Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

[Epidemiology and clinical characteristics of patients with chronic hepatitis B (CHB) in Germany - results of a nationwide cross-sectional study]

BACKGROUND AND AIMS

Knowledge about the epidemiology, demography and social status of patients with replicative chronic hepatitis B (CHB) in Germany is still scarce. This cross-sectional study evaluated in patients with chronic hepatitis B infection, with a serum HBV-DNA concentration of at least 10,000 copies/mL (> 2000 IU/mL) at documentation visit, the epidemiology, socio-demographics, time of diagnosis, history of disease, prior therapies as well the therapeutic decision.

METHODS

74 German centres with predominately hepatologic focus, recorded in an online-survey the pseudonymised data of patients with chronic HBV-infection with a serum HBV-DNA-concentration of at least 10,000 copies/mL (n = 35).

RESULTS

65 % of the patients were male. The mean age was 40 ± 14 years. 63 % were immigrants (i. e., country of birth not being Germany). 37 % were HBeAg-positive. Mean ALT value 114 ± 183 IU/mL in males and 77 ± 176 IU/mL in females. ALT was above the upper limit of normal (ULN) in 59 % and 9 % of the patients were cirrhotic. The large immigrant groups, Turks (22 %), people from the former USSR (11 %) or from Southeast Asia (10 %) differed in terms of age, sex, HBeAg-status and clinical parameters clearly from each other as well as from German patients. 55 % of the patients from SE-Asia were female and overall considerably younger than German patients. 69 % of the patients with HBV-DNA > 10,000 copies/mL combined with ALT-levels above ULN, and 87 % with advanced fibrosis recieved antiviral treatment.

CONCLUSIONS

This database currently contains the largest collection of epidemiological data of CHB patients in Germany. It therefore allows a representative overview on the disease in Germany. In Germany CHB epidemiology is triggered by migration from countries with higher CHB prevalence. However, the high proportion of patients coming from states of the former USSR is likely to be a historical peculiarity of Germany. The sometimes weak German language skills as well as the cultural specifics in the different immigrant groups are still a challenge for health-care providers. The high proportion of viraemic patients, already being treated, could indicate a suboptimal efficacy of the available therapeutic options at the time documentation.

Expert opinion on the treatment of patients with chronic hepatitis C

The current preferred treatment for patients with hepatitis C virus (HCV) is combination therapy consisting of pegylated interferon alfa and ribavirin (RBV) for 24-48 weeks. Although this approach appears to be highly effective for patients with HCV genotypes 2 or 3, who have a sustained virological response (SVR) of approximately 80%, the treatment algorithm is less effective for patients with HCV genotype 1, as these patients have SVR rates of just 40-50%. In order to improve treatment outcomes, this article explores potential approaches for the optimization of treatment for patients with HCV genotype 1: considering shorter treatment periods for patients with a rapid virological response (RVR), increasing treatment periods for slow responders, and increasing RBV dose are all suggestions. Results from clinical trials suggest that approximately 20% of the HCV genotype 1-infected population are slow responders, and around 15% of all HCV genotype-1 infected patients could benefit from a shorter treatment duration without compromising the SVR rate. Interest has also focused on whether treatment duration could be individualized in some patients with genotype 2 and 3 infection. Here all the findings from recent studies are translated into practical advice, to help practitioners make evidence-based treatment decisions in everyday clinical practice. Although there are areas where currently available data do not provide conclusive evidence to suggest amending treatment approaches, there is clearly potential for individualized treatment in all aspects of hepatitis treatment in the future.

[Epidemiology of chronic hepatitis C in Germany--an analysis of 10,326 patients in hepatitis centres and outpatient units]

Little is known about the epidemiology of chronic hepatitis C (CHC) in Germany and especially about the importance of transmission, duration of infection, genotypes, symptoms and quality of life of the patients. The current study prospectively evaluates epidemiological and clinical data of patients infected with the hepatitis C virus (HCV). Using online data entry, various characteristics of 10,326 untreated patients with CHC were documented from March 2003 until May 2006 in 352 centres all over Germany. Mean age of patients was 43.4 years. Patients infected by i.v. drug abuse were considerably younger (36.5 years) than the remaining patients (49.2 years). As indicated by their native language, 64.4% of the patients came from Germany and 19.2% from Russia. 61.7% were infected with genotype 1 and 34.9% with genotype 2 or 3. 45.5% of the patients had been infected by i.v. drug abuse. In at least 5.4% of the patients liver cirrhosis had been proved by biopsy. 63.5% of the patients felt an impairment of quality of life caused by CHC. In many patients infected with hepatitis C socio-economic issues are existent. This is reflected, i.e., in very high rates of unemployment in special subpopulations. Coinfections with hepatitis B and HIV occurred in 1.5% and 4.7%, respectively. Nearly 80% of patients were managed near their homes. The data of the 10 326 patients represent about 2% of all German patients with CHC. This database is up to now the largest of its kind and gives a representative insight into the epidemiological situation of CHC in Germany.

Renal tubular dysfunction in patients with inflammatory bowel disease treated with aminosalicylate

BACKGROUND

An increasing number of case reports indicate potential nephrotoxicity of 5-aminosalicylic acid (5-ASA), which shares similarities with the chemical structures of both phenacetin and acetylsalicylic acid.

AIM

In a point prevalence study the occurrence of sensitive indices indicative of early kidney malfunction was assessed in outpatients with inflammatory bowel disease.

METHODS

Routine indices of kidney function (creatinine clearance, urinary protein content, pH, electrolytes, and microscopy) were investigated in 223 patients with inflammatory bowel disease as well as sensitive markers of glomerular or tubular dysfunction (microproteinuria by SDS polyacrylamide gel electrophoresis (SDS-PAGE), urinary concentrations of N-acetyl-beta-D-glucosaminidase, alpha 1-microglobulin, gamma-glutamyltransferase (GGT), alkaline phosphatase (AP), and albumin). Histories of exposure to 5-ASA were assessed by questionnaire.

RESULTS

Patients receiving high amounts of 5-ASA, both actual as well as on a lifetime basis, showed an increased prevalence of tubular proteinuria by SDS-PAGE. Raised values for urinary AP and GGT indicate proximal tubular epithelial cells as the source. All other kidney function tests were normal. Analysis of covariates indicated strong associations between disease activity and size of 5-ASA doses as well as alterations in kidney tubular function.

CONCLUSION

The possibility exists that high doses of 5-ASA may be associated with proximal tubular proteinuria. This point prevalence study cannot dissect the possible impact of chronic inflammation from high dose 5-ASA treatment and further prospective studies are warranted.

Ornithine decarboxylase levels in patients with normal colonic mucosa

We describe a systematic examination of ornithine decarboxylase activity in 120 colonic mucosal samples which were obtained from 20 subjects without colonic disease to establish the normal mean and standard deviation from proximal to distal colon. Ornithine decarboxylase activity was determined by releasing CO2 from DL-[1-14C]ornithine. The mean ornithine decarboxylase levels (CO2 liberated) ranged from 0.26 +/- 0.08 nmol/h.mg protein in the caecum to 0.44 +/- 0.16 nmol/h.mg protein in the rectum. There was no difference between sex and age. Ornithine decarboxylase was not stimulated by guanosine 5'-triphosphate. alpha-Difluoromethylornithine showed an ornithine decarboxylase inhibition of 97.1%. Ornithine decarboxylase activity can be measured with reliable precision and reproducibility. The knowledge of the normal range of ornithine decarboxylase activity in normal human colonic mucosa is necessary for the determination of ornithine decarboxylase activity in pathological findings, especially in malignant transformation.

[Endosonographic findings in the upper gastrointestinal tract in staging of malignant nodal and extranodal lymphomas]

Endoscopic ultrasound has not yet become a routine procedure for the diagnosis and therapy planning of malignant lymphomas, and it was always restricted to patients with gastric or bowel involvement. From 1990 to 1992, 33 endoscopic ultrasound investigations have been performed in 25 patients with malignant lymphomas at the Cologne University Hospital. In addition, 21 of these patients had other (conventional) diagnostic procedures at the same time serving as reference. Endoscopic ultrasound showed lymphomas in 16/21 patients, and no evidence of lymphomas in 5/21 patients. The referencial investigations together showed lymphomas in 17/21 patients, and no evidence of lymphomas in 4/21 patients. Therefore, sensitivity was 94%. 5 of the patients in addition had involvement of the upper gastrointestinal tract's wall, proven by referencial investigations, which was diagnosed correctly in all cases. The pathological lymph nodes appeared mostly as echopoor, rather sharply demarcated and homogeneous. Their size was 7 mm to 55 mm in diameter, median 11 mm. The different histological types of lymphomas could not be distinguished by means of these criteria. Endoscopic ultrasound allows a detailed view at the mediastinal and epigastrical lymph node stations and may give important informations for the staging of malignant lymphomas.

Cisapride increases gallbladder volume in gallstone patients before and after extracorporeal shock wave lithotripsy

We have previously shown that oral cisapride causes a dose-related increase of fasting gallbladder volume in healthy subjects. The present study investigates the effect of cisapride on gallbladder motility in 16 patients with gallbladder stones; 8 patients had no biliary symptoms, but the other 8 patients with symptomatic gallstone disease were studied before and 6 weeks after extracorporeal shock wave lithotripsy (ESWL). For each study the patients received a single oral dose of 20 mg cisapride; fasting gallbladder volume was measured by ultrasound before, and for 120 minutes after, drug administration. In the 8 asymptomatic patients a mean maximal increase of the fasting volume to 152.7 +/- 7.6% of the initial value was observed at a mean 97.5 +/- 8.3 minutes after cisapride ingestion. Similarly, in the 8 patients with biliary pain mean fasting volume after cisapride ingestion increased to 141.3 +/- 5.7% before ESWL treatment and to 145.0 +/- 5.8% after ESWL and 6 weeks of oral litholytic therapy. There were no significant differences between the results in the symptomatic and asymptomatic patients. Our results indicate that cisapride increases the gallbladder volume in gallstone patients regardless of biliary symptoms. Similar volume changes were observed before therapy and after ESWL with bile acid therapy. The therapeutic efficacy of litholytic agents could be diminished by simultaneous cisapride administration.

Induced gall-bladder contraction accelerates fragment clearance after extracorporeal shockwave lithotripsy

At the end of extracorporeal shockwave lithotripsy (ESWL) gallstone fragments are dispersed throughout the gall-bladder. In this state they should be expelled more easily than when later sedimented to the gall-bladder fundus. Thus, a randomized study was performed to evaluate the clinical benefit of induced gall-bladder contraction after ESWL. One hundred and five patients with radiolucent gallstones (1-3 stones, diameter < or = 30 mm) were randomized to received either saline or an infusion of 0.2 micrograms/kg ceruletide. Stone clearance rates and incidence of biliary symptoms were recorded. Clearance rates at 6 weeks and 3 months after ESWL were significantly (P < 0.025) improved by the ceruletide infusion. This effect, resulting in shortened bile acid therapy, was limited to patients with small solitary stones and dependent on a good initial fragmentation. Major side effects attributable to ceruletide were not observed. These results suggest that induced gall-bladder contraction can be successfully applied as an adjuvant treatment in a subgroup of patients with small solitary gallstones.

Comparison between endoscopic laser and different surgical treatments for palliation of advanced rectal cancer

The results of different treatment modalities in 196 patients with rectal carcinoma were analyzed. Patients were treated by palliative endoscopic laser therapy (n = 37), palliative surgery (n = 42), and curative surgery (n = 117). Laser therapy was successful for recanalization of the stenosis with 1.3 (range, one to five) sessions. Bleeding stopped always after a single session. If necessary, treatment was repeated monthly. Good results were seen in 35/37 patients (95 percent). They received an average of four sessions during their remaining lifetime, the median of which was eight months. No morbidity and no therapy-related mortality occurred. Palliative surgery (expanded and restricted resections) showed good results in 41/42 patients (98 percent). Morbidity was 3/42 (7 percent); mortality was 1/42 (2 percent). The median survival was 14 months for local surgical treatment and 6.3 months for deep anterior rectal resection and for abdominoperineal (Dixon's) resection. No significant difference (P = 0.15) in survival times between the palliatively treated patient groups could be detected. Survival prognosis was determined by tumor stage and outcome. In the curative (outcome R0) resection patients, morbidity and mortality were each 9/117 (8 percent). The three-year survival rate was 80 percent. If curative resection is impossible, laser therapy should be considered as an alternative to palliative surgery because of less hospitalization and seemingly less side effects. The decision on the kind of palliation in patients with rectal carcinoma should be made with regard to the patient's quality of life.

Combined treatment of large and calcified gallstones by ESWL and laparoscopic cholecystectomy

In order to facilitate laparoscopic cholecystectomy in the presence of large gallbladder stones seven patients underwent ESWL before operation. In six cases (83%) a fragmentation to less than or equal to 1 cm could be achieved by application of 1,605 to 2,900 (mean 2,266) shock waves with the spark-gap lithotripter Philips-Dornier MFL 5000. In these cases intraoperative stone destruction or an increase of the puncture incision size could be avoided, thus proving the efficacy of this combined treatment approach. Laparoscopic inspection was performed 2 to 48 hours after ESWL. Including two additional cases operated because of unsuccessful ESWL, hematomas of the liver and adjacent organs were observed in six of nine patients (67%). This high rate of subclinical tissue lesions warrants caution if repeated ESWL sessions are scheduled at short-term intervals.

Senna vs. bisacodyl in addition to Golytely lavage for colonoscopy preparation--a prospective randomized trial

Colonoscopy preparation with lavage is a clinically accepted procedure. After having shown that its results can be improved by the additional intake of Senna this randomized prospective trial was designed to evaluate the effects of different laxatives in a combined preparation regimen. The day before endoscopy either Bisacodyl or extractum Sennae was given to 120 patients. Immediately before examination all patients underwent whole gut irrigation with Golytely solution. Patient acceptance and effectiveness of the two procedures were excellent and no relevant intolerance was observed. Satisfactory cleansing results were achieved with Bisacodyl as well as with Senna (98.3 vs. 95%). There was no significant difference between the laxatives used. We conclude that both regimens are safe, generally well tolerated and effective ways of preparation for colonoscopy.

Addition of senna improves colonoscopy preparation with lavage: a prospective randomized trial

Attempts have been made to further improve the widely performed colonoscopy preparation with lavage. In a prospective study, 120 outpatients and inpatients scheduled for total colonoscopy were randomized to two preparatory regimens. The day before endoscopy either extractum sennae (N = 60) or a placebo solution (N = 60) was given. Just before examination all patients underwent whole gut irrigation with a polyethylene glycol electrolyte lavage solution (PEG-ELS). Adequacy of preparation, patient tolerance, and the necessary amount of PEG-ELS were assessed. Physician assessment of colon cleansing showed superiority in the group with additional laxative. The colon was free of solid debris in 66.7% of patients after PEG-ELS and in 90% after senna/PEG-ELS administration (p less than 0.01). Patient tolerance was similar in both groups with 86.7% vs. 83.3% of subjects rating the preparation as tolerable. Severe adverse events were not observed. In the senna/PEG-ELS group, significantly less (p less than 0.05) lavage fluid was needed. We conclude that the combination of senna and PEG-ELS is more effective than PEG-ELS in cleansing the colon for colonoscopy.

[A protracted course in Cardiobacterium hominis endocarditis]

A 69-year-old man without previous cardiac disease was found over the last 9 months to have a markedly elevated erythrocyte sedimentation rate (ESR: 120 mm/1. h), haemolytic anaemia (haemoglobin 8.2 g/dl, lactate dehydrogenase 304 U/l), markedly reduced exercise tolerance, backache and weight loss of 5 kg. Radiological, biochemical and endoscopic examinations failed to provide a diagnosis. Nine blood cultures grew, at normal body temperature, Cardiobacterium hominis, a rare Gram-negative organism which can cause endocarditis. Echocardiography revealed endocarditis of the aortic valve with regurgitation. Despite protracted and high-dosage antibiotics (4 times daily 10 million U penicillin G for 6 days, followed by four times 5 million U penicillin G for 6 days, followed by four times 5 million U daily for five weeks, and three times daily 60 mg gentamycin for 10 days), as well as treatment of extensive chronic parodontitis, anaemia, haemolysis and increased ESR have now persisted for over a year, with negative blood cultures. Immune-complex phenomena are thought to be the reason for the persistence of signs of infection.

[Pregnancy during cyclosporin medication following a kidney transplant]

A 33-year-old patient became pregnant two years after transplantation of a cadaver kidney and continuous cyclosporine administration. An uncomplicated spontaneous delivery of a healthy boy weighing 3360 g took place in the 40th week. Cyclosporine was demonstrated in umbilical cord and neonatal blood and in the mother's milk, but not in amniotic fluid. Because mother's milk contained one sixth the concentration of cyclosporine in maternal blood, the mother was dissuaded from breast feeding.