Previous hepatitis E virus infection is associated with increased liver stiffness in patients with autoimmune hepatitis

INTRODUCTION

Autoimmune hepatitis (AIH) is a chronic, progressive liver disease which, in most cases, may require lifelong immunosuppression. Hepatitis E virus (HEV) is a leading cause of acute, typically self-limited, hepatitis worldwide, although immunocompromised patients may develop chronic hepatitis.

OBJECTIVES

Here, we evaluated the impact of HEV seropositivity on the clinical course of AIH.

PATIENTS AND METHODS

A group of 374 adult patients with AIH (female 68%, age 34 (18-83) years, 38% with liver cirrhosis) was analyzed. Serum HEV IgG and IgM antibodies were measured by enzyme-linked immunosorbent assay, liver fibrosis was assessed by liver stiffness measurement (LSM), and liver cirrhosis was confirmed with liver histology or LSM.

RESULTS

Fifty-five (15%) patients with AIH were HEV IgG-positive. These patients were older (P <0.001) and had higher BMI and higher LSM (both P <0.05). In a multivariable model including ALT and immunoglobulin G, the HEV seropositive status was associated with an increased risk of advanced liver fibrosis with OR 3.69 (95% CI 1.26-10.77, P = 0.02) as reflected by liver stiffness ≥10.5 kPa. HEV IgG seropositivity was, however, not linked with the type of treatment or worse AIH outcome. The seroprevalence of HEV in patients with AIH was lower compared to results available for Polish blood donors (43%).

CONCLUSIONS

Patients with AIH and HEV IgG-positive status seem to be at risk of more advanced liver fibrosis. However, the overall seroprevalence of HEV IgG is a lower in patients with AIH than in the blood donors in Poland.

Free-Circulating Nucleic Acids as Biomarkers in Patients After Solid Organ Transplantation

A number types of extracellular DNA (eg, cell-free, cfDNA) circulate in human blood, including mitochondrial, transcriptome, and regulatory DNA, usually at low concentrations. Larger amounts of cfDNA appear in any inflammatory condition, including organ damage due to a variety of reasons. The role of cfDNA in solid organ transplantation is discussed in this review as a valuable additional tool in the standard of care of transplant patients. Post-transplant monitoring requires the use of high-quality biomarkers for early detection of graft damage or rejection to be able to apply early therapeutic intervention. CfDNA complements the traditional monitoring strategies, being a risk stratification tool and an important prognostic marker. However, improving the sensitivity and specificity of cfDNA detection is necessary to facilitate personalized patient management, warranting further research in terms of measurement, test standardization, and storage, processing, and shipping. A diagnostic test (Allosure, CareDx, Inc., Brisbane, CA) for kidney, heart and lung transplant patients is now commercially available, and validation for other organs (eg, liver) is pending. To date, donor-derived cfDNA in combination with other biomarkers appears to be a promising tool in graft rejection as it is minimally invasive, time-sensitive, and cost-effective. However, improvement of sensitivity and specificity is required to facilitate personalized patient management. Whether it could be an alternate to graft biopsy remains unclear.

A common variant in the hepatobiliary phospholipid transporter ABCB4 modulates liver injury in PBC but not in PSC: prospective analysis in 867 patients

BACKGROUND

The ATP-binding cassette subfamily B member 4 (ABCB4) gene encodes the hepatic phospholipid transporter. Variants in the ABCB4 gene are associated with various cholestatic phenotypes, some of which progress to liver fibrosis and cirrhosis. The aim of our study was to investigate the role of the cholestasis-associated variant ABCB4 c.711A > T (p.I237I, rs2109505) in patients with primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC).

RESULTS

Two cohorts of Polish patients took part in this study. The Szczecin cohort comprised 196 patients with PBC (174 females, 38% with cirrhosis) and 135 patients with PSC (39 females, 39% with cirrhosis). The Warsaw cohort consisted of 260 patients with PBC (241 females, 44% with cirrhosis) and 276 patients with PSC (97 females, 33% with cirrhosis). Two control cohorts-150 healthy blood donors and 318 patients without liver disease, were recruited in Szczecin and in Warsaw, respectively. The ABCB4 c.711A > T polymorphism was genotyped using TaqMan assay. In both PBC cohorts, carriers of the risk variant presented more frequently with cirrhosis (Szczecin: OR = 1.841, P = 0.025; Warsaw: OR = 1.528, P = 0.039). The risk allele was associated with increased serum AST, GGT and ALP (all P < 0.05) at inclusion. During the follow-up, patients in both cohorts significantly improved their laboratory results, independently of their ABCB4 c.711A > T genotype (P > 0.05). During 8 ± 4 years follow-up, a total of 22 patients in the Szczecin PBC group developed cirrhosis, and this risk was higher among carriers of the risk variant (OR = 5.65, P = 0.04). In contrast to PBC, we did not detect any association of ABCB4 c.711A > T with a liver phenotype in PSC cohorts.

CONCLUSIONS

The frequent pro-cholestatic variant ABCB4 c.711A > T modulates liver injury in PBC, but not in PSC. In particular, carriers of the major allele are at increased risk of progressive liver scarring.

Chronotropic incompetence in end-stage liver disease

Background

Cirrhosis causes alterations in the cardiovascular and autonomic nervous systems and leads to cirrhotic cardiomyopathy (CCM). CCM is defined as cardiac dysfunction characterized by an impaired systolic responsiveness to stress or exercise, and/or impaired diastolic function, as well as electrophysiological abnormalities, including chronotropic incompetence (CI), in the absence of other known cardiac disease. CI is a common feature of autonomic neuropathy in cirrhosis. The aim of the study is to assess the role of cardiac exercise stress test in the diagnosis of CCM.

Methods

The analysis included 160 end-stage liver disease (ESLD) patients who underwent a cardiac exercise stress test prior to the orthotopic liver transplantation. CI was defined as the inability to achieve the heart rate reserve (HRR). Pertaining to the therapy with beta-blockers: 80% of HRR was achieved in patients not taking beta-blockers and 62% in patients taking beta-blockers.

Results

In the analyzed population, 68.8% of patients met the criteria for CI. CI was more frequent in the more severe ESLD (with a higher MELD score and in a higher Child-Pugh class). In comparison to the viral hepatitis and other etiologies of ESLD, patients with alcoholic cirrhosis had a significantly lower rest heart rate (HR), lower maximal HR, lower median achieved percentage of maximal predicted HR (MPHR), a smaller percentage of patients achieved ≥ 85% of MPHR and a lower heart rate reserve. No significant relationship between the survival of OLT recipients and presence of chronotropic incompetence regarding to class of Child-Pugh scale, MELD score and etiology of ESLD were found.

Conclusions

The prevalence of CI is higher among liver transplant candidates than previously described. The altered chronotropic response may differ in regard to the severity of liver disease correlating with both the Child-Pugh and MELD scores, however CI does not seem to influence the long-term survival post OLT. Exercise stress test is a reliable, safe and useful tool for the diagnosis of CCM in liver transplant candidates and should be included in the standard cardiovascular assessment prior to OLT.

SARS-CoV-2 vaccination in liver transplant recipients: factors affecting immune response and refusal to vaccine

INTRODUCTION

The effectiveness of SARS-CoV-2 vaccination in liver transplant (LT) recipients varies between reports.

OBJECTIVES

Here, we analyzed the immune response to the vaccine, factors affecting response and reasons for vaccine refusal.

PATIENTS AND METHODS

Among 300 consecutive LT recipients, 75% were vaccinated. The humoral response was assessed by the quantitative determination of anti-trimeric spike-protein-specific-IgG antibodies to SARS-CoV-2. Thirty-four vaccinated patients with prior SARS-CoV-2 infection were analyzed separately.

RESULTS

Among 192 LT recipients vaccinated without past natural infection, 69% of them had an immune response (median time of 125 days after the second dose). Older age, worse kidney function and dual immunosuppression negatively affected the humoral response. Mycophenolate mofetil increased the risk of non-response (OR: 2.99; 95% CI: 1.45-6.19). The antibody concentration was higher in the first 90 days from the second dose and stable when comparing 90-150 days to >150 days. LT recipients with prior COVID-19 presented with a robust immune response (100%). The female gender, living in a rural area, lower BMI and younger age (all P <0.05) were associated with refusal of the vaccine.

CONCLUSIONS

The lower immune response after the vaccine among LT recipients compared to that of the general population rationalizes administering a third dose. However, more data are needed to recommend any therapy modification before vaccination.

Clinical Implication of Plasma CD163 in Patients With Acute-on-Chronic Liver Failure

BACKGROUND

It was postulated that CD163 plasma level should be incorporated into existing predictive systems to improve prognostic performance in patients with acute-on-chronic liver failure (ACLF).

PATIENTS AND METHODS

Plasma CD163 was assessed in 24 consecutive patients with ACLF (17 male, 7 female; mean age 54.9 years; 50% with alcohol-related liver disease) and compered with the existing scoring tools to predict the availability of transplantation or survival without liver transplant (LT).

RESULTS

There were no differences in plasma CD163 levels between graft recipients and deceased patients on the waiting list or transplant survivors vs nonsurvivors. CD163 did not correlate with CLIF-ACLF, CLIF Consortium organ failure score (CLIF-OF), and ACLF grades (all P < .05). However, sequential organ failure assessment (SOFA), CLIF Consortium acute-on-chronic liver failure score (CLIF-C) ACLF, and CLIF-C OF scores correlated significantly with mortality (P < .01) in contrast to Child-Pugh scale and Model for End-Stage Liver Disease score (all P > .05). Transplanted survivors and deceased individuals differed robustly with respect to the SOFA and CLIF-SOFA scores and the CLIF-C OF, CLIF-C Grade, and CLIF-C ACLF scales (all P < .05). CLIF-C performed well in ACLF prognostication with an area under receiver operating characteristic curve (AUROC) 0.893 (95% CI, 0.766-1), surpassing in that respect CD163 with AUROC of 0.664 (95% CI, 0417-0.911).

CONCLUSIONS

Our preliminary results showed that the plasma CD163 level in patients with ACLF played only a minor role in predicting LT futility/benefit, with no impact on the narrow transplant window. Moreover, to optimize LT outcomes, newly developed CLIF-C scales showed superior predictive value.

Evaluation of liver fibrosis in patients with Wilson's disease

OBJECTIVES

Staging of fibrosis in chronic liver disease is important for prognosis and treatment planning. Liver biopsy is the gold standard in fibrosis assessment; however, new methods for fibrosis and stiffness measurement exist which have not been evaluated in patients with Wilson's disease. To evaluate the accuracy of collagen proportionate area (CPA), transient elastography and shear wave elastography (SWE) in the assessment of liver fibrosis in adult patients with Wilson's disease.

METHODS

In this retrospective study of 60 patients with Wilson's disease, results of percutaneous cutting liver biopsy assessed using the Ishak fibrosis score and CPA were compared with liver stiffness measured with transient elastography and SWE.

RESULTS

CPA correlated with the Ishak score (r = 0.45; P = 0.001) and transient elastography results correlated with SWE measurements (r = 0.80; P = 0.0001). In contrast, transient elastography or SWE did not significantly correlate with the Ishak score or CPA.

CONCLUSION

Collagen content assessment may be useful for estimation of liver fibrosis in patients with Wilson's disease. However, single time-point elastographic liver stiffness measurements have a limited diagnostic value in Wilson's disease.

Kidney Function After Liver Transplantation in a Single Center

Background

Renal dysfunction in the peri-transplant period appears to complicate both short- and long-term outcome of liver transplantation (LT). The aim of this study was to analyze the impact of selected clinical features in the peri-liver transplant period, as well calcineurin inhibitor, particularly tacrolimus given after LT, on kidney function in a single liver transplant center’s experience.

Material/Methods

A total 125 consecutive liver-grafted individuals (82 M, 43 F), mean age 50±13 y (with alcohol-related liver disease in 48 (38%) patients) were included into the study. Their clinical data were collected in the database until 46 months of follow-up, and the Python packages Pandas (version 0.22.0) and scikit-learn (version 0.21.3) were used for data analysis.

Results

More advanced liver disease as judged by Child-Pugh class and MELD score differed significantly patients with preserved (serum creatinine SCr <1.5 mg/dL) and impaired (SCr ≥1.5 mg/dL) kidney function before LT. Older age and higher SCr pre-LT were associated with higher levels of SCr after LT in 2 time-points. SCr before LT was correlated with delta SCr for the highest and last recorded value (P<0.0001). Higher amounts of transfused colloids during surgery were associated with increased delta SCr for the highest value (P=0.019) after grafting in logistic regression analysis. There were no associations between SCr after LT and duration of anhepatic phase, urine output ≤100 mL/h, or post-reperfusion syndrome during transplantation (all P>0.05). There were no associations between SCr after LT and tacrolimus trough levels in analyses of correlations and linear regression analyses (all P>0.05).

Conclusions

We found that pretransplant serum creatinine was the only factor affecting kidney function after LT in our liver transplant center. The restricted fluid policy was safe and effective in terms of long-term renal function. The role of kidney-saving immunosuppressive protocols in preserving renal function long-term after LT was also confirmed.

Measurement of liver and spleen stiffness as complementary methods for assessment of liver fibrosis in autoimmune hepatitis

BACKGROUND AND AIMS

Liver stiffness measurements (LSM), commonly performed by transient elastography (TE) or two-dimensional shear wave elastography (2D-SWE), are used to quantify liver fibrosis. Active hepatitis, a hallmark of autoimmune hepatitis (AIH), could bias LSM. This bias might be overcome by measurement spleen 2D-SWE. Here, we compare liver and spleen 2D-SWE to TE and liver biopsy (LB) in prospectively recruited patients with AIH.

METHODS

We analysed liver and spleen 2D-SWE in relation to liver TE in 90 patients treated ≥ 6 months for AIH. Liver and spleen 2D-SWE were also compared to LB in 63 individuals with AIH. Finally, we evaluated these tools in 220 patients with AIH and during 18 months follow-up.

RESULTS

Liver 2D-SWE correlated with surrogate markers of active hepatitis (ALT and IgG, both P < .001) but there was no link between spleen 2D-SWE and ALT. Liver 2D-SWE, but not spleen 2D-SWE, was associated with histopathological inflammatory score (P < .01). When compared to LB, the optimal cut-offs for detecting cirrhosis by liver and spleen 2D-SWE were 16.1 kPa (AUROC 0.93) and 29.8 kPa (AUROC 0.95), respectively. In patients with active hepatitis the combined diagnostic approach including liver and spleen 2D-SWE had significantly better AUROC for detecting cirrhosis than liver 2D-SWE alone.

CONCLUSIONS

Liver and spleen 2D-SWE are reliable complementary methods for the diagnosis of advanced fibrosis in AIH. Spleen 2D-SWE seems to be less biased by inflammation and could facilitate fibrosis assessment in therapy-naïve patients or in the presence of active hepatitis.

Synergistic effects of extracellular vesicle phenotyping and AFP in hepatobiliary cancer differentiation

BACKGROUND

Biliary cancer, comprising cholangio- and gallbladder carcinomas, is associated with high mortality due to asymptomatic disease onset and resulting late diagnosis. Currently, no robust diagnostic biomarker is clinically available. Therefore, we explored the feasibility of extracellular vesicles (EVs) as a liquid biopsy tool for biliary cancer screening and hepatobiliary cancer differentiation.

METHODS

Serum EVs of biliary cancer, hepatocellular carcinoma, colorectal cancer and non-small cell lung cancer patients, as well as from healthy individuals, were isolated by sequential two-step centrifugation and presence of indicated EVs was evaluated by fluorescence activated cell sorting (FACS) analysis.

RESULTS

Two directly tumour-related antigen combinations (AnnV⁺ CD44v6⁺ and AnnV⁺ CD44v6⁺ CD133⁺ ) and two combinations related to progenitor cells from the tumour microenvironment (AnnV⁺ CD133⁺ gp38⁺ and AnnV⁺ EpCAM⁺ CD133⁺ gp38⁺ ) were associated with good diagnostic performances that could potentially be used for clinical assessment of biliary cancer and differentiation from other cancer entities. With 91% sensitivity and 69% specificity AnnV⁺ CD44v6⁺ EVs showed the most promising results for differentiating biliary cancers from HCC. Moreover using a combined approach of EV levels of the four populations with serum AFP values, we obtained a perfect separation of biliary cancer and HCC with sensitivity, specificity, positive and negative predictive value all reaching 100% respectively.

CONCLUSIONS

EV phenotyping, especially if combined with serum AFP, represents a minimally invasive, accurate liquid biopsy tool that could improve cancer screening and differential diagnosis of hepatobiliary malignancies.

Liver volume: a point of no return in liver transplantation?

INTRODUCTION

In patients with cirrhosis, only a 75% liver volume (LV) is expected compared with age‑matched healthy individuals. Changes in LV might be an indicator of therapeutic effectiveness or disease progression.

OBJECTIVES

To establish whether LV is a prognostic factor in chronic liver disease irrespective of etiology and LV impacts the outcomes of liver transplant (LT).

PATIENTS AND METHODS

In total, 135 consecutive LT recipients were prospectively included in this study: 38 women and 97 men. The median (minimum-maximum) age was 51 (21-70) years; body mass index (BMI), 27.3 (17.3-39.2) kg/m2; Child-Pugh class (CPC), C; Model of End‑Stage Liver Disease (MELD), 16 (7-47) points; and the third lumbar vertebra skeletal muscle index (L3SMI), 47.7 (19.7-73.4) cm2/m2. Liver volume and L3SMI were calculated based on computed tomography scans at listing for LT. The receiver operating characteristic (ROC) curve was analyzed to determine the accuracy of LV in mortality prediction after LT.

RESULTS

Liver volume differed significantly among patients in terms of chronic liver disease etiology, with the lowest values noted in those with hepatitis C virus infection. Liver volume was neither a prognostic factor of disease progression and need for LT with respect to the CPC and MELD scores nor correlated with BMI and L3SMI (P >0.05). The area under the ROC curve of LV in mortality prediction was 0.573 (95% CI, 0.403-0.743). Liver volume smaller than the median tended to be positively associated with the risk of prolonged intensive care unit stay and death (P = 0.057 and P = 0.058, respectively).

CONCLUSIONS

Low liver volume did not seem be a point of no return in LT candidates.

Acute liver injury, acute liver failure and acute on chronic liver failure: A clinical spectrum of poisoning due to Gyromitra esculenta

Gyromitra esculenta, also known as "false morel" is one of the most poisonous mushrooms. This species is found all over the world, growing in coniferous forest in early spring time. Common manifestation of poisoning includes gastrointestinal symptoms which include varied degrees of liver impairment. We describe three cases: acute liver injury, acute liver failure and acute-on-chronic liver failure due to G. esculenta poisoning. At admission patients presented with encephalopathy and features of liver failure. Two of them recovered completely following supportive management while the remaining patient who also had preexisting liver disease developed multiorgan failure and subsequently died. Although a rare occurrence, G. esculenta poisoning should be considered in the differential diagnosis of acute liver failure.

Acute-On-Chronic Liver Failure: The Role of Prognostic Scores in a Single-Center Experience

Background

Acute-on-chronic liver failure (ACLF) is associated with multi-organ failure and high short-term mortality. We evaluated the role of currently available prognostic scores for prediction of 90-day mortality in ACLF patients.

Material/Methods

Fifty-five (M/F=40/15, mean age 60.0±11.1years) consecutive cirrhotic patients with severe liver insufficiency (mean MELD 28.4±9.0, Child-Pugh score – C-12) were enrolled into the study. MELD variants and SOFA, CLIF-SOFA, and CLIF-C scores were calculated, mortality predicting factors were identified, and clinical comparisons between ACLF and AD patients were performed.

Results

In total, 30 (55%) patients were transplanted (22 ACLF and 8 AD), and 20 (30%) died (19 ACLF and 1 AD). Five (9%) patients survived without liver transplantation (LT) (3 ACLF and 2 AD), and 3 transplant recipients died within 1 month. SOFA, CLIF-SOFA, CLIF-C OF, and INR were significantly associated with the incidence of 90-day mortality in competing risk regression analysis (all p<0.001). The model based on SOFA had the lowest BIC, with the optimal cut-off for 90-day mortality prediction ≥12, with the area under the receiver operating characteristic (AUROC) of 0.901 (95% CI 0.779–1.000; p<0.001), and corresponding incidence of transplantation rates of 85.5% and 11.8%, respectively (p<0.001). Of note, the important role of 24-h urine output is emphasized.

Conclusions

In this series of ACLF patients, SOFA score outperformed the CLIF-C scores in predicting 90-day mortality. Multi-organ failure scores performed better in predicting patient mortality than conventional liver function assessment. LT is possible and remains effective in selected ACLF patients.

5-Lipooxygenase Derivatives as Serum Biomarkers of a Successful Dietary Intervention in Patients with NonAlcoholic Fatty Liver Disease

Background: It was previously shown that a bodyweight reduction among patients with nonalcoholic fatty liver (NAFLD) was connected to the lower concentration of arachidonic and linoleic acid derivatives in their blood. We hypothesized that the concentration of these lipids was correlated with the extent of their body mass reduction and, thus, liver steatosis. Methods: We analyzed 68 individuals who completed the dietary intervention. Patients were divided into two groups depending on their body mass reduction (more or less than 7%). Before and after the dietary intervention, all patients had the following measurements recorded: body mass, waist circumference, stage of steatosis, fatty liver index, liver enzymes, lipid parameters, insulin and glucose. Concentrations of lipoxins A4 (LTX A4), hydroxyeicosatetraenoic fatty acids (5(S)-HETE, 12(S)-HETE and 16(S)-HETE), hydroxyoctadecaenoic acids (9(S)-HODE and 13(S)-HODE) and 5-oxo-eicosatetraenoic acid (5-oxo-ETE) were measured in serum samples collected before and after the dietetic intervention using high-performance liquid chromatography (HPLC). Results: Patients who reduced their body mass by more than 7% revealed a significant improvement in their steatosis stage, waist circumference, fatty liver index, triglycerides and cholesterol. Conclusion: A reduction in body mass by more than 7% but not by less than 7% revealed a significant improvement in steatosis stage; waist circumference; fatty liver index; and levels of triglycerides, cholesterol, 5-oxo-ETE and LTXA-4.

Immunosuppressive treatment with everolimus in patients after liver transplant: 4 years of single-center experience

INTRODUCTION

Everolimus after liver transplant (LT) has been used to minimize the use of calcineurin inhibitors (CNIs), optimize renal function, and prevent recurre nce of hepatocellular carcinoma (HCC).

OBJECTIVES

We aimed to analyze a single‑center experience with switching from CNIs to everolimus in immunossupressive treatment of LT recipients.

PATIENTS AND METHODS

A total of 108 LT recipients (men, 65.7%; mean [SD] age, 53.2 [11.1] years) were prospectively enrolled into the study. In all patients, everolimus and CNIs were introduced (target trough levels of 3 to 6 ng/ml and 3 to 5 ng/ml, respectively). After 3 months, CNIs were discontinued in patients who tolerated everolimus well, while everolimus dosage was increased (blood trough levels, 6-12 ng/ml).

RESULTS

Everolimus monotherapy was introduced in 32 patients (29.6%), while a combination therapy with everolimus and CNIs was continued in 76 patients (70.4%). However, during a mean follow‑up of 27 months (range, 4-50 months), everolimus was withdrawn in 25 patients (33%) due to side effects. In the everolimus‑monotherapy group, all patients continued the therapy (P <0.005), but dyslipidemia was more frequent than in patients receiving everolimus and CNIs (40.6% vs 14.5%; P <0.03). Creatinine levels improved significantly in both groups: combination therapy, from 1.58 mg/dl to 1.24 mg/dl after 3 months, and everolimus monotherapy, from 1.19 mg/dl to more than 1 mg/dl. Renal function in the everolimus group was better than in the combination-therapy group (P <0.04). Recurrence of HCC was observed in both groups: combination therapy (9/46 [19.6%]) and everolimus monotherapy (1/17 [5.9%]; P <0.01).

CONCLUSIONS

This study showed that switching from CNIs to everolimus after LT allowed a safe weaning of CNIs and an improvement in creatinine levels. In patients on everolimus monotherapy, we observed dyslipidemia as a dose‑dependent side effect of the drug as well as a lower risk of HCC recurrence.

Intermittent high-flux albumin dialysis with continuous venovenous hemodialysis for acute-on-chronic liver failure and acute kidney injury

Acute-on-chronic liver failure (ACLF) requiring intensive medical care and associated with acute kidney injury (AKI) has a mortality rate as high as 90% due to the lack of effective therapies. In this study, we assessed the effects of intermittent high-flux single-pass albumin dialysis (SPAD) coupled with continuous venovenous hemodialysis (CVVHD) on 28-day and 90-day survival and an array of clinical and laboratory parameters in patients with severe ACLF and renal insufficiency. Sixteen patients were studied. The diagnosis of ACLF and AKI was made in accordance with current EASL Clinical Practice Guidelines, including the recommendations of the International Club of Ascites. All patients received SPAD/CVVHD treatments as the blood purification therapy to support liver, kidneys, and other organs. Five patients were transplanted and 11 were not listed for transplantation because of active alcoholism. Data at the initiation of SPAD/CVVHD were compared with early morning data after the termination of the extracorporeal treatment phase. All patients had ACLF and renal insufficiency with 13/16 additionally fulfilling the AKI criteria. A total of 37 SPAD/CVVHD treatments were performed [2.3 ± 1.4]. The baseline MELD-Na score was 37.6 ± 6.6 and decreased to 33.4 ± 8.7 after SPAD/CVVHD (P < 0.001). In parallel, the CLIF-C ACLF grade and OF score, estimated at 28- and 90-day mortality, AKI stage, hepatic encephalopathy grade, and liver function tests were lowered (P = 0.001-0.032). The 28- and 90-day survivals were 56.2% overall and 53.8% in AKI. Survival in patients not transplanted (n = 11) was 45.4%. In patients with severe ACLF and AKI, the renal replacement therapy coupled with high-performance albumin dialysis improved estimated 28- and 90-day survival and several key clinical and laboratory parameters. It is postulated that these results may be further improved with earlier intervention and more SPAD treatments per patient. High-performance albumin dialysis improves survival and key clinical and laboratory parameters in severe ACLF and AKI.

Fulminant liver failure following a marathon: Five case reports and review of literature

BACKGROUND

The growing popularity of marathon and half-marathon runs has led to an increased number of patients presenting with exertion-induced heat stroke. Mild hepatic involvement is often observed in these patients; however, fulminant liver failure may occur in approximately 5% of all cases. Liver transplantation is a potentially curative approach for exertion-induced liver failure, although there is a lack of consensus regarding the criteria and optimal timing of this intervention.

CASE SUMMARY

This paper describes 5 patients (4 men and 1 woman) who were referred to the department where this study was performed with the diagnosis of exertion-induced acute liver failure. Three patients underwent liver transplantation, 1 recovered spontaneously, and 1 patient died on day 11 following the exertion.

CONCLUSION

Exertion-induced heat stroke may present as fulminant liver failure. These patients may recover with conservative treatment, may require liver transplantation, or may die. No definitive criteria are available to determine patient suitability for a conservative vs surgical approach.

Renaissance of Modified Charlson Comorbidity Index in Prediction of Short- and Long-Term Survival After Liver Transplantation?

Background

Orthotopic liver transplantation (OLT) is the standard of care for end-stage liver disease. The Charlson Comorbidity Index (CCI) was originally created to assess the survival rate of patients with chronic diseases, although it was modified and adopted in OLT recipients as CCI-OLT.

Material/Methods

In total of 248 consecutive liver transplant recipients with viral cirrhosis in 98 (39.5%) patients were included. CCI-OLT was calculated assigning a weight of 3 to chronic obstructive pulmonary disease; weight of 2 to coronary artery disease, connective tissue disease, and renal insufficiency; and a weight of 1 to diabetes mellitus.

Results

CCI-OLT was significantly correlated with recipient age (p<0.001; R=0.333) and was a significant risk factor for early post-transplant mortality (p=0.004). The presence of diabetes mellitus significantly increased the odds of early mortality (p=0.010). The optimal cut-off for CCI-OLT in prediction of mortality during the first 90 days after transplantation was ≥1, with an AUROC of 0.780 (95% CI: 0.670–0.891; p<0.001). Increasing CCI-OLT was a significant risk factor for worse 5-year post-transplant survival (p=0.001), along with coronary artery disease (p=0.008) and diabetes mellitus (p=0.021). The optimal cut-off for prediction of 5-year mortality for CCI-OLT was ≥1, with the AUROC of 0.638 (95% CI: 0.544–0.733; p=0.004).

Conclusions

CCI-OLT is a useful tool for measuring the effect of pretransplant comorbidities and to stratify the effect of risk on both short- and long-term outcomes after OLT. Recipient age and diabetes strongly affected short-term survival after OLT, and metabolic and vascular complications were the leading causes of death at 5 years after OLT.

Etiology of Liver Disease and Cardiovascular Abnormalities in Patients on a Liver Transplantation Waiting List

BACKGROUND The classical cardiovascular risk factors and changes in the circulatory system secondary to end-stage liver disease (ESLD) are associated with an increased risk of cardiac abnormalities (CAs) in patients waiting for liver transplantation (LTx). The aim of this study was to assess the relationship between the etiology of liver disease and the presence of CAs in patients qualified for LTx. MATERIAL AND METHODS The study enrolled patients qualified to LTx due to ESLD at the Clinical Hospital of the Medical University of Warsaw between 2013 and 2016. Out of 396 patients: 65, 157, 117, and 57 had ESLD due to the alcoholic liver disease (ALD), viral infections (VIR), autoimmune disorders (AUTO), and different etiologies (OTHER), respectively. RESULTS An increased frequency of hypertension and diabetes mellitus were observed in ALD and VIR groups, while for hyperlipidemia, the highest rates were observed in ALD and AUTO groups. Significant differences in CAs rates were observed for resting tachycardia, prolonged QT interval, bradycardia, and left ventricular diastolic dysfunction. After adjustment for age, MELD, and Child-Pugh scores, hyperlipidemia (26% vs. 7-15%, p<0.048) was most frequently observed in the AUTO group, while poor aerobic capacity (49% vs. 21-34%, p<0.009) dominated in the OTHER group. CONCLUSIONS The frequency of hyperlipidemia, and poor aerobic capacity were directly related to the etiology of liver disease, while the remaining associations resulted from effects of age, MELD, and Child-Pugh score.

Long-Term Health-Related Quality of Life in Living Liver Donors

BACKGROUND In living donor liver transplantation (LDLT), 2 patients undergo surgery, and the advantages and disadvantages for both patients should be considered. This study evaluated the long-term quality of life in living liver donors, and its impact on their activities of daily living focusing on mood and mental health. MATERIAL AND METHODS In total, 101 living liver donors (69 female and 32 male patients, median age of 36.8 years) were surveyed at a median time of 61.8 months after liver donation (range 7-169 months). The generic Short Form Health Survey (SF-36), the Patient Health Questionnaire 9 (PHQ-9), and the Questionnaire of Physical Activity (IPAQ) were used. The results of SF-36 were compared to a matched control group (n=72) using the Wilcoxon test; the SF-36, the PHQ-9, and the IPAQ scores were analyzed using Spearman's rank correlation. Linear regression model was used to check for dependencies between variables of interest. The IPAQ results were compared between the study group and the general Polish population. RESULTS There were no significant differences in the SF-36 domains between the study group and control group except body pain, which was higher in the living liver donor group (P<0.05). In 30.6% of patients, the PHQ-9 survey revealed mood disturbances. The PHQ-9 scores were higher in female-donors (P<0.05). Both summary scores of the SF-36 correlated to the PHQ-9 (P<0.001). In 89.1% of patients, physical activity was below the population norm and was lower in female donors than in male donors (P<0.01). CONCLUSIONS LDLT had no impact on donors' physical and mental health. Physical activity of living liver donors was lower than that of the general population. The SF-36 and the IPAQ measures seem to be reliable in the care of living liver donors. The PHQ-9 survey results and the inclination to depression of female living liver donors requires further study.

Autoimmune hepatitis exerts a profound, negative effect on health-related quality of life: A prospective, single-centre study

BACKGROUND AND AIMS

Autoimmune hepatitis is a progressive chronic liver disease. Health-related quality of life in autoimmune hepatitis has not attracted much attention so far. We prospectively assessed various aspects of health-related quality of life in a well characterized group of patients with autoimmune hepatitis.

METHODS

In total, 140 patients with autoimmune hepatitis (mean age 40 ± 17 years) and 170 controls (mean age 36 ± 14 years) were included. Health-related quality of life was evaluated with following questionnaires: The Short Form (36) Health Survey, Modified Fatigue Impact Score, State-Trait Anxiety Inventory and Patient Health Questionnaire-9 assessing depression.

RESULTS

Patients with autoimmune hepatitis showed a significant impairment of health-related quality of life in all, but one, domains of The Short Form (36) Health Survey. Autoimmune hepatitis was associated with pronounced physical fatigue (P < 0.001), anxiety (P < 0.001) and depression (P < 0.001). As compared to males, female patients demonstrated greater impairment of physical aspects of The Short Form (36) Health Survey and Modified Fatigue Impact Score. Twenty-seven patients (19%) had moderate (Patient Health Questionnaire-9 >10) and 14 (10%) moderately severe depression (Patient Health Questionnaire-9 >15). Depression showed a very strong correlation with chronic fatigue (R = 0.68; P < 0.001); physical and mental components of The Short Form (36) Health Survey (R = 0.52/0.68 respectively; P < 0.001) and anxiety (R = 0.47; P < 0.001). There was a trend towards better life's quality in patients treated with budesonide in some aspects of their health-related quality of life. Duration of the disease, age at diagnosis, liver fibrosis and the presence of cirrhosis were not associated with health-related quality of life.

CONCLUSIONS

Health-related quality of life is significantly impaired in patients with autoimmune hepatitis. Depression seems to be a dominant symptom affecting their well-being, not associated with clinical and biochemical features of the disease.

Effects of liver transplantation on health-related quality of life in patients with primary biliary cholangitis

BACKGROUND

Patients with primary biliary cholangitis (PBC) have decreased health-related quality of life (HRQoL). Here, we investigate HRQoL in two cohorts of transplanted patients with PBC and compare their results to healthy subjects.

PATIENTS AND METHODS

We used generic SF-36 and disease-specific PBC-40 questionnaires to evaluate HRQoL in 26 patients with PBC (23 females, age 59.4 ± 5.7 years) before and after liver transplantation (LT), and in 107 patients with PBC (99 females, age 62.8 ± 6.7 years) who were previously transplanted. The control group was comprised of 60 healthy controls (55 females, age 54.6 ± 8.8 years).

RESULTS

Health-related quality of life improved after LT in 85% of PBC patients. The SF-36 measure showed significant (all P < 0.05) improvements in the majority of domains after LT, and in the summary scores both physical and mental. We also documented significant improvements in pruritus and fatigue after LT (all P < 0.01). However, liver graft recipients had significantly worse physical functioning, physical role, and emotional role domains, and physical component score (all P < 0.001), as compared to healthy subjects. No differences in HRQoL were detected between patients evaluated after short and prolonged post-LT periods (P > 0.05).

CONCLUSION

Liver transplantation substantially improves most aspects of life quality in PBC patients. Nevertheless, their HRQoL remains worse in comparison to healthy individuals, mainly in physical aspects.

Effect of S-Adenosyl-L-Methionine on Liver Biochemistry and Quality of Life in Patients with Primary Biliary Cholangitis Treated with Ursodeoxycholic Acid. A Prospective, Open Label Pilot Study

Background & Aims: Chronic liver disease induces an acquired deficiency of S-adenosyl-L-methionine (SAMe) leading to impairment of detoxifying processes in the liver. Ursodeoxycholic acid (UDCA) represents the standard treatment in primary biliary cholangitis (PBC). As both compounds exert their hepatoprotective effects by different mechanisms, it is conceivable that when used together their effect might be additive. The aim of this study was to analyse the effect of SAMe supplementation on liver biochemistry and health-related quality of life (HRQoL) in patients with PBC, treated with UDCA. Methods. In this prospective pilot, proof of the principle, non-randomized and open label study we enrolled 24 patients with PBC treated with UDCA for at least 6 months. They had received both UDCA in a standard dose of 13-15 mg/kg b.w. and SAMe in the dose of 1200 mg daily over a period of 6 months. A group of 24 patients with PBC treated with UDCA served as control for liver biochemistry (Study registered on the platform ClinicalTrials.gov under ID: NCT02557360). Results. We observed a significant decrease of ALP, GGT and total cholesterol in non-cirrhotic patients treated with SAMe. There was also a significant improvement of fatigue and pruritus in PBC-40 questionnaire and amelioration of anxiety in STAI 2 questionnaire in the SAMe group. Treatment with SAMe neither increased sulfation capacity of the liver nor had an effect on fibroblast growth factor-19 serum levels. Conclusions. Our pilot study demonstrates a positive effect of adding SAMe to UDCA in non-cirrhotic patients with PBC.

Evaluation of Liver Graft Recipient Workup in Predicting of Early Cardiovascular Events During Liver Transplantation: A Single-Center Experience

BACKGROUND

Cardiovascular events (CVE) contribute to serious complications and death after liver transplantation (LT). Troponin I (TnI) level >0.07 mg/L and prior cardiac disease are known to be the independent predictors for posttransplant CVE. We evaluated single-center cardiac workup to predict early cardiovascular morbidity and mortality after LT.

PATIENTS AND METHODS

We recruited 105 consecutive liver transplant recipients (male/female, 59/46; mean age, 51.66 ± 11.67 years). The cardiological assessment at evaluation for LT included medical history, electrocardiogram, echocardiography, Holter monitoring, and exercise test. We collected data regarding CVE including hypotonia with catecholamine usage, arrhythmia, sudden cardiac death, pulmonary edema, and myocardial infarction within 7 days after LT.

RESULTS

CVE during LT occurred in 42 recipients (40%) and after LT in 9 patients (8.57%). Proposed cutoff level of TnI >0.07 mg/L did not correlate with CVE during operation (P = .73) or after LT (P = .47). CVE during LT was associated with arterial hypertension in medical history (P <.001), right ventricular systolic pressure (P< .05), and clinical scores: Child-Pugh (P = .04), Model for End-Stage Liver Disease (MELD) (P = .04), MELD incorporating serum sodium (P<.03), and integrated MELD score (P = .01). CVE after LT correlated only with arrhythmia (P<.001) and catecholamine usage (P < .05) perioperatively. Of interest, catecholamine usage during LT was associated with prolonged stay at the intensive care unit (P < .05).

CONCLUSION

The single-center algorithm with noninvasive cardiac procedures without TnI assessment is optimal in evaluation before LT; however, medical history and severity of the liver disease are crucial for short-term cardiovascular morbidity after LT.

Pretransplant QT Interval: The Relationship with Severity and Etiology of Liver Disease and Prognostic Value After Liver Transplantation

BACKGROUND Prolonged QT interval is an integral part of the definition of cirrhotic cardiomyopathy. The aim of this study was to analyze the relationship between QT corrected (QTc) and the etiology and the severity of liver disease in relation to the complications of cirrhosis in candidates for orthotropic liver transplantation (OLTx). MATERIAL AND METHODS From 360 consecutive patients with end-stage liver disease (ESLD) consulted by a designated cardiologist, 160 patients underwent OLTx. The QTc was calculated according to 3 formulas in 151 ECG tracings with good quality. The severity of liver disease was assessed according to Child-Pugh classification and model for end-stage liver disease (MELD). This was a single-center study with register-based follow-up design. RESULTS Prolonged QTc over 440 ms was found in 51 subjects (33.8%), but none had prolonged QTc >500 ms. QTc corrected by Fridericia (F) formula was more suitable for patients with ESLD. We found no correlation between QTc interval and severity of liver disease. The QTc interval was higher in patients with alcoholic cirrhosis when compared to patients with viral hepatitis and ESLD of other etiologies. We observed a higher QTc interval in patients with gastroesophageal varices and encephalopathy. We did not notice any significant difference in the effect of the QTc interval on survival. CONCLUSIONS QTc interval might be associated with etiology and complication of ESLD. The prolonged QT interval is not associated with higher all-cause mortality after OLTx.

The Pre-Transplant Profile of Cardiovascular Risk Factors and Its Impact on Long-Term Mortality After Liver Transplantation

BACKGROUND Cardiovascular disease (CVD) is an important aggravating factor for orthotopic liver transplantation (OLT) outcomes. CVD still seems to be one of the most common cause of death in the long-term post-transplant period. Nevertheless, there are some limited data regarding the optimal strategy of risk assessment during OLT candidate evaluation. MATERIAL AND METHODS Routine pre-transplant cardiac workup in 360 patients with end stage liver disease (ESLD) included electrocardiogram, echocardiography, and exercise stress testing. The aim of this retrospective study was an analysis of the impact of cardiovascular risk profile on overall mortality in the 2-year follow-up of 160 patients who underwent liver transplantation. RESULTS Cardiovascular risk factors or a history of CVD were found in 23.1% of patients who received transplants. The cardiovascular risk factors most common in our group of transplant recipients with ESLD were: diabetes (26.3%), hypertension (25.6%), and hepatopulmonary syndrome (23.1%). Only 3.8% of patients had a positive exercise test. Coronary angiography revealed at least 50% stenosis in some epicardial arteries in 1.9% of patients. The risk of death in long-term follow-up of liver transplant recipients was most strongly associated with 3 cardiac variables: history of coronary artery disease (CAD), angiographically confirmed coronary stenosis, and reduced ejection fraction (EF). CONCLUSIONS Our study identified pre-transplant CAD with its consequences as a factor associated with increased risk of negative post-transplant outcomes.

Risk Factors of Prolonged ICU Stay in Liver Transplant Recipients in a Single-Center Experience

BACKGROUND

Prolonged initial intensive care unit (ICU) stay after liver transplantation (LT) is associated with prolonged total hospitalization, increased hospital mortality, and impaired patient and graft survival. Recent data suggested that model for end-stage liver disease (MELD) score at the time of LT and the length of surgery were the two independent risk factors for an ICU stay longer than 3 days after LT. We further identified factors influencing prolonged ICU stay in single-center liver graft recipients.

PATIENTS AND METHODS

One hundred fifty consecutive LT recipients (M/F 94/56, median age 55 (range, 39-60), 36% with viral hepatitis, were prospectively enrolled into the study. Associations between clinical factors and prolonged ICU stay were evaluated using logistic regression models. Receiver operating characteristic curves were analyzed to determine the appropriate cutoffs for continuous variables. Threshold for significance was P ≤ .05.

RESULTS

Highly prolonged (≥8 days) and moderately prolonged (≥6 days) postoperative ICU stay was noted in 19 (12.7%) and 59 (39.3%) patients, respectively. Serum bilirubin (P = .001) and creatinine concentrations (P = .011), international normalized ratio (P = .004), and sodium-MELD (P < .001) were all significantly associated with postoperative intensive care unit stay over or equal to 75th percentile (6 days). Sodium-MELD was significantly associated with postoperative care unit stay greater or equal to the 90th percentile (8 days; P = .018).

CONCLUSIONS

Sodium-MELD might be a novel risk factor of prolonged ICU stay in this single-center experience.

Does transient elastography correlate with liver fibrosis in patients with PSC? Laennec score-based analysis of explanted livers

BACKGROUND AND AIMS

Previous studies demonstrated a close correlation between transient elastography (TE) and liver histology in chronic liver diseases. Data on the accuracy of TE in primary sclerosing cholangitis (PSC) remains scarce. Here, we investigated the association between TE, serum marker of liver injury and histology of explanted livers in PSC patients.

METHODS

Thirty patients were prospectively recruited. TE (Fibroscan^®) and blood sampling were performed during evaluation for liver transplantation (LT); the second blood sampling was performed on the day of LT. Fibrosis of explanted livers according to the seven-point Laennec staging system and liver collagen contents were measured.

RESULTS

TE correlated with Laennec stages of fibrosis (p = .001), collagen contents (p < .001) and with diameter of thickest septa (p = .034) in explanted livers. It also correlated with serum indices of liver injury, namely AST, bilirubin as well as FIB-4 and APRI scores (all p < .05). In a multivariate model, only liver fibrosis, according to either Laennec score (p = .035) or collagen contents (p = .005), was significantly associated with TE. Finally, patients with cirrhosis had increased liver stiffness (p = .002) and the TE cut-off of 13.7 kPa showed the best predictive value (AUC = .90, 95% CI: 0.80-1.00, p < .001) for detecting cirrhosis.

CONCLUSIONS

TE correlates with liver fibrosis and markers of liver injury in patients with PSC. However, liver fibrosis seems to be the strongest predictor of liver stiffness assessed with TE. Hence, we postulate that TE is a reliable tool for non-invasive monitoring of PSC.

Plasmapheresis exerts a long-lasting antipruritic effect in severe cholestatic itch

BACKGROUND & AIMS

The amelioration of refractory cholestatic pruritus after plasmapheresis has been reported in single patients. Here, we analyse the efficacy of plasmapheresis in a cohort of patients with primary biliary cholangitis (PBC).

METHODS

Seventeen consecutive patients with PBC (age range 39-85 years, 16 females, 9 with cirrhosis) and refractory pruritus underwent 129 plasmapheresis procedures during 40 admissions. Pruritus was quantified by the 10-point numeric rating scale (NRS) before and after plasmapheresis, as well as ~30 and ~90 days later.

RESULTS

The mean pruritus before plasmapheresis did not differ between patients with and without cirrhosis (P>.05). Cirrhotics presented, however, with significantly higher serum alanine aminotransferase (ALT), aspartate transaminase (AST), gamma-glutamyl transpeptidase (GGT), alkaline phosphatase (ALP) and bilirubin before plasmapheresis. Plasmapheresis decreased itching to NRS≤5 in all but five admissions: Mean pruritus decreased from 8.3±1.4 to 3.1±2.2 (P<.0001) in the entire cohort. It also led to a significant decrease in serum ALT, ALP, AST, GGT (all P<.001) and bilirubin (P=.002). Antipruritic effect persisted throughout the 90-days follow-up (P<.0001). The amelioration of pruritus was not affected by the presence of cirrhosis.

CONCLUSIONS

Plasmapheresis is a promising method for reducing intractable itch in a significant proportion of PBC patients regardless of liver fibrosis. Long-lasting improvement of symptoms requires repeated procedures.

Good outcome following liver transplantation using pericardial-peritoneum window for hepato-atrial anastomosis to overcome advanced hepatic alveolar echinococcosis and secondary Budd-Chiari Syndrome - a case report

BACKGROUND

This report presents a case of a 57- year old female with advanced Hepatic Alveolar Echinococcosis causing a secondary Budd-Chiari Syndrome due to infiltration of the suprahepatic inferior vena cava treated successfully by liver transplantation.

CASE PRESENTATION

A temporary veno-venous bypass was introduced, but a typical end to end cavo-caval anastomosis wasn't possible in this case. In order to access a disease free part of the inferior vena cava, an oval window of the diaphragm was excised, providing communication between the peritoneum and pericardium. A vascular clamp was placed onto the right atrium which allowed for an atrial-caval anastomosis. The remainder of hepatectomy was performed in a conventional manner. In the post-operative period and during the 18 month follow-up there were no complications. The patient remains in good general condition with optimal graft function.

CONCLUSIONS

A hepato-atrial anastomosis with a pericardial-peritoneum window during liver transplantation is feasible and extends the curability potential for patients with advanced Hepatic Alveolar Echinococcosis considered for liver transplantation.

A novel approach to genome-wide association analysis identifies genetic associations with primary biliary cholangitis and primary sclerosing cholangitis in Polish patients

Background

Primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) are forms of hepatic autoimmunity, and risk for both diseases has a strong genetic component. This study aimed to define the genetic architecture of PBC and PSC within the Polish population.

Methods

Subjects were 443 women with PBC, 120 patients with PSC, and 934 healthy controls recruited from Gastroenterology Departments in various Polish hospitals. Allelotyping employed a pooled-DNA sample-based genome-wide association study (GWAS) approach, using Illumina Human Omni2.5-Exome BeadChips and the following novel selection criteria for risk loci: blocks of at least 10 single nucleotide polymorphisms (SNPs) in strong linkage disequilibrium, where the distance between each adjacent SNP pair in the block was less than 30 kb, and each SNP was associated with disease at a significance level of P < 0.005. A selected index SNP from each block was validated using TaqMan SNP genotyping assays.

Results

Nineteen and twenty-one SNPs were verified as associated with PBC and PSC, respectively, by individual genotyping; 19 (10/9, PBC/PSC) SNPs reached a stringent (corrected) significance threshold and a further 21 (9/12, PBC/PSC) reached a nominal level of significance (P < 0.05 with odds ratio (OR) > 1.2 or < 0.83), providing suggestive evidence of association. The SNPs mapped to seven (1p31.3, 3q13, 6p21, 7q32.1, 11q23.3, 17q12, 19q13.33) and one (6p21) chromosome region previously associated with PBC and PSC, respectively. The SNP, rs35730843, mapping to the POLR2G gene promoter (P = 1.2 × 10^-5, OR = 0.39) demonstrated the highest effect size, and was protective for PBC, whereas for PSC respective SNPs were: rs13191240 in the intron of ADGRB3 gene (P = 0.0095, OR = 0.2) and rs3822659 (P = 0.0051, OR = 0.236) along with rs9686714 (P = 0.00077, OR = 0.2), both located in the WWC1 gene.

Conclusions

Our cost-effective GWAS approach followed by individual genotyping confirmed several previously identified associations and discovered new susceptibility loci associated with PBC and/or PSC in Polish patients. However, further functional studies are warranted to understand the roles of these newly identified variants in the development of the two disorders.

Electronic supplementary material

The online version of this article (doi:10.1186/s12920-016-0239-9) contains supplementary material, which is available to authorized users.

Metabolic risk factors of coronary heart disease in relation to anthropometric measures in nonalcoholic fatty liver disease patients following dietary intervention

Wstęp:Niealkoholowa stłuszczeniowa choroba wątroby (NAFLD) jest związana z wysokim ryzykiem zaburzeń metabolicznych (zespół metaboliczny, cukrzyca typu 2) oraz choroby wieńcowej.Materiały i metody: Grupę badaną stanowiło 108 osób dorosłych rasy kaukaskiej (39 kobiet i 69 mężczyzn) w wieku 20–77 lat z rozpoznaną NAFLD. Podstawą diagnozy było dokładne badanie USG wątroby oraz analiza parametrów wątrobowych: aminotransferazy alaninowej i aminotransferazy asparaginianowej w surowicy. Wszystkie badania przeprowadzono podczas pierwszej i ostatniej wizyty pacjentów w placówce badawczej (po 6 miesiącach od interwencji dietetycznej). Dokonywano także pomiarów antropometrycznych (wskaźnik masy ciała – BMI, obwód pasa – WC, wskaźnik talia–biodra – WHR, wskaź- nik talia–wzrost – WHtR, wskaźnik stożkowatości – C -Index) w odniesieniu do metabolicznych czynników ryzyka choroby niedokrwiennej serca (podwyższone stężenie w surowicy: triacylogliceroli, cholesterolu lipoprotein niskiej gęstości, cholesterolu całkowitego, glukozy oraz obniżone stężenie cholesterolu lipoprotein wysokiej gęstości).Wyniki: Zarówno w grupie kobiet, jak i mężczyzn wykazano istotną statystycznie redukcję wartości parametrów takich jak: masa ciała, BMI, WC, WHR, WHtR i C -Index (p < 0,05), co miało wpływ na poprawę stężenia triacylogliceroli w surowicy u obu płci (p < 0,05). Wskaźniki identyϐikujące otyłość brzuszną (WC, WHR, WHtR, C -Index) korelowały istotnie z wartością glikemii (p < 0,05) zarówno przed interwencją dietetyczną, jak i po niej oraz ze stężeniem lipidów w surowicy przed interwencją lub po (p < 0,05) u obu płci.Wnioski: Rozpowszechnienie użycia prostych narzędzi antropometrycznych (przede wszystkim C -Index i WHtR) wydaje się być korzystne, zwłaszcza na szczeblu podstawowej opieki zdrowotnej. Narzędzia te mogą służyć zarówno do prewencji, jak i wczesnego wykrywania metabolicznych czynników ryzyka choroby niedokrwiennej serca, a co za tym idzie potencjalnie śmiertelnych konsekwencji incydentów wieńcowych u pacjentów z NAFLD lub z innymi zaburzeniami metabolizmu.

The effect of short term treatment with probiotic VSL#3 on various clinical and biochemical parameters in patients with liver cirrhosis

The evidence is mounting that alterations of innate immunity and gut microbiota contribute to chronic liver disease and its complications. Modulation of intestinal microbiota is an emerging therapeutic strategy in hepatology. Probiotics through modulation of intestinal milieu have the potential to affect the course of liver disease. The data concerning the influence of probiotics on various plasma molecules and compounds involved in the pathogenesis of hyperdynamic circulatory state in liver cirrhosis is still not confluent and require further evaluation. In our study twenty patients with compensated and decompensated liver cirrhosis and ten healthy controls received probiotic VSL#3 daily for 28 days. Plasma levels of interleukin 6 (IL-6), vascular endothelial growth factor (VEGF), plasminogen activator inhibitor (PAI), macrophage inflammatory protein 3/α (MIP-3 α/CCL20), monocyte chemotactic protein-1α (MCP-1/CCL2), human myeloperoxidase (MPO), nitric oxide (NO), prostaglandins, thromboxane (TXB₂) and big-endothelin were measured at baseline, day 14 and 28 of probiotic administration. The incidence of hepatic encephalopathy was assessed with critical flicker frequency. Changes in clinical, biochemical and microbiological parameters were evaluated. The stage of liver cirrhosis correlated with an increase in plasma levels of pro-inflammatory cytokines (IL-6) and chemotactic chemokines involved in immune cell trafficking (MIP-3α/CCL20). Probiotic administration in patients with liver cirrhosis led to modulation of plasma levels of several molecules and compounds measured (MIP-3α/CCL20, NO, big-endothelin, TXB₂ and MPO). The grade of encephalopathy during the course of probiotic supplementation remained unaffected in both groups of patients. VSL#3 treatment was well tolerated and safe in patients with liver disease. In patients with compensated and decompensated liver cirrhosis, VSL#3 manipulates selected plasma molecules and compounds involved in hyperdynamic circulatory dysfunction. Short term VSL#3 administration affects several clinical and biochemical parameters commonly altered in liver cirrhosis.

Assessment of health related quality of life in polish patients with primary biliary cirrhosis

BACKGROUND

Most patients with primary biliary cirrhosis (PBC) have impaired health related quality of life (HRQoL), as assessed by PBC-specific HRQoL (PBC-40) and generic (SF-36) questionnaires. Data on the applicability of PBC-27, a shorter version of PBC-40, have been limited.

AIMS

To assess HRQoL in Polish PBC patients, applying PBC-40, PBC-27 and SF-36 and to associate clinical or laboratory parameters with HRQoL factors.

METHODS

A total of 205 PBC patients (188 females) were analyzed using PBC-40, PBC-27 and SF-36; 85 disease-free demographically matched (in terms of age, gender, ethnicity) individuals were used as normal controls.

RESULTS

When compared to controls, PBC patients had significantly impaired HRQoL across all the domains of SF-36. HRQoL impairment by PBC-40 and PBC-27 was comparable between cirrhotics and non-cirrhotics, except for significantly worse Itch in cirrhotics (6.5±4.9 vs 5.1±4.3; P=0.03). In PBC-40/27, alkaline phosphatase (ALP) levels correlated with itch (P=0.0003). Female patients had marginally impaired cognitive function compared to males by PBC-40 (P=0.06). Other gender-related differences were not found. Anti-gp210 positive, as well as AMA negative PBC patients, had worse HRQoL features in itch and social/emotional domains of PBC-40/PBC-27 questionnaires. Very strong correlations (P<0.0001) between PBC-40/PBC-27 and SF-36 were seen for several domains.

CONCLUSIONS

HRQoL is significantly impaired in Polish patients with PBC, independently of gender and disease severity. PBC-40 and PBC-27 questionnaires are efficient in detecting HRQoL impairment in Polish PBC patients. The striking correlation between PBC-40/PBC-27 and SF-36 confirms the usefulness of the former HRQoL measures in PBC patients from Central-Eastern Europe.

Heterozygous Inactivation of the Nuclear Receptor PXR/NR1I2 in a Patient With Anabolic Steroid-Induced Intrahepatic Cholestasis

INTRODUCTION

The incidence of liver damage due to steroid consumption is increasing due to the omnipresence of the idealized body image and the widespread availability of drugs via the Internet. The genetic factors underlying individual susceptibility are not presently known.

CASE PRESENTATION

A male patient developed cholestatic liver injury two weeks after a two-month course of anabolic steroids. Next-generation sequencing (NGS) of 24 cholestasis-related genes revealed a heterozygous two-basepair deletion in exon 1 of the pregnane X receptor gene (PXR). Serum bile salt levels showed marked imbalances, strongly resembling the changes observed in patients with biliary obstruction.

CONCLUSIONS

This case of PXR haploinsufficiency reveals transcriptional regulatory functions activated in the liver under xenobiotic stress by steroids, which appear to require two functional copies of the nuclear receptor gene. Deranged bile salt levels outline the central role of PXR in bile acid synthesis, modification, and export.

Factors Affecting Exercise Test Performance in Patients After Liver Transplantation

BACKGROUND

Cardiovascular diseases are a leading cause of morbidity and mortality in solid organ transplant recipients. In addition, low physical activity is a risk factor for cardiac and cerebrovascular complications.

OBJECTIVES

This study examined potential relationships between physical activity, health-related quality of life (HRQoL), risk factors for cardiovascular disease, and an exercise test in liver-graft recipients.

PATIENTS AND METHODS

A total of 107 participants (62 men/45 women) who had received a liver transplantation (LT) at least 6 months previously were evaluated. Physical activity was assessed using three different questionnaires, while HRQoL was assessed using the medical outcomes study short form (SF)-36 questionnaire, and health behaviors were evaluated using the health behavior inventory (HBI). The exercise test was performed in a standard manner.

RESULTS

Seven participants (6.5%) had a positive exercise test, and these individuals were older than those who had a negative exercise test (P = 0.04). A significant association between a negative exercise test and a higher level of physical activity was shown by the Seven-day physical activity recall questionnaire. In addition, HRQoL was improved in various domains of the SF-36 in participants who had a negative exercise test. No correlations between physical activity, the exercise test and healthy behaviors, as assessed via the HBI were observed.

CONCLUSIONS

Exercise test performance was affected by lower quality of life and lower physical activity after LT. With the exception of hypertension, well known factors that affect the risk of coronary artery disease had no effect on the exercise test results.

Metabolites of arachidonic acid and linoleic acid in early stages of non-alcoholic fatty liver disease--A pilot study

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a spectrum of liver conditions related to fat infiltration. The role of liver triacylglycerol accumulation in NAFLD is not fully understood.

METHODS

Twenty-four patients, 12 in the first and 12 in the second stage of NAFLD, were prospectively enrolled in this study. Biochemical parameters and eicosanoids (HETE and HODE) were compared between the first and the second stage of hepatic steatosis and the effect of a 6-month dietary intervention on these parameters was evaluated. Eicosanoid profiles were extracted from 0.5 ml of plasma using solid-phase extraction RP-18 SPE columns. The HPLC separations were performed on a 1260 liquid chromatograph.

RESULTS

Patients with stage I NAFLD had a significantly higher level of HDL cholesterol and a lower level of 5-HETE. Patients with grade II steatosis had higher concentrations of 9-HODE. Following the six-month dietary intervention, hepatic steatosis resolved completely in all patients. This resulted in a significant decrease in the concentrations of all eicosanoids (LX4, 16-HETE, 13-HODE, 9-HODE, 15-HETE, 12-HETE, 5-oxoETE, 5-HETE) and key biochemical parameters (BMI, insulin, HOMA-IR, liver enzymes).

CONCLUSION

A significant reduction in the analyzed eicosanoids and a parallel reduction in fatty liver confirmed the usefulness of HETE and HODE in the assessment of NAFLD.