Increased expression of hepatocyte nuclear factor 4 alpha transcribed by promoter 2 indicates a poor prognosis in hepatocellular carcinoma

Strategic Replication of the Hepatic Zonation In Vitro Employing a Biomimetic Approach

The varied functions of the liver are dependent on the metabolic heterogeneity exhibited by the hepatocytes within the liver lobule spanning the porto-central axis. This complex phenomenon plays an important role in maintaining the physiological homeostasis of the liver. Standard in vitro culture models fail to mimic this spatial heterogeneity of hepatocytes, assuming a homogeneous population of cells, which leads to inaccurate translation of results. Here, we demonstrate the development of an in vitro model of hepatic zonation by mimicking the microarchitecture of the liver using a 3D printed mini bioreactor and decellularized liver matrix to provide the native microenvironmental cues. There was a differential expression of hypoxic and metabolic markers across the developed mini bioreactor, showing the establishment of gradients of oxygen, Wnt/β-catenin pathway, and other metabolic pathways. The model also showed the establishment of zone-dependent toxicity on treatment with acetaminophen. The developed model would thus be a promising avenue in the field of tissue engineering for understanding the liver physiology and pathophysiology and for drug screening to evaluate the potential of new pharmaceutical interventions.

HNF4α isoforms regulate the circadian balance between carbohydrate and lipid metabolism in the liver

Hepatocyte Nuclear Factor 4α (HNF4α), a master regulator of hepatocyte differentiation, is regulated by two promoters (P1 and P2) which drive the expression of different isoforms. P1-HNF4α is the major isoform in the adult liver while P2-HNF4α is thought to be expressed only in fetal liver and liver cancer. Here, we show that P2-HNF4α is indeed expressed in the normal adult liver at Zeitgeber time (ZT)9 and ZT21. Using exon swap mice that express only P2-HNF4α we show that this isoform orchestrates a distinct transcriptome and metabolome via unique chromatin and protein-protein interactions, including with different clock proteins at different times of the day leading to subtle differences in circadian gene regulation. Furthermore, deletion of the Clock gene alters the circadian oscillation of P2- (but not P1-)HNF4α RNA, revealing a complex feedback loop between the HNF4α isoforms and the hepatic clock. Finally, we demonstrate that while P1-HNF4α drives gluconeogenesis, P2-HNF4α drives ketogenesis and is required for elevated levels of ketone bodies in female mice. Taken together, we propose that the highly conserved two-promoter structure of the Hnf4a gene is an evolutionarily conserved mechanism to maintain the balance between gluconeogenesis and ketogenesis in the liver in a circadian fashion.

Identification of a TRP channel-related risk model for predicting prognosis and therapeutic effects of patients with hepatocellular carcinoma

PURPOSE

TRP channels have been implicated in cancer progression. Our study seeks to establish a prognostic model for hepatocellular carcinoma (HCC) by utilizing genes related to TRP channels.

METHODS

We used the TCGA and ICGC databases as training and validation cohorts, respectively. We calculated the risk scores using Lasso-Cox regression analysis based on the expression levels of prognostic genes and performed survival analysis to compare overall survival between high- and low-risk groups. Then we compared the clinicopathologic characteristics and conducted biological functional analysis. We also explored immune cell infiltration and compared the drug sensitivity.

RESULTS

Using bioinformatics algorithms, we identified 11 TRP-related genes and calculated the risk scores. Patients in the high-risk group demonstrated worse overall survival, as well as more advanced T stage and pathologic stage. The risk score showed a significant association with the cell cycle. The high-risk group had more ICI and RTK targets with elevated expression and showed better therapeutic effect to chemotherapy including 5-fluorouracil, camptothecin, docetaxel, doxorubicin, gemcitabine, and paclitaxel. Overall, an individualized nomogram was constructed by integrating the risk score and requisite clinicopathologic parameters to predict the overall survival of HCC patients.

CONCLUSIONS

We successfully established a highly accurate prognostic model for predicting overall survival and therapeutic effects using TRP channel-related genes.

Differential spatial distribution of HNF4α isoforms during dysplastic progression of intraductal papillary mucinous neoplasms of the pancreas

Hepatocyte Nuclear Factor 4-alpha (HNF4α) comprises a nuclear receptor superfamily of ligand-dependent transcription factors that yields twelve isoforms in humans, classified into promoters P1 or P2-associated groups with specific functions. Alterations in HNF4α isoforms have been associated with tumorigenesis. However, the distribution of its isoforms during progression from dysplasia to malignancy has not been studied, nor has it yet been studied in intraductal papillary mucinous neoplasms, where both malignant and pre-malignant forms are routinely clinically identified. We examined the expression patterns of pan-promoter, P1-specific, and P2-specific isoform groups in normal pancreatic components and IPMNs. Pan-promoter, P1 and P2 nuclear expression were weakly positive in normal pancreatic components. Nuclear expression for all isoform groups was increased in low-grade IPMN, high-grade IPMN, and well-differentiated invasive adenocarcinoma. Poorly differentiated invasive components in IPMNs showed loss of all forms of HNF4α. Pan-promoter, and P1-specific HNF4α expression showed shifts in subnuclear and sub-anatomical distribution in IPMN, whereas P2 expression was consistently nuclear. Tumor cells with high-grade dysplasia at the basal interface with the stroma showed reduced expression of P1, while P2 was equally expressed in both components. Additional functional studies are warranted to further explore the mechanisms underlying the spatial and differential distribution of HNF4α isoforms in IPMNs.

The HNF4A-CHPF pathway promotes proliferation and invasion through interactions with MAD1L1 in glioma

Chondroitin polymerizing factor (CHPF) is an important glycosyltransferases that participates in the biosynthesis of chondroitin sulfate (CS). Our previous study showed that silencing CHPF expression inhibited glioma cell proliferation in vitro, but the molecular mechanisms by which CHPF contributes to development of glioma have not been characterized. In this study, we found that CHPF was up-regulated in glioma tissues and was positively correlated with malignant clinical pathological characteristics of patients with glioma. Silencing CHPF expression inhibited proliferation, colony formation, migration, and cell cycle of glioma cells. Moreover, silencing CHPF suppressed glioma malignance in vivo. Immunoprecipitation, co-immunoprecipitation, GST pulldown, and liquid chromatography-mass spectrometry (LC-MS/MS) assays were used to verify the interaction between CHPF and Mitotic arrest deficient 1-like 1 (MAD1L1). In addition, Chromatin Immunoprecipitation (ChIP)-PCR analysis showed that HNF4A bound to the CHPF promoter region, which indicated that the transcription factor hepatocyte nuclear factor 4A (HNF4A) could regulate the expression of CHPF in glioma cells.

HNF4α in Hepatocyte Health and Disease

Hepatocyte nuclear factor 4 α (HNF4α) is a highly conserved member of the nuclear receptor superfamily expressed at high levels in the liver, kidney, pancreas, and gut. In the liver, HNF4α is exclusively expressed in hepatocytes, where it is indispensable for embryonic and postnatal liver development and for normal liver function in adults. It is considered a master regulator of hepatic differentiation because it regulates a significant number of genes involved in hepatocyte-specific functions. Loss of HNF4α expression and function is associated with the progression of chronic liver disease. Further, HNF4α is a target of chemical-induced liver injury. In this review, we discuss the role of HNF4α in liver pathophysiology and highlight its potential use as a therapeutic target for liver diseases.

Progressive loss of hepatocyte nuclear factor 4 alpha activity in chronic liver diseases in humans

BACKGROUND AND AIMS

Hepatocyte nuclear factor 4 alpha (HNF4α) is indispensable for hepatocyte differentiation and critical for maintaining liver health. Here, we demonstrate that loss of HNF4α activity is a crucial step in the pathogenesis of chronic liver diseases (CLDs) that lead to development of HCC.

APPROACH AND RESULTS

We developed an HNF4α target gene signature, which can accurately determine HNF4α activity, and performed an exhaustive in silico analysis using hierarchical and K-means clustering, survival, and rank-order analysis of 30 independent data sets containing over 3500 individual samples. The association of changes in HNF4α activity to CLD progression of various etiologies, including HCV- and HBV-induced liver cirrhosis (LC), NAFLD/NASH, and HCC, was determined. Results revealed a step-wise reduction in HNF4α activity with each progressive stage of pathogenesis. Cluster analysis of LC gene expression data sets using the HNF4α signature showed that loss of HNF4α activity was associated with progression of Child-Pugh class, faster decompensation, incidence of HCC, and lower survival with and without HCC. A moderate decrease in HNF4α activity was observed in NAFLD from normal liver, but a further significant decline was observed in patients from NAFLD to NASH. In HCC, loss of HNF4α activity was associated with advanced disease, increased inflammatory changes, portal vein thrombosis, and substantially lower survival.

CONCLUSIONS

In conclusion, these data indicate that loss of HNF4α function is a common event in the pathogenesis of CLDs leading to HCC and is important from both diagnostic and therapeutic standpoints.

HNF1A POU Domain Mutations Found in Japanese Liver Cancer Patients Cause Downregulation of HNF4A Promoter Activity with Possible Disruption in Transcription Networks

Hepatocyte nuclear factor 1A (HNF1A) is the master regulator of liver homeostasis and organogenesis and regulates many aspects of hepatocyte functions. It acts as a tumor suppressor in the liver, evidenced by the increased proliferation in HNF1A knockout (KO) hepatocytes. Hence, we postulated that any loss-of-function variation in the gene structure or composition (mutation) could trigger dysfunction, including disrupted transcriptional networks in liver cells. From the International Cancer Genome Consortium (ICGC) database of cancer genomes, we identified several HNF1A mutations located in the functional Pit-Oct-Unc (POU) domain. In our biochemical analysis, we found that the HNF1A POU-domain mutations Y122C, R229Q and V259F suppressed HNF4A promoter activity and disrupted the binding of HNF1A to its target HNF4A promoter without any effect on the nuclear localization. Our results suggest that the decreased transcriptional activity of HNF1A mutants is due to impaired DNA binding. Through structural simulation analysis, we found that a V259F mutation was likely to affect DNA interaction by inducing large conformational changes in the N-terminal region of HNF1A. The results suggest that POU-domain mutations of HNF1A downregulate HNF4A gene expression. Therefore, to mimic the HNF1A mutation phenotype in transcription networks, we performed siRNA-mediated knockdown (KD) of HNF4A. Through RNA-Seq data analysis for the HNF4A KD, we found 748 differentially expressed genes (DEGs), of which 311 genes were downregulated (e.g., HNF1A, ApoB and SOAT2) and 437 genes were upregulated. Kyoto Encyclopedia of Genes and Genomes (KEGG) mapping revealed that the DEGs were involved in several signaling pathways (e.g., lipid and cholesterol metabolic pathways). Protein–protein network analysis suggested that the downregulated genes were related to lipid and cholesterol metabolism pathways, which are implicated in hepatocellular carcinoma (HCC) development. Our study demonstrates that mutations of HNF1A in the POU domain result in the downregulation of HNF1A target genes, including HNF4A, and this may trigger HCC development through the disruption of HNF4A–HNF1A transcriptional networks.

HNF4A Regulates the Proliferation and Tumor Formation of Cervical Cancer Cells through the Wnt/β-Catenin Pathway

Hepatocyte nuclear factor 4 alpha (HNF4A) is a transcriptional factor which plays an important role in the development of the liver, kidney, and intestines. Nevertheless, its role in cervical cancer and the underlying mechanism remain unknown. In this study, both immunohistochemistry and western blotting revealed that the expression of HNF4A was downregulated in cervical cancer. Xenograft assays suggested that HN4A could inhibit tumorigenic potential of cervical cancer in vivo. Functional studies illustrated that HNF4A also inhibited the proliferation and viability of cervical cancer cells in vitro. In addition, FACS analysis implied that HNF4A could induce cell cycle arrest from the G0/G1 phase to S phase. Further studies suggested that HNF4A downregulated the activity of the Wnt/β-catenin pathway. Altogether, our data demonstrated that HNF4A inhibited tumor formation and proliferation of cervical cancer cells through suppressing the activity of the Wnt/β-catenin pathway.

Antisense RNAs Influence Promoter Usage of Their Counterpart Sense Genes in Cancer

Multiple noncoding natural antisense transcripts (ncNAT) are known to modulate key biological events such as cell growth or differentiation. However, the actual impact of ncNATs on cancer progression remains largely unknown. In this study, we identified a complete list of differentially expressed ncNATs in hepatocellular carcinoma. Among them, a previously undescribed ncNAT HNF4A-AS1L suppressed cancer cell growth by regulating its sense gene HNF4A, a well-known cancer driver, through a promoter-specific mechanism. HNF4A-AS1L selectively activated the HNF4A P1 promoter via HNF1A, which upregulated expression of tumor suppressor P1-driven isoforms, while having no effect on the oncogenic P2 promoter. RNA-seq data from 23 tissue and cancer types identified approximately 100 ncNATs whose expression correlated specifically with the activity of one promoter of their associated sense gene. Silencing of two of these ncNATs ENSG00000259357 and ENSG00000255031 (antisense to CERS2 and CHKA, respectively) altered the promoter usage of CERS2 and CHKA. Altogether, these results demonstrate that promoter-specific regulation is a mechanism used by ncNATs for context-specific control of alternative isoform expression of their counterpart sense genes. SIGNIFICANCE: This study characterizes a previously unexplored role of ncNATs in regulation of isoform expression of associated sense genes, highlighting a mechanism of alternative promoter usage in cancer.

Hepatocyte Nuclear Factor 4 alpha 2 Messenger RNA Reprograms Liver-Enriched Transcription Factors and Functional Proteins in End-Stage Cirrhotic Human Hepatocytes

The only definitive therapy for end-stage liver disease is whole-organ transplantation. The success of this intervention is severely limited by the complexity of the surgery, the cost of patient care, the need for long-term immunosuppression, and the shortage of donor organs. In rodents and humans, end-stage degeneration of hepatocyte function is associated with disruption of the liver-specific transcriptional network and a nearly complete loss of promoter P1-driven hepatocyte nuclear factor 4-alpha (P1-HNF4α) activity. Re-expression of HNF4α2, the predominant P1-HNF4α, reinstates the transcriptional network, normalizes the genes important for hepatocyte function, and reverses liver failure in rodents. In this study, we tested the effectiveness of supplementary expression of human HNF4α2 messenger RNA (mRNA) in primary human hepatocytes isolated from explanted livers of patients who underwent transplant for end-stage irreversibly decompensated liver failure (Child-Pugh B, C) resulting from alcohol-mediated cirrhosis and nonalcoholic steatohepatitis. Re-expression of HNF4α2 in decompensated cirrhotic human hepatocytes corrects the disrupted transcriptional network and normalizes the expression of genes important for hepatocyte function, improving liver-specific protein expression. End-stage liver disease in humans is associated with both loss of P1-HNF4α expression and failure of its localization to the nucleus. We found that while HNF4α2 re-expression increased the amount of P1-HNF4α protein in hepatocytes, it did not alter the ability of hepatocytes to localize P1-HNF4α to their nuclei. Conclusion: Re-expression of HNF4α2 mRNA in livers of patients with end-stage disease may be an effective therapy for terminal liver failure that would circumvent the need for organ transplantation. The efficacy of this strategy may be enhanced by discovering the cause for loss of nuclear P1-HNF4α localization in end-stage cirrhosis, a process not found in rodent studies.

Human cell transformation by combined lineage conversion and oncogene expression

Cancer is the most complex genetic disease known, with mutations implicated in more than 250 genes. However, it is still elusive which specific mutations found in human patients lead to tumorigenesis. Here we show that a combination of oncogenes that is characteristic of liver cancer (CTNNB1, TERT, MYC) induces senescence in human fibroblasts and primary hepatocytes. However, reprogramming fibroblasts to a liver progenitor fate, induced hepatocytes (iHeps), makes them sensitive to transformation by the same oncogenes. The transformed iHeps are highly proliferative, tumorigenic in nude mice, and bear gene expression signatures of liver cancer. These results show that tumorigenesis is triggered by a combination of three elements: the set of driver mutations, the cellular lineage, and the state of differentiation of the cells along the lineage. Our results provide direct support for the role of cell identity as a key determinant in transformation and establish a paradigm for studying the dynamic role of oncogenic drivers in human tumorigenesis.

Prognostic value of postoperative change in liver stiffness in patients with HBV-related hepatocellular carcinoma

Objective

To investigate the prognostic value of change in liver stiffness following surgery, in patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC).

Methods

Patients with HBV-related HCC were included. Preoperative (baseline) liver stiffness and postoperative dynamic change in liver stiffness was evaluated.

Results

Out of 158 patients in total, postoperative liver stiffness was increased in 98 patients and decreased in 60 patients compared with baseline values. Kaplan-Meier analysis revealed that patients with elevated liver stiffness had significantly worse overall survival outcomes than those with decreased liver stiffness. Similar trends were observed for diseases-free survival and recurrence outcomes. Multivariate analyses showed that Child–Turcotte–Pugh score (hazard ratio [HR] 1.209) and liver stiffness changes (HR 1.891) were independent factors associated with overall survival. Liver stiffness changes (HR 1.521) and α-fetoprotein level (HR 1.210) were found to be independent factors for disease-free survival in patients with HCC.

Conclusion

Increased postoperative liver stiffness may be an independent risk factor of HCC prognosis. Patients with increased liver stiffness following surgery should undergo additional examinations during follow-up.

Controversial roles of hepatocyte nuclear receptor 4 α on tumorigenesis

Hepatocyte nuclear receptor 4 α (HNF4α) is known to be a master transcription regulator of gene expression in multiple biological processes, particularly in liver development and liver function. To date, the function of HNF4α in human cancers has been widely investigated; however, the critical roles of HNF4α in tumorigenesis remain unclear. Numerous controversies exist, even in studies from different research groups but on the same type of cancer. In the present review, the critical roles of HNF4α in tumorigenesis will be summarized and discussed. Furthermore, HNF4α expression profile and alterations will be examined by pan-cancer analysis through bioinformatics, in order to provide a better understanding of the functional roles of this gene in human cancers.

Phosphorylation of PED/PEA-15 at Ser116 and phosphorylation of p27 at Thr187 indicates a poor prognosis in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) constitutes a deadly cancer with a high rate of recurrence and metastasis. Phosphoprotein enriched in diabetes/phosphoprotein enriched in astrocytes-15 (PED/PEA-15) is a protein involved in the metabolism of glucose that regulates numerous cellular processes, including cell division, apoptosis and migration in numerous types of cancer. However, PED/PEA-15 may act as a tumor-promotor or a tumor-suppressor depending on its phosphorylation status. In the present study, the association between the phosphorylation of PED/PEA-15 at Ser116 [PED/PEA-15(S116)], the phosphorylation of P27 at Thr187 [P-p27(T187)] and the clinicopathological features and prognosis of patients with HCC was assessed. The levels of PED/PEA-15(S116) and P-p27(T187) were determined using immunohistochemistry and western blotting analysis in resected liver tumor tissues and adjacent non-cancerous tissues obtained from 60 patients with HCC as well as normal liver tissues from 12 patients with benign lesions. The association between the expression levels of these two markers and the clinicopathological features of patients with HCC was explored. Using the Kaplan-Meier method, the prognostic value of PED/PEA-15(S116) and P-p27(T187) expression levels was determined. The results demonstrated that the levels of PED/PEA-15(S116) and P-p27(T187) proteins were remarkably higher in the HCC group compared with those in the adjacent and normal tissue groups (both P<0.05). In addition, a moderate positive correlation was observed between the levels of PED/PEA-15(S116) and P-p27(T187) (r=0.434; P<0.05). The levels of these two proteins were associated with the Edmondson grade, Tumor-Node-Metastasis (TNM) stage, vascular invasion and tumor multiplicity (all P<0.05). Furthermore, the Kaplan-Meier analysis results demonstrated that patients with HCC that presented with positive expression of PED/PEA-15(S116) and P-p27(T187) exhibited a dismal prognosis compared with that in patients with negative expression regarding the overall survival (OS), as well as disease-free survival (both P<0.05). Multivariate Cox analysis revealed that the TNM stage (P<0.05), vascular invasion (P<0.05), PED/PEA-15(S116) levels (P<0.001) and P-p27(T187) levels (P<0.05) were independent prognostic factors for OS in patients with HCC. In conclusion the results of the present study demonstrated that PED/PEA-15(S116) and P-p27(T187) levels were upregulated in HCC tissues compared with those in the adjacent and normal tissues; PED/PEA-15(S116) and P-p27(T187) expression may serve as an indicator of a poor prognosis in patients with HCC, suggesting that these proteins may be prospective therapeutic targets for HCC.

Impact of tenofovir antiviral treatment on survival of chronic hepatitis B related hepatocellular carcinoma after hepatectomy in Chinese individuals from Qingdao municipality

The impact of different antiviral regimen on prognosis of chronic hepatitis B (CHB) related hepatocellular carcinoma (HCC) remains to be explored.A total of 479 CHB-related HCC patients after curative liver resection were enrolled receiving tenofovir (TDF, TDF group) or lamivudine, telbivudine, and entecavir (non-TDF group). Both the overall survival and diseases-free survival were analyzed and compared.A total of 242 patients received TDF treatment and 237 patients received other antiviral regimen. Child-Pugh score, serum α-fetoprotein (AFP) level, total bilirubin level, status of hepatitis B e antigen (HBeAg), and cirrhosis were compared between groups. Kaplan-Meier analysis revealed that patients with TDF treatment had significantly longer overall survival than those of patients with other regimen (P = .015). Similarly, compared with patients with non-TDF treatment, disease-free survival time was longer (P = .042) in those with TDF treatment. Multivariate analysis showed that TDF treatment (P = .04), AFP level (P = .03) were significant independent factors associated with overall survival of CHB-related HCC patients. While TDF treatment (P = .04) and serum AFP level (P = .03) were independent factors associated with disease-free survival.Anti-virus treatment with TDF benefits for both overall survival and disease-free survival of CHB-related patients than other Nucleos(t)ide analogues.

Guide to the Assessment of Mature Liver Gene Expression in Stem Cell-Derived Hepatocytes

Differentiation of stem cells to hepatocyte-like cells (HLCs) holds great promise for basic research, drug and toxicological investigations, and clinical applications. There are currently no protocols for the production of HLCs from stem cells, such as embryonic stem cells or induced pluripotent stem cells, that produce fully mature hepatocytes with a wide range of mature hepatic functions. This report describes a standard method to assess the maturation of stem cell-derived HLCs with a moderately high-throughput format, by analysing liver gene expression by quantitative RT-qPCR. This method also provides a robust data set of the expression of 62 genes expressed in normal liver, generated from 17 fetal and 25 mature human livers, so that investigators can quickly and easily compare the expression of these genes in their stem cell-derived HLCs with the values obtained in authentic fetal and mature human liver. The simple methods described in this study will provide a quick and accurate assessment of the efficacy of a differentiation protocol and will help guide the optimization of differentiation conditions.

FOX transcription factor family in hepatocellular carcinoma

The pathogenesis of hepatocellular carcinoma (HCC) is a multistep process, involving the progressive accumulation of molecular alterations and transcriptomic alterations. The Forkhead-box (FOX) transcription factor family is characterized by its unique DNA binding domain (FKH or winged-helix domain). Human FOX family consists of about 17 subfamilies, at least 43 members. Some of them are liver-enriched transcription factors, suggesting that they may play a crucial role in the development or/and functions of the liver. Dysregulation of FOX transcription factors may contribute to the pathogenesis of HCC because they can activate or suppress the expression of various tumor-related molecules, and pinpoint different molecular and cellular events. Here we summarized, analyzed and discussed the status and the functions of the human FOX family of transcription factors in HCC, aiming to help the further development of them as potential therapeutic targets or/and diagnostic/prognostic markers for HCC.

Comparison of clinical features and outcomes between HBV-related and non-B non-C hepatocellular carcinoma

Objective

To evaluate the difference between hepatitis B virus related hepatocellular carcinoma (HBV-HCC) and non-HBV non-HCV hepatocellular carcinoma (NBNC-HCC) patients based on clinical features and prognosis.

Methods

A total of 175 patients with HCC were enrolled. Patients’ characteristics were extracted from medical records. Among them, 107 patients were positive for HBsAg and negative for HCV-Ab while 68 patients were negative for HBsAg and HCV-Ab.

Results

The patients in the NBNC-HCC group were significantly older than those in the HBV-HCC group (P = 0.045). Moreover, vascular invasion was found in 23.4% of HBV-HCC patients, which was significantly higher than that in the NBNC-HCC patients with 10.3% (P = 0.029). Kaplan-Meier analysis revealed that HBV-HCC patients had significantly worse outcomes in terms of overall survival (P = 0.036). Compared with the NBNC-HCC patients, the HBV-HCC patients had a significantly worse disease-free survival (P = 0.0018). The multivariate analysis results indicated that TNM stage (HR = 1.541, 95%CI 1.072–2.412, P = 0.002) and HBV infection (HR = 1.087, 95%CI 1.012–1.655, P = 0.042) were independent risk variables for overall survival. While vascular invasion (HR = 1.562, 95%CI 1.013–2.815, P = 0.042) and HBV infection (HR = 1.650, 95%CI 1.017–2.676, P = 0.037) were independent risk factors associated with disease-free survival.

Conclusion

Our data revealed that HBV-HCC is more common in young males with vascular invasion, while NBNC-HCC occurs mostly in elderly patients, and overall survival rate is significantly better than that of HBV-HCC. Our study therefore provides evidence that patients with HBV-HCC require closer follow-up due to their poor prognosis.

Increased expression of protease-activated receptors 2 indicates poor prognosis in HBV related hepatocellular carcinoma

OBJECTIVE

To investigate the potential role of protease-activated receptor 2 (PAR2) in the prognosis of hepatocellular carcinoma (HCC).

METHODS

A total of 202 HCC patients who underwent liver resections were included. Tissue microarray was established with specimens of both HCC and paired adjacent liver tissues. PAR2 expression was detected by immunohistochemistry (IHC) assays.. A semi-quantification method was used to define the expression level of PAR2. The correlations between PAR2 expression and clinical features of patients with HCC was explored. The association of different PAR2 expressions with both overall survival and disease-free survival was analyzed.

RESULTS

Results showed that the expression of PAR2 in HCC tissues was higher than that in paired para-cancerous liver tissues (4.12 ± 3.55 vs. 2.71 ± 2.56, P < 0.001). Higher expression of PAR2 was associated with poor differentiation (P < 0.001) and advanced tumor-node-metastasis stage (P = 0.015). Kaplan-Meier survival analysis indicated that HCC patients with high PAR2 expression had decreased overall survival (P = 0.033) and disease-free survival (P = 0.043) compared to patients with lower PAR2 expression. Multivariate analysis indicated that PAR2 expression (P = 0.032) was a significant independent prognostic factor for both overall survival and disease-free survival (P = 0.032; P = 0.032, respectively).

CONCLUSION

Our data revealed that PAR2 expression was increased in HCC. High PAR2 expression was correlated with both decreased overall survival and disease-free survival in patients with HCC. High PAR2 expression indicated a poor prognosis.

Genotypic Resistance Remains A Concern In Chronic Hepatitis B Patients With High Viral Load After Lamivudine And Adefovir Combination Therapy

Aims

Previous studies have shown that baseline high viral load is closely related to treatment response in chronic hepatitis B (CHB). This study was designed to evaluate the differences of treatment responses between de novo lamivudine (LAM) plus adefovir (ADV) combination therapy compared with entecavir monotherapy (ETV).

Methods

A total of 185 HBeAg-positive CHB patients with high viral load were enrolled and assigned to the LAM+ADV group (n=90) or ETV group (n=95). Clinical variables are extracted from medical records.

Results

No significant differences in baseline variables were found between the two groups before antiviral treatment. After 104 weeks of antiviral therapy, the mean HBV DNA viral load in the LAM+ADV group decreased from 8.01±0.65 log₁₀ copies/mL to 0.41±1.04 log₁₀ copies/mL, compared with 8.04±0.57 log₁₀ copies/mL to 0.57±1.28 log₁₀ copies/mL in the ETV group (P=0.35). The virological response rate of LAM+ADV group was 82.2% (74/90) at 104 weeks of treatment, and 80.0% (76/95) in the ETV group (P=0.70). For HBeAg serological responses, HBeAg loss occurred in 23.3% (21/90) and 17.9% (17/95) in the LAM+ADV group and the ETV group, respectively (P=0.36). HBeAg seroconversion was observed in 15.6% (14/90) and 15.8% (15/95) in the LAM+ADV group and ETV group, respectively (P=0.96). However, after 104 weeks of treatment, genotypic resistance was confirmed in 8 cases in the LAM+ADV group, a proportion of 8.8% (8/90), compared with an absence of genotypic resistance in the ETV group (P=0.003).

Conclusion

Both de novo combination therapy of LAM+ADV and ETV monotherapy could effectively inhibit HBV replication in patients with high viral load. However, the rate of genotypic resistance in LAM+ADV treatment remains a concern. For CHB patients with high viral load, ETV treatment may be superior.

Decreased expression levels of ELOVL6 indicate poor prognosis in hepatocellular carcinoma

The present study aimed to investigate the expression of elongation of very long-chain fatty acids family member 6 (ELOVL6) in hepatocellular carcinoma (HCC) tissues, and to determine its role in the development of HCC. A total of 377 HCC specimens were collected for tissue microarray and immunohistochemistry analyses. The ELOVL6 IHC score for HCC tissues was 0.97±0.71, which was significantly lower than that of the matched adjacent normal tissues (1.32±0.68; P<0.001). Patients with low levels of ELOVL6 expression were older (P=0.014) and possessed larger sized tumors (P=0.039) than patients with high expression levels. Additionally, Kaplan-Meier analysis revealed that patients with low ELOVL6 expression levels also had significantly poorer overall (P<0.001) and disease-free (P=0.029) survival times, and a greater probability of recurrence. The tumor size, tumor-node-metastasis (TNM) stage, vascular invasion and ELOVL6 expression were all shown to be prognostic variables for overall survival in patients with HCC. Multivariate analysis revealed that vascular invasion (P<0.001), TNM stage (P<0.001) and ELOVL6 expression (P=0.001) were independent prognostic variables for overall survival. In addition, vascular invasion (P=0.032) and ELOVL6 expression (P=0.041) were independent risk factors for disease-free survival, and vascular invasion (P=0.019) and ELOVL6 expression (P=0.045) were independent risk factors associated with HCC recurrence. The present study revealed that in patients with HCC, ELOVL6 expression level was reduced in HCC tissues, and that higher ELOVL6 expression levels correlated with longer survival times. This indicates that ELOVL6 may serves as an independent marker of poor patient outcome.

HNF4α-Deficient Fatty Liver Provides a Permissive Environment for Sex-Independent Hepatocellular Carcinoma

The incidence of hepatocellular carcinoma (HCC) is on the rise worldwide. Although the incidence of HCC in males is considerably higher than in females, the projected rates of HCC incidence are increasing for both sexes. A recently appreciated risk factor for HCC is the growing problem of nonalcoholic fatty liver disease, which is usually associated with obesity and the metabolic syndrome. In this study, we showed that under conditions of fatty liver, female mice were more likely to develop HCC than expected from previous models. Using an inducible knockout model of the tumor-suppressive isoform of hepatocyte nuclear factor 4 alpha ("P1-HNF4α") in the liver in combination with prolonged high fat (HF) diet, we found that HCC developed equally in male and female mice as early as 38 weeks of age. Similar sex-independent HCC occurred in the "STAM" model of mice, in which severe hyperglycemia and HF feeding results in rapid hepatic lipid deposition, fibrosis, and ultimately HCC. In both sexes, reduced P1-HNF4α activity, which also occurs under chronic HF diet feeding, increased hepatic lipid deposition and produced a greatly augmented circadian rhythm in IL6, a factor previously linked with higher HCC incidence in males. Loss of HNF4α combined with HF feeding induced epithelial-mesenchymal transition in an IL6-dependent manner. Collectively, these data provide a mechanism-based working hypothesis that could explain the rising incidence of aggressive HCC. SIGNIFICANCE: This study provides a mechanism for the growing incidence of hepatocellular carcinoma in both men and women, which is linked to nonalcoholic fatty liver disease.

Role of hepatocyte nuclear factor 4-alpha in gastrointestinal and liver diseases

Hepatocyte nuclear factor 4-alpha (HNF4α) is a highly conserved member of nuclear receptor superfamily of ligand-dependent transcription factors that is expressed in liver and gastrointestinal organs (pancreas, stomach, and intestine). In liver, HNF4α is best known for its role as a master regulator of liver-specific gene expression and essential for adult and fetal liver function. Dysregulation of HNF4α expression has been associated with many human diseases such as ulcerative colitis, colon cancer, maturity-onset diabetes of the young, liver cirrhosis, and hepatocellular carcinoma. However, the precise role of HNF4α in the etiology of these human pathogenesis is not well understood. Limited information is known about the role of HNF4α isoforms in liver and gastrointestinal disease progression. There is, therefore, a critical need to know how disruption of the expression of these isoforms may impact on disease progression and phenotypes. In this review, we will update our current understanding on the role of HNF4α in human liver and gastrointestinal diseases. We further provide additional information on possible use of HNF4α as a target for potential therapeutic approaches.

Impaired heart rate recovery as a predictor for poor health-related quality in patients with transient ischemic attack

We aimed to investigate heart rate recovery (HRR) in patients with transient ischemic attack (TIA) and the relationship between HRR and health-related quality of life (HRQOL).All available patients were enrolled during the enrollment period. A total of 120 patients with TIA and 120 healthy controls were included in this study. A treadmill stress test was performed to calculate the HRR. The HRR were calculated as follows: HRR 1, 2, 3, and 5 minutes = heart rate at peak during exercise - heart rate at 1, 2, 3, and 5 minutes at rest. All patients enrolled were asked to fill in the Short Form 36 Health Survey to calculate HRQOL.We found that the maximum heart rate of TIA patients was significantly higher than that of healthy controls (166 ± 11 vs. 162 ± 14 beats/min, P = .015). Similarly, maximum systolic blood pressure (SBP) and diastolic blood pressure (DBP) were higher in TIA group compared with healthy control group (SBP: 172 ± 15 vs. 165 ± 14 mm Hg, P < .001; DBP: 102 ± 12 vs. 93 ± 16 mm Hg, P < .001). The HRR were significantly lower in TIA group compared with control group (TIA vs. controls, HRR1: 17 ± 7 vs. 30 ± 8 beats/min, HRR2: 32 ± 11 vs. 49 ± 9 beats/min, HRR3: 43 ± 13 vs. 63 ± 12 beats/min, HRR5: 54 ± 16 vs. 73 ± 15 beats/min, all P < .001). Multivariate analysis showed that older age (P = .03) and high BMI (P = .04) were risk factors associated with abnormal HRR in patients with TIA. With regard to HRQOL, we found that role limitations due to physical problems, general health, vitality, and role limitations due to emotional problems were significantly lower in patients with abnormal HRR compared with patients with normal HRR. Multivariate analysis showed that older age (P = .04) and abnormal HRR (P = .03) were predictors for poor HRQOL in TIA patients.HRR was impaired in patients with TIA. In addition, TIA patients with abnormal HRR suffered from a significantly poorer HRQOL. Hence, given the prognostic value of HRR, patients with TIA should be monitored to prevent cardiovascular events and to improve HRQOL.

Risk factors associated with hepatic osteopathy in HBV related cirrhosis measured by liver stiffness: An Observational study

To investigate the differences in bone mineral density between patients with liver cirrhosis and healthy control, and to analyze the risk factors of hepatic osteoporosis in patients with HBV related liver cirrhosis.A total of 189 patients with liver cirrhosis and 207 health controls were enrolled. The bone mineral density of lumbar spine and femoral neck was examined by dual energy X-ray absorptiometry. -2.0 <T value <-1.0 defined as osteopenia, T value ≤-2.0 defined as osteoporosis.Bone mineral density in the cirrhotic group was significantly lower than that in the control group (lumbar: 1.02 ± 0.16 vs 1.08 ± 0.13, P < .001; femoral neck: 0.86 ± 0.14 vs 0.91 ± 0.14, P < .001). Both 2 groups showed a tendency that decrease bone density correlated with age and decrease body mass index (BMI). Multivariate correlation analysis showed that women (OR = 6.931, P = .002), age (OR = 1.096, P < .001), low BMI (OR = 0.874, P = .037), and high liver stiffness value (OR = 1.125, P = .046) were independent risk factors for osteopenia and low body weight (OR = 0.934, P = .006) and high liver stiffness value (OR = 1.246, P = .034) were independent risk factors for osteoporosis.Our study shows that bone mineral density in patients with liver cirrhosis decreased significantly, especially in the elderly and low BMI patient. For HBV-related cirrhosis with risk factors, a regular bone density screening should be given, and timely intervention should be taken into consideration.

Dynamic change of depression and anxiety after chemotherapy among patients with ovarian cancer

Psychological state of patients with ovarian cancer is worthy of attention. We aimed to investigate the levels of anxiety and depression in patients with ovarian cancer. We also investigated the dynamic changes in anxiety and depression levels after chemotherapy.A total of 228 females were included in this study. Among them, a total of 111 participants had ovarian cancer and 117 females who underwent a physical examination were selected as healthy controls. All patients enrolled were asked to fill in the Self-rating Depression Scale and the Self-rating Anxiety Scale. For patients with ovarian cancer, repeat questionnaires were measured after cycle 1 chemotherapy.The depression score of patients with ovarian cancer was 45.90 ± 10.19, significantly higher than in controls (36.08 ± 9.06, P < .001). Similar results were observed in respect of anxiety score. The score of ovarian cancer patients was 39.53 ± 12.92, significantly higher than of controls (32.15 ± 7.44, P < .001). Multivariate analyses were conducted, and the results showed that young age was the independent risk factor associated with depression among patients with ovarian cancer, while young age and singleness were the independent risk factors associated with anxiety. Repeat questionnaires were measured after chemotherapy. Interestingly, we found depression scores decreased from 45.90 ± 10.19 to 36.29 ± 8.98 after chemotherapy (P < .001), while anxiety score increased from 39.53 ± 12.92 to 42.75 ± 9.96 after chemotherapy (P = .009). Multivariate analysis suggested that only higher income and higher baseline depression score were the independent and most relevant risk factors associated with depression remission after chemotherapy. For patients with anxiety remission, only higher baseline anxiety score was the independent risk factor associated with anxiety remission.This study suggests that for patients with ovarian cancer, timely monitoring of the patient's psychological state, especially before and after chemotherapy treatment, is very important. Assessing the changes in the patient's psychological state, screening the population with risk factors, and prompt intervention by mobilizing social support may be effective in preventing depression and anxiety in such population.

Association between abdominal obesity and liver steatosis and fibrosis among patients with chronic hepatitis B measured by Fibroscan

The present cross-sectional study aimed to assess hepatic fibrosis in chronic hepatitis B (CHB) patients with abdominal obesity and to explore the associated indicators. A total of 615 CHB patients were enrolled and 287 of them had abdominal obesity. The liver stiffness value was measured using Fibroscan. The diagnosis of liver fibrosis was confirmed by a liver stiffness value of >7.4 kPa, and a value of >10.6 kPa was considered to indicate advanced liver fibrosis. The Fibroscan results suggested that the liver stiffness value in patients with abdominal obesity was significantly higher than that in patients without abdominal obesity (9.94±11.59 vs. 7.47±7.58 kPa; P=0.002). The proportions of patients with liver fibrosis and advanced liver fibrosis among patients with abdominal obesity were significantly higher than those among patients without abdominal obesity (P=0.011). Multivariate logistic regression analysis indicated that a high aspartate aminotransferase (AST) level [odds ratio (OR)=2.991; P<0.001], smoking (OR=2.002; P=0.019) and diabetes mellitus (OR=2.047; P=0.029) were independent indicators for liver fibrosis in CHB patients with abdominal obesity. Furthermore, a high AST level (OR=1.024; P<0.001), alcohol consumption (OR=1.994; P=0.032) and diabetes mellitus (OR=1.977; P=0.045) were independent indicators for advanced hepatic fibrosis. The indicators associated with liver steatosis included high body weight (OR=1.113; P<0.001) and high diastolic blood pressure (OR=1.079; P=0.002). In conclusion, the present study indicated that abdominal obesity significantly exacerbates liver fibrosis in CHB patients. For CHB patients with abdominal obesity and a risk of developing liver fibrosis, priority screening and timely intervention should be provided.

Dynamic Changes of the Aspartate Aminotransferase-to-Platelet Ratio and Transient Elastography in Predicting a Histologic Response in Patients With Chronic Hepatitis B After Entecavir Treatment

OBJECTIVES

To evaluate the dynamic changes of the aspartate aminotransferase (AST)-to-platelet ratio and transient elastography (FibroScan; Echosens, Paris, France) in predicting a histologic response in patients with chronic hepatitis B (CHB) after entecavir treatment.

METHODS

A total of 148 patients with CHB were enrolled. Patient information was collected. All patients received liver biopsy and FibroScan before and after 96 weeks of entecavir treatment.

RESULTS

Baseline liver biopsy results showed that there were 7 patients without liver fibrosis (fibrosis stage F0; 4.7%), 51 patients with mild liver fibrosis (F1; 34.5%), and 90 patients with advanced liver fibrosis (>F1; 60.9%). The liver stiffness value and AST-to-platelet ratio increased significantly as the METAVIR score of the patients increased from F0 to F4 (P < .001). After antiviral therapy for 96 weeks, the average liver stiffness value measured by FibroScan and the AST-to-platelet ratio showed a significant decrease. When we use a decreased liver stiffness value to predict a histologic response, the area under the receiver operating characteristic curve was 0.70 (95% confidence interval, 0.61-0.79; P < .001), and the sensitivity and specificity were 74.3% and 68.8%, respectively. The decrease of the AST-to-platelet ratio also could predict the histologic response of patients with CHB; the area under the receiver operating characteristic curve was 0.77 (95% confidence interval, 0.69-0.86; P < .001) with sensitivity of 76.2% and specificity of 70.2%. A multivariate analysis indicated that a high hepatitis B virus DNA viral load (odds ratio, 1.44; P = .04) and high METAVIR score (odds ratio, 1.38; P = .02) were independent risk factors for the histologic response.

CONCLUSIONS

Both the AST-to-platelet ratio and FibroScan value can effectively predict a histologic response in patients with CHB during entecavir treatment. Therefore, they can be used to monitor these patients during antiviral treatment to avoid multiple liver biopsies.

Comparison of pegylated interferon monotherapy and de novo pegylated interferon plus tenofovir combination therapy in patients with chronic hepatitis B

Background and aim: We aimed to evaluate the effectiveness of pegylated interferon (Peg-IFN) monotherapy (IFN group) and combination therapy with tenofovir (TDF) and Peg-IFN (IFN+TDF group) in chronic hepatitis B (CHB) patients. Patients and methods: Data of 143 CHB patients were analyzed in this study. All patients enrolled received liver biopsy. Virologic responses were defined as hepatitis B virus (HBV) DNA <100 IU/mL, biochemical responses were defined as normalization of alanine aminotransferse (ALT) levels, and HBeAg serological response was defined as HBeAg loss or HBeAg seroconversion to HBeAb. HBsAg serological response was defined as HBsAg loss or HBsAg seroconversion to HBsAb. Results: We observed that a total of 16.7% (11/66) and 33.8% (26/77) patients in IFN and IFN+TDF group achieved complete viral suppression after 48 weeks treatment (P=0.02). Although HBeAg levels in CHB patients in the IFN+TDF group decreased more rapidly during the 48-week treatment, we did not observe significant differences in HBeAg serological loss or seroconversion rates between the two groups at 24 and 48 weeks. HBsAg loss was observed in 13.0% (10/77) of CHB patients in the IFN+TDF group at 48 weeks, compared with only 3% (2/66) patients in the IFN group (P=0.032). No significant difference was observed in HBsAg seroconversion rate between the two groups during 48-week treatment. The biochemical response rate was also significantly higher in the IFN+TDF group than that in the IFN group at week 48 (P=0.015). Multivariate logistic analysis showed that IFN+TDF treatment (OR=4.41, P=0.003), severe baseline hepatic inflammation (OR=4.16, P<0.001), and lower baseline serum HBV DNA levels (OR=0.98, P=0.03) were strong predictors for the virological response. Younger age (OR=0.89, P=0.01), higher baseline ALT level (OR=1.01, P=0.038), and lower baseline HBeAg level (OR=0.99, P=0.008) were independent predictors for HBeAg sero-response after 48 weeks treatment. While only severe liver fibrosis (OR=1.69, P=0.028) and lower baseline HBsAg level (OR=0.22, P=0.005) were independent factors associated with HBsAg sero-response after 48 weeks treatment. Conclusion: Peg-IFN combined with TDF may increase the virological response rate, biochemical response rate, and HBsAg loss rate in patients with CHB infection. The combination treatment is more suitable for those patients who are likely to respond to the treatment.

Effectiveness of tenofovir or telbivudine in preventing HBV vertical transmission for pregnancy

To evaluate the efficacy and safety of telbivudine (LdT) and tenofovir (TDF) for preventing hepatitis B virus (HBV) vertical transmission for HBV-positive pregnant women.Pregnant women (n = 145) from January 2013 to June 2017 were enrolled when they met inclusion criteria, which included HBV DNA ≥1.0 × 10 copies/mL and increased alanine aminotransferase (ALT) levels. Groups A (n = 58) and B (n = 51) were treated with LdT and TDF, respectively. Group C (n = 36) received no antiviral treatment. All infants were vaccinated with hepatitis B immunoglobulin and HBV vaccine. Vertical transmission of HBV was indicated by the presence of hepatitis B surface antigen (HBsAg) in infants 6 months and 12 months after birth.There is no difference of clinical characteristics of patients among the 3 groups. Serum HBV DNA levels of the 3 groups were similar at baseline (Group A vs. Group B vs. Group C, 7.88 ± 0.65 vs. 7.91 ± 0.75 vs. 7.69 ± 0.53 P = .25). In addition, the after anti-HBV treatment in Groups A and B were significantly decreased. Also, the serum HBV DNA levels in both Groups A and B were lower than that of Group C (P < .01, both). The HBV infection rate in Group A treated with LdT was not different from Group B treated with TDF. The dynamic changes of serum ALT level were similar. ALT levels were similar among the 3 Groups (P = .171), while there is statistically significant difference between A and C, and between B and C before delivery (P < .01). For the infants, there were no significant differences among body weight, height, head circumference, or Apgar score. However, the HBsAg positivity rates of infants in Groups A, B, C at postpartum 24 weeks and 48 weeks was 0%, 0%, and 11.1%, respectively (P < .001).Administration of LdT or TDF to HBV-infected mothers are effective and safe to block mother-to-infant HBV transmission.

Health related quality of life in stroke patients and risk factors associated with patients for return to work

To clarify dynamic change of quality of life (QOL) in patients with stroke after treatment, and to explore the predictors associated with return to work (RTW) within 48 weeks.Patients diagnosed with stroke were enrolled. All patients enrolled were asked to fill in the Short Form 36 Health Survey. For patients with stroke, SF-36 questionnaires were measured repeatedly 4 weeks after treatment. We used phone call to find out if the patient was RTW. The investigation time was 48 weeks.Patients with stroke had lower scores in terms of physiological dimensions, such as physical functional, role limitations due to physical problems, and general health (P < .001). While patients with strokes scored significantly lower in all mental dimensions including vitality, social functioning, role limitations due to emotional problems, and mental health (P < .001). After 4-weeks treatment, we found that, except for bodily pain, scores in dimensions like physical functioning, role limitations due to physical problems, and general health had increased significantly (P < .001). Multivariate logistic regression analysis was conducted, and the result showed that older age (P = .04) and singleness (P = .03) were risk factors associated with QOL improvement in stroke patients after treatment. Outcomes of stroke patients within 48 weeks were explored. The results showed that 108 out of 136 patients RTW within 48 weeks. Average days it took for patients with cerebral infarction to return to work were 77 ± 79, significantly less than patients with cerebral hemorrhage (206 ± 159 days) and patients with subarachnoid hemorrhage (117 ± 113 days, P < .001). Multivariate analysis indicated that only QOL improvement (P = .04) and subtype of stroke (P = .01) were independent factors associated with RTW within 48 weeks.QOL of stroke patients was significantly reduced. After treatments, the physiological quality of stroke patients increased, but the psychological quality remained low. In addition, patients with cerebral hemorrhage and patients with no significant improvement in QOL are independent risk factors for RTW. Therefore, for this subgroup of the population, early diagnosis, close follow-up and monitor of the psychological state should be provided to avoid the occurrence of adverse events.

Risk factors associated with fatigue in chronic hepatitis B patients

AIM

To evaluate fatigue in chronic hepatitis B patients and its related independent factors, as well as the relationship between fatigue and health-related quality of life (HRQoL).

MATERIALS AND METHODS

The study enrolled 400 patients who met the selection criteria, and their sociodemographic information was collected. The 36-item Short-Form Health Survey (SF-36) and Multidimensional fatigue inventory 20 (MFI-20) were adopted to evaluate HRQoL and fatigue level.

RESULTS

Significant differences between the fatigue group and non-fatigue group were observed for the female proportion (p=0.021), height (p=0.003), and weight (p=0.010), with or without regular exercise (p=0.001). We further determined the dimensions of fatigue that were affected by these factors and found that male patients showed significantly lower results than female patients in terms of physical fatigue (p=0.048), mental fatigue (p=0.017), and reduced motivation (p=0.025). In patients who exercised regularly, the fatigue scores for the three dimensions of general fatigue (p<0.001), physical fatigue (p=0.046), and reduced activity (p=0.008) were significantly better than in those without exercise habits. Multivariate analysis was conducted, which suggested that only height and regular exercise habits were the independent factors affecting the patients' fatigue levels. We further analyzed the relationship between quality of life and fatigue. With respect to physiological HRQoL, the average fatigue score of patients with high HRQoL was 41.91, which was significantly lower than that of patients with low physiological HRQoL (56.18, p<0.001). Moreover, the average fatigue score in patients with low psychological HRQoL was 55.25, which was significantly higher than that of patients with high psychological HRQoL (41.23, p<0.001). Correlation analysis showed that the physiological HRQoL and psychological HRQoL scores were negatively correlated with fatigue score (r = -0.639, p<0.001 and r= -0.655, p<0.001, respectively).

CONCLUSIONS

In this study, we found that the fatigue dimensions of chronic hepatitis B patients differed between various subpopulations. Height and regular exercise habits were the independent factors that affected the patients' fatigue levels. Moreover, HRQoL was correlated with fatigue level. For patients with risk factors of fatigue, target intervention is advised in order to decrease fatigue and increase HRQoL.

Concurrent and reactivation of hepatitis B virus infection in diffuse large B-cell lymphoma: risk factors and survival outcome

Objective

To determine the clinical features and survival difference of HBV related and Non-HBV related diffuse large B-cell lymphoma (DLBCL) and to evaluate the occurrence of HBV reactivation in DLBCL patients and related risk factors for HBV reactivation after R-CHOP therapy.

Methods

A total of 246 patients diagnosed with CD20+ DLBCL were enrolled from June 2010 to June 2015. The medical records and survival data were analysed. Multivariate logistic regression analysis was used to identify predictors of HBV reactivation. Survival curves were performed by the Kaplan-Meier method.

Results

Among patients enrolled, 80 patients were HBsAg sero-positive and 166 patients were HBsAg sero-negative. Findings showed that HBsAg sero-negative patients were significantly older than that of patients with HBsAg sero-positive (P <  0.001). Proportion of B symptom positive patients in HBsAg sero-positive were higher (p = 0.002). Higher LDH level (P = 0.019) and late Ann Arbor stage (P = 0.010) were more often observed in patients with HBsAg sero-positive. The rate of complete response, partial response, stable disease and progress disease in HBsAg sero-negative group were 63.9, 16.9, 1.1 and 18.1%, respective, which is significantly higher than that in HBsAg sero-positive group (36.2, 18.8, 1.2 and 43.8%). Kaplan-Meier analysis showed that DLBCL patients with HBsAg sero-negative had better prognosis. In total, 17 patients showed HBV reactivation among 166 patients (10.2%) with HBsAg sero-negative after R-CHOP treatment, while a significant higher HBV reactivation 18.75% (9/48) in HBsAb negative group were observed, with 8.25% (8/97) patients in HBsAb level 10-100 U/mL group, and 0% patients in HBsAb level higher than 100 U/mL group. Multivariable analysis showed that serum HBsAb and serum HBcAb were independent risk factors for HBV reactivation in DLBCL patients.

Conclusion

Our data revealed that characteristics and prognosis were significantly different between HBV related DLBCL than non-HBV related DLBCL patients. DLBCL patients with resolved hepatitis B are at a higher risk of developing HBV reactivation after R-CHOP chemotherapy compared with HBsAg-negative/HBcAb negative patients.

Increased expression of osteopontin indicates poor prognosis in hepatocellular carcinoma

OBJECTIVE

To investigate the potential prognostic value of osteopontin (OPN) in hepatocellular carcinoma (HCC) patients after hepatectomy.

METHODS

A total of 384 HCC specimens with paired adjacent non-tumorous tissues from liver resections were collected to construct a tissue microarray for immunohistochemistry (IHC) analysis to detect the expression of OPN. OPN expression was semi-quantified with scores according to IHC staining. The potential correlations between OPN expression and neoplastic features of HCC were analyzed. The survivals in patients stratified with different OPN expression levels were calculated and compared. Uni- and multi-variate analysis were conducted to identify the potential prognostic value of OPN in HCC patients received liver resections.

RESULTS

The OPN in HCC tissues was 0.82 ± 0.68, significantly higher than that in matched nontumorous tissue (0.45 ± 0.59; P < 0.001). Higher OPN expression was associated with vascular invasion (P = 0.019). Patients with high OPN expression had worse overall survival (P < 0.001), disease-free survival (P = 0.045) and higher probability of recurrence (P = 0.048), compared with the patients of low OPN expression. Multivariate analysis indicated that OPN expression was an independent risk factor for overall survival (P = 0.045), disease-free survival (P = 0.048), and HCC recurrence (P = 0.044).

CONCLUSION

OPN expression was elevated in HCC tissues. High OPN expression was correlated with HCC vascular invasion. High OPN expression in HCC tissues is an independent factor for DFS and OS. OPN could be a predictor of HCC patients and a potential therapeutic target for the disease.

Mitofusin-2 acts as biomarker for predicting poor prognosis in hepatitis B virus related hepatocellular carcinoma

OBJECTIVE

To investigate the expression of Mitofusin-2 (MFN2) in HCC tissues and its role in the development of HCC.

METHODS

A total of 107 HCC specimens were collected for tissue microarray analysis and immunohistochemistry (IHC) analysis. The relationship between MFN2 expression and clinical features of patients with HCC was analyzed.

RESULTS

Expression level of MFN2 in HCC tissues was 0.92 ± 0.78, significantly lower than that of matched paracancerous liver tissues (1.25 ± 0.75). Patients with low expression of MFN2 had significantly higher rates of cirrhosis than those with high expression of MFN2 (P = 0.049). Kaplan-Meier survival analysis showed that HCC patients with low expression of MFN2 had a worse prognosis in overall survival than HCC patients with high expression of MFN2 (P = 0.027). Patients with high expression of MFN2 had a better prognosis in disease-free survival compared with HCC patients with low expression of MFN2 (P = 0.047). Vascular invasion and MFN2 expression were shown to be prognostic variables for overall survival in patients with HCC. Multivariate analysis showed that vascular invasion (P < 0.001) and MFN2 expression (P = 0.045) were independent prognostic factors for overall survival. Vascular invasion (P < 0.001) and MFN2 expression (P = 0.042) were independent risk factors associated with disease-free survival.

CONCLUSION

Our data revealed that MFN2 expression was decreased in HCC samples. High MFN2 expression was correlated with longer survival times in patients with HCC and served as an independent factor for better outcomes. Our study therefore provides a promising biomarker for the prognostic prediction of HCC and a potential therapeutic target for the disease.

Altered epidermal fatty acid-binding protein expression in hepatocellular carcinoma predicts unfavorable outcomes

Objective

Hepatocellular carcinoma (HCC) is a rapidly proliferating malignancy that requires large amounts of fatty acids to synthesize cellular membranes and provide energy. Epidermal fatty acid-binding protein (EFABP) is uniquely expressed in epidermal cells, but its role and expression in HCC are not clear.

Subjects and methods

A total of 804 HCC specimens were collected to construct a tissue microarray (TMA) and for immunohistochemistry (IHC) analysis. The relationship between EFABP expression and clinical features of patients with HCC was analyzed.

Results

The EFABP IHC score for HCC tissue was 0.76±0.69, being significantly higher than that for matched nontumorous tissue (0.48±0.55; P<0.001). Using the median IHC score (ie, 0.8) in the tumorous tissue, a high level of EFABP expression was found in 57.3% (461/804) of the cases. Patients with HCC displaying high EFABP expression had poorer tumor differentiation (P=0.029), more vascular invasion (P=0.006), and a higher proportion of late TNM stage disease (P=0.042). Kaplan-Meier analysis revealed that the patients with high EFABP expression had significantly worse outcomes in terms of overall survival (P=0.003), worse disease-free survival (P=0.021), and a higher probability of recurrence (P=0.014). Multivariate analysis indicated that EFABP expression was an independent prognostic variable for overall survival (P=0.021) and disease-free survival (P=0.044). For HCC recurrence, only vascular invasion (P=0.020) and EFABP expression (P=0.026) were independent risk factors.

Conclusion

Our data revealed that EFABP expression was increased in HCC samples. High EFABP expression was correlated with shorter survival times in patients with HCC and served as an independent factor for worse outcomes. Our study therefore provides a promising bio-marker for the prognostic prediction of HCC and a potential therapeutic target for the disease.

Poor adherence is a contributor to viral breakthrough in patients with chronic hepatitis B

Objective

The objective of this study was to explore the risk factors of poor adherence of nucleoside analogs (NUC) treatment in chronic hepatitis B (CHB) patients and the virological changes in patients with poor adherence.

Subjects and methods

A total of 205 CHB patients were enrolled. The patients’ demographic data and family history were collected. NUC adherence was calculated every 12 weeks as follows: number of NUC tablets taken by the patients was divided by the number of NUC tablets prescribed. NUC adherence > 90% was defined as good adherence of NUC treatment.

Results

NUC adherence of male patients was significantly lower than that of female patients. Adherence among patients with previous NUC treatment was poorer than that of patients without previous NUC treatment. Multivariate analysis indicated that female gender (OR =0.367, P=0.013) was the protective factor for NUC adherence in CHB patients, while pretreatment with NUC was the risk factor for NUC adherence (OR =3.209, P=0.002). A total of six patients in the good adherence group experienced virological breakthroughs while 15 of 77 patients in the poor adherence group experienced virological breakthroughs (P=0.001). Similar trends were observed in NUC resistance. Four of the 128 patients with good adherence developed NUC resistance while nine of the 77 patients with poor adherence developed resistance (P=0.015). Multivariate analysis suggested that pretreatment with NUC (OR =3.133, P=0.031), NUC drugs (OR = 3.951, P=0.010), and adherence (OR =2.749, P=0.046) were independent risk factors associated with virological breakthroughs and that NUC drugs (OR =7.083, P=0.005) and poor adherence (OR =4.951, P=0.009) were independent risk factors for NUC resistance.

Conclusion

Male gender and pretreatment with NUC were risk factors associated with NUC adherence. Poor NUC adherence is more likely to induce virological breakthroughs and NUC resistance. For patients with poor NUC adherence, it is necessary to give timely education to improve treatment adherence.

Aberrant expression of alternative isoforms of transcription factors in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most prevalent malignancies worldwide and the second leading cause of death among all cancer types. Deregulation of the networks of tissue-specific transcription factors (TFs) observed in HCC leads to profound changes in the hepatic transcriptional program that facilitates tumor progression. In addition, recent reports suggest that substantial aberrations in the production of TF isoforms occur in HCC. In vitro experiments have identified distinct isoform-specific regulatory functions and related biological effects of liver-specific TFs that are implicated in carcinogenesis, which may be relevant for tumor progression and clinical outcome. This study reviews available data on the expression of isoforms of liver-specific and ubiquitous TFs in the liver and HCC and their effects, including HNF4α, C/EBPs, p73 and TCF7L2, and indicates that assessment of the ratio of isoforms and targeting specific TF variants may be beneficial for the prognosis and treatment of HCC.

Incompatibility of the circadian protein BMAL1 and HNF4α in hepatocellular carcinoma

Hepatocyte nuclear factor 4 alpha (HNF4α) is a master regulator of liver-specific gene expression with potent tumor suppressor activity, yet many liver tumors express HNF4α. This study reveals that P1-HNF4α, the predominant isoform expressed in the adult liver, inhibits expression of tumor promoting genes in a circadian manner. In contrast, an additional isoform of HNF4α, driven by an alternative promoter (P2-HNF4α), is induced in HNF4α-positive human hepatocellular carcinoma (HCC). P2-HNF4α represses the circadian clock gene ARNTL (BMAL1), which is robustly expressed in healthy hepatocytes, and causes nuclear to cytoplasmic re-localization of P1-HNF4α. We reveal mechanisms underlying the incompatibility of BMAL1 and P2-HNF4α in HCC, and demonstrate that forced expression of BMAL1 in HNF4α-positive HCC prevents the growth of tumors in vivo. These data suggest that manipulation of the circadian clock in HNF4α-positive HCC could be a tractable strategy to inhibit tumor growth and progression in the liver.

A model combining TNM stage and tumor size shows utility in predicting recurrence among patients with hepatocellular carcinoma after resection

Objective

Hepatocellular carcinoma (HCC) recurrence is a clinical challenge. An accurate prediction system for patients with HCC is needed, since the choice of HCC treatment strategies is very important.

Patients and methods

A total of 804 patients with HCC who underwent curative resection at Sun Yat-sen University Cancer Center were included in this study. Demographics, clinicopathological data, and follow-up information were collected.

Results

A logistic regression analysis was conducted to investigate the relationships between clinical features and HCC recurrence. Tumor size (OR=1.454, 95% CI: 1.047–2.020, P=0.026) and TNM stage (OR=1.360, 95% CI: 1.021–1.813, P=0.036) were independent predictors of HCC recurrence after curative resection. Therefore, the following equation was established to predict HCC recurrence: 0.308×TNM+0.374×tumor size–0.639. The equation score was 0.53±0.23 in patients who experienced HCC recurrence compared with 0.47±0.24 in other patients. A similar trend was observed in patients who survived after the last follow-up, compared with those who did not, with scores of 0.37±0.26 vs 0.52±0.22, respectively (P<0.001). The Kaplan–Meier analysis showed that patients with HCC with equation values >0.5 had significantly worse outcomes than those with equation values ≤0.5 (P<0.001) for overall survival (OS) and recurrence (P=0.043). Multivariate Cox analyses showed that tumor multiplicity (P=0.039), involucrum (P=0.029), vascular invasion (P<0.001), and equation value (P<0.001) were independent prognostic variables for OS, whereas tumor multiplicity (P=0.01), tumor differentiation (P=0.007), vascular invasion (P<0.001), involucrum (P=0.01), and equation value (P<0.001) were independent prognostic variables for HCC recurrence.

Conclusion

We established a novel and effective equation for predicting the probability of recurrence and OS after curative resection. Patients with a high recurrence score, based on this equation, should undergo additional high-end imaging examinations.

Risk factors associated with nonalcohol fatty liver disease and fibrosis among patients with type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) is closely related to hepatic steatosis and fibrosis. The aim of this study was to analyze the occurrence of hepatic steatosis and fibrosis in patients with T2DM and to explore the risk factors.A total of 629 patients with T2DM were enrolled. Liver stiffness value (LSV) and controlled attenuation parameters (CAP) were measured using Fibroscan. Liver fibrosis was diagnosed when LSV was greater than 7.4 kPa, and advanced liver fibrosis was diagnosed when LSV was greater than 10.6 kPa. Hepatic steatosis diagnosis was made when CAP value was greater than 238 dB/m. Demographic information, physical examination data, and laboratory tests results were collected. The 629 patients were classified into 2 groups by the liver fibrosis and liver steatosis, and then the difference was analyzed.Among patients enrolled, 231 patients were diagnosed as liver fibrosis. The age of the patients in the fibrosis group was significantly greater than that in the non-fibrosis group, and similar trends were observed in the waist-hip ratio (WHR), systolic blood pressure, and diastolic blood pressure. The proportion of smoking and alcoholic consumption was significantly lower in patients with non-fibrosis group. A total of 426 patients were diagnosed with liver steatosis. Body mass index (BMI), WHR, systolic blood pressure, and diastolic blood pressure in patients with steatosis were significantly higher than those in non-steatosis group. We observed that the LSV (P = .042) and CAP value (P < .001) are positively correlated with metabolic syndrome components in T2DM patients. Older age (OR = 1.099, P = .001), high BMI (OR = 1.088, P = .003), low platelet level (OR = 0.996, P = .014), and smoking (OR = 1.653, P = .013) were independent risk factors of liver fibrosis among T2DM patients. High BMI (OR = 1.369, P < .001), high diastolic blood pressure (OR = 1.048, P < .001), and high gamma glutamyl transpeptidase (OR = 1.018, P = .009) were independent risk factors for liver steatosis among T2DM patients.This study suggested risk factors screening of liver fibrosis and steatosis. Timely intervention should be taken into consideration among high risk patients to prevent progress liver diseases.

Effectiveness of telbivudine antiviral treatment in patients with hepatitis B virus-associated glomerulonephritis: A 104-week pilot study

The aim of this study was to evaluate clinical efficacy of telbivudine in treatment of hepatitis B virus-associated glomerulonephritis (HBV-GN).A total of 43 HBV-GN patients combined with chronic hepatitis B were treated with telbivudine for 104 weeks. Serum levels of HBV DNA viral load, HBeAg, HBeAb, alanine aminotransferase (ALT), aspartate aminotransferase (AST), serum creatinine (Cr), and 24-hour urinary protein were evaluated after telbivudine treatment of 12, 24, 52, 76, and 104 weeks. Estimated glomerular filtration rate (eGFR) was calculated at baseline, 24 weeks, 52 weeks, and 104 weeks of treatment, respectively. Complete remission (CR) was defined as urinary protein <0.3 g/day, with normal ALT, AST, Cr, and eGFR. Criteria for partial remission include: 24-hour urinary protein excretion decreased by >50% compared with baseline level, and ALT and AST decreased >50%.Proteinuria level gradually decreased in patients with HBV-GN after telbivudine treatment. The percentages of PR + CR were 90.7% and 95.3%, respectively, at 52 and 104 weeks. Compared to baseline, eGFR were significantly increased from 69.2 ± 23.1 mL/min/1.73 m to 116.2 ± 26.3 mL/min/1.73 m at 104 weeks of treatment. Multivariate analysis indicated that baseline HBV DNA viral load (odds ratio [OR] = 1.19, 95% confidence interval [CI] 1.11-2.19, P = .02) and baseline urinary protein (OR = 1.08, 95% CI 1.04-2.44, P = .03) were independent risk factors associated with CR after telbivudine treatment among patients with HBV-GN.Our study demonstrates that telbivudine can be used to treat HBV-GN and effectively improve eGFR in these patients.

Decreased expression of peroxisome proliferator-activated receptor alpha indicates unfavorable outcomes in hepatocellular carcinoma

Introduction

Hepatocellular carcinoma (HCC) has a close relationship with lipid metabolism. Peroxisome proliferator-activated receptor α (PPARα) plays a crucial role in the regulation of fatty acid oxidation in the liver. However, the role of PPARα in HCC remains unclear.

Methods

A total of 804 HCC specimens were collected to construct a tissue microarray and for immunohistochemical analysis. The relationship between PPARα expression and clinical features of HCC patients was analyzed. Kaplan–Meier analysis was conducted to assess the prognostic value of PPARα expression levels.

Results

The expression of PPARα in HCC was noticeably decreased in HCC tissues. HCC patients with high levels of PPARα expression in cytoplasm had smaller tumors (P=0.027), less vascular invasion (P=0.049), and a higher proportion of complete involucrum (P=0.038). Kaplan–Meier analysis showed that HCC patients with low PPARα expression in the cytoplasm had significantly worse outcomes in terms of overall survival (P<0.001), disease-free survival (P=0.024), and the probability of recurrence (P=0.037). Similarly, overall survival was significantly shorter in HCC patients with negative PPARα expression in the nucleus (P=0.034). Multivariate Cox analyses indicated that tumor size (P=0.001), TNM stage (P<0.001), vascular invasion (P<0.001), and PPARα expression in the cytoplasm (P<0.001) were found to be independent prognostic variables for overall survival.

Conclusion

Our data revealed that PPARα expression was decreased in HCC samples. High PPARα expression was correlated with longer survival times in HCC patients, and served as an independent factor for better outcomes. Our study therefore provides a promising biomarker for prognostic prediction and a potential therapeutic target for HCC.

Intraperitoneal hypertension, a novel risk factor for sepsis-associated encephalopathy in sepsis mice

Sepsis associated encephalopathy (SAE), appears often indicates the deterioration of the sepsis disease and which have high risk of death. Although several mechanism and hypotheses have been proposed and studied, there is no breakthrough in the treatment of SAE. We performed a systematic research to evaluate the effect of intraperitoneal pressure on SAE. A mice model of sepsis was established by intraperitoneal injection of endotoxin. A total of 48 female BALB/c mouse (30 days old) were randomly divided into a control group (n = 12) and an injection of endotoxin referred to bacterial lipopolysaccharide (LPS) group (n = 12). Intraperitoneal hypertension (IAH) referred to IAH group (n = 12), and LPS + IAH group (n = 12). Following sepsis induction, diagnosis, the brains were analyzed for both function and ultrastructural morphology.We determined that IAH exacerbated sepsis induces sepsis-associated encephalopathy when examining low score of neurological function and more delta wave in EEG, increased neuronal edema in LPS + IAH group, as well as an escalation of Bax and Cleaved-caspase-3, Cleaved-parp, and reduction of Bcl-2 and Mfsd2a in LPS + IAH group. Therefore, IAH can exacerbate and increase incident rate of sepsis-related encephalopathy in sepsis mice by promoting neuronal apoptosis and destruction of the blood-brain barrier.