for the optimal management of chronic HBV infection. The CPGs do not fully address prevention including vaccination. In addition, despite the increasing knowledge, areas of uncertainty still exist and therefore clinicians, patients, and public health authorities must continue to make choices on the basis of the evolving evidence.

The optimal dose of omega-3 supplementation for non-alcoholic fatty liver disease - Uncorrected Proof

Yan Li, Dongfeng Chen — 2012-03-19

Non-alcoholic fatty liver disease (NAFLD) is a burgeoning health problem that affects one-third of adults and an increasing number of children in developed countries . It was previously reported that various therapeutic regimens can be adopted for NAFLD , including weight loss agents, bariatric surgery, insulin-sensitizing agents, lipid-lowering agents, antioxidants, and other novel compounds. However, there is no consensus on its treatment. Both lifestyle therapy and pharmacotherapy have limitations due to poor compliance and side effects. Therefore, new therapeutic approaches to managing NAFLD are urgently needed.