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Gabbay U, Issachar A, Cohen-Naftaly M, Brown M, Nesher E. Gender specific survival rates after deceased donor liver transplantation: A retrospective cohort. Ann Med Surg (Lond) 2022; 79:103933. [PMID: 35860137 PMCID: PMC9289308 DOI: 10.1016/j.amsu.2022.103933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 05/30/2022] [Accepted: 06/02/2022] [Indexed: 11/27/2022] Open
Abstract
Background According to the literature, there are sex allocation inequalities in liver transplantation (LT). Sex disparities in outcomes after LT have been debated. This study aimed to evaluate sex-specific outcomes after LT, specifically short-term mortality and long-term survival rates. Methods A retrospective cohort of the entire LT series from to 2010–2019 in a single center in which the inclusion criteria were adults ≥18 YO age who underwent primary deceased donor LT. Mortality rate was evaluated within 30 days and 6 months. Survival rate was evaluated at 1,3 and 5 years of age. Results A total of 240 primary and deceased donor LTs (153 men and 87 women) were included. Mean age 55.2Y men and 51.6Y women (p = 0.02). Hepatocellular carcinoma (HCC) was the direct indication in 32.7% of the men and only 17.4% of the women. The leading primary liver morbidities were viral hepatitis (B, C, and D) in 38.3% (N = 92) and nonalcoholic steatohepatitis (NASH) in 20.8% (N = 50) of patients. Thirty-day mortality was 14%, which was significantly higher in men (18%) than in women (8%). Survival rates after 5 years were 64.9% and 78.3%, respectively. Multivariate analysis through logistic regression that included age, direct indication, MELD, and primary liver morbidity revealed statistically significant female to male Odds-Ratio of 0.4 in 30 days, 6 m mortality and a statistically significant higher long-term survival. Conclusions Our observations revealed better female outcomes, namely, lower short-term mortality and higher long-term survival. Given the consistency after stratification and given the multivariate analysis, this is unlikely to be attributable to confounders. Such findings suggesting consistently better female outcomes have not been previously reported; hence, multi center study is encouraged. Gender outcome disparities after liver transplantation (LT) is debated. We present retrospective cohort of 240 consecutive LT in a single center. We found significant lower short-term mortality rates and better long-term survival in women. The outcome disparity was consistent in most underlying liver diseases. We had not identified factors that may confound sex outcome disparity.
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Etzion O, Dahari H, Yardeni D, Issachar A, Nevo-Shor A, Cohen-Naftaly M, Ashur Y, Uprichard SL, Arbib OS, Munteanu D, Braun M, Cotler SJ, Abufreha N, Keren-Naus A, Shemer-Avni Y, Mor O, Murad J, Novack V, Shlomai A. Response guided therapy for reducing duration of direct acting antivirals in chronic hepatitis C infected patients: a Pilot study. Sci Rep 2020; 10:17820. [PMID: 33082372 PMCID: PMC7575564 DOI: 10.1038/s41598-020-74568-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/30/2020] [Indexed: 02/06/2023] Open
Abstract
The advent of direct-acting antivirals (DAAs) has transformed the landscape of hepatitis C virus (HCV) management. We aimed to prospectively (real-time) evaluate the feasibility of using a response-guided therapy approach, based on mathematical modeling of early viral kinetics, to reduce the duration of DAAs therapy. Patients were treated with DAAs according to the physicians' preference. HCV was measured at baseline and at day 2 and weeks 1, 2 and 4 after treatment initiation. The primary endpoint was the proportion of patients with sustained-virological response (SVR) at 12 and/or 24 weeks post-treatment. Twenty-nine patients (mean age 54 ± 16, 44% females, 73% with HCV genotype 1), were enrolled and all completed therapy. Treatment duration was shortened in 11 of the 29 patients (38%). SVR was achieved in 28 of the 29 patients (97%). Relapse occurred post treatment in a single case of a non-cirrhotic male with genotype 3, who was treated with sofosbuvir/velpatasvir for 6 weeks. Virus sequencing did not identify baseline or treatment emergent resistance associated substitutions. Real-time mathematical modeling of early HCV kinetics can be utilized for shortening DAAs duration in approximately 40% of patients without compromising treatment efficacy.Clinical trial registration: ClinicalTrials.gov Identifier: NCT03603327.
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Affiliation(s)
- Ohad Etzion
- grid.412686.f0000 0004 0470 8989Department of Gastroenterology and Liver Diseases, Soroka University Medical Center, 151 Rager Yitzhak Blvd, 84171 Beer-Sheva, Israel ,grid.7489.20000 0004 1937 0511Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Harel Dahari
- grid.164971.c0000 0001 1089 6558The Program for Experimental and Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Chicago, 2160 S. First Ave, Maywood, IL 60153 USA
| | - David Yardeni
- grid.412686.f0000 0004 0470 8989Department of Gastroenterology and Liver Diseases, Soroka University Medical Center, 151 Rager Yitzhak Blvd, 84171 Beer-Sheva, Israel ,grid.7489.20000 0004 1937 0511Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Assaf Issachar
- grid.413156.40000 0004 0575 344XDepartment of Medicine D and The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Anat Nevo-Shor
- grid.412686.f0000 0004 0470 8989Department of Gastroenterology and Liver Diseases, Soroka University Medical Center, 151 Rager Yitzhak Blvd, 84171 Beer-Sheva, Israel ,grid.7489.20000 0004 1937 0511Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Michal Cohen-Naftaly
- grid.413156.40000 0004 0575 344XDepartment of Medicine D and The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yaffa Ashur
- grid.412686.f0000 0004 0470 8989Medical Management Unit, Soroka University Medical Center, Beer-Sheva, Israel
| | - Susan L. Uprichard
- grid.164971.c0000 0001 1089 6558The Program for Experimental and Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Chicago, 2160 S. First Ave, Maywood, IL 60153 USA
| | - Orly Sneh Arbib
- grid.413156.40000 0004 0575 344XDepartment of Medicine D and The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Daniela Munteanu
- grid.412686.f0000 0004 0470 8989Department of Gastroenterology and Liver Diseases, Soroka University Medical Center, 151 Rager Yitzhak Blvd, 84171 Beer-Sheva, Israel ,grid.7489.20000 0004 1937 0511Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Marius Braun
- grid.413156.40000 0004 0575 344XDepartment of Medicine D and The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Scott J. Cotler
- grid.164971.c0000 0001 1089 6558The Program for Experimental and Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Chicago, 2160 S. First Ave, Maywood, IL 60153 USA
| | - Naim Abufreha
- grid.412686.f0000 0004 0470 8989Department of Gastroenterology and Liver Diseases, Soroka University Medical Center, 151 Rager Yitzhak Blvd, 84171 Beer-Sheva, Israel ,grid.7489.20000 0004 1937 0511Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ayelet Keren-Naus
- grid.412686.f0000 0004 0470 8989Laboratory of Clinical Virology, Soroka University Medical Center, Beer-Sheva, Israel
| | - Yonat Shemer-Avni
- grid.412686.f0000 0004 0470 8989Laboratory of Clinical Virology, Soroka University Medical Center, Beer-Sheva, Israel
| | - Orna Mor
- grid.413795.d0000 0001 2107 2845Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat Gan, Israel
| | - Jayanah Murad
- grid.412686.f0000 0004 0470 8989Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - Victor Novack
- grid.412686.f0000 0004 0470 8989Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - Amir Shlomai
- grid.413156.40000 0004 0575 344XDepartment of Medicine D and The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Gozlan Y, Bucris E, Shirazi R, Rakovsky A, Ben-Ari Z, Davidov Y, Veizman E, Saadi T, Braun M, Cohen-Naftaly M, Shlomai A, Shibolet O, Zigmond E, Katchman H, Menachem Y, Safadi R, Galun E, Zuckerman E, Nimer A, Hazzan R, Maor Y, Saif AM, Etzion O, Lurie Y, Mendelson E, Mor O. High frequency of multiclass HCV resistance-associated mutations in patients failing direct-acting antivirals: real-life data. Antivir Ther 2020; 24:221-228. [PMID: 30880684 DOI: 10.3851/imp3301] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Direct-acting antiviral (DAA) therapy has dramatically increased sustained virological response rates in HCV-infected patients. However, resistance-associated substitutions (RAS) interfering with NS3- and NS5A-targeted therapy, still emerge. This real-life study analysed the type and frequency of RAS in rare cases of patients failing DAA regimens in 12 clinical centres in Israel. METHODS Blood samples and clinical data from 49 patients who failed various DAAs were collected. RAS identified in the NS3 and NS5A regions by population (Sanger) and next-generation sequencing (NGS) were compared by treatment regimen and HCV subtypes. RESULTS The majority (71.4%, 35/49) of patients were infected with the genotype (GT)1b strain, while 12.2% (6/49) carried GT1a and 14.3% GT3a/b (7), GT4a (1) and GT1b/GT3a. RAS were identified in 85.7% (42/49) of failures, of which 90.5% (38/42) were clinically relevant RAS (known to be associated with a specific GT and DAA in patients failing therapy or those with more than twofold change in in vitro replicon assays). The most abundant RAS were 168A/E/Q/G/N/V (32.6%, 16/49) identified in NS3, and 93H/N (61.2%, 30/49), 31I/M/V (34.7%, 17/49) and 30R/H/K (12.2%, 6/49), identified in NS5A. Significantly more clinically relevant RAS were identified in NS5A (82.2%, 37/45) than in NS3 (35.7%, 10/28; P<0.01). While RAS were identified in all GT1a, GT3b and GT4a failures (100%, 10/10), only 71.8% (28/39) of GT1b or GT3a failures had RAS (P=0.09). In four cases, NGS identified additional clinically relevant RAS and in one patient, NGS deciphered coexistence of GT3a and GT1b infections. CONCLUSIONS Our findings, together with additional real-life data, will contribute to the optimization of retreatment in DAA failure, when cost-related and suboptimal regimens must be employed.
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Affiliation(s)
- Yael Gozlan
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat Gan, Israel
| | - Efrat Bucris
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat Gan, Israel
| | - Rachel Shirazi
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat Gan, Israel
| | - Avia Rakovsky
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat Gan, Israel
| | - Ziv Ben-Ari
- Liver Disease Center, Sheba Medical Center, Ramat Gan, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yana Davidov
- Liver Disease Center, Sheba Medical Center, Ramat Gan, Israel
| | - Ella Veizman
- Liver Unit, Rambam Medical Center, Haifa, Israel
| | - Tarek Saadi
- Liver Unit, Rambam Medical Center, Haifa, Israel
| | - Marius Braun
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Michal Cohen-Naftaly
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Amir Shlomai
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Oren Shibolet
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Ehud Zigmond
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Helena Katchman
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Yoram Menachem
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel
| | | | - Eitan Galun
- Liver Unit, Hadassah Medical Center, Jerusalem, Israel
| | | | - Assy Nimer
- Faculty of Medicine in the Galilee, Bar-Ilan University, Ramat Gan, Israel.,Internal Medicine Department, Galilee Medical Center, Nahariya, Israel
| | - Rawi Hazzan
- Liver Unit, Haemek Medical Center, Afula, Israel
| | - Yaakov Maor
- The Institute of Gastroenterology and Hepatology, Kaplan Medical Center, Rehovot, Israel.,The Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Abu Moch Saif
- Liver Unit, Hillel Yaffe Medical Center, Hadera, Israel
| | - Ohad Etzion
- Department of Gastroenterology & Liver Diseases, Soroka University Medical Center, Beer Sheva, Israel
| | - Yoav Lurie
- Liver Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Ella Mendelson
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat Gan, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orna Mor
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat Gan, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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4
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Peleg N, Issachar A, Sneh Arbib O, Cohen-Naftaly M, Harif Y, Oxtrud E, Braun M, Leshno M, Barsheshet A, Shlomai A. Liver steatosis is a major predictor of poor outcomes in chronic hepatitis C patients with sustained virological response. J Viral Hepat 2019; 26:1257-1265. [PMID: 31243878 DOI: 10.1111/jvh.13167] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 05/10/2019] [Accepted: 05/28/2019] [Indexed: 12/24/2022]
Abstract
Sustained virological response (SVR) results in reduced incidence of hepatocellular carcinoma (HCC) and mortality among chronic hepatitis C (CHC) patients with advanced fibrosis. Since both advanced fibrosis and liver steatosis (LS) may coexist in CHC patients, we evaluated their individual effects on a composite outcome of all-cause mortality and HCC in CHC patients with SVR following direct-acting antivirals (DAA) treatment. We retrospectively evaluated inception cohort of 515 CHC patients who achieved SVR following treatment with DAA, with a mean follow-up of 24 months. Baseline liver fibrosis was assessed by transient elastography, and LS was validated by at least three independent ultrasonographic examinations. 211 of 515 patients (41%) had baseline LS. Patients with LS had a higher cumulative rate of all-cause mortality and HCC at 2 years of follow-up compared to patients without LS (15.75% and 2.79%, respectively, P < 0.001), although they did not have increased incidence of advanced fibrosis or cirrhosis. Consistently, multivariate analysis showed that LS was associated with a significant 7.5-fold increased risk of all-cause mortality and HCC (HR 7.51, 95% C.I 3.61-13.36, P < 0.001) even upon adjustment to components of the metabolic syndrome, whereas advanced fibrosis showed only a trend towards statistical significance (HR 2.32, 95% C.I 0.97-6.59, P = 0.06). In conclusion, LS is a major predictor of all-cause mortality and HCC in patients who achieved SVR following DAA treatment regardless of fibrosis stage. These patients should be rigorously screened for HCC.
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Affiliation(s)
- Noam Peleg
- The Division of Gastroenterology and Hepatology, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | - Assaf Issachar
- The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Sneh Arbib
- The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | - Michal Cohen-Naftaly
- The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Harif
- The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | - Evelin Oxtrud
- The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | - Marius Braun
- The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Leshno
- Coller School of Management, Tel Aviv University, Tel Aviv, Israel
| | - Alon Barsheshet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Amir Shlomai
- The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
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5
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Peleg N, Issachar A, Sneh Arbib O, Cohen-Naftaly M, Braun M, Leshno M, Barsheshet A, Shlomai A. Liver steatosis is a strong predictor of mortality and cancer in chronic hepatitis B regardless of viral load. JHEP Rep 2019; 1:9-16. [PMID: 32039349 PMCID: PMC7001543 DOI: 10.1016/j.jhepr.2019.02.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 02/09/2023] Open
Abstract
Liver steatosis may occur concomitantly in patients with chronic hepatitis B infection (CHB) and is implicated in increased morbidity and mortality. Hepatitis B virus (HBV) viral load is a marker for disease progression and long-term outcomes in CHB. We investigated the association between liver steatosis and HBV viral load and their individual effects on all-cause mortality and the development of cancer in patients with CHB and liver steatosis. Methods This retrospective study included 524 treatment-naïve patients with CHB, with a mean follow-up of 6 years. Liver biopsy was available for 170 patients and liver steatosis was validated by at least 3 ultrasonographic examinations. Results A total of 241/524 (46%) patients with CHB had liver steatosis, with a strong correlation between the degree of liver steatosis as assessed by ultrasonography or by liver biopsy (r = 0.9, p < 0.001). Although liver steatosis was not significantly associated with advanced fibrosis, a multivariate analysis showed that liver steatosis was associated with a 4-fold increased risk of all-cause mortality and cancer (hazard ratio 4.35; 95% CI 1.69–8.99; p < 0.001), irrespective of other major metabolic factors. However, baseline HBV viral load was not significantly associated with this composite outcome (hazard ratio 1.65; p = 0.29). In addition, liver steatosis was inversely associated with HBV viral load. Conclusion Patients with CHB and liver steatosis have an increased risk of all-cause mortality and cancer development compared to patients with CHB without liver steatosis, regardless of their baseline HBV viral load. Although tending to have a lower baseline viral load, patients with CHB and liver steatosis should be closely monitored irrespective of viral load. Lay summary Patients with chronic hepatitis B infection (CHB) may have liver steatosis at the same time. Here we show that in patients with CHB, liver steatosis is significantly associated with all-cause mortality and cancer, irrespective of other major metabolic factors, and the effect of liver steatosis on mortality and cancer is stronger than the effect of hepatitis B viral load on these outcomes. Thus, patients with CHB and liver steatosis should be closely monitored, irrespective of their viral load. HBV viral load is an important predictor of adverse outcomes in patients with chronic HBV (CHB). Liver steatosis may co-occur with CHB but its effect on all-cause mortality and cancer has not been determined. Liver steatosis is significantly associated with all-cause mortality and cancer in patients with CHB. The effect of liver steatosis on mortality and cancer is stronger than the effect of HBV viral load. Patients with CHB and liver steatosis should be closely monitored, irrespective of their viral load.
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Affiliation(s)
- Noam Peleg
- Department of Medicine D, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
| | - Assaf Issachar
- Department of Medicine D, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel.,The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Sneh Arbib
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
| | - Michal Cohen-Naftaly
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
| | - Marius Braun
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Leshno
- Coller School of Management, Tel Aviv University, Tel Aviv, Israel
| | - Alon Barsheshet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Amir Shlomai
- Department of Medicine D, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel.,The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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6
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Peleg N, Sneh Arbib O, Issachar A, Cohen-Naftaly M, Braun M, Shlomai A. Noninvasive scoring systems predict hepatic and extra-hepatic cancers in patients with nonalcoholic fatty liver disease. PLoS One 2018; 13:e0202393. [PMID: 30106985 PMCID: PMC6091950 DOI: 10.1371/journal.pone.0202393] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 08/02/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Liver fibrosis predicts liver-related morbidity and mortality in patients with non-alcoholic fatty liver disease (NAFLD). Non-invasive scores correlate with the degree of liver fibrosis in these patients. AIMS AND METHODS To investigate the accuracy of noninvasive scoring systems in predicting long-term outcomes and cancer incidence of patients with NAFLD, we performed a single-center retrospective study of patients with biopsy proven NAFLD. Mean follow up period was 100 months. Outcomes included liver-related complications, hospitalizations, overall mortality and the development of any malignancies. RESULTS 32 patients had advanced fibrosis (F3-F4) per biopsy at baseline and 121 patients had mild to moderate fibrosis (F0-F2). Both advanced histologic fibrosis stage as well as higher non-invasive scores predicted repeated hospitalizations and longer hospitalization stays. In a multivariate analysis, liver fibrosis (p = 0.002), FIB-4 score (p<0.001), NFS (p<0.001) but not APRI score (p = 0.07) were predictors of overall mortality, and the occurrence of malignancies was associated with higher APRI (p<0.001), FIB-4 (p<0.001) and NFS (p = 0.008) scores, but not with advanced fibrosis, as determined by liver biopsy (p = 0.105). CONCLUSIONS In NAFLD patients, noninvasive scoring systems are good predictors of morbidity and mortality and may have an additive value in predicting the development of hepatic and extra-hepatic cancers.
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Affiliation(s)
- Noam Peleg
- Department of Medicine D, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
| | - Orly Sneh Arbib
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
| | - Assaf Issachar
- Department of Medicine D, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Cohen-Naftaly
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
| | - Marius Braun
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Shlomai
- Department of Medicine D, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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7
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Shirin D, Peleg N, Sneh-Arbib O, Cohen-Naftaly M, Braun M, Shochat T, Issachar A, Shlomai A. The Pattern of Elevated Liver Function Tests in Nonalcoholic Fatty Liver Disease Predicts Fibrosis Stage and Metabolic-Associated Comorbidities. Dig Dis 2018; 37:69-76. [PMID: 30016799 DOI: 10.1159/000491428] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 06/21/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patients with nonalcoholic fatty liver disease (NAFLD) and with abnormal liver function tests (LFTs) most commonly present with elevated hepatocellular enzymes (H pattern), but a subset of patients is found to have elevated cholestatic enzymes (C pattern) or a mixed (M) pattern. AIMS AND METHODS To determine whether the epidemiologic background and comorbidities, as well as the degree of liver fibrosis, differ between NAFLD patients with different patterns of elevated LFTs by retrospectively analyzing data of 106 patients with a biopsy-proven diagnosis of NAFLD. The pattern of elevated LFTs was determined by adopting the "R-Ratio" formula commonly used for drug-induced liver injury. RESULTS Advanced fibrosis (F > 2) was found in 15 out of 48 (31.3%) patients with a C pattern of elevated LFTs as compared to 2 out of 44 (4.5%) in M patients and 2 out of 11 (18.2%) in H patients (p = 0.004). Group C patients are older and also had a higher prevalence of diabetes, a higher mean hemoglobin A1c, and a higher prevalence of hypertension, as well as a trend for a higher prevalence of hypertriglyceridemia. CONCLUSIONS Using a simple formula incorporating routine LFTs can help to categorize NAFLD patients as low or high risk for advanced fibrosis stage and metabolic-associated comorbidities.
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Affiliation(s)
- Dor Shirin
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Noam Peleg
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,The Liver Institute, Rabin Medical Center, Beilinson hospital, Petah-Tikva, Israel
| | - Orly Sneh-Arbib
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petah-Tikva, Israel
| | - Michal Cohen-Naftaly
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petah-Tikva, Israel
| | - Marius Braun
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petah-Tikva, Israel.,The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tzipora Shochat
- Biostatistics Core, Rabin Medical Center, Petah-Tikva, Israel
| | - Assaf Issachar
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,The Liver Institute, Rabin Medical Center, Beilinson hospital, Petah-Tikva, Israel
| | - Amir Shlomai
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, .,The Liver Institute, Rabin Medical Center, Beilinson hospital, Petah-Tikva, .,The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv,
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8
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Moore A, Cohen-Naftaly M, Tobar A, Kundel Y, Benjaminov O, Braun M, Issachar A, Mor E, Sarfaty M, Bragilovski D, Hur RB, Gordon N, Stemmer SM, Allen AM. Stereotactic body radiation therapy (SBRT) for definitive treatment and as a bridge to liver transplantation in early stage inoperable Hepatocellular carcinoma. Radiat Oncol 2017; 12:163. [PMID: 29052532 PMCID: PMC5649060 DOI: 10.1186/s13014-017-0899-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 10/06/2017] [Indexed: 12/30/2022] Open
Abstract
Background and Purpose Stereotactic body radiotherapy (SBRT) is an emerging modality for definitive treatment of Hepatocellular carcinoma (HCC). Materials and Methods This retrospective study included all early stage HCC patients who were not candidates for primary resection and/or local therapy, treated with SBRT between 11/2011 and 1/2016. Results Twenty-three patients were included. The median age was 62 years; 70% males; 30% females; 70% viral hepatitis carriers; 100% cirrhotic; 13 Child Pugh [CP]-A and 10 [CP]-B. The median tumor volume was 12.7cm3 (range, 2.2–53.6 cm3). Treatment was well tolerated. With the exception of one patient who developed RILD, no other patient had significant changes in 12 weeks of laboratory follow-up. SBRT was a bridge to transplantation in 16 patients and 11 were transplanted.. No surgical difficulties or complications were reported following SBRT, and none of the transplanted patients had local progression before transplantation. The median prescribed dose to the tumor was 54Gy (range, 30-54Gy), the median dose to the uninvolved liver was 6.0Gy(range, 1.6–12.6Gy). With a median follow-up time of 12 months, the median overall-survival for the 11 transplanted patients was not reached (range, 2.0–53.7+ months) and was 23 months for the 12 non-transplanted patients. The median progression-free survival for the transplanted patients was not reached (54+ months) and was 14.0 months for the non-transplanted patients. There was no SBRT-related mortality. Liver explant post SBRT revealed pathological complete response in 3(27.3%), pathological partial response in 6(54.5%), and pathological stable disease in 2(18.2%) tumors. Conclusions SBRT is safe and effective and can be used as a bridge to transplantation without comprising the surgical procedure.
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Affiliation(s)
- Assaf Moore
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Michal Cohen-Naftaly
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Anna Tobar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Pathology, Rabin Medical Center, Petah Tikva, Israel
| | - Yulia Kundel
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Benjaminov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Imaging, Rabin Medical Center, Petah Tikva, Israel
| | - Marius Braun
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Assaf Issachar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Eytan Mor
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Organ Transplantation, Rabin Medical Center, Petah Tikva, Israel
| | - Michal Sarfaty
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dimitri Bragilovski
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Ran Ben Hur
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Noa Gordon
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Salomon M Stemmer
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Aaron M Allen
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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9
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Gozlan Y, Ben-Ari Z, Moscona R, Shirazi R, Rakovsky A, Kabat A, Veizman E, Berdichevski T, Weiss P, Cohen-Ezra O, Lurie Y, Gafanovich I, Braun M, Cohen-Naftaly M, Shlomai A, Shibolet O, Zigmond E, Zuckerman E, Carmiel-Haggai M, Nimer A, Hazzan R, Maor Y, Kitay-Cohen Y, Shemer-Avni Y, Kra-Oz Z, Schreiber L, Peleg O, Sierra S, Harrigan PR, Mendelson E, Mor O. HCV genotype-1 subtypes and resistance-associated substitutions in drug-naive and in direct-acting antiviral treatment failure patients. Antivir Ther 2017; 22:431-441. [PMID: 28067632 DOI: 10.3851/imp3123] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Direct-acting antiviral (DAA) treatment regimens and response rates of patients with HCV genotype-1 (GT1) are currently considered subtype-dependent. Identification of clinically relevant resistance-associated substitutions (RASs) in the NS3 and NS5A proteins at baseline and in DAA failures, may also impact clinical decisions. METHODS In a multicentre cohort study (n=308), NS3 or NS5B sequencing (n=248) was used to discriminate between GT1 subtypes. The correlation between baseline NS3 and NS5A RASs on the 12-week sustained virological response (SVR12) rates of 160 of the patients treated with second-generation DAAs was also assessed. Post-treatment resistance analysis was performed on samples from 58 patients exhibiting DAA virological failure. RESULTS GT1a, GT1b and GT1d subtypes were identified in 23.0%, 75.4% and 1.2% of tested samples. GT1b was most prevalent (97.7%, 128/131) among patients born in the former Soviet Union. The Q80K NS3 RAS was identified in 17.5% (10/57) of the GT1a carriers, most of whom were Israeli-born. NS3 and NS5A baseline RASs showed a negligible correlation with SVR12 rates. Treatment-emergent RASs were observed among 8.9% (4/45) and 76.9% (10/13) of first- and second-generation DAA failures, respectively, with D168V/E (NS3), Y93H and L31M (NS5A) being the most prevalent mutations. CONCLUSIONS NS3 sequencing analysis can successfully discriminate between GT1 subtypes and identify NS3 amino acid substitutions. While pre-treatment NS3 and NS5A RASs marginally affect second-generation DAA SVR12 rates, post-treatment resistance analysis should be considered prior to re-therapy.
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Affiliation(s)
- Yael Gozlan
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat-Gan, Israel
| | - Ziv Ben-Ari
- Liver Disease Center, Sheba Medical Center, Ramat-Gan, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roy Moscona
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat-Gan, Israel
| | - Rachel Shirazi
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat-Gan, Israel
| | - Aviya Rakovsky
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat-Gan, Israel
| | - Arij Kabat
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat-Gan, Israel
| | - Ella Veizman
- Liver Disease Center, Sheba Medical Center, Ramat-Gan, Israel
| | | | - Peretz Weiss
- Liver Disease Center, Sheba Medical Center, Ramat-Gan, Israel
| | | | - Yoav Lurie
- Liver Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Marius Braun
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah-Tikva, Israel
| | - Michal Cohen-Naftaly
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah-Tikva, Israel
| | - Amir Shlomai
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah-Tikva, Israel
| | - Oren Shibolet
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Ehud Zigmond
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Tel-Aviv Medical Center, Tel Aviv, Israel
| | | | - Michal Carmiel-Haggai
- Liver Unit, Galilee Medical Center, Naharya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Ramat-Gan, Israel
| | - Assy Nimer
- Faculty of Medicine in the Galilee, Bar-Ilan University, Ramat-Gan, Israel.,Internal Medicine Department, Galilee Medical Center, Naharya, Israel
| | - Rawi Hazzan
- Liver Unit, Haemek Medical Center, Afula, Israel
| | - Yaakov Maor
- Division of Gastroenterology, Kaplan Health Sciences Centre, Department of Medicine, Faculty of Medicine, Hebrew University, Rehovot, Israel
| | - Yona Kitay-Cohen
- Gastroenterology and Hepatology Institute, Meir Medical Center, Kfar Saba, Israel
| | | | - Zipi Kra-Oz
- Virology Laboratory, Rambam Medical Center, Haifa, Israel
| | | | | | - Saleta Sierra
- Institute of Virology, University of Cologne, Cologne, Germany
| | | | - Ella Mendelson
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat-Gan, Israel.,School of Public Health, Tel Aviv University, Tel Aviv, Israel
| | - Orna Mor
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat-Gan, Israel
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10
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Moore A, Cohen-Naftaly M, Benjaminov O, Braun M, Issachar A, Mor E, Tovar A, Sarfaty M, Gordon N, Stemmer SM. Radiotherapy and Sorafenib in the Management of Patients with Hepatocellular Carcinoma Have Led to Improved Survival: A Single Center Experience. J Cancer 2016; 7:883-9. [PMID: 27313777 PMCID: PMC4910579 DOI: 10.7150/jca.14721] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/22/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND & AIMS Hepatocellular Carcinoma (HCC) is the sixth most common malignancy and the third most common cause of cancer mortality worldwide. We aimed to assess the effect of novel treatment options on the survival of HCC patients. METHODS This retrospective study included all HCC patients diagnosed between 2000 and 2013 referred to the Davidoff center and treated by a multidisciplinary team. RESULTS The analysis included 321 patients (median age, 64 years; 74.8% males; 74.1% viral carriers; 76.0% cirrhosis; 56.7% diagnosis at an early stage). The estimated hazard ratio by multivariate analysis for the effect of the period of diagnosis (2007-2013 vs. 2000-2006) on survival was 0.72 (95% CI: 0.54-0.96; p=0.027). There was no difference in the distribution by CP score, by BCLC stage at diagnosis or in the proportion of patients undergoing surgical procedures (liver transplantation or resection). In the later time frame, there was a significant decrease in the proportion of patients undergoing percutaneous treatments (14.6% vs.4.2%, p=0.004) and embolization (46.9% vs.24.6%, p=0.001), and a significant increase in radiotherapy (1.5% vs. 8.4%, p=0.009) and treatment with sorafenib (6% vs. 18.3%, p=0.002). CONCLUSION Technological/pharmaceutical innovations have led to advancement in HCC treatment. Since there was no significant difference in the proportion of patients undergoing surgical procedures during the evaluated timeframe, the improved survival may stem from better management of advanced stage patients by a multidisciplinary team.
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Affiliation(s)
- Assaf Moore
- 1. Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Michal Cohen-Naftaly
- 3. Liver Institute; Rabin Medical Center, Petah Tikva, Israel;; 2. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Benjaminov
- 2. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel;; 4. Department of Imaging; Rabin Medical Center, Petah Tikva, Israel
| | - Marius Braun
- 2. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel;; 3. Liver Institute; Rabin Medical Center, Petah Tikva, Israel
| | - Assaf Issachar
- 2. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel;; 3. Liver Institute; Rabin Medical Center, Petah Tikva, Israel
| | - Eitan Mor
- 2. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel;; 5. Department of Organ Transplantation; Rabin Medical Center, Petah Tikva, Israel
| | - Anna Tovar
- 2. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel;; 6. Department of Pathology, Rabin Medical Center, Petah Tikva, Israel
| | - Michal Sarfaty
- 1. Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel;; 2. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Gordon
- 1. Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Salomon M Stemmer
- 1. Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel;; 2. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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11
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Vetter D, Cohen-Naftaly M, Villaneuva A, Lee YA, Kocabayoglu P, Hannivoort R, Narla G, Llovet JM, Thung SN, Friedman SL. Enhanced hepatocarcinogenesis in mouse models and human hepatocellular carcinoma by coordinate KLF6 depletion and increased messenger RNA splicing. Hepatology 2012; 56:1361-70. [PMID: 22535637 PMCID: PMC3412196 DOI: 10.1002/hep.25810] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Accepted: 04/11/2012] [Indexed: 12/23/2022]
Abstract
UNLABELLED KLF6-SV1 (SV1), the major splice variant of KLF6, antagonizes the KLF6 tumor suppressor by an unknown mechanism. Decreased KLF6 expression in human hepatocellular carcinoma (HCC) correlates with increased mortality, but the contribution of increased SV1 is unknown. We sought to define the impact of SV1 on human outcomes and experimental murine hepatocarcinogenesis and to elucidate its mechanism of action. In hepatitis C virus (HCV)-related HCC, an increased ratio of SV1/KLF6 within the tumor was associated with features of more advanced disease. Six months after a single injection of diethylnitrosamine (DEN), SV1 hepatocyte transgenic mice developed more histologically advanced tumors, whereas Klf6-depleted mice developed bigger tumors compared to the Klf6fl(+/+) control mice. Nine months after DEN, SV1 transgenic mice with Klf6 depletion had the greatest tumor burden. Primary mouse hepatocytes from both the SV1 transgenic animals and those with hepatocyte-specific Klf6 depletion displayed increased DNA synthesis, with an additive effect in hepatocytes harboring both SV1 overexpression and Klf6 depletion. Parallel results were obtained by viral SV1 transduction and depletion of Klf6 through adenovirus-Cre infection of primary Klf6fl(+/+) hepatocytes. Increased DNA synthesis was due to both enhanced cell proliferation and increased ploidy. Coimmunoprecipitation studies in 293T cells uncovered a direct interaction of transfected SV1 with KLF6. Accelerated KLF6 degradation in the presence of SV1 was abrogated by the proteasome inhibitor MG132. CONCLUSION An increased SV1/KLF6 ratio correlates with more aggressive HCC. In mice, an increased SV1/KLF6 ratio, generated either by increasing SV1, decreasing KLF6, or both, accelerates hepatic carcinogenesis. Moreover, SV1 binds directly to KLF6 and accelerates its degradation. These findings represent a novel mechanism underlying the antagonism of tumor suppressor gene function by a splice variant of the same gene.
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Affiliation(s)
- Diana Vetter
- Department of Medicine/Division of Liver Diseases, Mount Sinai School of Medicine, New York, NY,Department of Abdominal Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Michal Cohen-Naftaly
- Department of Medicine/Division of Liver Diseases, Mount Sinai School of Medicine, New York, NY
| | - Augusto Villaneuva
- HCC Translational Research Laboratory, Barcelona-Clinic Liver Cancer Group, Liver Unit. Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS); Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Hospital Clinic, Barcelona, Spain
| | - Youngmin A. Lee
- Department of Medicine/Division of Liver Diseases, Mount Sinai School of Medicine, New York, NY
| | - Peri Kocabayoglu
- Department of Medicine/Division of Liver Diseases, Mount Sinai School of Medicine, New York, NY
| | - Rebekka Hannivoort
- Department of Medicine/Division of Liver Diseases, Mount Sinai School of Medicine, New York, NY,Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Goutham Narla
- Department of Medicine/Division of Liver Diseases, Mount Sinai School of Medicine, New York, NY, Departments of Genetics & Genomic Sciences, Mount Sinai School of Medicine, New York, NY
| | - Josep Maria Llovet
- Department of Medicine/Division of Liver Diseases, Mount Sinai School of Medicine, New York, NY,HCC Translational Research Laboratory, Barcelona-Clinic Liver Cancer Group, Liver Unit. Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS); Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Hospital Clinic, Barcelona, Spain,Institució Catalana de Recerca i Estudis Avançats, Mount Sinai School of Medicine, New York, NY
| | - Swan N. Thung
- Department of Pathology, Mount Sinai School of Medicine, New York, NY
| | - Scott L. Friedman
- Department of Medicine/Division of Liver Diseases, Mount Sinai School of Medicine, New York, NY
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12
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Muñoz Ú, Puche JE, Hannivoort R, Lang UE, Cohen-Naftaly M, Friedman SL. Hepatocyte growth factor enhances alternative splicing of the Kruppel-like factor 6 (KLF6) tumor suppressor to promote growth through SRSF1. Mol Cancer Res 2012; 10:1216-27. [PMID: 22859706 DOI: 10.1158/1541-7786.mcr-12-0213] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Alternative splicing of the Krüppel-like factor 6 (KLF6) tumor suppressor into an antagonistic splice variant 1 (SV1) is a pathogenic event in several cancers including hepatocellular carcinoma (HCC) because elevated SV1 is associated with increased tumor metastasis and mortality. Ras activation is one factor that can enhance KLF6 splicing in cancer cells, however pathways driving KLF6 splicing are unknown. Splice site selection is regulated by splice factors that include serine/arginine-rich (SR) proteins such as SRSF1 (ASF-SF2), which in turn is controlled by phosphoinositide 3-kinase (PI3K)/Akt and the mitogen-activated protein kinase (MAPK) signaling pathway. Because signaling pathways downstream of the liver mitogen hepatocyte growth factor (HGF) include Akt, we explored whether HGF induces KLF6 alternative splicing. In HepG2 cells, HGF (25 ng/mL) significantly increases the ratio of SV1/KLF6 full by 40% through phosphorylation of Akt and subsequent downregulation of two splicing regulators, SRSF3 (SRp20) and SRSF1. Decreased SRSF3 levels regulate SRSF1 levels by alternative splicing associated with the nonsense-mediated mRNA decay pathway (AS-NMD), which stimulates cell growth by decreasing p21 levels. Enhanced cell replication through increased KLF6 alternative splicing is a novel growth-promoting pathway of HGF that could contribute to the molecule's mitogenic activity in physiologic liver growth and hepatocellular carcinoma.
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Affiliation(s)
- Úrsula Muñoz
- Division of Liver Diseases, Mount Sinai School of Medicine, New York, NY 10029, USA
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13
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Abstract
Fibrosis accumulation is a dynamic process resulting from a wound-healing response to acute or chronic liver injury of all causes. The cascade starts with hepatocyte necrosis and apoptosis, which instigate inflammatory signaling by chemokines and cytokines, recruitment of immune cell populations, and activation of fibrogenic cells, culminating in the deposition of extracellular matrix. These key elements, along with pathways of transcriptional and epigenetic regulation, represent fertile therapeutic targets. New therapies include drugs specifically designed as antifibrotics, as well as drugs already available with well-established safety profiles, whose mechanism of action may also be antifibrotic. At the same time, the development of noninvasive fibrogenic markers, and techniques (e.g. fibroscan), as well as combined scoring systems incorporating serum and clinical features will allow improved assessment of therapy response. In aggregate, the advances in the elucidation of the biology of fibrosis, combined with improved technologies for assessment will provide a comprehensive framework for design of antifibrotics and their analysis in well-designed clinical trials. These efforts may ultimately yield success in halting the progression of, or reversing, liver fibrosis.
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Affiliation(s)
| | - Scott L. Friedman
- Fishberg Professor of Medicine, Division of Liver Diseases, Box 1123, Mount Sinai School of Medicine, 1425 Madison Avenue, Room 11-70C, New York, NY 10029-6574, USA
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