Sustained biochemical and histologic remission of primary biliary cirrhosis in response to medical treatment

Digital pathology and spatial omics in steatohepatitis: Clinical applications and discovery potentials

Steatohepatitis with diverse etiologies is the most common histological manifestation in patients with liver disease. However, there are currently no specific histopathological features pathognomonic for metabolic dysfunction-associated steatotic liver disease, alcohol-associated liver disease, or metabolic dysfunction-associated steatotic liver disease with increased alcohol intake. Digitizing traditional pathology slides has created an emerging field of digital pathology, allowing for easier access, storage, sharing, and analysis of whole-slide images. Artificial intelligence (AI) algorithms have been developed for whole-slide images to enhance the accuracy and speed of the histological interpretation of steatohepatitis and are currently employed in biomarker development. Spatial biology is a novel field that enables investigators to map gene and protein expression within a specific region of interest on liver histological sections, examine disease heterogeneity within tissues, and understand the relationship between molecular changes and distinct tissue morphology. Here, we review the utility of digital pathology (using linear and nonlinear microscopy) augmented with AI analysis to improve the accuracy of histological interpretation. We will also discuss the spatial omics landscape with special emphasis on the strengths and limitations of established spatial transcriptomics and proteomics technologies and their application in steatohepatitis. We then highlight the power of multimodal integration of digital pathology augmented by machine learning (ML)algorithms with spatial biology. The review concludes with a discussion of the current gaps in knowledge, the limitations and premises of these tools and technologies, and the areas of future research.

What Makes Cirrhosis Irreversible?-Consideration on Structural Changes

Several studies have shown that liver fibrosis, and even cirrhosis can be reversed, disproving the old “dogma” that cirrhosis is irreversible. In addition to scaring, vascular alterations appear to be critically important in the progression of chronic liver diseases. To overcome the “tipping-point” of cirrhosis, we need to understand in depth what might make it irreversible in some cases. Morphologically, the initial, as well as the advanced stages of cirrhosis are characterized by specific structural changes. The hallmark of the initial stage is the division of the original liver parenchyma by centro-central or porto-portal septa. No significant vascular changes are observed in this stage. The advanced stage is characterized by several morphological alterations: (i) The main feature is the parenchymal extinction, with intact portal vein branches, hepatic artery branches, and biliary ductules; (ii) In the extinct areas we observed numerous loops in the ductular network, indicating the disruption of the hepato-biliary junctions; (iii) Although the ductular progenitor cells are able to generate hepatocytes via the budding process, the newly formed hepatocyte nodules cannot re-establish the original lobular architecture due to their disorganized growth. In conclusion, this regenerative process characteristic for the advanced stage, contributes to circulatory disorders, perpetuates parenchymal injury and may lead to the irreversibility of cirrhosis.

Regression of Hepatic Fibrosis and Evolution of Cirrhosis: A Concise Review

Fibrosis is not a unidirectional, linear process, but a dynamic one resulting from an interplay of fibrogenesis and fibrolysis depending on the extent and severity of a biologic insult, or lack thereof. Regression of fibrosis has been documented best in patients treated with phlebotomies for hemochromatosis, and after successful suppression and eradication of chronic hepatitis B and C infections. This evidence mandates a reconsideration of the term "cirrhosis," which implies an inevitable progression towards liver failure. Furthermore, it also necessitates a staging system that acknowledges the bidirectional nature of evolution of fibrosis, and has the ability to predict if the disease process is progressing or regressing. The Beijing classification attempts to fill this gap in contemporary practice. It is based on microscopic features termed "the hepatic repair complex," defined originally by Wanless and colleagues. The elements of the hepatic repair complex represent the 3 processes of fragmentation and regression of scar, vascular remodeling (resolution), and parenchymal regeneration. However, regression of fibrosis does not imply resolution of cirrhosis, which is more than just a stage of fibrosis. So far, there is little to no evidence to suggest that large regions of parenchymal extinction can be repopulated by regenerating hepatocytes. Similarly, the vascular lesions of cirrhosis persist, and there is no evidence of complete return to normal microcirculation in cirrhotic livers. In addition, the risk of hepatocellular carcinoma is higher compared with the general population and these patients need continued screening and surveillance.

Regression of Fibrosis Stage With Treatment Reduces Long-Term Risk of Liver Cancer in Patients With Hemochromatosis Caused by Mutation in HFE

BACKGROUND & AIMS

Fibrosis stage can decrease following treatment in patients with hemochromatosis caused by mutations in the homeostatic iron regulator gene (HFE), but the effects on cirrhosis are not clear. We assessed regression of severe fibrosis and the ensuing risk of liver cancer after treatment.

METHODS

We performed a retrospective analysis of data from 106 patients in France or Australia who were homozygous for the C282Y mutation in HFE with F3 fibrosis (n = 40) or F4 fibrosis (n = 66) at diagnosis and from whom at least 1 liver biopsy was collected during follow up. We collected data from the time of first biopsy and during follow-up period on patient demographics, treatment, smoking habits, alcohol consumption, infection with hepatitis B or C viruses, and other diseases. The median time between first and last liver biopsy was 9.5 years (range, 3.5-15.6 years). We collected results of tests for liver function, markers of iron stores, and platelet levels. Patients were followed for a median 17.6 years (range, 9.8-24.1 years) for development of liver cancer occurrence.

RESULTS

At last liver biopsy, 41 patients (38.6%) had fibrosis scores of F2 or less. Liver cancer occurred in 34 patients (52.3%) with F3 or F4 fibrosis at last liver biopsy vs 2 patients (4.8%) with fibrosis scores of F2 or less at last liver biopsy (P < .001). Liver cancer incidences were 32.8 per 1000 person-years (95% CI, 22.7-45.9 per 1000 person-years) in patients with F3 or F4 fibrosis and 2.3 per 1000 person-years (95% CI, 0.2-8.6 per 1000 person-years) in patients with fibrosis scores of F2 or less (P < .001). In multivariate analysis, male sex (hazard ratio [HR], 6.09; 95% CI, 1.21-30.4), age at diagnosis (HR, 1.16; 95% CI, 1.09-1.25), presence of diabetes (HR, 3.07; 95% CI, 1.35-6.97), excess alcohol consumption (HR, 3.1; 95% CI, 1.47-6.35), serum level of ferritin at diagnosis (P < .01), and regression to fibrosis scores of F2 or less (HR, 0.08; 95% CI, 0.01-0.62) were significantly associated with risk of liver cancer.

CONCLUSIONS

In a retrospective analysis of patients with hemochromatosis caused by the C282Y mutation in HFE, we found that severe liver fibrosis can regress with treatment. In patients with fibrosis regression to a stage F2 or less, the long-term risk for liver cancer is significantly reduced.

Update on Emerging Treatment Options for Primary Biliary Cholangitis

Primary biliary cholangitis (PBC) is a rare autoimmune cholestatic liver disease that may progress to fibrosis or cirrhosis. Treatment options are currently limited. Ursodeoxycholic acid (UDCA) remains first-line therapy and has been proven to normalize serum biochemistries, halt histologic disease progression, and lead to patient survival comparable to the general population. Obeticholic acid (OCA) was recently approved as adjunct therapy in PBC patients with inadequate response or intolerance to UDCA. However, OCA has been associated with worsening pruritus in clinical studies which may limit its use in this patient population. Several studies are currently underway to address the lack of treatment options for PBC. Of these, fibrates, which have been used in Japan for over a decade, have produced promising results. Furthermore, as currently approved therapies for PBC do not address the potentially debilitating clinical symptoms of PBC such as pruritus and fatigue, supplemental therapy is often required for symptom control.

Regression of human cirrhosis: an update, 18 years after the pioneering article by Wanless et al

Cirrhosis has been traditionally viewed as an irreversible, end-stage condition. Eighteen years ago, Wanless, Nakashima, and Sherman published a study that was based on the concept that hepatic architecture is under constant remodeling in the course of chronic liver diseases, even during their most advanced stages; depending on the balance between injury and repair, the histologic changes might be progressing or regressing. These authors described in detail the morphologic features of regressing cirrhosis, identified a set of histologic features of regression that they called the "hepatic repair complex," and provided convincing morphologic evidence that incomplete septal cirrhosis represents regressed cirrhosis. In the years that followed publication of this pioneering article, a number of clinical studies with performance of pre- and post-treatment liver biopsies provided abundant evidence that cirrhosis can regress after successful therapy of chronic hepatitis B, chronic hepatitis C, autoimmune hepatitis, and genetic hemochromatosis. Evidence for other chronic liver diseases may also be provided in the future, pending ongoing studies. Successful therapy allows resorption of fibrous septa, which can be followed by loss of nodularity and architectural improvement; however, many vascular lesions of cirrhotic livers are not thought to regress. Cases of cirrhosis that are considered more likely to improve than others include those of recent onset, with relatively thin fibrous septa and mild vascular changes. Histologic examination of liver biopsy specimens from patients with chronic liver diseases provides the opportunity to appreciate the features of the hepatic repair complex on a routine diagnostic basis; however, interpretation is often difficult, and can be aided by immunohistochemical stains. Clinicopathologic correlation is essential for a meaningful assessment of such cases. For many patients, cirrhosis is not an end-stage condition anymore; therefore, use of the term "cirrhosis" has been challenged, almost 200 years after its invention. However, regression of cirrhosis does not imply regression of molecular changes involved in hepatocarcinogenesis; therefore, surveillance for hepatocellular carcinoma should be continued in these patients.

肝纤维化逆转机制的研究进展及治疗概况

肝纤维化是肝脏对慢性损伤的一种修复反应, 多是持续性肝脏损伤或纤维化刺激因子刺激产生的共有病理改变, 是一项严重的全球性健康难题. 近年来临床研究发现, 由病毒性肝炎造成肝纤维化或肝硬化的患者, 在成功接受病毒性肝炎治疗后, 其肝纤维化甚至肝硬化发生了逆转现象. 因此研究和了解肝纤维化逆转的机制有利于发现新的针对肝纤维化的治疗靶向. 本文就近年来有关肝纤维化逆转机制的研究以及治疗概况作一综述, 以期为肝纤维化的研究提供帮助.

Risk of liver injury among methotrexate users: A meta-analysis of randomised controlled trials

OBJECTIVE

Methotrexate is an effective treatment for a variety of inflammatory diseases. Robust evidence on the risk of serious liver injury is lacking. The aim of this study was to evaluate the relative risk and severity of liver disease among patients treated with methotrexate.

METHODS

We searched PubMed and the Cochrane Central Register of Controlled Trials from 1 January 1990 to 24 April 2014 for double-blind randomised controlled trials of methotrexate versus comparator agents in adults with rheumatoid arthritis, psoriasis, psoriatic arthritis or inflammatory bowel disease. Studies with less than 100 subjects or of less than 24 weeks' duration were excluded. Two investigators independently searched both the databases. All authors reviewed the selected studies. We compared relative risk (RR) differences using the Mantel-Haenszel random effects method to assess total liver adverse events, minor liver enzyme abnormalities (≤ 3 ULN), major liver enzyme abnormalities (>3 ULN or treatment withdrawal) and a composite outcome of liver failure, fibrosis, cirrhosis or death.

RESULTS

A total of 32 studies with 13,177 participants met our inclusion criteria. Methotrexate was associated with an increased risk of total adverse liver events, RR = 2.19 (95% CI: 1.73-2.77, I(2) = 68%), as well as minor and major liver enzyme abnormalities, RR = 2.16 (95% CI: 1.67-2.79, I(2) = 68%) and RR = 2.63 (95% CI: 1.90-3.64, I(2) = 10%), respectively. Patients treated with methotrexate were not at increased risk of liver failure, cirrhosis or death, RR = 0.12 (95% CI: 0.01-1.09, I(2) = 0%).

CONCLUSION

Our study found an increased risk of elevated transaminases but not liver failure, cirrhosis or death with methotrexate compared to other agents. We were unable to assess long-term liver toxicity due to the short duration of included clinical trials.

Clinical application of transient elastography in patients with chronic viral hepatitis receiving antiviral treatment

Accurate evaluation of the degree of liver fibrosis in patients with chronic liver diseases (CLD) is crucial, as liver fibrosis is important in determining the prognosis of liver diseases. Currently, liver biopsy (LB) is considered the gold standard for staging liver fibrosis or cirrhosis. However, utilization of LB in clinical practice is often limited because of its invasive nature, sampling error and interobserver variability. Recently, transient elastography (TE) was introduced as a noninvasive, highly reproducible technique for assessing the degree of liver fibrosis. After extensive studies, TE is now regarded as a reliable surrogate marker for grading the severity of liver fibrosis in patients with CLD. In the past few years, the role of TE in monitoring liver stiffness and determining prognosis in patients with chronic hepatitis B (CHB) or chronic hepatitis C (CHC) who are undergoing antiviral treatment has been investigated. In patients with CHB, liver stiffness values decrease with antiviral treatment. TE can also be used to predict the incidence of liver-related events during antiviral treatment. In patients with CHC, TE can be used to monitor potential regression of liver fibrosis after antiviral treatment and may predict the treatment outcome of CHC. In addition, TE is an adjunct tool for distinguishing inactive hepatitis B virus carriers from patients with chronic active hepatitis. This review article discusses the important findings from recent studies focusing on the clinical application of TE in patients with chronic viral hepatitis who are undergoing antiviral treatments.

Review article: The prevention and reversal of hepatic fibrosis in autoimmune hepatitis

BACKGROUND

Immunosuppressive treatment of autoimmune hepatitis can prevent or reverse hepatic fibrosis, but these anti-fibrotic effects are inconsistent secondary gains.

AIM

To describe the anti-fibrotic effects of current therapies for autoimmune hepatitis, discuss the pathogenic mechanisms of hepatic fibrosis that might be targeted by anti-fibrotic interventions, indicate the non-invasive diagnostic tests of hepatic fibrosis that must be validated in autoimmune hepatitis and to suggest promising treatment opportunities.

METHODS

Studies cited in PubMed from 1972 to 2013 for autoimmune hepatitis, hepatic fibrosis, cirrhosis, anti-fibrotic therapy and non-invasive tests of hepatic fibrosis were selected.

RESULTS

Hepatic fibrosis improves in 53-57% of corticosteroid-treated patients with autoimmune hepatitis; progressive fibrosis slows or is prevented in 79%; and cirrhosis may be reversed. Progressive hepatic fibrosis is associated with liver inflammation, and the inability to fully suppress inflammatory activity within 12 months is associated with progression to cirrhosis (54%) and death or need for liver transplantation (15%). Liver tissue examination remains the gold standard for assessing hepatic fibrosis, but laboratory and radiological tests may be useful non-invasive methods to measure the fibrotic response. Severe liver inflammation can confound radiological assessments, and the preferred non-invasive test in autoimmune hepatitis is uncertain. Individualised treatment adjustments and adjunctive anti-fibrotic therapies are poised for study in this disease.

CONCLUSIONS

The prevention and reversal of hepatic fibrosis are achievable objectives in autoimmune hepatitis. Strategies that evaluate individualised therapies adjusted to the rapidity and completeness of the inflammatory response, and the use of adjunctive anti-fibrotic interventions, must be evaluated.

Translating an understanding of the pathogenesis of hepatic fibrosis to novel therapies

The response to injury is one of wound healing and fibrogenesis, which ultimately leads to fibrosis. The fibrogenic response to injury is a generalized one across virtually all organ systems. In the liver, the injury response, typically occurring over a prolonged period of time, leads to cirrhosis (although it should be pointed out that not all patients with liver injury develop cirrhosis). The fact that many different diseases result in cirrhosis suggests a common pathogenesis. The study of hepatic fibrogenesis over the past 2 decades has been remarkably active, leading to a considerable understanding of this process. It clearly has been shown that the hepatic stellate cell is a central component in the fibrogenic process. It also has been recognized that other effector cells are important in the fibrogenic process, including resident fibroblasts, bone marrow-derived cells, fibrocytes, and even perhaps cells derived from epithelial cells (ie, through epithelial to mesenchymal transition). A key aspect of the biology of fibrogenesis is that the fibrogenic process is dynamic; thus, even advanced fibrosis (or cirrhosis) is reversible. Together, an understanding of the cellular basis for liver fibrogenesis, along with multiple aspects of the basic pathogenesis of fibrosis, have highlighted many exciting potential therapeutic opportunities. Thus, although the most effective antifibrotic therapy is simply treatment of the underlying disease, in situations in which this is not possible, specific antifibrotic therapy is likely not only to become feasible, but will soon become a reality. This review highlights the mechanisms underlying fibrogenesis that may be translated into future antifibrotic therapies and to review the current state of clinical development.

Clinical evidence for the regression of liver fibrosis

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

[Histological regression of liver fibrosis with immunosuppressive therapy in autoimmune hepatitis]

Reversibility of liver fibrosis with immunosuppressive therapy (IT) has been described in autoimmune hepatitis (AIH).

OBJECTIVE

To compare initial fibrosis and fibrosis after IT in patients with AIH.

METHODS

A total of 54 patients were admitted with positive ANA or AML antibodies, or both, elevated IgG immunoglobulins and who met international criteria for a diagnosis of AIH. The mean age was 39 years (range 13-65) and there were 47 women (87%). Two liver biopsies were taken: one at diagnosis and another at a mean of 28±8 months after initiation of IT with prednisone and azathioprine. The degree of inflammation (0-18) and fibrosis (0-6) according to Ishak score was compared between the initial and the follow-up biopsy.

RESULTS

Fibrosis decreased from 2.9±0.3 to 2.2±0.3 (p=0.005) and histological activity index from 6.8±0.45 to 2.6±0.2 (P<.001). In subgroups, fibrosis decreased from 3.6±0.4 to 1.4±0.3 (P<.001) in 22 patients (41%), was unchanged in 27 (50%) and increased in five (9%). There were seven patients with histological cirrhosis at IT initiation. After IT, four showed a reduction in Ishak score (achieving scores of 0-3). Transaminase values were not associated with histological improvement.

CONCLUSION

Fibrosis in patients with AIH significantly improved with IT, emphasizing the importance of studying the prognostic factors associated with this favorable response.

Methotrexate in patients with primary biliary cirrhosis who respond incompletely to treatment with ursodeoxycholic acid

BACKGROUND

Approximately 35% of PBC patients have progressive disease despite treatment with UDCA.

AIMS

We offered treatment with methotrexate and colchicine to PBC patients who had not responded fully to UDCA, after at least 1 year of treatment.

METHODS

A total of 91 PBC patients failed to respond adequately to UDCA, defined as patients whose liver biopsies showed persistent interface hepatitis and whose serum alkaline phosphatase levels remained more than 50% above normal after at least 12 months on UDCA. We added colchicine (0.6 mg orally twice daily) for 6 months. If there was no decrease in alkaline phosphatase, methotrexate (0.25 mg/kg lean body weight orally per week) was added. Liver biopsies were performed at least three times: at diagnosis, after a patient had been on UDCA for at least 1 year (mean 3.4 years), and after a patient had been on methotrexate for at least 6 months (mean 2.2 years). A fourth liver biopsy was performed in 51 patients after they had been on methotrexate for at least another year (mean 3.5 years).

RESULTS

From the time that methotrexate was begun until the final visit, there were significant decreases in the mean levels of alkaline phosphatase, 323 to 151, ALT, 73 to 39, fibrosis, 2.5 to 2.0, and inflammation scores, 2.0 to 1.0, (p < 0.0001 for all). Based on pre-specified definitions, 73 patients (80%) responded to methotrexate while 18 (20%) did not.

CONCLUSIONS

In 91 PBC patients who responded incompletely to UDCA, colchicine and methotrexate significantly improved liver enzyme tests and liver histology.

Non-invasive assessment of changes in liver fibrosis via liver stiffness measurement in patients with chronic hepatitis B: impact of antiviral treatment on fibrosis regression

BACKGROUND

Liver stiffness measurement (LSM) can assess liver fibrosis in patients with chronic hepatitis B (CHB). We evaluated whether LSM can be used to assess changes in liver fibrosis during antiviral treatment using nucleos(t)ide analogs in patients with CHB.

METHODS

We recruited 41 patients with CHB who had significant liver fibrosis, normal or slightly elevated serum alanine aminotransferase (ALT) levels (≤2 × upper limit of normal), and detectable serum hepatitis B virus DNA before antiviral treatment. Patients in Group 1 (n = 23) and Group 2 (n = 18) underwent follow-up LSM after antiviral treatment for 1 and 2 years, respectively.

RESULTS

The mean age, ALT and LSM value of all patients (34 men and 7 women) before antiviral treatment were 46.6 ± 9.5 years, 40.6 ± 17.2 IU/L and 12.9 ± 8.6 kPa, respectively. Hepatitis B e antigen (HBeAg) was detected in 31 patients (75.6%). Fibrosis stage was F2 in 12 (29.3%), F3 in 6 (14.6%) and F4 in 23 (56.1%) patients. After antiviral treatment, LSM values and DNA positivity decreased significantly as compared to baseline (P = 0.018 and P < 0.001 in Group 1; P = 0.017 and P < 0.001 in Group 2, respectively), whereas ALT levels were unchanged (P = 0.063 in Group 1; P = 0.082 in Group 2).

CONCLUSIONS

Our preliminary data suggest that LSM can be used to assess liver fibrosis regression after antiviral treatment using nucleos(t)ide analogs in patients with CHB.

Colchicine reduces procollagen III and increases pseudocholinesterase in chronic liver disease

AIM: To test whether colchicine would be an effective antifibrotic agent for treatment of chronic liver diseases in patients who could not be treated with α-interferon.

METHODS: Seventy-four patients (46 males, 28 females) aged 40-66 years (mean 53 ± 13 years) participated in the study. The patients were affected by chronic liver diseases with cirrhosis which was proven histologically (n = 58); by chronic active hepatitis C (n = 4), chronic active hepatitis B (n = 2), and chronic persistent hepatitis C (n = 6). In the four patients lacking histology, cirrhosis was diagnosed from anamnesis, serum laboratory tests, esophageal varices and ascites. Patients were assigned to colchicine (1 mg/d) or standard treatment as control in a randomized, double-blind trial, and followed for 4.4 years with clinical and laboratory evaluation.

RESULTS: Survival at the end of the study was 94.6% in the colchicine group and 78.4% in the control group (P = 0.001). Serum N-terminal peptide of type III procollagen levels fell from 34.0 to 18.3 ng/mL (P = 0.0001), and pseudocholinesterase levels rose from 4.900 to 5.610 mU/mL (P = 0.0001) in the colchicine group, while no significant change was seen in controls. Best results were obtained in patients with chronic hepatitis C and in alcoholic cirrhotics.

CONCLUSION: Colchicine is an effective and safe antifibrotic drug for long-term treatment of chronic liver disease in which fibrosis progresses towards cirrhosis.

Paediatric cholestatic liver disease: Diagnosis, assessment of disease progression and mechanisms of fibrogenesis

Cholestatic liver disease causes significant morbidity and mortality in children. The diagnosis and management of these diseases can be complicated by an inability to detect early stages of fibrosis and a lack of adequate interventional therapy. There is no single gold standard test that accurately reflects the presence of liver disease, or that can be used to monitor fibrosis progression, particularly in conditions such as cystic fibrosis. This has lead to controversy over how suspected liver disease in children is detected and diagnosed. This review discusses the challenges in using commonly available methods to diagnose hepatic fibrosis and monitor disease progression in children with cholestatic liver disease. In addition, the review examines the mechanisms hypothesised to be involved in the development of hepatic fibrogenesis in paediatric cholestatic liver injury which may ultimately aid in identifying new modalities to assist in both disease detection and therapeutic intervention.

Methotrexate for primary biliary cirrhosis

BACKGROUND

Methotrexate has been used to treat patients with primary biliary cirrhosis as it possesses immunosuppressive properties. The previously prepared version of this review from 2005 showed that methotrexate seemed to significantly increase mortality in patients with primary biliary cirrhosis. Since that last review version, follow-up data of the included trials have been published.

OBJECTIVES

To assess the beneficial and harmful effects of methotrexate for patients with primary biliary cirrhosis.

SEARCH STRATEGY

Randomised clinical trials were identified by searching The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, and EMBASE (from their inception until September 2009). Reference lists were also read through. Authors of trials were contacted.

SELECTION CRITERIA

We searched to include randomised clinical trials comparing methotrexate with placebo, no intervention, or another drug irrespective of blinding, language, year of publication, or publication status.

DATA COLLECTION AND ANALYSIS

Our primary outcomes were mortality, and mortality or liver transplantation combined. Dichotomous outcomes were reported as relative risks (RR) and hazard ratios (HR) if applicable. Continuous outcomes were reported as mean differences (MD).

MAIN RESULTS

Five trials were included. Four trials with 370 patients compared methotrexate with placebo or no intervention (three trials added an equal dose of ursodeoxycholic acid to the intervention groups). The bias risk of these trials was high. We did not find statistically significant effects of methotrexate on mortality (RR 1.32, 95% CI 0.66 to 2.64), mortality or liver transplantation combined, pruritus, fatigue, liver complications, liver biochemistry, liver histology, or adverse events. The pruritus score (MD - 0.17, 95% CI - 0.25 to - 0.09) was significantly lower in patients receiving methotrexate. The prothrombin time was significantly worsened in patients receiving methotrexate (MD 1.60 s, 95% CI 1.18 to 2.02). One trial with 85 patients compared methotrexate with colchicine. The trial had low risk of bias. Methotrexate, when compared to colchicine, did not significantly effect mortality, fatigue, liver biopsy, or adverse events. Methotrexate significantly benefited pruritus score (MD - 0.68, 95% CI - 1.11 to - 0.25), serum alkaline phosphatases (MD - 0.41 U/l, 95% CI - 0.70 to - 0.12), and plasma immunoglobulin M (MD - 0.47 mg/dl, 95% CI - 0.74 to - 0.20) compared with colchicine. Other outcomes showed no statistical difference.

AUTHORS' CONCLUSIONS

Methotrexate had no statistically significant effect on mortality in patients with primary biliary cirrhosis nor the need for liver transplantation. Although methotrexate may benefit other outcomes (pruritus score, serum alkaline phosphatase, immunoglobulin M levels), there is no sufficient evidence to support methotrexate for patients with primary biliary cirrhosis.

Hepatic stellate cell activation and hepatic fibrosis in children with type 1 autoimmune hepatitis: an immunohistochemical study of paired liver biopsies before treatment and after clinical remission

OBJECTIVES

The activation of hepatic stellate cells (HSC) is considered the most important event in hepatic fibrogenesis. The precise mechanism of this process is unknown in autoimmune hepatitis (AIH), and more evidence is needed on the evolution of fibrosis. The aim of this study was to assess these aspects in children with type 1 AIH.

METHODS

We analyzed 16 liver biopsy samples from eight patients, paired before treatment and after clinical remission, performed an immunohistochemical study with anti-alpha actin smooth muscle antibody and graded fibrosis and inflammation on a scale of 0-4 (Batts and Ludwig scoring system).

RESULTS

There was no significant reduction in fibrosis scores after 24+/-18 months (2.5+/-0.93 vs. 2.0+/-0.53, P=0.2012). There was an important decrease in inflammation: portal (2.6+/-0.74 vs. 1.3+/-0.89, P=0.0277), periportal/periseptal (3.0+/-0.76 vs. 1.4+/-1.06, P=0.0277), and lobular (2.8+/-1.04 vs. 0.9+/-0.99, P=0.0179). Anti-alpha actin smooth muscle antibodies were expressed in the HSC of the initial biopsies (3491.93+/-2051.48 mum), showing a significant reduction after remission (377.91+/-439.47 microm) (P=0.0117).

CONCLUSION

HSC activation was demonstrated in the AIH of children. The reduction of this activation after clinical remission, which may precede a decrease in fibrosis, opens important perspectives in the follow-up of AIH.

Serum BAFF and APRIL levels in patients with PBC

B-cell-activating factor belonging to the TNF family (BAFF) and a proliferation-inducing ligand (APRIL) are known to be involved in the occurrence of autoimmune diseases. We assessed serum levels of these cytokines in PBC patients. Serum BAFF levels were significantly higher in PBC patients than in healthy controls (1253.9+/-741.4 vs. 722.8+/-199.2 pg/ml; p<0.0001) and HCV-infected patients (1253.9+/-741.4 vs. 871.0+/-251.1 pg/ml; p=0.015). Whereas changes in serum APRIL levels were not significant among these groups, there was a significant correlation between BAFF and AST (R=0.278, p=0.003) or total bilirubin (R=0.363, p=0.0006) in PBC patients. Furthermore, serum BAFF levels were elevated in PBC patients with advanced interface hepatitis. Our data indicate that serum levels of BAFF and APRIL are differentially regulated and serum BAFF levels are significantly elevated in PBC patients. These findings suggest that BAFF may serve as a modulator of the clinical and/or serological manifestation in PBC patients.

Management of autoimmune and cholestatic liver disorders

The management of autoimmune and cholestatic liver disorders is a challenging area of hepatology. Autoimmune and cholestatic liver diseases represent a comparatively small proportion of hepatobiliary disorders, yet their appropriate management is of critical importance for patient survival. In this article, management strategies are discussed, including the indications and expectations of pharmacologic therapy, endoscopic approaches, and the role of liver transplantation.

Regression of fibrosis in paediatric autoimmune hepatitis: morphometric assessment of fibrosis versus semiquantiatative methods

Background

Regression of hepatic fibrosis in patients with autoimmune hepatitis (AIH) has been described in response to immunosuppressive therapy. These studies, however, besides being few in number, were conducted on adult populations. Our aim was to assess the regression of hepatic fibrosis, using morphometric assessment of fibrosis versus semi-quantitative methods, in children with AIH who achieved clinical and biochemical remission. Thirteen patients who achieved clinical and biochemical remission were included in the study, out of 62 children with AIH. Repeat biopsy was performed after 6 to 12 months of clinical and biochemical remission. Morphometric assessment of fibrosis was performed and correlated with METAVIR and Ishak semi-quantitative scores.

Results

The study group included eight male and five female patients. The median age at presentation was 4 years (range 2 to 12 years). The mean duration of treatment was 22 ± 7.3 months, and the mean interval between biopsies was 26.2 ± 6.5 months. Following therapy, there was significant reduction in aspartate aminotransferase, ALT and IgG levels as well as improvement of necroinflammation. The mean fibrosis scores were significantly decreased from 4.5 ± 1.19 and 2.9 ± 0.7 before therapy to 2.7 ± 1.16 and 2 ± 0.8 after treatment as assessed by Ishak and METAVIR scores, respectively (P = 0.001 and 0.004). The mean morphometric assessment of fibrosis before treatment was 20% ± 9.7 and following therapy it decreased to 5.6% ± 3.9 (P = 0.000).

Conclusion

Significant regression of fibrosis in paediatric AIH could occur with current therapeutic regimens. Morphometric assessment of fibrosis is more sensitive than semi-quantitative methods to identify changes in fibrosis.

Current and future anti-fibrotic therapies for chronic liver disease

Chronic injury results in a wound healing response that eventually leads to fibrosis. The response is generalized, with features common among multiple organ systems. In the liver, various different types of injury lead to fibrogenesis, implying a common pathogenesis. Although several specific therapies for patients who have different liver diseases have been successfully developed, including antiviral therapies for those who have hepatitis B and hepatitis C virus infection, specific and effective antifibrotic therapy remains elusive. Over the past 2 decades, great advances in the understanding of fibrosis have been made and multiple mechanisms underlying hepatic fibrogenesis uncovered. Elucidation of these mechanisms has been of fundamental importance in highlighting novel potential therapies. Preclinical studies have indicated several putative therapies that might abrogate fibrogenesis. This article emphasizes mechanisms underlying fibrogenesis and reviews available and future therapeutics.

Brief communication: the relationship of regression of cirrhosis to outcome in chronic hepatitis C

BACKGROUND

The effect of regression of cirrhosis in chronic hepatitis C is unknown.

OBJECTIVE

To evaluate the relation between regression of cirrhosis and clinical outcome in patients with chronic hepatitis C after antiviral therapy.

DESIGN

A cohort of patients with cirrhosis treated between 1988 and 2001.

SETTING

Hepatology unit of a tertiary care center in France.

PATIENTS

96 patients with chronic hepatitis C and biopsy-proven cirrhosis (METAVIR score F4) who were treated with an interferon-based regimen and had at least 1 posttreatment liver biopsy. Patients were followed until November 2006.

MEASUREMENTS

Occurrence of a combined end point of liver-related events (ascites, hepatic encephalopathy, variceal bleeding, spontaneous bacterial peritonitis, hepatocellular carcinoma, or liver transplantation) and death in patients with regression of cirrhosis (defined as a decrease from 4 to <or=2 METAVIR units on posttherapy liver biopsy).

RESULTS

The median follow-up was 118 months (interquartile range, 86 to 138 months). Eighteen patients had regression of cirrhosis. The incidence of the combined end point per 100 patient-years was 0 in patients with regression of cirrhosis and 4 in patients without regression of cirrhosis (P = 0.002, log-rank test). The transplantation-free survival rate at 10 years was 100% in patients with regression of cirrhosis and 74.2% in patients without regression of cirrhosis (P = 0.025).

LIMITATIONS

Selection of patients was retrospective; selection and survival biases may have influenced the estimates of the overall rate of regression of cirrhosis. The low number of patients who experienced regression of cirrhosis precludes analysis of factors that could predict regression of cirrhosis.

CONCLUSION

Regression of cirrhosis occurs after antiviral therapy in some patients with chronic hepatitis C. Regression is associated with decreased disease-related morbidity and improved survival.

Clinical features and management of primary biliary cirrhosis

Primary biliary cirrhosis (PBC), which is characterized by progressive destruction of intrahepatic bile ducts, is not a rare disease since both prevalence and incidence are increasing during the last years mainly due to the improvement of case finding strategies. The prognosis of the disease has improved due to both the recognition of earlier and indolent cases, and to the wide use of ursodeoxycholic acid (UDCA). New indicators of prognosis are available that will be useful especially for the growing number of patients with less severe disease. Most patients are asymptomatic at presentation. Pruritus may represent the most distressing symptom and, when UDCA is ineffective, cholestyramine represents the mainstay of treatment. Complications of long-standing cholestasis may be clinically relevant only in very advanced stages. Available data on the effects of UDCA on clinically relevant end points clearly indicate that the drug is able to slow but not to halt the progression of the disease while, in advanced stages, the only therapeutic option remains liver transplantation.

Effect of treatment of hepatic histopathology in children and adolescents with autoimmune hepatitis

OBJECTIVE

To evaluate the effects of treatment on liver histopathology of children and adolescents diagnosed with autoimmune hepatitis.

PATIENTS AND METHODS

Histopathological evaluation of liver biopsies performed at diagnosis or early during treatment, compared with biopsies after immunosuppressive treatment of 20 children and adolescents diagnosed with autoimmune hepatitis who presented clinical and biochemical remission for at least 24 months. Liver histopathology was assessed by 2 pathologists. Agreement between their interpretations was analyzed with kappa statistics.

RESULTS

The age at diagnosis of the 20 patients varied from 1.7 years to 11.6 years (median = 6.6 years); 18 were females. The mean duration of clinical and biochemical remission, up to performance of liver biopsy, was 4.1 years. The mean interval between the initial and posttreatment biopsies was 4.6 years (range 2-9.7 years). Assessing the necroinflammatory activity, a mean reduction by 6.3 (observer 1) and 7.3 (observer 2) in the grading score was observed (P = 0.00000). When staging was assessed, a mean reduction by 1.8 (observers 1 and 2) in the score was observed after treatment (P = 0.00008), and there was no progression toward cirrhosis. No regression of cirrhosis was observed.

CONCLUSIONS

On histopathological evaluation, the immunosuppressive treatment improved the fibrosis scores, with an arrest in its progression and no development into cirrhosis. Fibrosis control is mainly associated with regression of necroinflammatory activity, which is the main treatment component in autoimmune hepatitis.

Orlistat reverse fatty infiltration and improves hepatic fibrosis in obese patients with nonalcoholic steatohepatitis (NASH)

Nonalcoholic steatohepatitis (NASH) may cause progressive hepatic fibrosis, cirrhosis, and hepatocellular carcinoma. Treatment, thus far, has been restricted to diet and weight loss, but without compelling results. In this study we aimed to evaluate the efficacy of orlistat therapy in obese patients with NASH. Fourteen obese patients with NASH underwent liver biopsy prior to and subsequent to 6 months treatment with orlistat (120 mg tid). Hepatic fat extension was graded as normal, mild, moderate, or severe. Hepatic fibrosis was scored on a scale from 0 to 4, with 0 denoting no fibrosis and 4, cirrhosis. Portal inflammation was scored as 0-3, with 0 = normal, 1 = mild, 2 = moderate, and 3 = severe inflammation. Fourteen patients had NASH associated with diabetes, hyperlipidemia, or obesity. Orlistat reduced fatty infiltration in 10 patients (70%; P<0.01), 3 of whom had normal liver fat content after treatment. Orlistat improved inflammatory activity by 2 grades in 28% and by 1 grade in 50% of patients and effected no change in 22% of patients. Five patients (35%) returned to normal inflammatory activity. Orlistat improved hepatic fibrosis by 2 grades in three patients (21%) and by 1 grade in seven patients (50%). There was no change in four patients (28%). Orlistat lowered aminotransferases levels, total cholesterol, triglycerides and low-density lipoprotein, respectively. Insulin resistance index and malonyl dialdehyde levels improved significantly after orlistat therapy, whereas HbAic remained unchanged. In conclusion, in obese patients with NASH, liver fibrosis and inflammation improved after therapy with orlistat.

Reversal of liver cirrhosis: a desirable clinical outcome and its pathogenic background

Cirrhosis is the final stage of chronic liver damage of various etiologies. It used to be considered an irreversible lesion, but enormous advances in our understanding of hepatic cellular and molecular biology in the past 2 decades have challenged this view. There is now substantial evidence that cirrhosis can be a reversible process. This concept is supported by an increasing number of clinical reports showing the disappearance of cirrhotic lesions from liver biopsies taken from patients cured of their liver disease. The reversal of cirrhosis usually occurs in patients with short-lived liver disease, after the successful treatment of the underlying liver damage. Recently, however, we observed the spontaneous reversal of cirrhosis after the loss of hepatitis B viremia in 2 men, 21 and 28 years old, who had developed cirrhosis as young children. Several questions and controversial issues concerning the definition of advanced cirrhosis, the limitations of liver biopsy (eg, sampling, interpretation error), and the applicability of noninvasive methods to the assessment of fibrosis, are being addressed. Future prospects include the possibility of antifibrotic therapy to prevent fibrosis or favor its degradation.

Reversibility of Cirrhosis in HIV/HBV Coinfection

HIV infection worsens the course and the natural history of chronic hepatitis B (HBV) leading to rapid progression to cirrhosis and to end-stage liver disease. Highly active antiretroviral therapy (HAART) regimens including nucleoside and/or nucleotide analogues with activity against both HIV reverse transcriptase and hepatitis B virus polymerase have clearly improved the survival rates of HIV/HBV-coinfected patients. How HAART beneficially affects the natural course of chronic hepatitis B in coinfected patients is not known. We report a biopsy-proven case of reversal of HBV-related cirrhosis in a coinfected patient, parallelling long-term suppression of HBV replication with tenofovir disoproxil fumarate as part of a HAART. Pathological reversibility of cirrhosis was ascertained by normalization of biochemical (platelet count) and morphological (abdominal ultrasonography and gastrointestinal endoscopy) tests as well as non-invasive markers of fibrosis. In conclusion, a HAART regimen including tenofovir disoproxil fumarate in a HBV/HIV-coinfected cirrhotic patient might lead to sustained HBV viral suppression and result in cirrhosis reversal.

New therapies in hepatitis C virus and chronic liver disease: antifibrotics

Fibrotic liver disease occurs after any of the various forms of injury to the liver. Fibrosis is a critical factor leading to hepatic dysfunction and portal hypertension and its complications. The fibrogenic cascade is complex but leads to accumulation of extracellular matrix proteins, followed by nodular fibrosis, tissue contraction, and alteration in blood flow. A critical concept emerging is that activation of effector cells, which produce extracellular matrix, underlies the fibrogenic process. The aggregate data has not only helped lead to an understanding of the pathophysiologic basis of hepatic fibrogenesis, but it has also provided an important context with which to base novel antifibrotic therapy.

Resolving fibrosis in the diseased liver: translating the scientific promise to the clinic

Liver fibrosis and its end-stage disease cirrhosis are a major cause of mortality and morbidity throughout the world. Fibrosis is a response to chronic liver injury or infection that if unabated leads to the replacement of normal functional liver tissue with scar tissue. Basic research over the past decade has generated a vastly improved knowledge of the cell and molecular biology of liver fibrosis that provides a framework on which to design and develop therapeutics. The field has also witnessed a genuine paradigm shift from the original dogma that liver fibrosis is only ever a progressive process, to the new understanding that liver fibrosis even in an advanced stage can be reversible. There is therefore renewed optimism that liver fibrosis may be cured providing that we develop therapies that halt the fibrogenic process and encourage the natural regenerative properties of the liver. The key to the design of effective therapeutics will be to exploit the ongoing discoveries pertaining to the biology and function of fibrogenic hepatic myofibroblasts and their interplay with other liver cells and with the hepatic extracellular matrix. This review provides a critique of those discoveries in basic research that provide the most promise for translation to the clinic. In addition, we review the latest developments in the search for minimal invasive diagnostic tests for fibrosis that will be essential for determining the efficacy of anti-fibrotic drugs.

Methotrexate therapy for the symptomatic treatment of primary biliary cirrhosis patients, who are biochemical incomplete responders to ursodeoxycholic acid therapy

BACKGROUND

Ursodeoxycholic acid is widely used as the standard therapy for the treatment of primary biliary cirrhosis and other cholestatic liver diseases. Although it has been shown to improve biochemical markers and delay disease progression, its effect upon fatigue and pruritus, is at best uncertain.

AIM

To assess the safety and efficacy of methotrexate for treating symptomatic primary biliary cirrhosis patients who were biochemical partial responders or non-responders to ursodeoxycholic acid therapy.

METHODS

We treated eight consecutive primary biliary cirrhosis patients with methotrexate who were followed in a single hepatology clinical practice, who were symptomatic, and who had had an incomplete biochemical response to ursodeoxycholic acid therapy. Pruritus and fatigue were assessed at each clinic visit and graded from 0 (asymptomatic) to 4 (incapacitating).

RESULTS

The median dose of methotrexate was 13.75 mg/week (range 7.5-15) and the mean duration of methotrexate therapy was 49 months (range 11-126). At the end of follow-up pruritus in six of seven patients had improved, and fatigue in all patients had improved with the addition of methotrexate therapy (pruritus: baseline 2.9 +/- 1.1 vs. end of treatment 0.6 +/- 1.5, P < or = 0.0175, and fatigue: baseline 3.0 +/- 0.8, vs. end of treatment 1.0 +/- 0.8, P < or = 0.0023). Improvement in symptoms was associated with a significant improvement in biochemical markers of cholestasis. No significant adverse effects of methotrexate were documented.

CONCLUSIONS

Methotrexate should be considered as a potential additive treatment for symptomatic primary biliary cirrhosis patients who are incomplete biochemical responders to ursodeoxycholic acid therapy.

Reversal of fibrosis: no longer a pipe dream?

The reversal of liver fibrosis is not a new phenomenon. Treatment of the primary disease remains the most effective strategy, but new approaches to promote resolution of fibrosis are being built on the foundations that were provided by research into the basic mechanisms of fibrogenesis. A return to normal hepatic architecture from advanced fibrosis is achievable in some cases, and cirrhosis itself may be partly remediable.

Reversibility of hepatic fibrosis in treated genetic hemochromatosis: a study of 36 cases

The current study was undertaken to assess whether fibrosis could regress under venesection therapy in patients with C282Y homozygous genetic hemochromatosis. The 36 patients studied were recruited from a subfile of our database consisting of 125 C282Y homozygotes with either severe fibrosis or cirrhosis (F3 or F4 fibrosis stage, respectively, according to the METAVIR grading system). The second liver biopsy was performed for management of liver cancer, extrahepatic surgery, or assessment of liver fibrosis. All paired biopsies were reviewed by two pathologists without knowledge of clinical data. Among the 13 patients who had F3 fibrosis on their initial liver biopsy, 3 had F0, 6 had F1, and 2 had F2 on their second liver biopsy. Among the 23 patients with cirrhosis on their initial liver biopsy, 1 had F0, 4 had F1, 3 had F2, and 2 had F3 on their second liver biopsy. When defining regression of fibrosis as a decrease of at least 2 METAVIR units, fibrosis regressed in 9 of 13 (69%) F3 and in 8 of 23 (35%) F4. When the ratio of gammaglobulins (g/L) to (platelets [n/mm(3)] x prothrombin activity [%]) was greater than 7.5, fibrosis never regressed. In conclusion, these data extend the concept of regression of fibrosis to patients with treated genetic hemochromatosis and suggest that some simple biochemical tests would be predictive of further regression of fibrosis as a result of venesection therapy. If confirmed on larger series, this could modify the ultrasound screening policy of hepatocellular carcinoma in genetic hemochromatosis.

Portal collagenase administration reverses carbon tetrachloride-induced rabbit liver cirrhosis

AIM: To investigate whether portal collagenase administration can reverse liver cirrhosis.

METHODS: Four normal controls (group A) received olive oil subcutaneously (sc) for 12 weeks followed by normal saline portal perfusion for 12 weeks. Another four rabbits (group B) received carbon tetrachloride (CCl₄) sc for 12 weeks and then 6 mg of collagenase portally for 12 weeks, while three control rabbits (group C) received CCl₄ for 12 weeks followed by saline for 12 weeks.

RESULTS: After 12 weeks of CCl₄ and another 12 weeks of portal vein perfusion, liver hydroxyproline content in collagenase-treated rabbits was significantly decreased as compared with that in saline-treated controls (177.5 ± 35.6 μg/g vs 446.3 ± 150.1 μg/g; F = 13.78, P < 0.01). Further, liver histology showed complete regression of cirrhosis in the collagenase-treated animals. No toxicity of liver, kidney, lung, brain or heart was observed histologically. Anaphylaxis occurred in 2 animals and one was fatal.

CONCLUSION: Portal administration of collagenase can promote the reversion of established liver cirrhosis in the rabbit CCl₄ model.

The role and regulation of hepatic stellate cell apoptosis in reversal of liver fibrosis

Liver fibrosis and its end-stage disease cirrhosis are major world health problems arising from chronic injury of the liver by a variety of etiological factors including viruses, alcohol and drug abuse, the metabolic syndrome, autoimmune disease and hereditary disorders of metabolism. Fibrosis is a progressive pathological process in which wound-healing myofibroblasts of the liver respond to injury by promoting replacement of the normal hepatic tissue with a scar-like matrix composed of cross-linked collagen. Until recently it was believed that this process was irreversible. However emerging experimental and clinical evidence is starting to show that even cirrhosis is potentially reversible. Key to this is the discovery that reversion of fibrosis is accompanied by clearance of hepatic stellate cells (HSC) by apoptosis. Furthermore, proof-of-concept studies in rodents have demonstrated that experimental augmentation of HSC apoptosis will promote the resolution of fibrosis. Consequently there is now considerable interest in determining the molecular events that regulate HSC apoptosis and the discovery of drugs that will stimulate HSC apoptosis in a selective manner. This review will consider the regulatory role played by growth factors (e.g. NGF, IGF-1, TGFbeta), death receptor ligands (TRAIL, FAS), components and regulators of extracellular matrix (integrins, collagen, matrix metalloproteinases and their tissue inhibitors) and signal transduction proteins and transcription factors (Rho/Rho kinase, Jun N-terminal Kinase (JNK), IkappaKinase (IKK), NF-kappa B). The potential for known pharmacological agents such as gliotoxin, sulfasalazine, benzodiazepine ligands, curcumin and tanshinone I to induce HSC apoptosis and therefore to be used therapeutically will be explored.

Spontaneous regression of hepatitis B virus-associated cirrhosis developed in childhood

We reported two cases of hepatitis B virus infection-related cirrhosis developed during childhood and followed up for more than 20 years. Both the subjects remained untreated, and ultimately regression of cirrhosis was documented by clinical (including ultrasound) and histological examination. Recent studies have already suggested that hepatitis B virus-related cirrhosis may regress after treatment, but this is the first demonstration that hepatitis B virus-associated cirrhosis developed in childhood may be a spontaneously reversible process. Subsidence of virus replication and of necro-inflammatory process and the efficiency of liver regeneration and repair might contribute to this favourable outcome.

Reversibility of experimental rabbit liver cirrhosis by portal collagenase administration

The regression of cirrhosis is associated with increased intrahepatic collagenolytic enzyme activity. We investigated whether collagenase supplementation via portal vein infusion can retard cirrhosis development and/or reverse cirrhosis. In all, 35 rabbits were initially assigned to study. However, because of high surgical mortality and infection, only 15 animals completed study. Four normal controls (group I) received olive oil subcutaneously (SC) for 12 weeks followed by normal saline portal perfusion for 12 weeks. Four (group II) received CCl(4) SC for 6 weeks followed by portal vein collagenase, 6 mg twice weekly, plus SC CCl(4) for 6 additional weeks and then killed. Four rabbits (group III) received CCl(4) SC for 12 weeks and then 6 mg of collagenase portally for 12 weeks, while three control rabbits (group IV) received CCl(4) for 12 weeks followed by saline for 12 weeks. After 12 weeks of CCl(4), liver hydroxyproline content of collagenase-treated group II (361.1+/-106.6 microg/g) was significantly reduced compared with group III+IV that had not yet received collagenase (589.0+/-162.9 microg/g; P<0.05). In the main comparison, hydroxyproline content of collagenase-treated group III (177.5+/-35.6 microg/g) was significantly decreased compared with saline-treated controls (446.3+/-150.1 microg/g; P<0.01). Further, liver histology showed complete regression of cirrhosis in the collagenase-treated animals. No toxicity of liver, kidney, lung, brain or heart was observed histologically. Anaphylaxis occurred in 2/35 original animals (one fatal). In conclusion, this study provides 'proof of principle' that collagenase portal administration can retard cirrhosis development and speed regression of established cirrhosis in the rabbit CCl(4) model. Potential application to humans is premature, but feasible, if these findings are confirmed in additional animal studies.

Methotrexate for primary biliary cirrhosis

BACKGROUND

Methotrexate, a folic acid antagonist with immunosuppressive properties, has been used to treat patients with primary biliary cirrhosis. The therapeutic responses to methotrexate in randomised clinical trials have been heterogeneous.

OBJECTIVES

To assess the beneficial and harmful effects of methotrexate for patients with primary biliary cirrhosis.

SEARCH STRATEGY

Relevant randomised clinical trials were identified by searching The Cochrane Hepato-Biliary Group Controlled Trials Register (June 2004), The Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 2, 2004), MEDLINE (January 1966 to August 2004), EMBASE (January 1980 to August 2004), and manual searches of bibliographies. We contacted authors of trials and pharmaceutical companies.

SELECTION CRITERIA

Randomised clinical trials comparing methotrexate with placebo, no intervention, or another drug were included irrespective of blinding, language, year of publication, and publication status.

DATA COLLECTION AND ANALYSIS

Our primary outcomes were mortality and mortality or liver transplantation. Dichotomous outcomes were reported as relative risk (RR) and hazard ratio (HR) if applicable. Continuous outcomes were reported as weighted mean difference (WMD). We examined intervention effects by using both a random-effects model and a fixed-effect model. Heterogeneity was investigated by subgroup analyses and sensitivity analyses.

MAIN RESULTS

We identified four trials (370 patients) that compared methotrexate with placebo with or without ursodeoxycholic acid as co-intervention. One additional trial (87 patients) compared methotrexate with colchicine without and later with ursodeoxycholic acid as co-intervention. The methodological quality of the trials was low. We did not find significant effects of methotrexate on pruritus, fatigue, liver complications, liver biochemistry, liver histology, or adverse events. The pruritus score (WMD - 0.68, 95% CI - 1.11 to - 0.25), the levels of serum alkaline phosphatases (WMD - 0.41, 95% CI - 0.70 to - 0.12) and plasma immunoglobulin M (WMD - 0.47, 95% CI - 0.74 to - 0.20) were significantly lower in the patients receiving methotrexate.

AUTHORS' CONCLUSIONS

Methotrexate increased mortality in patients with primary biliary cirrhosis. We do not recommend methotrexate for patients with primary biliary cirrhosis outside randomised trials.

Antioxidant and antiproliferative activities of Spirulina and Chlorella water extracts

Liver fibrosis is a chronic liver disease that will further develop to cirrhosis if severe damage continues to form. A potential treatment for liver fibrosis is to inhibit activated hepatic stellate cell (HSC) proliferation and, subsequently, to induce HSC apoptosis. It has been reported that antioxidants are able to inhibit the proliferation of HSCs. In this study, the aqueous extract of spirulina was chosen as the source of antioxidant to investigate the inhibitory effect on the proliferation of HSC. The growth inhibitory effects of aqueous spirulina and chlorella extract on human liver cancer cells, HepG2, were also studied and compared in pairs. Results indicated that the total phenol content of spirulina was almost five times greater than that of chlorella (6.86 +/- 0.58 vs 1.44 +/- 0.04 mg tannic acid equivalent/g of algae powder, respectively). The antioxidant activity of spirulina determined by the ABTS*+ method was higher than chlorella (EC50: 72.44 +/- 0.24 micromol of trolox equivalent/g of spirulina extract vs 56.09 +/- 1.99 micromol of trolox equivalent/g of chlorella extract). Results of DPPH* assay also showed a similar trend as the ABTS*+ assay (EC50: 19.39 +/- 0.65 micromol of ascorbic acid equivalent/g of spirulina extract vs 14.04 +/- 1.06 micromol of ascorbic acid equivalent/g of chlorella extract). The aqueous extracts of these two algae both showed antiproliferative effects on HSC and HepG2, but spirulina was a stronger inhibitor than chlorella. Annexin-V staining showed that aqueous extract of spirulina induced apoptosis of HSC after 12 h of treatment. In addition, the aqueous extract of spirulina triggered a cell cycle arrest of HSC at the G2/M phase.

Antifibrotic therapy in chronic liver disease

The response to injury is one of wound healing and, subsequently, fibrosis. This response is generalized, occurring in diverse organ systems. Injury and wounding in the liver ultimately lead to cirrhosis in many patients (although not all patients), and are the result of many different diseases. The fact that various diseases result in cirrhosis suggests a common pathogenesis. Study over the past 2 decades has shed considerable light on the pathogenesis of fibrosis and cirrhosis. A growing body of literature indicates that the hepatic stellate cell is a central component in the fibrogenic process. Stellate cells undergo a transformation during injury that has been termed activation. Activation is complex and multifaceted, but one of its most prominent features is the synthesis of large amounts of extracellular matrix, resulting in deposition of scar or fibrous tissue. The fibrogenic process is dynamic; it is noteworthy that even advanced fibrosis (or cirrhosis) is reversible. The best antifibrotic therapy is treatment of the underlying disease. For example, eradication of hepatitis B or C virus can lead to the reversal of fibrosis. In situations in which treating the underlying process is not possible, specific antifibrotic therapy is desirable. A number of specific antifibrotic therapies have been tried, but have been met with poor or mediocre success. However, elucidation of the mechanisms responsible for fibrogenesis, with particular emphasis on stellate cell biology, has highlighted many putative novel therapies. This article emphasizes mechanisms underlying fibrogenesis, and reviews current antifibrotic therapies as well as potential future approaches.

Improved effects of viral gene delivery of human uPA plus biliodigestive anastomosis induce recovery from experimental biliary cirrhosis

Gene therapy may represent a new avenue for the development of multimodal treatment for diverse forms of cirrhosis. This study explores the potential benefits of combining adenovirus-mediated human urokinase-plasminogen activator (AdHuPA) gene delivery and biliodigestive anastomosis to enhance the therapeutic efficacy of each treatment alone for cholestatic disorders resulting in secondary biliary cirrhosis. In an experimental model of secondary biliary cirrhosis, application of 6 x 10(11) vp/kg AdHuPA adenovirus vector resulted in 25.8% liver fibrosis reduction and some improvement in liver histology. The relief of bile cholestasis by a surgical procedure (biliodigestive anastomosis) combined with AdHuPA hepatic gene delivery rendered a synergistic effect, with a substantial 56.9 to 42.9% fibrosis decrease. AdHuPA transduction resulted in clear-cut expression of human uPA protein detected by immunohistochemistry and induction of up-regulation in the expression of metalloproteinases MMP-3, MMP-9, and MMP-2. Importantly, functional hepatic tests, specifically direct bilirubin, were improved. Also, hepatic cell regeneration, rearrangement of hepatic architecture, ascites, and gastric varices improved in cirrhotic rats treated with AdHuPA but not in counterpart AdGFP cirrhotic animals. We believe this might represent a novel therapeutic strategy for human cholestatic diseases.

Clinical, biochemical and imaging-verified regression of hepatitis B-induced cirrhosis

In a 65-year-old patient with ascites, jaundice and positive hepatitis B surface antigen (HBsAg), the histological diagnosis of cirrhosis with knodell total score 13 was made in 1995. The patient was followed up for 8 years. Spontaneous seroconversion of HBsAg appeared. Except for slight hyperbilirubinemia, all pathologic, clinical laboratory data remained normal from the second year of diagnosis till 8 years of follow-up. In the last follow up, the markers of liver fibrosis were all normal. The portal vein diameter was decreased and the esophageal varices disappeared. The imaging of liver by sonography and CT-scan did not reveal any abnormality.