Physical activity in liver transplant recipients: a large multicenter study

AIM

Healthy lifestyle and appropriate diet are of critical importance after liver transplant (LT). We provided an analysis of the main patterns of physical activity and found factors associated with physical activity itself.

METHODS

Clinically stable LT recipients were enrolled between June and September 2021. Patients completed a composite questionnaire about physical activity, adherence to Mediterranean Diet (MD), quality of life (QoL), and employment. Correlations were analysed using the Pearson coefficients while different subgroups were compared by t-test for independent samples or ANOVAs. Multivariable logistic regression analysis was conducted to find predictors of inactivity.

RESULTS

We enrolled 511 subjects (71% males, mean age 63 ± 10.8 years). One hundred and ninety-three patients reported high level of physical activity, 197 a minimal activity and 121 declared insufficient activity. Among these latter, 29 subjects were totally inactive. Considering the 482 LT recipients performing some kind of physical activity, almost all reported a low-quality, non-structured activity. At multivariate analysis, time from LT (odds ratio 0.94, 95% CI 0.89-0.99, p = 0.017), sedentary lifestyle (odds ratio 0.99, 95% CI 0.19-0.81, p = 0.012), low adherence to MD (odds ratio 1.22, 95% CI 1.01-1.48, p = 0.049), and low level of QoL (physical dimension) (odds ratio 1.13, 95% CI 1.08-1.17, p < 0.001), were independently associated with total inactivity.

CONCLUSION

A large portion of LT recipients report an insufficient level of physical activity or are wholly inactive. Inactivity increases with time from LT and was strongly associated with suboptimal diet and low QoL.

Robot-assisted excision of hemangioma of the right renal vein

Hemangiomas, benign vascular masses, occasionally occur in the kidneys, presenting as rare, small, unilateral, and solitary growths. Venous hemangiomas, a renal subtype, are atypical. While clinically nonspecific, they are typically asymptomatic and may be incidentally discovered during unrelated clinical workups. Diagnosing renal hemangioma preoperatively is challenging due to rarity, lacking standard radiographic criteria, and poor differentiation from aggressive renal neoplasms on contrast-enhanced imaging. These tumors commonly follow a benign course, with no documented recurrence. This video article showcases the robot-assisted excision of a renal vein hemangioma, addressing the expertise needed in managing this uncommon condition robotically.

Trends in liver transplantation for primary sclerosing cholangitis

BACKGROUND

Primary sclerosing cholangitis is a cholestatic disease with a low prevalence in Italy. Indications for liver transplantation and the time of listing are not stated.

AIM

We performed a national survey to investigate the listing criteria, comorbidities, and outcomes.

METHODS

In April 2022, we surveyed liver transplantation in primary sclerosing cholangitis nationwide for the last 15 years.

RESULTS

From 2007 to 2021, 445 patients were included on waiting lists, and 411 had undergone liver transplants. The median age at transplantation was 46 years (males 63.9%); 262 patients (59%) presented an inflammatory bowel disease. Transplants increased over the years, from 1.8 % in 2007 to 3.0 % in 2021. Cholangitis (51%) and hepatic decompensation (45%) were the main indications for listing. The disease recurred in 81 patients (20%). Patient survival after the first transplant was 94 %, 86% and 84% at one, five, and ten years. Twenty-four died in the first year (50% surgical complications, 25% infections); 33 between one to five years (36% recurrence, 21% cholangiocarcinoma recurrence) and nine after five years (56% de novo cancer, 44% recurrence).

CONCLUSIONS

Primary sclerosing cholangitis has been an increasing indication for transplantation in Italy. Cholangitis and decompensation were the main indications for listing. Recurrence and cancer were the leading causes of death.

Impairment in Activities of Daily Living Assessed by the Barthel Index Predicts Adverse Oncological Outcomes After Radical Cystectomy for Bladder Cancer

INTRODUCTION

We tested the association between functional impairment in activities of daily living (ADL) assessed through the Barthel Index (BI), and oncological outcomes following radical cystectomy (RC) for bladder cancer (BCa).

PATIENTS AND METHODS

We retrospectively analyzed data of 262 clinically nonmetastatic BCa patients, who underwent RC between 2015 and 2022, with available follow-up. According to preoperative BI, patients were divided in 2 groups: BI ≤90 (moderate/severe/total dependency in ADL) versus BI 95 to 100 (slight dependency/independency in ADL). Kaplan-Meier plots compared disease recurrence (DR)-, cancer-specific mortality (CSM)-, and overall mortality (OM)-free survival according to established categories. Multivariable Cox regression models tested the BI as an independent predictor of oncological outcomes.

RESULTS

According to the BI, the patient cohort was distributed as follows: 19% (n = 50) BI ≤90 versus 81% (n = 212) BI 95-100. Compared to patients with BI 95 to 100, patients with BI ≤90 were less likely to receive intravesical immuno- or chemotherapy (18% vs. 34%, p = .028), and more frequently underwent less complex urinary diversion as ureterocutaneostomy (36% vs. 9%, p < .001), or harbored muscle-invasive BCa at final pathology (72% vs. 56%, p = .043). In multivariable Cox regression models adjusted for age, ASA physical status score, pathological T and N stage, and surgical margins status, BI ≤90 independently predicted higher DR (HR [hazard ratio]:2.00, 95%CI [confidence interval]:1.21-3.30, p = .007), CSM (HR:2.70, 95%CI:1.48-4.90, p = .001), and OM (HR:2.09, 95%CI:1.28-3.43, p = .003).

CONCLUSION

Preoperative impairment in ADL was associated with adverse oncological outcomes following RC for BCa. The integration of the BI into clinical practice may improve the risk assessment of BCa patients candidates to RC.

The Italian data on SARS-CoV-2 infection in transplanted patients support an organ specific immune response in liver recipients

Introduction

The study of immune response to SARSCoV-2 infection in different solid organ transplant settings represents an opportunity for clarifying the interplay between SARS-CoV-2 and the immune system. In our nationwide registry study from Italy, we specifically evaluated, during the first wave pandemic, i.e., in non-vaccinated patients, COVID-19 prevalence of infection, mortality, and lethality in liver transplant recipients (LTRs), using non-liver solid transplant recipients (NL-SOTRs) and the Italian general population (GP) as comparators.

Methods

Case collection started from February 21 to June 22, 2020, using the data from the National Institute of Health and National Transplant Center, whereas the data analysis was performed on September 30, 2020.To compare the sex- and age-adjusted distribution of infection, mortality, and lethality in LTRs, NL-SOTRs, and Italian GP we applied an indirect standardization method to determine the standardized rate.

Results

Among the 43,983 Italian SOTRs with a functioning graft, LTRs accounted for 14,168 patients, of whom 89 were SARS-CoV-2 infected. In the 29,815 NL-SOTRs, 361 cases of SARS-CoV-2 infection were observed. The geographical distribution of the disease was highly variable across the different Italian regions. The standardized rate of infection, mortality, and lethality rates in LTRs resulted lower compared to NL-SOTRs [1.02 (95%CI 0.81-1.23) vs. 2.01 (95%CI 1.8-2.2); 1.0 (95%CI 0.5-1.5) vs. 4.5 (95%CI 3.6-5.3); 1.6 (95%CI 0.7-2.4) vs. 2.8 (95%CI 2.2-3.3), respectively] and comparable to the Italian GP.

Discussion

According to the most recent studies on SOTRs and SARS-CoV-2 infection, our data strongly suggest that, in contrast to what was observed in NL-SOTRs receiving a similar immunosuppressive therapy, LTRs have the same risk of SARS-CoV-2 infection, mortality, and lethality observed in the general population. These results suggest an immune response to SARS-CoV-2 infection in LTRS that is different from NL-SOTRs, probably related to the ability of the grafted liver to induce immunotolerance.

From Listing to Recovery: A Review of Nutritional Status Assessment and Management in Liver Transplant Patients

Liver transplantation (LT) is a complex surgical procedure requiring thorough pre- and post-operative planning and care. The nutritional status of the patient before, during, and after LT is crucial to surgical success and long-term prognosis. This review aims to assess nutritional status assessment and management before, during, and after LT, with a focus on patients who have undergone bariatric surgery. We performed a comprehensive topic search on MEDLINE, Ovid, In-Process, Cochrane Library, EMBASE, and PubMed up to March 2023. It identifies key factors influencing the nutritional status of liver transplant patients, such as pre-existing malnutrition, the type and severity of liver disease, comorbidities, and immunosuppressive medications. The review highlights the importance of pre-operative nutritional assessment and intervention, close nutritional status monitoring, individualised nutrition care plans, and ongoing nutritional support and monitoring after LT. The review concludes by examining the effect of bariatric surgery on the nutritional status of liver transplant recipients. The review offers valuable insights into the challenges and opportunities for optimising nutritional status before, during, and after LT.

Pneumocystis jirovecii pneumonia in patients with decompensated cirrhosis: a case series

OBJECTIVES

Pneumocystis jirovecii pneumonia (PCP) incidence is increasing in people without HIV. Decompensated liver cirrhosis is not currently considered a risk factor for PCP. The aim of this paper is to describe a case series of patients with decompensated liver cirrhosis and PCP.

METHODS

All consecutive patients hospitalized with decompensated cirrhosis and microbiology-confirmed PCP at Policlinico Modena University Hospital from January 1, 2016 to December 31, 2021 were included in our series.

RESULTS

Eight patients were included. All patients had advanced-stage liver disease with a model for end-stage liver disease score above 15 (6/8 above 20). Four were on an active orthotopic liver transplant waiting list at the time of PCP diagnosis. Five patients did not have any traditional risk factor for PCP, whereas the other three were on glucocorticoid treatment for acute-on-chronic liver failure. All patients were treated with cotrimoxazole, except two who died before the diagnosis. Five patients died (62.5%), four of them within 30 days from PCP diagnosis. Of the remaining three, one patient underwent liver transplantation.

CONCLUSION

Although further studies are needed, liver cirrhosis can be an independent risk factor for PCP in patients with decompensated cirrhosis that is mainly due to severe alcoholic hepatitis and who are on corticosteroids therapy, and primary prophylaxis for PCP should be considered.

Impact of functional impairment and cognitive status on perioperative outcomes and costs after radical cystectomy: The role of Barthel Index

OBJECTIVES

To investigate the association between Barthel Index (BI), which measures level of patients independence during daily living activities (ADL), and perioperative outcomes in a large cohort of consecutive bladder cancer (BCa) patients, who underwent radical cystectomy (RC) at a tertiary referral center.

METHODS

We retrospectively evaluated data from clinically nonmetastatic BCa patients treated with RC between 2015 and 2022. For each patient, BI was assessed preoperatively. According to BI score, patients were divided into three groups: ≤60 (total/severe dependency) vs. 65-90 (moderate dependency) vs. 95-100 (slight dependency/independency). Regression analyses tested the association between BI score and major postoperative complications (Clavien-Dindo >2), length of in-hospital stay (LOHS), 90-days readmission, and total costs.

RESULTS

Overall, 288 patients were included. According to BI score, the patient cohort was distributed as follows: 4% (n = 11) BI ≤60 vs. 15% (n = 42) BI 65-90 vs. 81% (n = 235) BI 95-100. Patients with BI ≤60 had more frequent ureterocutaneostomy performed, shorter operative time, higher rates of postoperative complications, longer LOHS, higher rates of readmission, and were associated with higher total costs, compared to patients with BI 65-90 and 95-100. In multivariable regression models, BI ≤60 remained an independent predictor of increased risk of major postoperative complications (odds ratio: 6.62, p = 0.006), longer LOHS (rate ratio: 1.25, p < 0.001), and higher costs (β: 2.617, p = 0.038).

CONCLUSIONS

Total/severe dependency in ADL assessed by BI was associated with higher rates of major postoperative complications, longer hospitalization, and higher costs in BCa patients treated with RC. BI assessment should be considered during patients selection process and counseling before surgery.

AB0 blood groups and oncological and functional outcomes in bladder cancer patients treated with radical cystectomy

OBJECTIVES

We investigated AB0 blood groups prevalence according to preoperative and pathological tumor characteristics, and their association with oncological outcomes, and renal function decline in a contemporary large cohort of bladder cancer (BCa) patients, who underwent radical cystectomy (RC) at a tertiary referral center.

MATERIALS AND METHODS

We retrospectively evaluated data of patients with histologically confirmed and clinically non metastatic BCa, who underwent RC between 2014 and 2021 at our Institution. Kaplan-Meier (KM) plots and Cox regression (CR) models tested the relationship between AB0 blood groups and local recurrence-, metastasis-, cancer specific mortality-, and overall mortality-free survival. Logistic regression (LR) models tested the association between AB0 blood groups and renal function decline, defined as an estimated Glomerular Filtration Rate (eGFR) < 60 mL/min, at post-operative day 1, discharge and 6- months of follow-up.

RESULTS

Of 301 included patients, 128 (42.5%) had group A, 126 (41.9%) had group 0, 28 (9.3%) had group B, and 19 (6.3%) had group AB. Patients with group 0 developed higher rates of muscle- invasive BCa (p = 0.028) with high-grade features (p = 0.005) at last bladder resection, and less frequently received preoperative immunotherapy with Bacillus of Calmette-Guerin (p = 0.044), than their non-0 counterparts. Additionally, these patients harbored more advanced pathologic tumor stage at RC (p = 0.024). KM plots showed no differences among all tested cancer control outcomes between AB0 blood groups (p > 0.05 in all cases). Patients with group AB presented the lowest median eGFR at each time point. In multivariable LR analyses addressing renal function decline, group AB was independently associated with eGFR< 60 mL/min at discharge (Odds Ratio: 4.28, p = 0.047).

CONCLUSIONS

Among AB0 blood groups, patients with group 0 exhibited the most aggressive tumor profile. However, no differences were recorded in recurrence or survival rates. Group AB independently predicted renal function decline at discharge.

Abstract PO003: Combination therapy with Nivolumab/Bevacizumab is safe and effective in patients with recurrent hepatocellular carcinoma after liver transplant

Recurrent hepatocellular carcinoma (HCC-R) after Liver Transplant (LT) is difficult to manage and often characterized by relevant aggressiveness and extrahepatic localizations. Currently TKIs are the only therapeutic option, but results in term of overall survival (OS) and progression-free survival are disappointing. Immune checkpoint inhibitors in association with recombinant humanized monoclonal antibody to VEGF were to be proved effective in non-LT patients with metastatic hepatocellular carcinoma in determining tumor stabilization and improved survival. However, as in LT patients immunotherapy may increase the risk of acute liver rejection, such combination therapy has not been used so far. We designed a proof-of-concept study to analyze safety and efficacy of Nivolumab and Bevacizumab in LT patients as treatment for HCC-R after LT. Combination therapy received nominal authorization from the Provincial Medicines Commission. Candidate patients underwent routine blood test (hepatic, renal, and cardiac function), echocardiogram and a total body CT as baseline assessment. Patients with creatinine higher than 1.5 ULN or with ejection fraction lower than 45% were excluded. Five patients who experienced HCC-R 2 to 8 years after LT with pulmonary, lymph node, adrenal, bones, and hepatic localization and were either intolerant to TKIs or had had progression on TKIs, were included. All recurrent tumors and extra-hepatic localizations were characterized by high biologic aggressiveness. Patients received Nivolumab infusion every 14 days at a dose of 240 mg. Total body CT scan was performed every 8 weeks. When progression disease (PD) was detected at CT scan, Bevacizumab was added at a dose of 5 mg/kg every 14 days. One patient received a single Nivolumab infusion but was withdrawn because of rapid tumor progression, eventually followed by death. Another patient experienced moderate/severe rejection, which resolved with 1g/day Methylprednisolone e.v. for 3[EV1] days followed by Prednisone 50mg/day for 1 week then tapered and stopped. This patient was maintained on double therapy without residual problems. The 4 alive patients are still on double therapy after a mean period of treatment of 36±21 weeks. Disease stability with the combination of Nivolumab/Bevacizumab has been achieved in all patients at hepatic and all extra-hepatic HCC localization but bone, where 2/2 patients experienced progression. It should be underlined, however, that progression was very slow and mean survival of these two patients on combination therapy is 54±2 weeks. Combination therapy was very well tolerated, with few side effects throughout treatment period. These results indicate that the combination Nivolumab/Bevacizumab can be safely used in liver transplant patients. The risk of acute allograft rejection is minimal and manageable. Bone metastases remain an unsolved issue and need further alternative therapeutic approach. For patients with hepatic or other extra-hepatic localization, this combination obtained a relevant and protracted stabilization of disease.

Citation Format: Lorenza Di Marco, Alessandra Pivetti, Nicola De Maria, Francesco Giuseppe Foschi, Dante Romagnoli, Federico Casari, Cristian Caporali, Paolo Magistri, Barbara Catellani, Fabrizio Di Benedetto, Erica Villa. Combination therapy with Nivolumab/Bevacizumab is safe and effective in patients with recurrent hepatocellular carcinoma after liver transplant [abstract]. In: Proceedings of the AACR Special Conference: Advances in the Pathogenesis and Molecular Therapies of Liver Cancer; 2022 May 5-8; Boston, MA. Philadelphia (PA): AACR; Clin Cancer Res 2022;28(17_Suppl):Abstract nr PO003.

Quality of life in liver transplant recipients during the Corona virus disease 19 pandemic: A multicentre study

BACKGROUND

Liver transplant recipients require specific clinical and psychosocial attention given their frailty. Main aim of the study was to assess the quality of life after liver transplant during the current pandemic.

METHODS

This multicentre study was conducted in clinically stable, liver transplanted patients. Enrollment opened in June and finished in September 2021. Patients completed a survey including lifestyle data, quality of life (Short Form health survey), sport, employment, diet. To examine the correlations, we calculated Pearson coefficients while to compare subgroups, independent samples t-tests and ANOVAs. To detect the predictors of impaired quality of life, we used multivariable logistic regression analysis.

RESULTS

We analysed data from 511 patients observing significant associations between quality of life's physical score and both age and adherence to Mediterranean diet (p < .01). A significant negative correlation was observed between mental score and the sedentary activity (p < .05). Female patients scored significantly lower than males in physical and mental score. At multivariate analysis, females were 1.65 times more likely to report impaired physical score than males. Occupation and physical activity presented significant positive relation with quality of life. Adherence to Mediterranean diet was another relevant predictor. Regarding mental score, female patients were 1.78 times more likely to show impaired mental score in comparison with males. Sedentary activity and adherence to Mediterranean diet were further noteworthy predictors.

CONCLUSIONS

Females and subjects with sedentary lifestyle or work inactive seem to show the worst quality of life and both physical activity and Mediterranean diet might be helpful to improve it.

Predictors of solid extra-hepatic non-skin cancer in liver transplant recipients and analysis of survival: A long-term follow-up study

INTRODUCTION AND OBJECTIVES

De novo malignancies represent an important cause of death for liver transplant recipients. Our aim was to analyze predictors of extra-hepatic non-skin cancer (ESNSC) and the impact of ESNSC on the long-term outcome.

PATIENTS

We examined data from patients transplanted between 2000 and 2005 and followed-up in five Italian transplant clinics with a retrospective observational cohort study. Cox Regression was performed to identify predictors of ESNSC. A 1:2 cohort sub-study was developed to analyze the impact of ESNSC on 10-year survival.

RESULTS

We analyzed data from 367 subjects (median follow-up: 15 years). Patients with ESNSC (n = 47) more often developed post-LT diabetes mellitus (DM) (57.4% versus 35,9%, p = 0.004). At multivariate analysis, post-LT DM independently predicted ESNSC (HR 1.929, CI 1.029-3.616, p = 0.040). Recipients with ESNSC showed a lower 10-year survival than matched controls (46,8% versus 68,1%, p = 0.023).

CONCLUSIONS

Post-LT DM seems to be a relevant risk factor for post-LT ESNSC. ESNSC could have a noteworthy impact on the long-term survival of LT recipients.

Safe pregnancy after liver transplantation: Evidence from a multicenter Italian collaborative study

BACKGROUND

Women who have undergone liver transplantation (LT) enjoy better health, and possibility of childbearing. However, maternal and graft risks, optimal immunosuppression, and fetal outcome is still to clarify.

AIM

Aim of the study was to assess outcomes of pregnancy after LT at national level.

METHODS

In 2019, under the auspices of the Permanent Transplant Committee of the Italian Association for the Study of the Liver, a multicenter survey including 14 Italian LT-centers was conducted aiming at evaluating the outcomes of recipients and newborns, and graft injury/function parameters during pregnancy in LT-recipients.

RESULTS

Sixty-two pregnancies occurred in 60 LT-recipients between 1990 and 2018. Median age at the time of pregnancy was 31-years and median time from transplantation to conception was 8-years. During pregnancy, 4 recipients experienced maternal complications with hospital admission. Live-birth-rate was 100%. Prematurity occurred in 25/62 newborns, and 8/62 newborns had low-birth-weight. Cyclosporine was used in 16 and Tacrolimus in 37 pregnancies, with no different maternal or newborn outcomes. Low-birth-weight was correlated to high values of AST, ALT and GGT.

CONCLUSION

Pregnancy after LT has good outcome; however, maternal complications and prematurity may occur. Compliance with the immunosuppression is fundamental to ensure the stability of graft function and prevent graft-deterioration.

Herpes Simplex Virus Re-Activation in Patients with SARS-CoV-2 Pneumonia: A Prospective, Observational Study

Background: Herpes simplex 1 co-infections in patients with COVID-19 are considered relatively uncommon; some reports on re-activations in patients in intensive-care units were published. The aim of the study was to analyze herpetic re-activations and their clinical manifestations in hospitalized COVID-19 patients, performing HSV-1 PCR on plasma twice a week. Methods: we conducted a prospective, observational, single-center study involving 70 consecutive patients with severe/critical SARS-CoV-2 pneumonia tested for HSV-1 hospitalized at Azienda Ospedaliero-Universitaria of Modena. Results: of these 70 patients, 21 (30.0%) showed detectable viremia and 13 (62%) had clinically relevant manifestations of HSV-1 infection corresponding to 15 events (4 pneumonia, 5 herpes labialis, 3 gingivostomatitis, one encephalitis and two hepatitis). HSV-1 positive patients were more frequently treated with steroids than HSV-1 negative patients (76.2% vs. 49.0%, p = 0.036) and more often underwent mechanical ventilation (IMV) (57.1% vs. 22.4%, p = 0.005). In the unadjusted logistic regression analysis, steroid treatment, IMV, and higher LDH were significantly associated with an increased risk of HSV1 re-activation (odds ratio 3.33, 4.61, and 16.9, respectively). The association with the use of steroids was even stronger after controlling for previous use of both tocilizumab and IMV (OR = 5.13, 95% CI:1.36–19.32, p = 0.016). The effect size was larger when restricting to participants who were treated with high doses of steroids while there was no evidence to support an association with the use of tocilizumab Conclusions: our study shows a high incidence of HSV-1 re-activation both virologically and clinically in patients with SARS-CoV-2 severe pneumonia, especially in those treated with steroids.

Two Fatal Cases of Acute Liver Failure Due to HSV-1 Infection in COVID-19 Patients Following Immunomodulatory Therapies

We reported two fatal cases of acute liver failure secondary to Herpes Simplex Virus 1 infection in COVID-19 patients, following tocilizumab and corticosteroid therapy.Screening for and prompt recognition of Herpes Simplex Virus 1 reactivation in these patients, undergoing immunomodulatory treatment, may have potentiallyrelevant clinical consequences.

Pre-transplant diabetes predicts atherosclerotic vascular events and cardiovascular mortality in liver transplant recipients: a long-term follow-up study

Background Early after surgery, liver transplant (LT) recipients often develop weight gain. Metabolic disorders and cardiovascular disease represent main drivers of morbidity and mortality. Our aim was to identify predictors of atherosclerotic vascular events (AVE) and to assess the impact of AVE on the long-term outcome. Methods We retrospectively analyzed data from patients transplanted between 2000 and 2005 and followed-up in five Italian transplant clinics. Cox Regression analysis was performed to identify predictors of AVE, global mortality, and cardiovascular mortality. Survival analysis was performed using the Kaplan-Meier method. Results We analyzed data from 367 subjects during a median follow-up of 14 years. Thirty-seven post-LT AVE were registered. Patients with AVE more frequently showed pre-LT diabetes mellitus (DM) (48.6 vs 13.9%, p=0.000). In the post-LT period, patients with AVE satisfied criteria of metabolic syndrome in 83.8% vs. 36.7% of subjects without AVE (p=0.000). At multivariate analysis, pre-LT DM independently predicted AVE (HR 2.250, CI 4.848-10.440, p=0.038). Moreover, both pre-LT DM and AVE strongly predicted cardiovascular mortality (HR 5.418, CI 1.060-29.183, p=0.049, and HR 86.097, CI 9.510-779.480, p=0.000, respectively). Conclusions Pre-LT DM is the main risk factor for post-LT AVE. Pre-LT DM and post-LT AVE are strong, long-term predictors of cardiovascular mortality. Patients with pre-LT DM should obtain a personalized follow-up for prevention or early diagnosis of AVE.

Safety and clinical activity of combination treatment with regorafenib and milciclib in liver transplant patients with hepatocellular carcinoma recurrence

e16634

Background: Recurrence of hepatocellular carcinoma after liver transplant (LT-HCC), affects ~40% of patients. As LT-HCC drastically limits therapeutic options, combination of drugs with different mechanism of actions might be an attractive approach. Primary objective of this MiHRCO (Milciclib and Half Regorafenib CO-administration) protocol (87/2019/COMP/MiHRCO) is to evaluate safety and clinical activity of combination of Regorafenib (a tyrosine kinase inhibitor with higher clinical activity in aggressive HCC) with Milciclib (a pan cyclin dependent kinase inhibitor with clinical activities in refractory solid malignancy patients and HCC) in LT-HCC patients. Methods: Seven patients with LT-HCC are enrolled to date. Regorafenib administered at half the prescribed dose (80mg/day) for 3 weeks followed by 1 week Off and milciclib at 100 mg daily for 4 day On/3 day Off. Patients were maintained on this combination regimen until disease progression and/or unacceptable side effects. Primary endpoint was safety and secondary endpoints included progression free survival, time to progression, and clinical benefit rate. Results: This single-arm, single-center operative protocol in LT-HCC patients with extra-hepatic metastasis, not eligible to first line therapy with sorafenib (Todesca P. et al. Hepatology; doi: 10.1002/hep.30588), is currently ongoing. The combination treatment is well-tolerated with manageable toxicities (mostly related with regorafenib), i.e. moderate diarrhea, slight increase of hypertension in previously hypertensive patients and moderate hand and foot syndrome. Patients continuing with therapy are currently in 2 to 10 months of treatment period. All patients are exhibiting stable disease with reduced clinical symptoms. The mean AFP (□-fetoprotein) level (1310±200 ng/ml) at enrollment was reduced by 20% with in the first month of therapy. Importantly, AFP levels in 2 patients, treated for longer period, were reduced by 50%. Conclusions: Regorafenib and milciclib combination was well-tolerated. Most patients showed disease stabilization along with reduction in AFP levels within the first month of therapy. The encouraging clinical activity in difficult-to-treat patients with LT-HCC warrants continuation of this protocol and further evaluation in a larger controlled study. Clinical trial information: 87/2019/COMP/MiHRCO .

Nonalcoholic steatohepatitis before and after liver transplant: keeping up with the times

In the last years, nonalcoholic steatohepatitis (NASH) has become a leading indication for liver transplant (LT). After transplant, both recurrent and de novo nonalcoholic fatty liver disease (NAFLD) can be commonly diagnosed. However, dedicated surveillance programs for patients with pre- or post-transplant NAFLD are not available. Areas covered: Patients waiting for LT for NASH show specific peculiarities and would deserve targeted stratification of mortality risk. Obesity, hyperlipidemia, and diabetes mellitus can be often found after transplant. These conditions, together with immunosuppressive regimen, make LT recipients a high-risk population for both recurrent and de novo NAFLD. Development of fatty liver disease after LT has a relevant impact on both morbidity and mortality. Expert commentary: A targeted stratification of neoplastic and cardiovascular risk for patients with NASH waiting for LT would be mandatory. In both pre- and post-transplant period, NAFLD should be considered not only a liver disease but also a cardiovascular risk factor. Patients within Transplant Program, especially those with known metabolic risk factors, should be followed with personalized diagnostic and life-style interventions before and after LT.

Non-alcoholic fatty liver disease phenotypes in patients with inflammatory bowel disease

Non-alcoholic fatty liver disease (NAFLD) can be detected in up to 33.6% of inflammatory bowel disease (IBD) patients, often in absence of metabolic risk factors. Nevertheless, most of previous studies on such issue were conducted within the IBD population only. The primary aim of this study was to compare clinical and metabolic features of NAFLD in patients with and without IBD (w/o IBD) and to identify specific NAFLD phenotypes within the IBD population. Among 223 NAFLD patients, 78 patients with IBD were younger compared to 145 without (w/o) IBD, were less likely to have altered liver enzymes, had lower mean body weight, smaller waist circumference and lower body mass index (BMI); at the same time, MetS was more prevalent among patients w/o IBD (56.6 vs. 23.1%, p < 0.001). Within IBD population, patients with severe IBD showed more often severe steatosis (S3) at ultrasound (US) (32.1 vs. 16.6%, p = 0.01), compared to mild-to-moderate disease. Independent risk factors for S3 US steatosis in IBD patients at the multivariate logistic regression analysis were: more than 1 IBD relapse per year during disease history (OR 17.3, 95% CI 3.6-84), surgery for IBD (OR 15.1, 95% CI 3.1-73.7) and more extensive intestinal involvement (OR 19.4, 95% CI 3.4-110.9); the ongoing anti-Tumor Necrosis Factor alpha (antiTNFα) therapy was the only independent factor which protect toward the presence of altered liver enzymes (OR 0.15, 95% CI 0-0.8, p = 0.02). In conclusion, NAFLD in IBD patients is different from that in patients w/o IBD, who seem to develop different NAFLD phenotypes according to intestinal disease clinical course. More severe IBD seem to predict the presence of more severe steatosis. Therapy with antiTNFα antibodies could prevent alteration of liver enzymes in such population.

Anticoagulation in cirrhosis: a new paradigm?

The liver plays a crucial role in coagulation cascade. Global hemostatic process is profoundly influenced by the presence of liver disease and its complications. Patients with cirrhosis have impaired synthesis of most of the factors involved in coagulation and fibrinolysis process due to a reduced liver function and altered platelet count secondary to portal hypertension. Altered routine tests and thrombocytopenia were considered in the past as associated with increased risk of bleeding. These concepts explain both the routine use of plasma and/or platelets transfusion in patients with liver cirrhosis, especially before invasive procedures, and why these patients were considered "auto-anticoagulated". New recent evidences show that patients with liver cirrhosis have a more complex hemostatic alteration. Despite the presence of altered levels of factors involved in primary hemostasis, coagulation and fibrinolysis, patients with stable cirrhosis have a rebalanced hemostatic, which however can easily be altered by decompensation or infection, both in hemorrhagic or thrombotic direction. Patients with cirrhosis have an increased risk of venous thrombotic events (namely portal vein thrombosis) while bleeding seems to be related to the grade of portal hypertension rather than to a hemostatic imbalance. The use of anticoagulants both as treatment or prophylaxis is safe, reduces the rate of portal vein thrombosis and decompensation, and improves survival. Standard laboratory coagulation tests are unable to predict bleeding and are inadequate for the assessment of hemostatic status in these patients, hence more comprehensive tests are required to guide the management of thrombotic and bleeding complications.

Antimicrobial stewardship in a Gastroenterology Department: Impact on antimicrobial consumption, antimicrobial resistance and clinical outcome

BACKGROUND

A major cause of the increase in antimicrobial resistance is the inappropriate use of antimicrobials.

AIMS

To evaluate the impact on antimicrobial consumption and clinical outcome of an antimicrobial stewardship program in an Italian Gastroenterology Department.

METHODS

Between October 2014 and September 2015 (period B), a specialist in infectious diseases (ID) controlled all antimicrobial prescriptions and decided about the therapy in agreement with gastroenterologists. The defined daily doses of antimicrobials (DDDs), incidence of MDR-infections, mean length of stay and overall in-hospital mortality rate were compared with those of the same period in the previous 12-months (period A).

RESULTS

During period B, the ID specialist performed 304 consultations: antimicrobials were continued in 44.4% of the cases, discontinued in 13.8%, not recommended in 12.1%, de-escalated 9.9%, escalated in 7.9%, and started in 4.0%. Comparing the 2 periods, we observed a decreased of antibiotics consumption (from 109.81 to 78.45 DDDs/100 patient-days, p=0.0005), antifungals (from 41.28 to 24.75 DDDs/100pd, p=0.0004), carbapenems (from 15.99 to 6.80 DDDsx100pd, p=0.0032), quinolones (from 35.79 to 17.82 DDDsx100pd, p=0.0079). No differences were observed in incidence of MDR-infections, length of hospital stay (LOS), and mortality rate.

CONCLUSIONS

ASP program had a positive impact on reducing the consumption of antimicrobials, without an increase in LOS and mortality.

Neoangiogenesis-related genes are hallmarks of fast-growing hepatocellular carcinomas and worst survival. Results from a prospective study

OBJECTIVE

The biological heterogeneity of hepatocellular carcinoma (HCC) makes prognosis difficult. We translate the results of a genome-wide high-throughput analysis into a tool that accurately predicts at presentation tumour growth and survival of patients with HCC.

DESIGN

Ultrasound surveillance identified HCC in 78 (training set) and 54 (validation set) consecutive patients with cirrhosis. Patients underwent two CT scans 6 weeks apart (no treatment in-between) to determine tumour volumes (V0 and V1) and calculate HCC doubling time. Baseline-paired HCC and surrounding tissue biopsies for microarray study (Agilent Whole Human Genome Oligo Microarrays) were also obtained. Predictors of survival were assessed by multivariate Cox model.

RESULTS

Calculated tumour doubling times ranged from 30 to 621 days (mean, 107±91 days; median, 83 days) and were divided into quartiles: ≤53 days (n=19), 54-82 days (n=20), 83-110 days (n=20) and ≥111 days (n=19). Median survival according to doubling time was significantly lower for the first quartile versus the others (11 vs 41 months, 42, and 47 months, respectively) (p<0.0001). A five-gene transcriptomic hepatic signature including angiopoietin-2 (ANGPT2), delta-like ligand 4 (DLL4), neuropilin (NRP)/tolloid (TLL)-like 2 (NETO2), endothelial cell-specific molecule-1 (ESM1), and nuclear receptor subfamily 4, group A, member 1 (NR4A1) was found to accurately identify rapidly growing HCCs of the first quartile (ROC AUC: 0.961; 95% CI 0.919 to 1.000; p<0.0001) and to be an independent factor for mortality (HR: 3.987; 95% CI 1.941 to 8.193, p<0.0001).

CONCLUSIONS

The hepatic five-gene signature was able to predict HCC growth in individual patient and the consequent risk of death. This implies a role of this molecular tool in the future therapeutic management of patients with HCC.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT01657695.

Abstract A07: Gene analysis maps HCC heterogeneity and orientates personalized therapy

Hepatocellular carcinoma (HCC) has variable prognosis depending both on the severity of underlying liver disease and of its biological characteristic. We recently identified, in a prospective series of HCCs at first presentation, a 5-genes transcriptomic signature, which accurately and significantly predicts growth speed and survival (Gut. 2015 Feb 9. pii:gutjnl-2014-308483. doi: 10.1136/gutjnl-2014-308483). This signature encounters 5 up-regulated genes (ANGPT2, DLL4, NETO2, ESM1, NR4A1), all associated with neo-angiogenesis. Such gene analysis prompted us to characterize further the molecular pathways underlying tumor aggressiveness and consequently clinical outcome.

The cohort of 78 prospectively identified HCCs was further characterized. Transcriptomic analysis was performed by microarray experiments (Agilent Technologies, Palo Alto, CA; Genomics Service Department of Miltenyi Biotec GmbH Bergisch Gladbach, Germany). Circulating cytokines were measured using human Quantikine® ELISA kit (R&D Systems, Minneapolis, MN, USA). For PD-1 and PD-L1 immunohistochemistry, samples were incubated with mouse monoclonal antibody (Ventana), for 24 minutes at 37°C. Biological data were analyzed according to HCC growth speed and patients’ survival.

Genes down- or up-regulated affected prognosis and survival. In particular, the worst survival was correlated with down-regulation of CLEC4G and CLEC1B and up-regulation of MMP1, MMP10, MMP12 and WNT11. Next, we also measured a large panel of circulating cytokines tested, and among them TGF-β1 was the only significantly and positively associated with HCC aggressiveness. PD-1 and PD-L1 were strongly co-expressed especially at the boundary between tumoral and non-tumoral cirrhotic tissue but only in the most aggressive type. In slow-growing HCCs, PD-1/PD-L1 were only faintly expressed.

Bringing together all these results, the most aggressive and associated with a worst clinical outcome aggressively HCCs were characterized by genes regulating different molecular pathways, including neo-angiogenesis (ANGPT2, DLL4, NETO2, ESM1, NR4A1and, indirectly, CLEC4G and CLEC1B), tumoral spread (MMP1, MMP10, MMP12), tissue remodelling, loss of immune local control (hyperactivated PD-1 and PD-1L). Aberrant PD-L1 expression in cancers facilitates escape from immune attack. PD-1 ligation by PD-L1 down-modulates anti-tumor immune effector functions allowing the development of a subset of hyper-aggressive HCCs. All such different pathways contribute to explain HCC heterogeneity, leading to therapeutic failures, but at the same time, stimulate a better stratification of patients directing the options for personalized therapies.

Citation Format: Rosina Maria Critelli, Fabiola Milosa, Barbara Lei, Luca Marzi, Rosario Condello, Elena Turola, Nicola De Maria, Antonino Maiorana, Gianluigi Giannelli, Erica Villa. Gene analysis maps HCC heterogeneity and orientates personalized therapy. [abstract]. In: Proceedings of the AACR Special Conference: Developmental Biology and Cancer; Nov 30-Dec 3, 2015; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Res 2016;14(4_Suppl):Abstract nr A07.

Complete resolution of non-necrotizing lung granuloma and pyoderma gangrenosum after restorative proctocolectomy in a woman with severe ulcerative colitis and cytomegalovirus infection

Here, we report the unusual case of an ulcerative colitis female patient presenting together with cytomegalovirus infection, pyoderma gangrenosum and a noncaseating lung granuloma, both resistant to immunomodulatory drugs which dramatically obtained a clinical stable remission after restorative proctocolectomy.

Thrombelastography-guided blood product use before invasive procedures in cirrhosis with severe coagulopathy: A randomized, controlled trial

Bleeding is a feared complication of invasive procedures in patients with cirrhosis and significant coagulopathy (as defined by routine coagulation tests) and is used to justify preprocedure use of fresh frozen plasma (FFP) and/or platelets (PLT). Thromboelastography (TEG) provides a more comprehensive global coagulation assessment than routine tests (international normalized ratio [INR] and platelet count), and its use may avoid unnecessary blood product transfusion in patients with cirrhosis and significant coagulopathy (defined in this study as INR >1.8 and/or platelet count <50 × 10(9) /L) who will be undergoing an invasive procedure. Sixty patients were randomly allocated to TEG-guided transfusion strategy or standard of care (SOC; 1:1 TEG:SOC). The TEG group would receive FFP if the reaction time (r) was >40 min and/or PLT if maximum amplitude (MA) was <30 mm. All SOC patients received FFP and/or PLT per hospital guidelines. Endpoints were blood product use and bleeding complications. Baseline characteristics of the two groups were similar. Per protocol, all subjects in the SOC group received blood product transfusions versus 5 in the TEG group (100% vs. 16.7%; P < 0.0001). Sixteen SOC (53.3%) received FFP, 10 (33.3%) PLT, and 4 (13.3%) both FFP and PLT. In the TEG group, none received FFP alone (P < 0.0001 vs. SOC), 2 received PLT (6.7%; P = 0.009 vs. SOC), and 3 both FFP and PLT (not significant). Postprocedure bleeding occurred in only 1 patient (SOC group) after large-volume paracentesis.

CONCLUSIONS

In patients with cirrhosis and significant coagulopathy before invasive procedures, TEG-guided transfusion strategy leads to a significantly lower use of blood products compared to SOC (transfusion guided by INR and platelet count), without an increase in bleeding complications. Remarkably, even in patients with significant coagulopathy, postprocedure bleeding was rare, indicating that TEG thresholds should be reevaluated.

Biology of Hepatocellular Carcinoma

This chapter focuses on the identification of hepatocellular carcinoma (HCC) molecular signatures and the potentials of these signatures in prediction of HCC prognosis and driving of HCC therapeutic treatments. Progress in molecular profiling studies using DNA-microarray-based gene expression profiling has provided new insight about HCC pathogenesis, and gene signatures that can distinguish tumor subtypes assist clinical staging and predict patient outcomes. This provides the possibility to improve the stratification of HCC patients at a molecular level and, in the near future, will be potential in paving the way for tailored medicine in HCC patients.

Framingham score, renal dysfunction, and cardiovascular risk in liver transplant patients

Cardiovascular (CV) events represent major impediments to the long-term survival of liver transplantation (LT) patients. The aim of this study was to assess whether the Framingham risk score (FRS) at transplantation can predict the development of post-LT cardiovascular events (CVEs). Patients transplanted between 2006 and 2008 were included. Baseline features, CV risk factors, and CVEs occurring after LT (ischemic heart disease, stroke, heart failure, de novo arrhythmias, and peripheral arterial disease) were recorded. In total, 250 patients (69.6% men) with a median age of 56 years (range, 18-68 years) were included. At transplantation, 34.4%, 34.4%, and 33.2% of patients, respectively, had a low, moderate, and high FRS with a median FRS of 14.9 (range, 0.09-30); 14.4% of LT recipients developed at least 1 CVE at a median of 2.619 years (range, 0.006-6.945 years). In the univariate analysis, factors associated with the development of CVEs were the continuous FRS at LT (P = 0.003), age (P = 0.007), creatinine clearance [estimated glomerular filtration rate (eGFR); P = 0.020], and mycophenolate mofetil use at discharge (P = 0.011). In the multivariate analysis, only the eGFR [hazard ratio (HR), 0.98; 95% confidence interval (CI), 0.97-1.00; P = 0.009] and FRS (HR, 1.06; 95% CI, 1.02-1.10; P = 0.002) remained in the model. Moreover, an association was also found between the FRS and overall survival (P = 0.004) with 5-year survival rates of 82.5%, 77.8%, and 61.4% for the low-, moderate-, and high-risk groups, respectively. Continuous FRS, eGFR, and hepatitis C virus infection were independent risk factors for overall mortality. In our series, the FRS and eGFR at LT were able to predict the development of post-LT CVEs and poor outcomes. Liver Transpl 21:812-822, 2015. © 2015 AASLD.

Life Threatening, Allopurinol-related Dress Syndrome as a Rare Cause of Fever of Unknown Origin

Drug reaction eosinophilia with systemic symptoms (DRESS) syndrome is a potentially life threatening condition secondary to the usage of a wide type of drugs. A 38-year-old woman under allopurinol therapy for hyperuricemia was admitted in our department with fever and a diffuse cutaneous erythematous eruption. A few days after admission she developed rapidly progressive signs of acute liver and kidney failure. Subsequently, her clinical conditions shortly improved. The histologic findings obtained from skin and liver biopsies were consistent with a toxic drug reaction. The patient completely recovered and has been healthy for five years.

Enoxaparin prevents portal vein thrombosis and liver decompensation in patients with advanced cirrhosis

BACKGROUND & AIMS

We performed a randomized controlled trial to evaluate the safety and efficacy of enoxaparin, a low-molecular-weight heparin, in preventing portal vein thrombosis (PVT) in patients with advanced cirrhosis.

METHODS

In a nonblinded, single-center study, 70 outpatients with cirrhosis (Child-Pugh classes B7-C10) with demonstrated patent portal veins and without hepatocellular carcinoma were assigned randomly to groups that were given enoxaparin (4000 IU/day, subcutaneously for 48 weeks; n = 34) or no treatment (controls, n = 36). Ultrasonography (every 3 months) and computed tomography (every 6 months) were performed to check the portal vein axis. The primary outcome was prevention of PVT. Radiologists and hepatologists that assessed outcomes were blinded to group assignments. Analysis was by intention to treat.

RESULTS

At 48 weeks, none of the patients in the enoxaparin group had developed PVT, compared with 6 of 36 (16.6%) controls (P = .025). At 96 weeks, no patient developed PVT in the enoxaparin group, compared with 10 of 36 (27.7%) controls (P = .001). At the end of the follow-up period, 8.8% of patients in the enoxaparin group and 27.7% of controls developed PVT (P = .048). The actuarial probability of PVT was lower in the enoxaparin group (P = .006). Liver decompensation was less frequent among patients given enoxaparin (11.7%) than controls (59.4%) (P < .0001); overall values were 38.2% vs 83.0%, respectively (P < .0001). The actuarial probability of liver decompensation was lower in the enoxaparin group (P < .0001). Eight patients in the enoxaparin group and 13 controls died. The actuarial probability of survival was higher in the enoxaparin group (P = .020). No relevant side effects or hemorrhagic events were reported.

CONCLUSIONS

In a small randomized controlled trial, a 12-month course of enoxaparin was safe and effective in preventing PVT in patients with cirrhosis and a Child-Pugh score of 7-10. Enoxaparin appeared to delay the occurrence of hepatic decompensation and to improve survival.

Reproductive status is associated with the severity of fibrosis in women with hepatitis C

Introduction

Chronic hepatitis C is the main cause of death in patients with end-stage liver disease. Prognosis depends on the increase of fibrosis, whose progression is twice as rapid in men as in women. Aim of the study was to evaluate the effects of reproductive stage on fibrosis severity in women and to compare these findings with age-matched men.

Materials and Methods

A retrospective study of 710 consecutive patients with biopsy-proven chronic hepatitis C was conducted, using data from a clinical database of two tertiary Italian care centers. Four age-matched groups of men served as controls. Data about demographics, biochemistry, liver biopsy and ultrasonography were analyzed. Contributing factors were assessed by multivariate logistic regression analysis.

Results

Liver fibrosis was more advanced in the early menopausal than in the fully reproductive (P<0.0001) or premenopausal (P = 0.042) group. Late menopausal women had higher liver fibrosis compared with the other groups (fully reproductive, P<0.0001; premenopausal, P = <0.0001; early menopausal, P = 0.052). Multivariate analyses showed that male sex was independently associated with more severe fibrosis in the groups corresponding to premenopausal (P = 0.048) and early menopausal (P = 0.004) but not late menopausal pairs. In women, estradiol/testosterone ratio decreased markedly in early (vs. reproductive age: P = 0.002 and vs. premenopausal: P<0.0001) and late menopause (vs. reproductive age: P = 0.001; vs. premenopausal: P<0.0001). In men age-matched with menopausal women, estradiol/testosterone ratio instead increased (reproductive age group vs. early: P = 0.002 and vs. late M: P = 0.001).

Conclusions

The severity of fibrosis in women worsens in parallel with increasing estrogen deprivation and estradiol/testosterone ratio decrease. Our data provide evidence why fibrosis progression is discontinuous in women and more linear and severe in men, in whom aging-associated estradiol/testosterone ratio increase occurs too late to noticeably influence the inflammatory process leading to fibrosis.

Massive GI bleeding due to accidental ASA inhalation

This report describes a 38-year-old man admitted to hospital for a massive rectal bleeding and syncope. He was known to have idiopathic thrombocytopenia but he had never complained of bleeding until he was admitted to hospital with uncontrolled hemorrhage. Upper and lower endoscopic examination, performed 6 hours after occurrence of bleeding, were negative for ulcers or other bleeding lesions. However, capsule endoscopy did detect diffuse areas of petechial hemorrhage and erosions in the small bowel. Thromboelastography performed on the day of admission showed a marked decrease in platelet aggregation rate, that normalized two days after. The patient recovered with conservative treatment only. Thorough questioning did not evidence relevant events apart from inhalation of a massive quantity of acetylsalicylic acid: the patient, working as a farmer, had prepared, without protection, fodder for the animals containing a great amount of acetylsalicylic acid. Bleeding had started few hours thereafter. After recovery, bleeding did not recur despite persistent thrombocytopenia.

Hepatic apoptosis and proliferation in male and female rats fed alcohol: role of cytokines

BACKGROUND

The female liver is more sensitive to the toxic effect of chronic alcohol intake than the male liver. The aim of the study was to compare the influence of gender and sex hormonal status on apoptosis and cell proliferation following chronic ethanol intake.

METHODS

Male and female rats were pair fed for 8 weeks a liquid diet containing 36% of their total daily calories as ethanol (ETOH group) or sucrose (control group). Liver samples were analyzed for apoptosis and hepatocyte proliferation by immunohistochemistry. The hepatic production of factors able to influence cell death and proliferation, such as tumor necrosis factor alpha (TNFalpha) and interleukin 6 (IL-6) were determined.

RESULTS

In both male and female rats, ethanol intake promoted apoptosis in the liver. This effect of ethanol was more evident in female than male rat livers. Hepatic TNFalpha levels, which promote apoptosis, are significantly more elevated in female than in male livers. Hepatic IL-6 production, which promotes hepatocyte proliferation, was induced by ethanol only in males, but not female animals.

CONCLUSION

This observed difference in cytokine responses may contribute to the enhanced sensitivity of female liver to EtOH-induced injury.

Impaired response to high-dose interferon treatment in African-Americans with chronic hepatitis C

BACKGROUND/AIMS

The prevalence of hepatitis C virus infection in the USA is higher among African-Americans than among Caucasians. Despite this, little information is available on the course of hepatitis C virus infection in Blacks and in other minority groups. The aim of this retrospective case-control study was to determine the response rate to high dose interferon-alpha treatment in two racial groups with chronic hepatitis C virus infection.

METHODOLOGY

Thirty-one African-Americans and 62 Caucasians with chronic hepatitis C were considered in the study. The subjects were matched for gender, age, presence/absence of cirrhosis, histologic score, and viral genotype. All were treated with interferon-alpha (5 mU/day for 12 months). Three end-points (on-therapy, after 6 months of interferon-alpha, end-of-therapy, at the end of the 12 months of treatment, and off-therapy, 6 months after treatment) were chosen to describe the response to interferon-alpha treatment.

RESULTS

African-Americans had a significantly reduced response to interferon-alpha as compared to Caucasians at all end-points. At the on-therapy end-point, 26% of African-Americans were HCV-RNA negative and had normal transaminases level as compared to 60% of the Caucasians (P < 0.01); at the end-of-therapy end-point the rates were, respectively, 10% and 53% (P < 0.0001). No differences were detected in terms of pretreatment serum ALT, HCV-RNA, iron and ferritin levels or hepatic iron contents between the two groups.

CONCLUSIONS

African-Americans have a reduced response to high-dose interferon-alpha treatment as compared to Caucasians. Both environmental and genetic factors may be implicated in this impaired ability to clear hepatitis C virus infection.

Impaired antibody response rates after high dose short interval hepatitis B virus vaccination of immunosuppressed individuals

BACKGROUND/AIMS

Because a more rapid and high dose vaccination schedule may be advantageous in immunosuppressed individuals to induce an earlier immunization, the aim of the present study was to assess the response to high dose, short interval hepatitis B virus vaccination in various immunosuppressed-patient populations.

METHODOLOGY

A total of one hundred and thirty-eight immunosuppressed patients (86 cirrhotics, 42 dialysis patients, 10 allogeneic hematopoietic cell transplants) and 26 healthy subjects as controls were vaccinated utilizing a high dose vaccine (40 mcg) and a shortened immunization schedule.

RESULTS

Ninety-two percent of the controls responded to the high dose, short interval hepatitis B virus vaccination schedule. In contrast, only 48% of the immunosuppressed patients seroconverted to anti-HBs positivity (p < 0.001). No difference in the antibody response rate was seen between the various immunosuppressed populations studied. No significant hepatitis B virus vaccination-related adverse effects were seen in any of the groups vaccinated.

CONCLUSIONS

Although a high dose, short interval hepatitis B virus vaccination schedule is safe in immunosuppressed patients, the antibody response is still significantly reduced as compared to healthy subjects and only slightly greater than that achieved with standard vaccination schedules, as reported in literature. The possibility of achieving an earlier immunization, however, may be of some advantage to protect acquired viral infection.

Sex hormones and liver cancer

Hepatocellular carcinoma (HCC) is one of the most common malignancy in the world and it usually occurs in individuals with chronic liver disease. The neoplasm is predominant in the male gender, where it is characterized also by a worst prognosis than in females. The pathogenesis of HCC is obscure. Because of its striking male predominance, androgens have been investigated as potential factors able to induce or at least promote hepatic carcinogenesis; this hypothesis has been also supported by the ability of androgens of inducing liver neoplasms in experimental models. On the other hand, due to the fact that HCC occurs predominantly in male cirrhotics who present a characteristic hormone imbalance with a relative hyperestrogenic state, the potential role of estrogen in liver cancer has been studied as well. In this paper, the potential role of sex hormones in liver carcinogenesis has been reviewed.

Variant estrogen receptors and their role in liver disease

The liver presents estrogen receptors alpha and beta. As for breast cancer, a variant form of estrogen receptor alpha transcript (ER) has been described in hepatocellular carcinoma (HCC). It is derived by an exon 5-deleted transcript (vER), which lacks the hormone-binding domain of the receptor but, being intact in the DNA-binding domain, maintains constitutive transcriptional activity. HCCs presenting vER have an extremely aggressive clinical course and are unresponsive to the antiestrogen tamoxifen. On the other hand, megestrol, a drug able to block both the wild type and the variant form of ER, influence the clinical course of HCC presenting vER. The presence of vER is associated with elevated cancer cell proliferation rate.

Phytoestrogens and liver disease

Phytoestrogens are plant substances that are similar to 17-beta-estradiol and produce estrogenic effects. A protective role in the development of breast and prostate cancer has been hypothesized. Estrogen receptors and their variant forms play a significant role in the pathogenesis of hepatocellular carcinoma (HCC); therefore weak estrogenic substances in the diet may play a role in its development. To investigate the role of phytoestrogens in HCC an investigation of dietary intake of these substances has been performed. Cases, patients at first diagnosis of cirrhosis or HCC were chosen. Questionnaire was built up using indications from previously published papers, extending the registration of details of the diet to reconstruct intake of nutrients for the last year. Interviews were always performed by the same dietician. Quantities determined with the help of photos of servings. Data were analyzed with Winfood database completed with data regarding content in phytoestrogens of food, beverages and seasonings. So far 92 cirrhotic patients and 32 HCCs have been interviewed. No significant difference was registered among the two groups regarding total caloric intake or single nutrients (lipids, carbohydrates, proteins). A significant lower intake of genistein was evidenced in patients at first diagnosis of HCC in comparison with cirrhotics; no significant difference was found in daidzein intake. Lignans intake was strictly related with wine intake; intake was significantly lower in cases only when wine was taken into account otherwise it was similar. Results can be summarized as follows: (1) there are no clear-cut differences (both qualitative or quantitative) between cirrhotics and HCC patients in the overall daily caloric intake while; (2) definite differences exist in the intake of some of the phytoestrogens (genistein, SEC, MAT); (3) differences between cases and controls in SEC and MAT are mainly attributable to lower alcohol intake in cases while; (4) significantly lower genistein intake in HCC only seems due to personal preferences of patients. In conclusion, these differences that we have evidenced in the diet in regard to estrogen-like substances may be relevant in modulating the risk of developing HCC in cirrhotic patients.

Hepatocellular carcinoma: role of estrogen receptors in the liver

Experimental and clinical evidence indicates that estrogens have a relevant role in the pathogenesis of cancer of hormone-sensitive organs. Estrogen receptors (ERs) are present in liver cells. Normal liver expresses almost exclusively wild-type ERs derived from the full-length transcript of the gene. During progression of liver disease to hepatocellular carcinoma, variant forms of ERs have been demonstrated that greatly influence the course of the disease and the possibility of palliative treatment. Peritumoral cirrhotic tissue of patients with hepatocellular carcinoma, especially males, expresses a variant form of ER (vER) with an exon 5 deletion. In hepatocellular carcinoma, vER largely predominates and sometimes becomes the only form expressed. That the occurrence of vER alone is limited almost exclusively to males suggests that it could be one of the molecular events that eventually lead to the preferential development of hepatocellular carcinoma in males. In addition, the presence of vER appears most frequently in patients infected with the hepatitis B virus. The growth rate of hepatocellular carcinoma in patients with vER is also significantly higher than that in patients with tumors expressing wtER.

Impaired response to high-dose interferon treatment in African-Americans with chronic hepatitis C

BACKGROUND/AIMS

The prevalence of hepatitis C virus infection in the USA is higher among African-Americans than among Caucasians. Despite this, little information is available on the course of hepatitis C virus infection in Blacks and in other minority groups. The aim of this retrospective case-control study was to determine the response rate to high dose interferon-alpha treatment in two racial groups with chronic hepatitis C virus infection.

METHODOLOGY

Thirty-one African-Americans and 62 Caucasians with chronic hepatitis C were considered in the study. The subjects were matched for gender, age, presence/absence of cirrhosis, histologic score, and viral genotype. All were treated with interferon-alpha (5 mU/day for 12 months). Three end-points (on-therapy, after 6 months of interferon-alpha, end-of-therapy, at the end of the 12 months of treatment, and off-therapy, 6 months after treatment) were chosen to describe the response to interferon-alpha treatment.

RESULTS

African-Americans had a significantly reduced response to interferon-alpha as compared to Caucasians at all end-points. At the on-therapy end-point, 26% of African-Americans were HCV-RNA negative and had normal transaminases level as compared to 60% of the Caucasians (P < 0.01); at the end-of-therapy end-point the rates were, respectively, 10% and 53% (P < 0.0001). No differences were detected in terms of pretreatment serum ALT, HCV-RNA, iron and ferritin levels or hepatic iron contents between the two groups.

CONCLUSIONS

African-Americans have a reduced response to high-dose interferon-alpha treatment as compared to Caucasians. Both environmental and genetic factors may be implicated in this impaired ability to clear hepatitis C virus infection.