1
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Gatselis NK, Zachou K, Loza AJM, Cançado ELR, Arinaga-Hino T, Muratori P, Efe C, Floreani A, Invernizzi P, Takahashi A, Takaki A, Beretta-Piccoli BT, van Hoek B, Lytvyak E, Guedes LV, Purnak T, Cazzagon N, Lygoura V, Arvaniti P, Rigopoulou EI, Muratori L, Dalekos GN. Prevalence and significance of antimitochondrial antibodies in autoimmune hepatitis (AIH): Results from a large multicentre study of the International AIH Group. Eur J Intern Med 2023; 116:43-50. [PMID: 37302951 DOI: 10.1016/j.ejim.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/21/2023] [Accepted: 06/06/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND & AIMS Antimitochondrial antibodies (AMA) are specific markers for the diagnosis of primary biliary cholangitis (PBC) but can also be found occasionally in patients with autoimmune hepatitis (AIH). The present large multicentre cohort study assessed the prevalence and significance of AMA in AIH-patients. METHODS 123 AMA-positive AIH-patients were investigated and compared with 711 age-matched AMA-negative AIH-patients and 69 patients with AIH/PBC variant. RESULTS AMA prevalence in AIH-patients was 5.1% (range: 1.2%-11.8%). AMA-positivity was associated with female sex (p = 0.031) in AMA-positive AIH-patients but not with liver biochemistry, bile duct injury on liver biopsy, disease severity at baseline and response to treatment compared to AMA-negative AIH-patients. Comparing AMA-positive AIH-patients to those with AIH/PBC variant, there was no difference in disease severity. Regarding liver histology, AIH/PBC variant patients were characterized by the presence of at least one feature of bile duct damage (p<0.001). Response to immunosuppressive treatment was similar among groups. From AMA-positive AIH patients only those with evidence of non-specific bile duct injury had higher risk to progress to cirrhosis (HR=4.314, 95%CI: 2.348-7.928; p<0.001). During follow-up, AMA-positive AIH-patients had higher risk to develop histological bile duct injury (HR 4.654, 95%CI 1.829-11.840; p = 0.001). CONCLUSIONS AMA presence is relatively common among AIH-patients, but their clinical significance seems important only when they co-exist with non-specific bile duct injury at the histological level. Therefore, a careful evaluation of liver biopsy seems of utmost importance in these patients.
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Affiliation(s)
- Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Kalliopi Zachou
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Aldo J Montano Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Canada
| | | | - Teruko Arinaga-Hino
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Paolo Muratori
- Division of Internal Medicine, Morgagni-Pierantoni Hospital, Forlì 47100, Department of Science for the Quality of Life, University of Bologna, Bologna, Italy
| | - Cumali Efe
- Department of Gastroenterology, Gazi Yaşargil Education and Research Hospital, Diyarbakir, Turkey
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; Scientific Institute for Research, Hospitalization and Healthcare, Negrar, Verona, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology, Centre for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Athushi Takahashi
- Department of Gastroenterology, Fukushima Medical University School of Medicine Fukushima, Japan
| | - Akinobu Takaki
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | | | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ellina Lytvyak
- Division of Preventive Medicine, University of Alberta, Edmonton, Canada
| | - Laura Vilar Guedes
- University of Sao Paulo, School of Medicine, Department of Gastroenterology, Sao Paulo, Brazil
| | - Tugrul Purnak
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Nora Cazzagon
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Vasiliki Lygoura
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Pinelopi Arvaniti
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Eirini I Rigopoulou
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Luigi Muratori
- Division of Internal Medicine, Morgagni-Pierantoni Hospital, Forlì 47100, Department of Science for the Quality of Life, University of Bologna, Bologna, Italy
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece.
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2
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Efe C, Kulkarni AV, Terziroli Beretta-Piccoli B, Magro B, Stättermayer A, Cengiz M, Clayton-Chubb D, Lammert C, Bernsmeier C, Gül Ö, la Tijera FHD, Anders M, Lytvyak E, Akın M, Purnak T, Liberal R, Peralta M, Ebik B, Duman S, Demir N, Balaban Y, Urzua Á, Contreras F, Venturelli MG, Bilgiç Y, Medina A, Girala M, Günşar F, Londoño MC, Androutsakos T, Kisch A, Yurci A, Güzelbulut F, Çağın YF, Avcı E, Akyıldız M, Dindar-Demiray EK, Harputluoğlu M, Kumar R, Satapathy SK, Mendizabal M, Silva M, Fagiuoli S, Roberts SK, Soylu NK, Idilman R, Yoshida EM, Montano-Loza AJ, Dalekos GN, Ridruejo E, Schiano TD, Wahlin S. Liver injury after SARS-CoV-2 vaccination: Features of immune-mediated hepatitis, role of corticosteroid therapy and outcome. Hepatology 2022; 76:1576-1586. [PMID: 35567545 PMCID: PMC9348326 DOI: 10.1002/hep.32572] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS A few case reports of autoimmune hepatitis-like liver injury have been reported after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. We evaluated clinical features, treatment response and outcomes of liver injury following SARS-CoV-2 vaccination in a large case series. APPROACH AND RESULTS We collected data from cases in 18 countries. The type of liver injury was assessed with the R-value. The study population was categorized according to features of immune-mediated hepatitis (positive autoantibodies and elevated immunoglobulin G levels) and corticosteroid therapy for the liver injury. We identified 87 patients (63%, female), median age 48 (range: 18-79) years at presentation. Liver injury was diagnosed a median 15 (range: 3-65) days after vaccination. Fifty-one cases (59%) were attributed to the Pfizer-BioNTech (BNT162b2) vaccine, 20 (23%) cases to the Oxford-AstraZeneca (ChAdOX1 nCoV-19) vaccine and 16 (18%) cases to the Moderna (mRNA-1273) vaccine. The liver injury was predominantly hepatocellular (84%) and 57% of patients showed features of immune-mediated hepatitis. Corticosteroids were given to 46 (53%) patients, more often for grade 3-4 liver injury than for grade 1-2 liver injury (88.9% vs. 43.5%, p = 0.001) and more often for patients with than without immune-mediated hepatitis (71.1% vs. 38.2%, p = 0.003). All patients showed resolution of liver injury except for one man (1.1%) who developed liver failure and underwent liver transplantation. Steroid therapy was withdrawn during the observation period in 12 (26%) patients after complete biochemical resolution. None had a relapse during follow-up. CONCLUSIONS SARS-CoV-2 vaccination can be associated with liver injury. Corticosteroid therapy may be beneficial in those with immune-mediated features or severe hepatitis. Outcome was generally favorable, but vaccine-associated liver injury led to fulminant liver failure in one patient.
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Affiliation(s)
- Cumali Efe
- Department of GastroenterologyHarran University HospitalŞanlıurfaTurkey
| | - Anand V Kulkarni
- Department of Hepatology and Liver TransplantationAsian Institute of Gastroenterology HospitalsHyderabadIndia
| | | | - Bianca Magro
- Gastroenterology Hepatology and TransplantationASST Papa Giovanni XXIII-BergamoBergamoItaly
| | - Albert Stättermayer
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Mustafa Cengiz
- Department of GastroenterologyGülhane Training and Research HospitalAnkaraTurkey
| | | | - Craig Lammert
- Department of Medicine IndianaUniversity School of MedicineIndianapolisIndianaUSA
| | - Christine Bernsmeier
- Department of BiomedicineUniversity of BaselBaselSwitzerland.,University Centre for Gastrointestinal and Liver DiseasesBaselSwitzerland
| | - Özlem Gül
- Department of GastroenterologyKırıkkale UniversityKırıkkaleTurkey
| | | | - Margarita Anders
- Hepatology and Liver Transplant UnitHospital AlemánCiudad Autónoma de Buenos AiresArgentina
| | - Ellina Lytvyak
- Division of Gastroenterology and Liver UnitUniversity of AlbertaEdmontonAlbertaCanada
| | - Mete Akın
- Department of GastroenterologyAkdeniz University Faculty of MedicineAntalyaTurkey
| | - Tugrul Purnak
- Division of GastroenterologyHepatology and NutritionMcGovern Medical SchoolHoustonTexasUSA
| | - Rodrigo Liberal
- Gastroenterology and Hepatology DepartmentCentro Hospitalar e Universitário de São JoãoPortoPortugal.,World Gastroenterology Organization (WGO) Porto Training CenterPortoPortugal
| | - Mirta Peralta
- Hepatology SectionHospital Francisco J MuñizCiudad Autónoma de Buenos AiresArgentina.,Latin American Liver Research Educational and Awareness Network (LALREAN)PilarArgentina
| | - Berat Ebik
- Department of GastroenterologyGazi Yaşargil Education and Research HospitalDiyarbakirTurkey
| | - Serkan Duman
- Department of GastroenterologyAnkara University Medical FacultyAnkaraTurkey
| | - Nurhan Demir
- Department of GastroenterologyHaseki Training and Research HospitalIstanbulTurkey
| | - Yasemin Balaban
- Department of GastroenterologyFaculty of MedicineHacettepe UniversityAnkaraTurkey
| | - Álvaro Urzua
- Gastroenterology and Hepatology UnitHospital Clínico Universidad de ChileSantiago de ChileChile
| | | | | | - Yılmaz Bilgiç
- Department of GastroenterologyInönü University School of MedicineMalatyaTurkey
| | - Adriana Medina
- Gastroenterology and Hepatology UnitHospital de Clínicas, Universidad Nacional de AsunciónSan LorenzoParaguay
| | - Marcos Girala
- Gastroenterology and Hepatology UnitHospital de Clínicas, Universidad Nacional de AsunciónSan LorenzoParaguay
| | - Fulya Günşar
- Department of GastroenterologyEge University School of MedicineİzmirTurkey
| | | | - Theodoros Androutsakos
- Department of PathophysiologyNational and Kapodistrian University of AthensMedical SchoolAthensGreece
| | - Ayelen Kisch
- Hepatology SectionHospital Bonorino UdaondoCiudad Autónoma de Buenos AiresArgentina
| | - Alper Yurci
- Department of GastroenterologyErciyes University School of MedicineKayseriTurkey
| | - Fatih Güzelbulut
- Department of GastroenterologyHaydarpaşa Numune Education and Research HospitalİstanbulTurkey
| | - Yasir Furkan Çağın
- Department of GastroenterologyInönü University School of MedicineMalatyaTurkey
| | - Enver Avcı
- Department of GastroenterologyKTO Karatay University Medical School Affiliated Konya Medicana HospitalKonyaTurkey
| | - Murat Akyıldız
- Department of GastroenterologyKoc University School of MedicineIstanbulTurkey
| | | | - Murat Harputluoğlu
- Department of GastroenterologyInönü University School of MedicineMalatyaTurkey
| | - Rahul Kumar
- Department of Gastroenterology and HepatologyChangi General HospitalMedicine Academic Clinical ProgrammeSing Health Duke-NUS Academic Medical CentreSingapore
| | - Sanjaya K Satapathy
- Department of Internal MedicineDonald and Barbara Zucker School of MedicineNorthwell HealthManhassetNew YorkUSA
| | - Manuel Mendizabal
- Latin American Liver Research Educational and Awareness Network (LALREAN)PilarArgentina.,Hepatology and Liver Transplant UnitHospital Universitario AustralPilarArgentina
| | - Marcelo Silva
- Latin American Liver Research Educational and Awareness Network (LALREAN)PilarArgentina.,Hepatology and Liver Transplant UnitHospital Universitario AustralPilarArgentina
| | - Stefano Fagiuoli
- Gastroenterology Hepatology and TransplantationASST Papa Giovanni XXIII-BergamoBergamoItaly
| | - Stuart K Roberts
- Department of GastroenterologyAlfred HealthMelbourneVictoriaAustralia.,Central Clinical SchoolDepartment of MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Neşe Karadağ Soylu
- Department of PathologyInönü University Faculty of MedicineMalatyaTurkey
| | - Ramazan Idilman
- Department of GastroenterologyAnkara University Medical FacultyAnkaraTurkey
| | - Eric M Yoshida
- Division of GastroenterologyUniversity of British Columbia and Vancouver General HospitalVancouverBritish ColumbiaCanada
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver UnitUniversity of AlbertaEdmontonAlbertaCanada
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal MedicineNational Expertise Center of Greece in Autoimmune Liver DiseasesGeneral University Hospital of LarissaLarissaGreece.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER)General University Hospital of LarissaLarissaGreece
| | - Ezequiel Ridruejo
- Latin American Liver Research Educational and Awareness Network (LALREAN)PilarArgentina.,Hepatology and Liver Transplant UnitHospital Universitario AustralPilarArgentina.,Hepatology SectionDepartment of MedicineCentro de Educación Médica e Investigaciones Clínicas, CEMICCiudad Autónoma de Buenos AiresArgentina
| | - Thomas D Schiano
- Division of Liver Diseasesthe Mount Sinai Medical CenterNew YorkNew YorkUSA
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI DiseasesKarolinska Institutet and Karolinska University HospitalStockholmSweden
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3
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Pape S, Snijders RJALM, Gevers TJG, Chazouilleres O, Dalekos GN, Hirschfield GM, Lenzi M, Trauner M, Manns MP, Vierling JM, Montano-Loza AJ, Lohse AW, Schramm C, Drenth JPH, Heneghan MA, Alvarez F, Andrade R, Arikan C, Assis D, Bardou-Jacquet E, Biewenga M, Cancado E, Cazzagon N, Chazouillères O, Colloredo G, Cuarterolo M, Dalekos G, Debray D, Robles-Díaz M, Drenth J, Dyson J, Efe C, Engel B, Ferri S, Fontana R, Gatselis N, Gerussi A, Halilbasic E, Halliday N, Heneghan M, Hirschfield G, van Hoek B, Hørby Jørgensen M, Indolfini G, Iorio R, Jeong S, Jones D, Kelly D, Kerkar N, Lacaille F, Lammert C, Leggett B, Lenzi M, Levy C, Liberal R, Lleo A, Lohse A, Ines Lopez S, de Martin E, McLin V, Mieli-Vergani G, Milkiewicz P, Mohan N, Muratori L, Nebbia G, van Nieuwkerk C, Oo Y, Ortega A, Páres A, Pop T, Pratt D, Purnak T, Ranucci G, Rushbrook S, Schramm C, Stättermayer A, Swain M, Tanaka A, Taubert R, Terrabuio D, Terziroli B, Trauner M, Valentino P, van den Brand F, Villamil A, Wahlin S, Ytting H, Zachou K, Zeniya M. Systematic review of response criteria and endpoints in autoimmune hepatitis by the International Autoimmune Hepatitis Group. J Hepatol 2022; 76:841-849. [PMID: 35066089 DOI: 10.1016/j.jhep.2021.12.041] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [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: 04/09/2021] [Revised: 11/18/2021] [Accepted: 12/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Autoimmune hepatitis (AIH) has been well characterised and codified through the development of diagnostic criteria. These criteria have been adapted and simplified and are widely used in clinical practice. However, there is a need to update and precisely define the criteria for both treatment response and treatment. METHODS A systematic review was performed and a modified Delphi consensus process was used to identify and redefine the response criteria in autoimmune hepatitis. RESULTS The consensus process initiated by the International Autoimmune Hepatitis Group proposes that the term 'complete biochemical response' defined as 'normalization of serum transaminases and IgG below the upper limit of normal' be adopted to include a time point at 6 months after initiation of treatment. An insufficient response by 6 months was a failure to meet the above definition. Non-response was defined as '<50% decrease of serum transaminases within 4 weeks after initiation of treatment'. Remission is defined as liver histology with a Hepatitis Activity Index <4/18. Intolerance to treatment was agreed to stand for 'any adverse event possibly related to treatment leading to potential drug discontinuation'. CONCLUSIONS These definitions provide a simple and reproducible framework to define treatment response and non-response, irrespective of the therapeutic intervention. A consensus on endpoints is urgently required to set a global standard for the reporting of study results and to enable inter-study comparisons. Future prospective database studies are needed to validate these endpoints. LAY SUMMARY Consensus among international experts on response criteria and endpoints in autoimmune hepatitis is lacking. A consensus on endpoints is urgently required to set a global standard for the reporting of study results and to enable the comparison of results between clinical trials. Therefore, the International Autoimmune Hepatitis Group (IAIHG) herein presents a statement on 5 agreed response criteria and endpoints: complete biochemical response, insufficient response, non-response, remission, and intolerance to treatment, which can be used to guide future reporting.
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Affiliation(s)
- Simon Pape
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Romée J A L M Snijders
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Tom J G Gevers
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht 6229HX, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Oliver Chazouilleres
- Hepatology Department, Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, Saint-Antoine Hospital Assistance Publique-Hôpitaux de Paris, Paris, France; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly Medical School, Larissa, Greece
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada
| | - Marco Lenzi
- Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - John M Vierling
- Departments of Medicine and Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Hepatology, University of Alberta Hospital, Edmonton, Canada
| | - Ansgar W Lohse
- 1(st) Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Christoph Schramm
- 1(st) Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom; European Reference Network on Hepatological Diseases (ERN RARE-LIVER).
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4
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Efe C, Lammert C, Taşçılar K, Dhanasekaran R, Ebik B, Higuera-de la Tijera F, Calışkan AR, Peralta M, Gerussi A, Massoumi H, Catana AM, Purnak T, Rigamonti C, Aldana AJG, Khakoo N, Nazal L, Frager S, Demir N, Irak K, Melekoğlu-Ellik Z, Kacmaz H, Balaban Y, Atay K, Eren F, Alvares-da-Silva MR, Cristoferi L, Urzua Á, Eşkazan T, Magro B, Snijders R, Barutçu S, Lytvyak E, Zazueta GM, Demirezer-Bolat A, Aydın M, Heurgue-Berlot A, De Martin E, Ekin N, Yıldırım S, Yavuz A, Bıyık M, Narro GC, Kıyıcı M, Akyıldız M, Kahramanoğlu-Aksoy E, Vincent M, Carr RM, Günşar F, Reyes EC, Harputluoğlu M, Aloman C, Gatselis NK, Üstündağ Y, Brahm J, Vargas NCE, Güzelbulut F, Garcia SR, Aguirre J, Anders M, Ratusnu N, Hatemi I, Mendizabal M, Floreani A, Fagiuoli S, Silva M, Idilman R, Satapathy SK, Silveira M, Drenth JPH, Dalekos GN, N Assis D, Björnsson E, Boyer JL, Yoshida EM, Invernizzi P, Levy C, Montano-Loza AJ, Schiano TD, Ridruejo E, Wahlin S. Effects of immunosuppressive drugs on COVID-19 severity in patients with autoimmune hepatitis. Liver Int 2022; 42:607-614. [PMID: 34846800 DOI: 10.1111/liv.15121] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [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: 09/02/2021] [Revised: 11/25/2021] [Accepted: 11/28/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND We investigated associations between baseline use of immunosuppressive drugs and severity of Coronavirus Disease 2019 (COVID-19) in autoimmune hepatitis (AIH). PATIENTS AND METHODS Data of AIH patients with laboratory confirmed COVID-19 were retrospectively collected from 15 countries. The outcomes of AIH patients who were on immunosuppression at the time of COVID-19 were compared to patients who were not on AIH medication. The clinical courses of COVID-19 were classified as (i)-no hospitalization, (ii)-hospitalization without oxygen supplementation, (iii)-hospitalization with oxygen supplementation by nasal cannula or mask, (iv)-intensive care unit (ICU) admission with non-invasive mechanical ventilation, (v)-ICU admission with invasive mechanical ventilation or (vi)-death and analysed using ordinal logistic regression. RESULTS We included 254 AIH patients (79.5%, female) with a median age of 50 (range, 17-85) years. At the onset of COVID-19, 234 patients (92.1%) were on treatment with glucocorticoids (n = 156), thiopurines (n = 151), mycophenolate mofetil (n = 22) or tacrolimus (n = 16), alone or in combinations. Overall, 94 (37%) patients were hospitalized and 18 (7.1%) patients died. Use of systemic glucocorticoids (adjusted odds ratio [aOR] 4.73, 95% CI 1.12-25.89) and thiopurines (aOR 4.78, 95% CI 1.33-23.50) for AIH was associated with worse COVID-19 severity, after adjusting for age-sex, comorbidities and presence of cirrhosis. Baseline treatment with mycophenolate mofetil (aOR 3.56, 95% CI 0.76-20.56) and tacrolimus (aOR 4.09, 95% CI 0.69-27.00) were also associated with more severe COVID-19 courses in a smaller subset of treated patients. CONCLUSION Baseline treatment with systemic glucocorticoids or thiopurines prior to the onset of COVID-19 was significantly associated with COVID-19 severity in patients with AIH.
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Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Harran University Hospital, Şanlıurfa, Turkey
| | - Craig Lammert
- Department of Medicine Indiana, University School of Medicine Indianapolis, Indianapolis, Indiana, USA
| | - Koray Taşçılar
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Renumathy Dhanasekaran
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, California, USA
| | - Berat Ebik
- Department of Gastroenterology, Gazi Yaşargil Education and Research Hospital, Diyarbakir, Turkey
| | | | - Ali R Calışkan
- Department of Gastroenterology, Adıyaman University, Adıyaman, Turkey
| | - Mirta Peralta
- Hepatology Section, Hospital Francisco J Muñiz, Ciudad Autónoma de Buenos Aires, Argentina.,Latin American Liver Research Educational and Awareness Network (LALREAN), Pilar, Argentina
| | - Alessio Gerussi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Hatef Massoumi
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Andreea M Catana
- Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Tugrul Purnak
- Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, Houston, Texas, USA
| | - Cristina Rigamonti
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Division of Internal Medicine, "AOU Maggiore della Carità", Novara, Italy
| | - Andres J G Aldana
- Gastroenterology and Hepatology Unit, Fundación Santa Fe de Bogotá y universidad de Los Andes, Bogotá, Colombia
| | - Nidah Khakoo
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Leyla Nazal
- Gastroenterology and Hepatology Unit, Clínica Las Condes, Santiago de Chile, Chile
| | - Shalom Frager
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Nurhan Demir
- Department of Gastroenterology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Kader Irak
- Department of Gastroenterology, SBU Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | | | - Hüseyin Kacmaz
- Department of Gastroenterology, Adıyaman University, Adıyaman, Turkey
| | - Yasemin Balaban
- Department of Gastroenterology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kadri Atay
- Departmant of Gastroenterology, Mardin State Hospital, Mardin, Turkey
| | - Fatih Eren
- Departmant of Gastroenterology, Ordu State Hospital, Ordu, Turkey
| | - Mario R Alvares-da-Silva
- Gastroenterology and Hepatology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Laura Cristoferi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Álvaro Urzua
- Gastroenterology and Hepatology Unit. Hospital Clínico, Universidad de Chile, Santiago de Chile, Chile
| | - Tuğçe Eşkazan
- Department of Gastroenterology, Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Bianca Magro
- Gastroenterology Hepatology and Transplantation, ASST Papa Giovanni XXIII-Bergamo, Bergamo, Italy
| | - Romee Snijders
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Nijmegen, The Netherlands
| | - Sezgin Barutçu
- Department of Gastroenterology, University of Gaziantep Medical Faculty, Gaziantep, Turkey
| | - Ellina Lytvyak
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Godolfino M Zazueta
- Gastroenterology Unit, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, México
| | | | - Mesut Aydın
- School of Medicine, Department of Gastroenterology, Van Yuzuncu Yil University, Van, Turkey
| | | | - Eleonora De Martin
- Centre Hepato-Biliaire, Hôpital Paul-Brousse, FHU Hepatinov, INSERM Unit UMR 1193, Univ Paris-Saclay, Gif-sur-Yvette, France
| | - Nazım Ekin
- Department of Gastroenterology, Gazi Yaşargil Education and Research Hospital, Diyarbakir, Turkey
| | - Sümeyra Yıldırım
- Department of Gastroenterology, Erciyes Hospital, Kayseri, Turkey
| | - Ahmet Yavuz
- Division of Gastroenterology, Meram School of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Murat Bıyık
- Division of Gastroenterology, Meram School of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Graciela C Narro
- Gastroenterology Unit, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, México
| | - Murat Kıyıcı
- Department of Gastroenterology, Medical Faculty, Uludag University, Bursa, Turkey
| | - Murat Akyıldız
- Department of Gastroenterology, Koc University School of Medicine, Istanbul, Turkey
| | | | - Maria Vincent
- Department of Internal Medicine, Donald and Barbara Zucker School of Medicine, Northwell Health, Manhasset, NY, USA
| | - Rotonya M Carr
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fulya Günşar
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Eira C Reyes
- Hepatology Unit. Hospital Militar Central de México, Ciudad de México, México
| | - Murat Harputluoğlu
- Department of Gastroenterology, Inönü University School of Medicine, Malatya, Turkey
| | - Costica Aloman
- Section of Hepatology, Rush University Medical Center, Chicago, Illinois, USA
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Yücel Üstündağ
- Department of Gastroenterology, Bulent Ecevit University of Medicine, Zonguldak, Turkey
| | - Javier Brahm
- Gastroenterology Unit, Clínica Las Condes, Santiago, Chile
| | - Nataly C E Vargas
- Hepatology Unit Hospital Nacional Almanzor Aguinaga Asenjo, Chiclayo, Perú
| | - Fatih Güzelbulut
- Department of Gastroenterology, Haydarpaşa Numune Education and Research Hospital, İstanbul, Turkey
| | - Sandro R Garcia
- Gastroenterology Unit, Hospital Víctor Lazarte Echegaray, Trujillo, Perú
| | - Jonathan Aguirre
- Hepatology Unit, Hospital Ángeles Pedregal, Ciudad de México, México
| | - Margarita Anders
- Hepatology and Liver Transplant Unit, Hospital Alemán, Buenos Aires, Argentina
| | - Natalia Ratusnu
- Hepatology Unit, Hospital Regional de Ushuaia, Ushuaia, Argentina
| | - Ibrahim Hatemi
- Department of Gastroenterology, Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Manuel Mendizabal
- Latin American Liver Research Educational and Awareness Network (LALREAN), Pilar, Argentina.,Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina
| | - Annarosa Floreani
- Scientific Consultant IRCCS Negrar, Verona, Italy.,Senior Scholar, University of Padova, Padova, Italy
| | - Stefano Fagiuoli
- Gastroenterology Hepatology and Transplantation, ASST Papa Giovanni XXIII-Bergamo, Bergamo, Italy
| | - Marcelo Silva
- Latin American Liver Research Educational and Awareness Network (LALREAN), Pilar, Argentina.,Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina
| | - Ramazan Idilman
- Department of Gastroenterology, Ankara University Medical Faculty, Ankara, Turkey
| | - Sanjaya K Satapathy
- Department of Internal Medicine, Donald and Barbara Zucker School of Medicine, Northwell Health, Manhasset, NY, USA
| | - Marina Silveira
- Department of Medicine, Section of Digestive Diseases Yale School of Medicine, New Haven, Connecticut, USA
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Nijmegen, The Netherlands
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - David N Assis
- Department of Medicine, Section of Digestive Diseases Yale School of Medicine, New Haven, Connecticut, USA
| | - Einar Björnsson
- Department of Internal Medicine, Section of Gastroenterology, Landspitali University Hospital, Reykjavik, Iceland
| | - James L Boyer
- Department of Medicine, Section of Digestive Diseases Yale School of Medicine, New Haven, Connecticut, USA
| | - Eric M Yoshida
- Division of Gastroenterology, University of British Columbia and Vancouver General Hospital, Vancouver, Canada
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Thomas D Schiano
- Division of Liver Diseases, The Mount Sinai Medical Center, New York, New York, USA
| | - Ezequiel Ridruejo
- Latin American Liver Research Educational and Awareness Network (LALREAN), Pilar, Argentina.,Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina.,Hepatology Section, Department of Medicine, Centro de Educación Médica e Investigaciones Clínicas, CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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5
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Purnak T, El Hajj II, Sherman S, Fogel EL, McHenry L, Lehman G, Gromski MA, Al-Haddad M, DeWitt J, Watkins JL, Easler JJ. Combined Versus Separate Sessions of Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography for the Diagnosis and Management of Pancreatic Ductal Adenocarcinoma with Biliary Obstruction. Dig Dis Sci 2021; 66:2786-2794. [PMID: 32852695 PMCID: PMC8121246 DOI: 10.1007/s10620-020-06564-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 12/09/2019] [Accepted: 08/12/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND A single-procedure session combining EUS and ERCP (EUS/ERCP) for tissue diagnosis and biliary decompression for pancreatic duct adenocarcinoma (PDAC) is technically feasible. While EUS/ERCP may offer expedience and convenience over an approach of separate procedures sessions, the technical success and risk for complications of a combined approach is unclear. AIMS Compare the effectiveness and safety of EUS/ERCP versus separate session approaches for PDAC. METHODS Study patients (2010-2015) were identified within our ERCP database. Patients were analyzed in three groups based on approach: Group A: Single-session EUS-FNA and ERCP (EUS/ERCP), Group B: EUS-FNA followed by separate, subsequent ERCP (EUS then ERCP), and Group C: ERCP with/without separate EUS (ERCP ± EUS). Rates of technical success, number of procedures, complications, and time to initiation of PDAC therapies were compared between groups. RESULTS Two hundred patients met study criteria. EUS/ERCP approach (Group A) had a longer index procedure duration (median 66 min, p = 0.023). No differences were observed between Group A versus sequential procedure approaches (Groups B and C) for complications (p = 0.109) and success of EUS-FNA (p = 0.711) and ERCP (p = 0.109). Subgroup analysis (> 2 months of follow-up, not referred to hospice, n = 126) was performed. No differences were observed for stent failure (p = 0.307) or need for subsequent procedures (p = 0.220). EUS/ERCP (Group A) was associated with a shorter time to initiation of PDAC therapies (mean, 25.2 vs 42.7 days, p = 0.046). CONCLUSIONS EUS/ERCP approach has comparable rates of success and complications compared to separate, sequential approaches. An EUS/ERCP approach equates to shorter time interval to initiation of PDAC therapies.
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Affiliation(s)
- Tugrul Purnak
- Hacettepe University Medical School, Department of Gastroenterology, Sihhiye/Ankara/Turkey
| | - Ihab I. El Hajj
- Division of Gastroenterology, Saint George Hospital University Medical Center, University of Balamand, Beirut, Lebanon
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Evan L. Fogel
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lee McHenry
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Glen Lehman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark A. Gromski
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John DeWitt
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - James L. Watkins
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeffrey J. Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
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6
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Efe C, Dhanasekaran R, Lammert C, Ebik B, Higuera‐de la Tijera F, Aloman C, Rıza Calışkan A, Peralta M, Gerussi A, Massoumi H, Catana AM, Torgutalp M, Purnak T, Rigamonti C, Gomez Aldana AJ, Khakoo N, Kacmaz H, Nazal L, Frager S, Demir N, Irak K, Ellik ZM, Balaban Y, Atay K, Eren F, Cristoferi L, Batıbay E, Urzua Á, Snijders R, Kıyıcı M, Akyıldız M, Ekin N, Carr RM, Harputluoğlu M, Hatemi I, Mendizabal M, Silva M, Idilman R, Silveira M, Drenth JP, Assis DN, Björnsson E, Boyer JL, Invernizzi P, Levy C, Schiano TD, Ridruejo E, Wahlin S. Outcome of COVID-19 in Patients With Autoimmune Hepatitis: An International Multicenter Study. Hepatology 2021; 73:2099-2109. [PMID: 33713486 PMCID: PMC8250536 DOI: 10.1002/hep.31797] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/01/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Data regarding outcome of COVID-19 in patients with autoimmune hepatitis (AIH) are lacking. APPROACH AND RESULTS We performed a retrospective study on patients with AIH and COVID-19 from 34 centers in Europe and the Americas. We analyzed factors associated with severe COVID-19 outcomes, defined as the need for mechanical ventilation, intensive care admission, and/or death. The outcomes of patients with AIH were compared to a propensity score-matched cohort of patients without AIH but with chronic liver diseases (CLD) and COVID-19. The frequency and clinical significance of new-onset liver injury (alanine aminotransferase > 2 × the upper limit of normal) during COVID-19 was also evaluated. We included 110 patients with AIH (80% female) with a median age of 49 (range, 18-85) years at COVID-19 diagnosis. New-onset liver injury was observed in 37.1% (33/89) of the patients. Use of antivirals was associated with liver injury (P = 0.041; OR, 3.36; 95% CI, 1.05-10.78), while continued immunosuppression during COVID-19 was associated with a lower rate of liver injury (P = 0.009; OR, 0.26; 95% CI, 0.09-0.71). The rates of severe COVID-19 (15.5% versus 20.2%, P = 0.231) and all-cause mortality (10% versus 11.5%, P = 0.852) were not different between AIH and non-AIH CLD. Cirrhosis was an independent predictor of severe COVID-19 in patients with AIH (P < 0.001; OR, 17.46; 95% CI, 4.22-72.13). Continuation of immunosuppression or presence of liver injury during COVID-19 was not associated with severe COVID-19. CONCLUSIONS This international, multicenter study reveals that patients with AIH were not at risk for worse outcomes with COVID-19 than other causes of CLD. Cirrhosis was the strongest predictor for severe COVID-19 in patients with AIH. Maintenance of immunosuppression during COVID-19 was not associated with increased risk for severe COVID-19 but did lower the risk for new-onset liver injury during COVID-19.
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7
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Efe C, Torgutalp M, Henriksson I, Alalkim F, Lytvyak E, Trivedi H, Eren F, Fischer J, Chayanupatkul M, Coppo C, Purnak T, Muratori L, Werner M, Muratori P, Rorsman F, Onnerhag K, Nilsson E, Heurgué-Berlot A, Demir N, Semela D, Kıyıcı M, Schiano TD, Montano-Loza AJ, Berg T, Ozaslan E, Yoshida EM, Bonder A, Marschall HU, Beretta-Piccoli BT, Wahlin S. Extrahepatic autoimmune diseases in primary biliary cholangitis: Prevalence and significance for clinical presentation and disease outcome. J Gastroenterol Hepatol 2021; 36:936-942. [PMID: 32790935 DOI: 10.1111/jgh.15214] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [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: 05/26/2020] [Revised: 07/28/2020] [Accepted: 08/09/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM The prevalence and clinical significance of extrahepatic autoimmune diseases (EHAIDs) have not been evaluated in a large cohort of primary biliary cholangitis (PBC). METHODS The medical records of 1554 patients with PBC from 20 international centers were retrospectively reviewed. Development of decompensated cirrhosis (ascites, variceal bleeding, and/or hepatic encephalopathy) and hepatocellular carcinoma were considered clinical endpoints. RESULTS A total of 35 different EHAIDs were diagnosed in 440 (28.3%) patients with PBC. Patients with EHAIDs were more often female (92.5% vs 86.1%, P < 0.001) and seropositive for anti-mitochondrial antibodies (88% vs 84%, P = 0.05) and antinuclear antibodies and/or smooth muscle antibodies (53.8% vs 43.6%, P = 0.005). At presentation, patients with EHAIDs had significantly lower levels of alkaline phosphatase (1.76 vs 1.98 × upper limit of normal [ULN], P = 0.006), aspartate aminotransferase (1.29 vs 1.50 × ULN, P < 0.001), and total bilirubin (0.53 vs 0.58 × ULN, P = 0.002). Patients with EHAIDs and without EHAIDs had similar rates of GLOBE high-risk status (12.3% vs 16.1%, P = 0.07) and Paris II response (71.4% vs 69.4%, P = 0.59). Overall, event-free survival was not different in patients with and without EHAIDs (90.8% vs 90.7%, P = 0.53, log rank). Coexistence of each autoimmune thyroid diseases (10.6%), Sjögren disease (8.3%), systemic sclerosis (2.9%), rheumatoid arthritis (2.7%), systemic lupus erythematosus (1.7%), celiac disease (1.7%), psoriasis (1.5%), and inflammatory bowel diseases (1.3%) did not influence the outcome. CONCLUSIONS Our study confirms that EHAIDs are frequently diagnosed in patients with PBC. The presence of EHAIDs may influence the clinical phenotype of PBC at presentation but has no impact on PBC outcome.
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Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Gazi Yaşargil Education and Research Hospital, Diyarbakir, Turkey
| | - Murat Torgutalp
- Department of Rheumatology, Ankara University Hospital, Ankara, Turkey
| | - Ida Henriksson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Fatema Alalkim
- Division of Gastroenterology, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Ellina Lytvyak
- University of Alberta Division of Gastroenterology and Liver Unit, Edmonton, Alberta, Canada
| | - Hirsh Trivedi
- Division of GI and Hepatology, Beth Israel Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Fatih Eren
- Department of Gastroenterology, Medical Faculty, Uludag University, Bursa, Turkey
| | - Janett Fischer
- Division of Gastroenterology, Clinic and Polyclinic for Oncology, Hepatology, Infectious Diseases and Pneumology, University Clinic Leipzig, Leipzig, Germany
| | - Maneerat Chayanupatkul
- Division of Liver Diseases, The Mount Sinai Medical Center, New York, New York, USA.,Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Claudia Coppo
- Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System, University of Bologna, Bologna, Italy
| | - Tugrul Purnak
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Luigi Muratori
- Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System, University of Bologna, Bologna, Italy
| | - Mårten Werner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Paolo Muratori
- Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System, University of Bologna, Bologna, Italy
| | - Fredrik Rorsman
- Department of Gastroenterology and Hepatology, Uppsala University Hospital, Uppsala, Sweden
| | - Kristina Onnerhag
- Department of Gastroenterology and Hepatology, Skåne University Hospital, Malmö, Sweden
| | - Emma Nilsson
- Department of Clinical Sciences, Gastroenterology Division, Skåne University Hospital, Lund, Sweden
| | | | - Nurhan Demir
- Department of Gastroenterology, Gazi Yaşargil Education and Research Hospital, Diyarbakir, Turkey
| | - David Semela
- Division of Gastroenterology and Hepatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Murat Kıyıcı
- Department of Gastroenterology, Medical Faculty, Uludag University, Bursa, Turkey
| | - Thomas D Schiano
- Division of Liver Diseases, The Mount Sinai Medical Center, New York, New York, USA
| | - Aldo J Montano-Loza
- University of Alberta Division of Gastroenterology and Liver Unit, Edmonton, Alberta, Canada
| | - Thomas Berg
- Division of Gastroenterology, Clinic and Polyclinic for Oncology, Hepatology, Infectious Diseases and Pneumology, University Clinic Leipzig, Leipzig, Germany
| | - Ersan Ozaslan
- Department of Gastroenterology, Ankara City Hospital, Ankara, Turkey
| | - Eric M Yoshida
- Division of Gastroenterology, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Alan Bonder
- Division of GI and Hepatology, Beth Israel Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Staffan Wahlin
- Hepatology Division, Centre for Digestive Diseases, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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8
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Pape S, Gevers TJG, Vrolijk JM, van Hoek B, Bouma G, van Nieuwkerk CMJ, Taubert R, Jaeckel E, Manns MP, Papp M, Sipeki N, Stickel F, Efe C, Ozaslan E, Purnak T, Nevens F, Kessener DJN, Kahraman A, Wedemeyer H, Hartl J, Schramm C, Lohse AW, Heneghan MA, Drenth JPH. High discontinuation rate of azathioprine in autoimmune hepatitis, independent of time of treatment initiation. Liver Int 2020; 40:2164-2171. [PMID: 32410363 PMCID: PMC7496382 DOI: 10.1111/liv.14513] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/20/2020] [Accepted: 05/07/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Guidelines regarding treatment for autoimmune hepatitis (AIH) favour two strategies for azathioprine (AZA) introduction: concurrent with steroids at induction or delayed by 2-4 weeks. The safety and efficacy of both strategies have been unexplored. METHODS We established a cohort of 900 AIH patients from 12 centres in 7 European countries. There were 631 patients who used AZA as part of the therapeutic regimen. We distinguished two groups: patients with early AZA (<2 weeks) or delayed AZA initiation (≥2 weeks). Primary outcome was discontinuation of AZA in the first year of treatment. Cox regression and propensity score matching was performed to determine difference in outcomes between groups. RESULTS Patients with early AZA initiation had significantly lower transaminases and bilirubin at baseline. Discontinuation rates of AZA did not differ between early and delayed starters (16.6% vs 14.2%), which did not reach statistical significance (hazard ratio 0.97, 95% confidence interval 0.61-1.55, P = .90). Stratification according to baseline disease activity or propensity score matching did not alter the results. Main reason for AZA discontinuation was intolerance to treatment (14.0% vs 13.2%, P = .78) with nausea and vomiting as main side effects. AIH remission rates were comparable among groups. CONCLUSION The discontinuation rate of AZA in AIH treatment is ~15% in the first year of treatment. Early or delayed AZA initiation does not differ in remission and discontinuation rates in AIH induction therapy. Our data suggest that either strategy may be used as part of AIH treatment.
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Affiliation(s)
- Simon Pape
- Department of Gastroenterology and HepatologyRadboud University Medical CenterNijmegenThe Netherlands,European Reference Network RARE‐LIVERHamburgGermany
| | - Tom J. G. Gevers
- Department of Gastroenterology and HepatologyRadboud University Medical CenterNijmegenThe Netherlands,European Reference Network RARE‐LIVERHamburgGermany
| | - Jan Maarten Vrolijk
- Department of Gastroenterology and HepatologyRijnstate HospitalArnhemThe Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and HepatologyLeiden University Medical CenterLeidenThe Netherlands
| | - Gerd Bouma
- Department of Gastroenterology and HepatologyVU University Medical CenterAmsterdamThe Netherlands
| | | | - Richard Taubert
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany,European Reference Network RARE‐LIVERHamburgGermany
| | - Elmar Jaeckel
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany,European Reference Network RARE‐LIVERHamburgGermany
| | - Michael P. Manns
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany,European Reference Network RARE‐LIVERHamburgGermany
| | - Maria Papp
- Division of GastroenterologyDepartment of Internal MedicineFaculty of MedicineUniversity of DebrecenDebrecenHungary
| | - Nora Sipeki
- Division of GastroenterologyDepartment of Internal MedicineFaculty of MedicineUniversity of DebrecenDebrecenHungary
| | - Felix Stickel
- Department of Gastroenterology and HepatologyUniversity Hospital of ZurichZurichSwitzerland
| | - Cumali Efe
- Department of GastroenterologyHarran University HospitalUrfaTurkey
| | - Ersan Ozaslan
- Department of GastroenterologyNumune Research and Education HospitalAnkaraTurkey
| | - Tugrul Purnak
- Department of GastroenterologyHacettepe UniversityAnkaraTurkey
| | - Frederik Nevens
- Department of Gastroenterology and HepatologyUniversity Hospital KU LeuvenLeuvenBelgium,European Reference Network RARE‐LIVERHamburgGermany
| | - Dominik J. N. Kessener
- Department of Gastroenterology and HepatologyUniversity Clinic of Essen DuisburgEssenGermany
| | - Alisan Kahraman
- Department of Gastroenterology and HepatologyUniversity Clinic of Essen DuisburgEssenGermany
| | - Heiner Wedemeyer
- Department of Gastroenterology and HepatologyUniversity Clinic of Essen DuisburgEssenGermany
| | - Johannes Hartl
- 1st Department of Internal MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany,European Reference Network RARE‐LIVERHamburgGermany
| | - Christoph Schramm
- 1st Department of Internal MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany,Martin Zeitz Centre for Rare DiseasesUniversity Medical Centre Hamburg‐EppendorfHamburgGermany,European Reference Network RARE‐LIVERHamburgGermany
| | - Ansgar W. Lohse
- 1st Department of Internal MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany,European Reference Network RARE‐LIVERHamburgGermany
| | - Michael A. Heneghan
- Institute of Liver StudiesKing's College HospitalLondonUK,European Reference Network RARE‐LIVERHamburgGermany
| | - Joost P. H. Drenth
- Department of Gastroenterology and HepatologyRadboud University Medical CenterNijmegenThe Netherlands,European Reference Network RARE‐LIVERHamburgGermany
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9
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Efe C, Ozaslan E, Purnak T. What Is the Optimal Dose of Predniso(lo)ne for Induction of Remission in Patients With Autoimmune Hepatitis? Clin Gastroenterol Hepatol 2020; 18:1896-1897. [PMID: 30807845 DOI: 10.1016/j.cgh.2019.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 02/20/2019] [Accepted: 02/20/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Harran University, Şanlıurfa, Turkey
| | - Ersan Ozaslan
- Department of Gastroenterology, Numune Research and Education Hospital, Ankara, Turkey
| | - Tugrul Purnak
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
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Pape S, Gevers TJG, Vrolijk JM, van Hoek B, Bouma G, van Nieuwkerk CMJ, Taubert R, Jaeckel E, Manns MP, Papp M, Sipeki N, Stickel F, Efe C, Ozaslan E, Purnak T, Nevens F, Kessener DJN, Kahraman A, Wedemeyer H, Hartl J, Schramm C, Lohse AW, Drenth JPH, Heneghan MA. Rapid Response to Treatment of Autoimmune Hepatitis Associated With Remission at 6 and 12 Months. Clin Gastroenterol Hepatol 2020; 18:1609-1617.e4. [PMID: 31715274 DOI: 10.1016/j.cgh.2019.11.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 08/09/2019] [Revised: 10/21/2019] [Accepted: 11/04/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Changes in serum levels of transaminases immediately after initiation of treatment for autoimmune hepatitis (AIH) might be associated with biochemical markers of remission and liver-related events. We assessed the outcomes of patients with vs without rapid response to treatment of AIH in a large international cohort. METHODS We performed a retrospective cohort study, collecting data from 2 independent cohorts of adults with AIH from 12 centers in 7 countries in Europe. We collected information on patient demographics; serologic, histologic, and biochemical analyses; and treatment. We used a receiver operating characteristic curve and Youden index to calculate the optimal percentage decrease in level of aspartate aminotransferase (AST) after 8 weeks of treatment that associated with normalization of transaminase levels after 26 weeks of treatment with predniso(lo)ne (primary outcome) in the first (discovery) cohort (n = 370). We evaluated the results in the second (validation) cohort (n = 370). Secondary outcomes were liver-related death or transplantation. We performed univariate and multivariable logistic and Cox regression with correction for confounders. RESULTS A significant decrease in level of AST after 8 weeks of treatment was significantly associated with normalization of transaminase levels at 26 and 52 weeks (P < .001); a decrease of more than 80% in level of AST was associated with optimal normalization. In both cohorts, rapid responders (≥80% decrease in level of AST after 8 weeks) were more likely to achieve normalization of transaminases at 26 and 52 weeks when compared to non-rapid responders. Rapid responders in the discovery cohort had lower risk of liver-related death or transplantation (adjusted hazard ratio 0.18; 95% CI 0.05-0.63; P = .007), although this was not confirmed in the validation cohort. Results from measurement of alanine aminotransferase did not differ significantly from those of AST for the primary outcome. Slow responders (without normalization of transaminases after 1 year) had the highest risk of liver transplantation or liver-related death. CONCLUSIONS In a retrospective study of patients with AIH, we found that a rapid response to treatment, based on level of AST after 8 weeks, associates with normalization of transaminase levels in the following year. Patients with a rapid response also have a lower risk of liver-related death or transplantation than patients without this rapid response.
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Affiliation(s)
- Simon Pape
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tom J G Gevers
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Maarten Vrolijk
- Department of Gastroenterology and Hepatology, Rijnstate hospital, Arnhem, The Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gerd Bouma
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Carin M J van Nieuwkerk
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Richard Taubert
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Elmar Jaeckel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Maria Papp
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Nora Sipeki
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Felix Stickel
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich, Switzerland
| | - Cumali Efe
- Department of Gastroenterology, Harran University Hospital, Urfa, Turkey
| | - Ersan Ozaslan
- Department of Gastroenterology, Numune Research and Education Hospital, Ankara, Turkey
| | - Tugrul Purnak
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospital KU Leuven, Leuven, Belgium
| | - Dominik J N Kessener
- Department of Gastroenterology and Hepatology, University Clinic of Essen Duisburg-Essen, Duisburg-Essen, Germany
| | - Alisan Kahraman
- Department of Gastroenterology and Hepatology, University Clinic of Essen Duisburg-Essen, Duisburg-Essen, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology and Hepatology, University Clinic of Essen Duisburg-Essen, Duisburg-Essen, Germany
| | - Johannes Hartl
- 1(st) Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Schramm
- 1(st) Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- 1(st) Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
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Koklu H, Imamoglu E, Tseveldorj N, Sokmensuer C, Purnak T, Kav T. Ulcerated colonic mass mimicking malignancy in an elderly patient. Geriatr Gerontol Int 2018; 18:651-653. [PMID: 29631339 DOI: 10.1111/ggi.13256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/22/2017] [Accepted: 12/10/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Hayretdin Koklu
- Department of Internal Medicine, Division of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Eylem Imamoglu
- Department of Pathology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Nomingerel Tseveldorj
- Department of Internal Medicine, Division of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Cenk Sokmensuer
- Department of Pathology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Tugrul Purnak
- Department of Internal Medicine, Division of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Taylan Kav
- Department of Internal Medicine, Division of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey
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Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Batman State Hospital, Batman, Turkey
| | - Ersan Ozaslan
- Department of Gastroenterology, Numune Research and Education Hospital, Ankara, Turkey
| | - Tugrul Purnak
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
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Efe C, Hagström H, Ytting H, Bhanji RA, Müller NF, Wang Q, Purnak T, Muratori L, Werner M, Marschall HU, Muratori P, Gunşar F, Klintman D, Parés A, Heurgué-Berlot A, Schiano TD, Cengiz M, May-Sien Tana M, Ma X, Montano-Loza AJ, Berg T, Verma S, Larsen FS, Ozaslan E, Heneghan MA, Yoshida EM, Wahlin S. Efficacy and Safety of Mycophenolate Mofetil and Tacrolimus as Second-line Therapy for Patients With Autoimmune Hepatitis. Clin Gastroenterol Hepatol 2017; 15:1950-1956.e1. [PMID: 28603052 DOI: 10.1016/j.cgh.2017.06.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [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: 08/26/2016] [Revised: 05/24/2017] [Accepted: 06/02/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Predniso(lo)ne, alone or in combination with azathioprine, is the standard-of-care (SOC) therapy for autoimmune hepatitis (AIH). However, the SOC therapy is poorly tolerated or does not control disease activity in up to 20% of patients. We assessed the efficacy of mycophenolate mofetil (MMF) and tacrolimus as second-line therapy for patients with AIH. METHODS We performed a retrospective study of data (from 19 centers in Europe, the United States, Canada, and China) from 201 patients with AIH who received second-line therapy (121 received MMF and 80 received tacrolimus), for a median of 62 months (range, 6-190 mo). Patients were categorized according to their response to SOC. Patients in group 1 (n = 108) had a complete response to the SOC, but were switched to second-line therapy as a result of side effects of predniso(lo)ne or azathioprine, whereas patients in group 2 (n = 93) had not responded to SOC. RESULTS There was no significant difference in the proportion of patients with a complete response to MMF (69.4%) vs tacrolimus (72.5%) (P = .639). In group 1, MMF and tacrolimus maintained a biochemical remission in 91.9% and 94.1% of patients, respectively (P = .682). Significantly more group 2 patients given tacrolimus compared with MMF had a complete response (56.5% vs 34%, respectively; P = .029) There were similar proportions of liver-related deaths or liver transplantation among patients given MMF (13.2%) vs tacrolimus (10.3%) (log-rank, P = .472). Ten patients receiving MMF (8.3%) and 10 patients receiving tacrolimus (12.5%) developed side effects that required therapy withdrawal. CONCLUSIONS Long-term therapy with MMF or tacrolimus generally was well tolerated by patients with AIH. The agents were equally effective in previous complete responders who did not tolerate SOC therapy. Tacrolimus led to a complete response in a greater proportion of previous nonresponder patients compared with MMF.
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Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey.
| | - Hannes Hagström
- Hepatology Division, Centre for Digestive Diseases, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Henriette Ytting
- Department of Hepatology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Rahima A Bhanji
- Division of Gastroenterology and Liver Unit, University of Alberta, Alberta, Canada
| | - Niklas F Müller
- Sektion Hepatologie, Klinik für Gastroenterologie und Rheumatologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Qixia Wang
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Cancer Institute, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Tugrul Purnak
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Luigi Muratori
- Centro per lo Studio e la Cura delle Malattie Autoimmuni del Fegato e delle Vie Biliari, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, Università di Bologna, Bologna, Italy
| | - Mårten Werner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Paolo Muratori
- Centro per lo Studio e la Cura delle Malattie Autoimmuni del Fegato e delle Vie Biliari, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, Università di Bologna, Bologna, Italy
| | - Fulya Gunşar
- Department of Gastroenterology, Ege University, Bornova, Izmir, Turkey
| | - Daniel Klintman
- Department of Molecular and Clinical Medicine, Skåne University Hospital, Lund, Sweden; Division of Gastroenterology University of British Columbia, Vancouver General Hospital, Vancouver, Canada
| | - Albert Parés
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | - Thomas D Schiano
- Division of Liver Diseases, The Mount Sinai Medical Center, New York, New York
| | - Mustafa Cengiz
- Department of Gastroenterology, Dr A.Y. Oncology Training and Research Hospital, Ankara, Turkey
| | - Michele May-Sien Tana
- The Liver Center at University of California, San Francisco, Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Xiong Ma
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Cancer Institute, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Alberta, Canada
| | - Thomas Berg
- Sektion Hepatologie, Klinik für Gastroenterologie und Rheumatologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Sumita Verma
- Department of Medicine, Brighton and Sussex Medical School, Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital, Brighton, United Kingdom
| | - Fin Stolze Larsen
- Department of Hepatology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ersan Ozaslan
- Department of Gastroenterology, Numune Research and Education Hospital, Ankara, Turkey
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Eric M Yoshida
- Division of Gastroenterology University of British Columbia, Vancouver General Hospital, Vancouver, Canada
| | - Staffan Wahlin
- Hepatology Division, Centre for Digestive Diseases, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Purnak T, Efe C, Kav T, Wahlin S, Ozaslan E. Treatment Response and Outcome with Two Different Prednisolone Regimens in Autoimmune Hepatitis. Dig Dis Sci 2017; 62:2900-2907. [PMID: 28871464 DOI: 10.1007/s10620-017-4728-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 06/29/2017] [Accepted: 08/18/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Beyond available guidelines, therapy of autoimmune hepatitis (AIH) shows wide variation among physicians. We compared two regimens for treatment naive AIH: one recommended protocol with an initial prednisolone dose of 30 mg/day and our own 40 mg/day prednisolone with a slow dose tapering protocol. We analyzed the safety, response rates, and outcomes for two groups of treated patients. PATIENTS AND METHODS We retrospectively evaluated data of 71 AIH patients including, group I (n = 32, prednisone 30 mg/day) and group II (n = 39, prednisone 40 mg/day). All patients also received azathioprine. RESULTS The frequency of complete biochemical response was significantly higher in group II than in group I (69.2 vs. 43.8%, p = 0.031) after 3 months of therapy, but not after 6 and 12 months (79.5 vs. 59.4%, p = 0.065 and 89.5 vs. 80.6%, p = 0.30). In patients with severe interface hepatitis, the complete response rates were significantly higher in group II than in group I after 3 (63.6 vs. 23.1%, p = 0.02) and 6 months (72.7 vs. 38.5%, p = 0.046), but not after 12 months of therapy (86.4 vs. 69.2%, p = 0.221). Relapses were observed in 50% of group I and in 35.9% of group II during maintenance therapy (p = 0.23). Overall survival was significantly better in group II than in group I (100 vs. 87.5%, log-rank, p = 0.048). No severe steroid-related side effects were observed in either group. CONCLUSIONS Our real-world experience suggests that an initial prednisolone dose of 40 mg/day with a slower tapering protocol induces earlier biochemical response, tends to result in less relapses during maintenance, and is associated with a better disease outcome.
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Affiliation(s)
- Tugrul Purnak
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Cumali Efe
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey.
| | - Taylan Kav
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Staffan Wahlin
- Hepatology Division, Centre for Digestive Disease, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Ersan Ozaslan
- Department of Gastroenterology, Numune Research and Education Hospital, Ankara, Turkey
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15
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Erdogan S, Yilmaz FM, Yazici O, Yozgat A, Sezer S, Ozdemir N, Uysal S, Purnak T, Sendur MA, Ozaslan E. Inflammation and chemerin in colorectal cancer. Tumour Biol 2015; 37:6337-42. [DOI: 10.1007/s13277-015-4483-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 11/23/2015] [Indexed: 01/06/2023] Open
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Beyazit Y, Dişibeyaz S, Suvak B, Purnak T, Torun S, Parlak E. [Evaluation of treatment results among patients with acute gastrointestinal bleeding due to Dieulafoy's lesion admitted to the emergency department]. ULUS TRAVMA ACIL CER 2015; 19:133-9. [PMID: 23599197 DOI: 10.5505/tjtes.2013.58740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Dieulafoy lesions (DL) are a rare cause of gastrointestinal bleeding (GIB), characterized by exteriorization of a large pulsatile arterial vessel through a minimal mucosal tear surrounded by normal mucosa. In the present study, we aimed to review the clinical experience with DL in our center, primarily focusing on clinical features and endoscopic therapeutic preferences according to clinical outcomes. METHODS Data from patients with upper GIB were admitted to the Turkiye Yuksek Ihtisas Training and Research Hospital gastrointestinal endoscopy unit between 2007 and 2011 and were reviewed for DL. Detailed clinical and endoscopic data were abstracted and collected. RESULTS Twenty-seven patients were identified with DL. Their ages ranged from 24 to 85 years (median age 70). Fifteen patients were male and twelve were female. Most of the DL occurred in the stomach and were most commonly localized in fundus (59.2%), followed by corpus (29.6%) and antrum (11.2%). The most common initial endoscopic therapeutic approaches were the application of hemoclips with (33.3%) or without adrenalin (40%) injection. CONCLUSION Our study revealed that DL occurred in relatively older patients with a male dominance. Primary hemostasis with endoscopic intervention is safe, successful and cost-effective.
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Affiliation(s)
- Yavuz Beyazit
- Department of Gastroenterology, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey.
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Affiliation(s)
- Omer Ozturk
- Department of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Omer Basar
- Department of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Seyfettin Koklu
- Department of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Osman Yuksel
- Department of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Tugrul Purnak
- Department of Gastroenterology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Cenk Sokmensuer
- Department of Pathology, Hacettepe University School of Medicine, Ankara, Turkey
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Beyazit Y, Efe C, Tanoglu A, Purnak T, Sayilir A, Taskıran I, Kekilli M, Turhan T, Ozaslan E, Wahlin S. Nitric oxide is a potential mediator of hepatic inflammation and fibrogenesis in autoimmune hepatitis. Scand J Gastroenterol 2015; 50:204-10. [PMID: 25495215 DOI: 10.3109/00365521.2014.974203] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [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] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite advances in the understanding of the pathophysiological basis of autoimmune hepatitis (AIH), it is still difficult to delineate the mechanisms involved in progression from hepatic inflammation toward fibrosis. Our aim was to study serum concentrations of NO in AIH of different histological severity and possible effects of immunosuppressive therapy on NO production. MATERIALS AND METHODS We studied serum NO metabolites (NOx) in 47 consecutive patients with AIH and in 28 age- and sex-matched controls. RESULTS Serum NOx concentrations were higher in AIH patients than in controls (10.3 (4.5-27.3 µmol/L) vs. 4.3 (1.6-14.3 µmol/L), p < 0.001). According to liver histology, median NOx concentrations were significantly higher in patients with severe interface hepatitis compared to patients with mild-moderate interface hepatitis (12.3 (4.5-27.3 µmol/L) vs. 9.3 (4.6-20.3 µmol/L), p = 0.029). Similarly, serum NOx concentrations were significantly higher in patients with advanced fibrosis than in those with early fibrosis (12.2 (4.6-27.3 µmol/L) vs. 9.3 (6.6-12.8 µmol/L), p = 0.018). NOx concentrations decreased in 16 AIH patients who were tested also after biochemical remission was achieved (12.6 (4.5-22.8 µmol/L) at baseline and 5.9 (2.8-10.5 µmol/L) after remission, p = 0.001). CONCLUSION This study shows that serum NOx levels are associated with the histological severity of AIH. Hepatocyte inflammation and injury may activate hepatic stellate cells and kupffer cells, and the consequences may include release of NO, which ultimately promotes hepatic fibrosis. Immunosuppressive therapy inhibits this process and the production of NO.
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Affiliation(s)
- Yavuz Beyazit
- Department of Gastroenterology, Canakkale State Hospital , Canakkale , Turkey
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Ozaslan E, Purnak T, Efe C, Ozaslan NG, Cengiz M. The comparison of two different 5.5 fr sphincterotomes for selective cannulation of the common bile duct: a prospective, randomized study. Dig Dis Sci 2014; 59:3078-84. [PMID: 24996379 DOI: 10.1007/s10620-014-3268-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 06/24/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM There are scarce data regarding the impact of sphincterotome design on cannulation success. We aimed to compare two different 5.5 Fr standard sphincterotomes to determine initial cannulation success. METHODS Adult patients with naive papillae were enrolled in a prospective, randomized, crossover study. Two different 5.5 Fr sphincterotomes preloaded with guidewire (GW) were used in two groups with 140 patients included per group. A total of five papillary attempts and two pancreatic channel entries were allowed as maximum targets. In a case of more than two pancreatic entries, a double GW technique was attempted before crossover. If choledochal cannulation was not achieved within ten papillary attempts or more than four pancreatic entries despite crossover, access papillotomy was performed. Successful biliary cannulation was the primary outcome. Secondary outcomes were incidence of early complications and overall cannulation success. RESULTS Higher initial cannulation success was achieved in group I compared with group II (88.5 vs. 77.1%, p = 0.011). The crossover and double GW techniques reduced the need for precut from 11.7 to 5.3%. The overall cannulation success including precut for failed cases was 99.2% (group I) and 98.5% (group II). Sphincterotome type, presence of crossover, and number of cannulation attempts were predictors of successful cannulation in multivariate analysis. CONCLUSIONS There was a significant difference in cannulation success between two different 5.5 Fr sphincterotomes. The cannulation success was mainly governed by sphincterotome design which serves a proper spatial orientation during the procedure. The combined use of crossover and double GW techniques may substantially decrease precut necessity.
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Affiliation(s)
- Ersan Ozaslan
- Department of Gastroenterology, Ankara Numune Education and Research Hospital, Çukurambar Mah. 1429. Cad. 24/2, Çankaya, Ankara, Turkey,
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Affiliation(s)
- S Purnak
- Department of Dermatology, Baskent University Faculty of Medicine, Ankara, 06490, Turkey.
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Koklu S, Gulsen MT, Tuna Y, Koklu H, Yuksel O, Yilmaz B, Karaca C, Ataseven H, Guner R, Kucukazman M, Kockar C, Demir M, Poyrazoglu OK, Ibis M, Purnak T, Etgul S, Alkan E, Coban S, Gokturk S, Biyik M, Baykal O, Basar O, Koklu N, Tatar G, Simsek H. Lamivudine treatment failure risks in chronic hepatitis B patients with low viral load. Digestion 2014; 88:266-71. [PMID: 24356645 DOI: 10.1159/000356312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 09/30/2013] [Indexed: 02/04/2023]
Abstract
AIM To analyze the risk factors of lamivudine treatment failure (LTF) for the long-term use in patients with low viral load (LVL). MATERIAL AND METHODS In this multicenter study, 548 antiviral naïve noncirrhotic adult patients with LVL (for HBeAg+ patients HBV DNA <10 9 copies/ml and for HBeAg–patients HBV DNA <10 7 copies/ml) were enrolled. As a control group, 46 lamivudine-initiated patients with high viral load (HVL) were included. Primary outcome was switching to or adding on another antiviral drug as a consequence of primary nonresponse, partial response, viral breakthrough or adverse events. Secondary outcomes included LTF rates at 1, 2, 3, 4 and 5 years and LTF-related viral and host factors. RESULTS Among 594 patients, 294 had to change lamivudine at the follow-up. Primary nonresponse, partial response, viral breakthrough or adverse events frequencies were 6.8, 1.6, 64.5 and 0.1%, respectively. Five-year LTF rates were 61.3 and 84.2% in patients with LVL and HVL, respectively. Among patients with LVL, patients with <100,000 copies/ml and ≥ 100,000 copies/ ml had 54.8 and 67.3% LTF rates at the end of the 5th year, respectively. Logistic regression analysis of risk factors showed HBeAg+, hepatic activity index, HBV DNA, virological response at 6 months and duration of follow-up were independent predictors for LTF (p values were 0.001, 0.008, 0.003, 0.020 and 0.003, respectively). CONCLUSION Similar to patients with HVL, first-line lamivudine therapy is not efficient for long-term use in patients with LVL. LTF risk is so high even in the absence of worse predictive factors.
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Efe C, Purnak T, Ozaslan E. Vitamin D levels in patients with chronic hepatitis B. Hepatology 2014; 60:768. [PMID: 24310781 DOI: 10.1002/hep.26962] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 11/08/2013] [Accepted: 12/02/2013] [Indexed: 12/31/2022]
Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Hacettepe University
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Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Hacettepe University
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Efe C, Kahramanoğlu-Aksoy E, Yilmaz B, Ozseker B, Takci S, Roach EC, Purnak T, Kav T, Ozaslan E, Wahlin S. Pregnancy in women with primary biliary cirrhosis. Autoimmun Rev 2014; 13:931-5. [PMID: 24879082 DOI: 10.1016/j.autrev.2014.05.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 05/20/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Primary biliary cirrhosis (PBC) may present in all decades of life, also in childbearing age. Data on maternal and fetal outcome is limited. We aimed to investigate the impact of pregnancy and childbirth on the disease course and possible effects of PBC on fetal outcome. METHODS Retrospective study of local cases and a compact review of published reports between 1950 and 2014. RESULTS Our cases along with literature review provided 98 pregnancies in 72 PBC patients. PBC was diagnosed during pregnancy in 26 (36%) patients and 46 (64%) had the diagnosis before conception. Twenty-four (30%) of the pregnancies were associated with biochemical flares and 55 (70%) with clinical improvement or stabilization. De novo onset or worsening of pruritus was seen in 49% (45/92). No maternal deaths were reported. Post-partum disease activation was observed in 60% (53/88). One patient was referred for liver transplantation after delivery. A miscarriage rate of 24% and three stillbirths were reported. Most patients were treated with ursodeoxycholic acid (UDCA) during breastfeeding and 12 patients also received UDCA during the first trimester without any identified side effects. CONCLUSION Most women with PBC maintain a stable disease during pregnancy, but post-partum biochemical flares are common. Symptomatic pruritus may be challenging in pregnant PBC patients. UDCA appears to be safe during pregnancy and breastfeeding. A successful pregnancy outcome is a realistic expectation for women with PBC.
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Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey.
| | | | - Bülent Yilmaz
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Burak Ozseker
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Sahin Takci
- Department of Neonatology, Gaziosmanpaşa University, Tokat, Turkey
| | | | - Tugrul Purnak
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Taylan Kav
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Ersan Ozaslan
- Department of Gastroenterology, Numune Research and Education Hospital, Ankara, Turkey
| | - Staffan Wahlin
- Department of Gastroenterology and Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Purnak T, Efe C, Basar O. Liver and atherosclerosis. Gastroenterology 2014; 146:1427. [PMID: 24681174 DOI: 10.1053/j.gastro.2014.01.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 01/06/2014] [Indexed: 12/02/2022]
Affiliation(s)
- Tugrul Purnak
- Hacettepe University Medical School, Department of Gastroenterology, Ankara, Turkey
| | - Cumali Efe
- Hacettepe University Medical School, Department of Gastroenterology, Ankara, Turkey
| | - Omer Basar
- Hacettepe University Medical School, Department of Gastroenterology, Ankara, Turkey
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Beyazit Y, Huri E, Purnak T, Guler MO, Haznedaroglu IC. Next generation nanomedicine in the genesis of "Ankaferd blood stopper nanohemostat": a novel chimeric topical hemostatic agent for clinical hemorrhages. Clin Appl Thromb Hemost 2013; 20:456-7. [PMID: 24363214 DOI: 10.1177/1076029613507336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Yavuz Beyazit
- 1Department of Gastroenterology, Canakkale State Hospital, Canakkale, Turkey
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Ozaslan E, Ozaslan NG, Purnak T, Ozkaya G. The impact of sphincterotome design on selective cannulation of the common bile duct. J Gastroenterol Hepatol 2013; 28:1573-7. [PMID: 23560869 DOI: 10.1111/jgh.12210] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Accepted: 03/25/2013] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM There is a paucity of data regarding the impact of sphincterotome design on cannulation success. METHODS We aimed to compare the 5.5 F standard sphincterotomes of two different manufacturers (sphincterotome 1: Endo-flex 5.5F [ENDO-FLEX GmbH, Voerde, Düsseldorf, Germany] vs sphincterotome 2: Ultratome 5.5F [Boston Scientific, Spencer, IN, USA]). Adult patients undergoing their first endoscopic retrograde cholangiopancreatography were included in two study groups. The sphincterotome preloaded with a guidewire was used for selective common bile duct cannulation in each group. Precut methods were applied in failed cases without crossover. Successful biliary cannulation in 10 attempts was the primary outcome. RESULTS Baseline features and indications were similar between groups (n = 100, group I, sphincterotome 1, vs n = 100, group II, sphincterotome 2). A higher success in initial cannulation was obtained in group II compared to group I (92% vs 81%, P = 0.03). Moreover, number of cannulation attempts and time to cannulation differed. No statistical significance was noted in group I (8%) versus group II (3%) regarding pancreatitis rate. The overall cannulation success after precut in failed cases was 95% (group I) and 97% (group II). CONCLUSIONS There was a significant difference in cannulation success between the two different sphincterotome. 5.5F Ultratome with guidewire was superior to 5.5F Endo-flex sphincterotome with guidewire in initial selective cannulation of common bile duct. The results may show the importance of sphincterotome features to overcome the obstacles during cannulation such as complex intrapapillary mucosal features.
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Affiliation(s)
- Ersan Ozaslan
- Department of Gastroenterology, Ankara Numune Education and Research Hospital, Ankara, Turkey
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Purnak T, Beyazit Y, Efe C, Ozaslan E, Yuksel O, Altiparmak E. Authors' reply: 'Mean platelet volume could be a promising biomarker to monitor dietary compliance in celiac disease'. Ups J Med Sci 2013; 118:208. [PMID: 23837597 PMCID: PMC3713390 DOI: 10.3109/03009734.2013.806617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tugrul Purnak
- Ankara Numune Education and Research Hospital, Department of Gastroenterology, Ankara, Turkey
| | - Yavuz Beyazit
- Ankara Numune Education and Research Hospital, Department of Gastroenterology, Ankara, Turkey
| | - Cumali Efe
- Hacettepe University Medical School, Department of Gastroenterology, Ankara, Turkey
| | - Ersan Ozaslan
- Ankara Numune Education and Research Hospital, Department of Gastroenterology, Ankara, Turkey
| | - Osman Yuksel
- Ankara Diskapi Education and Research Hospital, Department of Gastroenterology, Ankara, Turkey
| | - Emin Altiparmak
- Ankara Diskapi Education and Research Hospital, Department of Gastroenterology, Ankara, Turkey
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Efe C, Wahlin S, Ozaslan E, Purnak T, Muratori L, Quarneti C, Tatar G, Simsek H, Muratori P, Schiano TD. Diagnostic difficulties, therapeutic strategies, and performance of scoring systems in patients with autoimmune hepatitis and concurrent hepatitis B/C. Scand J Gastroenterol 2013; 48:504-8. [PMID: 23448312 DOI: 10.3109/00365521.2013.772231] [Citation(s) in RCA: 11] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The diagnosis of autoimmune hepatitis (AIH) is already difficult, and that of AIH with chronic viral hepatitis including hepatitis B (HBV) or hepatitis C (HCV) is even more challenging. To date, only a few case-based studies have described this association. AIM The aim was to retrospectively assess diagnostic difficulties, therapeutic approaches, and performance of the scoring systems in AIH patients with concurrent HBV and HCV. METHODS A total of 25 patients from United States, Sweden, Italy, and Turkey were retrospectively evaluated. Both revised and simplified criteria suggested by the International Autoimmune Hepatitis Group were applied for each patient. All study data were obtained from medical records. RESULTS Of the 25 patients, 20 (80%) had concomitant HCV and 5 (20%) had HBV. Based on the revised scoring system and simplified criteria, 18 (72%) and 12 (48%) patients were diagnosed as "probable" AIH. None of the patients were diagnosed as "definite" AIH according to both scoring systems. Patients with HCV initially were treated with immunosuppressive agents, and antiviral therapy was commenced when biochemical remission occurred. AIH patients with HBV were first treated with antiviral and thereafter, immunosuppressive therapy was started. CONCLUSIONS This large case series describes concurrent AIH and chronic viral hepatitis. The revised scoring system for AIH had a better performance than the simplified scoring system. However, neither scoring system is optimal for diagnosing AIH alone. In these patients, a definitive diagnosis of AIH should be based on a combination of serological profiles, histological findings, scoring systems, treatment response, and outcomes.
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Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey.
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Purnak T, Olmez S, Torun S, Efe C, Sayilir A, Ozaslan E, Tenlik I, Kalkan IH, Beyazit Y, Yuksel O. Mean platelet volume is increased in chronic hepatitis C patients with advanced fibrosis. Clin Res Hepatol Gastroenterol 2013; 37:41-6. [PMID: 22572524 DOI: 10.1016/j.clinre.2012.03.035] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 03/18/2012] [Accepted: 03/28/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Liver biopsy is the gold standard procedure for documenting liver damage in chronic hepatitis C (CHC), as for many other chronic liver diseases. Mean platelet volume (MPV) is a laboratory marker obtained from complete blood count (CBC) analysers in routine clinical practice. The goal of the present study was to evaluate whether MPV would be useful in predicting liver histologic severity in CHC. PATIENTS AND METHODS A total of 59 patients with CHC and 25 control subjects were recruited into the present study. There were 26 men and 33 women in the CHC group and 12 men and 13 women in the control group. MPV was recorded at the time of admission. The clinical characteristics of CHC patients, including demographics, laboratory and liver biopsy findings, were reviewed. RESULTS A statistically significant increase in MPV values was observed in CHC patients (8.54 ± 0.63 fL) compared to healthy controls (7.65 ± 0.42 fL) (P < 0.001). Moreover, MPV values were significantly higher among patients with advanced fibrosis as compared to those with mild fibrosis (8.99 ± 0.57 fL vs. 8.19 ± 0.50 fL P < 0.001). Receiver operator characteristic (ROC) curve analysis suggested that the optimum cut-off point for MPV value in advanced fibrosis was 8.75 fL. (Sensitivity: 80.8%, specificity: 81.8%, positive predictive value [PPV] 77.8%, negative predictive value [NPV] 84.4%, accuracy 81.3%, AUC: 0.98 P < 0.001) CONCLUSION The current study showed that MPV is increased in CHC with advanced fibrosis. Calculation of MPV along with the use of other markers may give further information about liver fibrosis severity in CHC.
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Affiliation(s)
- Tugrul Purnak
- Department of Gastroenterology, Ankara Numune Education and Research Hospital, Ankara, Turkey.
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Efe C, Ozaslan E, Wahlin S, Purnak T, Muratori L, Quarneti C, Yüksel O, Muratori P. Antibodies to soluble liver antigen in patients with various liver diseases: a multicentre study. Liver Int 2013; 33:190-6. [PMID: 23295051 DOI: 10.1111/liv.12022] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 10/04/2012] [Indexed: 02/13/2023]
Abstract
BACKGROUND Antibodies to soluble liver antigen (anti-SLA) are specific serological markers of autoimmune hepatitis (AIH). The clinical significance and frequency of anti-SLA have never been reported among AIH patients from Italy and Turkey. To retrospectively assess the estimated prevalence, sensitivity, specificity and clinical significance of anti-SLA in AIH and various liver diseases. METHODS A total of 986 patients who had been tested for serum anti-SLA were included in study. The presence of anti-SLA was detected using recombinant enzyme linked immunosorbent assay and immuno-blot. The general characteristics and outcome of patients were obtained from their medical records. RESULTS Antibodies to SLA were found in 30 (3%) of 986 patients. Of these, 27 (90%) had AIH and its variants, whereas the remaining three (10%) had primary biliary cirrhosis. The prevalence of anti-SLA was 9% in AIH patients from Italy and 15% in patients from Turkey. The specificity of these antibodies was 99.5%, whereas sensitivity was 11%. The positive predictive and negative predictive values were 90% and 77.5% respectively (95% confidence interval). Biochemical remission was achieved in 90% of anti-SLA positive AIH patients, but relapse after immunosuppressive withdrawal or during maintenance therapy was observed in 53% of the patients. CONCLUSIONS Seropositivity for anti-SLA occurs at similar frequencies in AIH patients from different geographical regions and ethnic groups. The sensitivity of anti-SLA is low, but it has high specificity for AIH. Additional studies are necessary to prove clinical significance of anti-SLA in AIH.
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Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Numune Research and Education Hospital, Ankara, Turkey.
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Purnak T, Beyazit Y, Efe C, Ozaslan E. Reply to Dr Onal: the importance of serum angiotensin-converting enzyme level in chronic hepatitis B. J Renin Angiotensin Aldosterone Syst 2012; 13:504. [PMID: 23166113 DOI: 10.1177/1470320312454767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Purnak T, Beyazit Y, Ibis M, Koklu S, Efe C, Ozaslan E, Ciftci A, Tenlik I. The involvement of nitric oxide in the physiopathology of hepatoportal sclerosis. Clin Biochem 2012; 45:1450-4. [PMID: 22820432 DOI: 10.1016/j.clinbiochem.2012.07.091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 07/03/2012] [Accepted: 07/08/2012] [Indexed: 12/16/2022]
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Beyazit Y, Kekilli M, Ibis M, Kurt M, Sayilir A, Onal IK, Purnak T, Oztas E, Tas A, Yesil Y, Arhan M. Can red cell distribution width help to discriminate benign from malignant biliary obstruction? A retrospective single center analysis. Hepatogastroenterology 2012; 59:1469-73. [PMID: 22683963 DOI: 10.5754/hge10676] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND/AIMS Differentiation of benign obstructive jaundice from malignant obstructive jaundice still remains difficult, despite improvements in diagnostic modalities. The aim of this study is to evaluate the usefulness of red cell distribution width (RDW) in differentiating benign and malignant causes of obstructive jaundice. METHODOLOGY One hundred and ninety four consecutive patients (101 malignant, 93 benign) with a history of obstructive jaundice were reviewed in the period between January 2008 and August 2009. Definition of biliary strictures was suggested by cholangiographic features and supported by brush cytology, fine needle aspiration (FNA) and the presence of mass or metastases by imaging and/or clinical followup. Patients were divided into two groups, benign and malignant, based on the discharge diagnosis. RESULTS The receiver operating characteristic analysis showed that a RDW of 14.8% was the best cut-off value for predicting a malignant biliary stricture with a sensitivity of 72% and a specificity of 69% (AUC=0.755, 95% CI=0.649-0.810). RDW was increased (>14.8%) in 31.6% of benign cases and 68.4% of malignancies. Depressed RDW levels (<14.8%) were found in 72.9% of benign cases and 27.1% of malignancies, which was statistically significant (p<0.001). CONCLUSIONS Our results show that RDW is useful in the differentiation of benign from malignant causes of biliary obstruction when using an optimized cut-off value. In patients in whom biliary obstruction is suspected, an elevated RDW value may be a reliable additional predictor for differentiating the underlying etiology of biliary obstruction.
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Affiliation(s)
- Yavuz Beyazit
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey.
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Purnak T, Beyazit Y, Ozaslan E, Efe C, Hayretci M. The evaluation of bone mineral density in patients with nonalcoholic fatty liver disease. Wien Klin Wochenschr 2012; 124:526-31. [PMID: 22850810 DOI: 10.1007/s00508-012-0211-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 07/01/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Nonalcoholic fatty liver diseases (NAFLD) are a clinical spectrum of disorders, of which nonalcoholic steatohepatitis (NASH) is the most strongly associated with inflammation. Inflammation is a known risk factor for low bone mass in the body. The primary goal of the present study was to evaluate the association between bone mineral density and liver function in patients with NASH. MATERIALS AND METHODS Consenting patients with a diagnosis of NAFLD were included in the study. Extent of fatty change was graded based on ultrasonographic appearance (Grade 1, mild; Grade 2, moderate; Grade 3, severe). Bone mineral density was measured using the dual-energy x-ray absorptiometry method. ALT and hs-CRP were considered as noninvasive marker of NASH. According to ALT levels, patients were divided into two subgroups. RESULTS A total of 102 patients with NAFLD and 54 healthy controls participated in the study. None of the patients with NAFLD had an abnormal bone mineral density. Furthermore, there was no difference between groups with regard to serum vitamin D levels. A subgroup analysis revealed that female patients with elevated serum ALT level had significantly lower bone mineral densities and higher hsCRP levels than female patients with normal ALT levels. The difference in vitamin D levels and body mass indices between the same subgroups was statistically insignificant. CONCLUSIONS Simple steatosis of the liver does not affect bone mineral density. However, in a subgroup of patients with NAFLD, the presence of elevated serum ALT and hs-CRP levels, which are suggestive of NASH, was associated with lower bone mineral densities. Better understanding of the biological basis and the complex interactions between NAFLD and bone mass may help guide the clinical management of bone diseases associated with inflammation of the liver.
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Affiliation(s)
- Tugrul Purnak
- Department of Gastroenterology, Ankara Numune Education and Research Hospital, Talatpasa Bulvari, Samanpazari, 06100, Ankara, Turkey.
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Efe C, Purnak T, Ozaslan E. Autoimmune hepatitis in the postpartum period. Clin Res Hepatol Gastroenterol 2012; 36:391-3. [PMID: 22481086 DOI: 10.1016/j.clinre.2012.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Revised: 01/31/2012] [Accepted: 02/07/2012] [Indexed: 02/04/2023]
Abstract
AIM Autoimmune hepatitis (AIH) presenting primarily in the postpartum period has rarely been reported. METHODS The medical data of 58 female patients diagnosed with AIH was assessed. RESULTS In the study population, three (5.1%) patients were diagnosed postpartum. Based on clinical, laboratory and liver biopsy findings, two of these patients were considered to have subclinical AIH and were diagnosed by disease flare after delivery. The remaining patient was considered as new onset of AIH in the postpartum period. CONCLUSIONS AIH can present in the postpartum and should be actively considered among the differential diagnosis if liver dysfunction is observed after delivery.
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Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Numune Research and Education Hospital, Yazgan sokak 21/12 Cebeci, Ankara, Turkey.
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Efe C, Roach EC, Purnak T, Ozaslan E. Chronic hepatitis C, inflammatory bowel disease and interferon therapy. J Crohns Colitis 2012; 6:626-7. [PMID: 22398083 DOI: 10.1016/j.crohns.2012.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 01/10/2012] [Indexed: 02/08/2023]
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Acar K, Beyazit Y, Sucak A, Haznedaroglu IC, Aksu S, Tuncer S, Ozturkkan D, Danisman N, Purnak T, Misirlioglu M, Kekilli M, Mollamahmutoglu L. Alterations in the 'local umbilical cord blood renin-angiotensin system' during pre-eclampsia. Acta Obstet Gynecol Scand 2012; 86:1193-9. [PMID: 17851801 DOI: 10.1080/00016340701552434] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Local autocrine-paracrine renin-angiotensin system (RAS), independently functioning from the circulating RAS, is present in major organs of the female reproductive tract. We have previously demonstrated 'a local RAS in human umbilical cord' via verifying the corresponding ACE, renin, and angiotensinogen mRNAs. The aim of this study is to search alterations of the local umbilical cord RAS during pre-eclampsia. METHODS Cord blood samples were obtained from 19 patients with pre-eclampsia (aged mean 26.6 ± 5.83 (range 18-42) years) and 20 women with normal pregnancy (aged mean 28.26 ± 7.30 (range 19-37) years). Women with uncomplicated pregnancy formed the control group. Real time quantitative PCR analysis for ACE, renin and angiotensinogen gene expressions were carried out using a LightCycler™ instrument. RESULTS The mean expression ratios were 0.0029 ± 0.0015 for renin, 0.153 ± 0.166 for angiotensinogen, and 0.220 ± 0.294 for ACE, in control samples. The mean expression ratios of pre-eclamptic patients were 0.0061 ± 0.00068, 0.035 ± 0.008, and 0.030 ± 0.006 for renin, angiotensinogen and ACE genes, respectively. While renin expressions increased in the local cord blood of pre-eclampsia in comparison to the normal cord blood, unpredictable decrements in the angiotensinogen and ACE expressions were observed within the same pre-eclamptic samples. There were no statistically significant differences between intrauterine growth restriction (IUGR) and appropriate for gestational age (AGA) newborns in respect to renin, angiotensinogen and ACE gene expressions. CONCLUSIONS These findings indicate that the gene expression in the major components of the local RAS does not represent a constant mathematical model, but is affected from the ongoing pathobiological events associated with the disease course. Local umbilical cord blood RAS alterations at the basis of genetic expression are evident in pre-eclampsia.
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Affiliation(s)
- Kadir Acar
- Department of Hematology, Zekai Tahir Burak Women's Health and Research Hospital, Ankara, Turkey
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Efe C, Ozaslan E, Purnak T, Ozseker B, Kav T, Bayraktar Y. Liver biopsy is a superior diagnostic method in some patients showing the typical laboratory features of autoimmune hepatitis. Clin Res Hepatol Gastroenterol 2012; 36:185-8. [PMID: 21974938 DOI: 10.1016/j.clinre.2011.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 08/01/2011] [Accepted: 08/07/2011] [Indexed: 02/04/2023]
Abstract
AIMS To investigate whether liver diseases other than autoimmune hepatitis (AIH) can present with the typical features of AIH, and to determine the impact of liver biopsy for differentiating AIH from these conditions. PATIENTS AND METHODS The study used data collected at Hacettepe university hospital and numune education and research hospital from 2007 to 2011. The clinical, laboratory and histological findings of patients diagnosed with non-alcoholic steatohepatitis, drug-induced liver injury, primary biliary cirrhosis, primary sclerosing cholangitis, hemochromatosis and Wilson's disease were evaluated to identify those who presented with the typical features of AIH, but had no liver histology compatible with or suggestive of AIH. RESULTS A total of 386 patients were evaluated, and four patients with typical features of AIH were identified. Three patients were positive for antinuclear antibodies, and one was positive for smooth muscle antibodies. Also, all four had increased levels of immunoglobulin G, and aminotransferase levels that were five times above the upper limit. According to simplified AIH criteria, all patients had a score of 6, indicating probable AIH. On liver biopsy, two patients were diagnosed with non-alcoholic steatohepatitis, another with drug-induced liver injury and a further one with primary biliary cirrhosis. CONCLUSION Liver diseases other than AIH can present with the typical laboratory features of AIH and, without liver biopsy, it is difficult to distinguish AIH than these conditions. Although histological findings have little impact on patients' management and outcomes, for a definitive diagnosis of AIH, liver biopsy is essential and should be performed in all patients in whom it is suitable and not contraindicated.
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Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Hacettepe University Faculty of Medicine, Ankara, Turkey.
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Purnak T, Efe C, Beyazit Y, Ozaslan E, Astan R, Milanloglu A, Ozbalkan Z, Rizzo M. Recent insights into the relationship between inflammatory liver diseases and atherosclerosis. J Investig Med 2012; 59:904-11. [PMID: 21441825 DOI: 10.2310/jim.0b013e318217f3a0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Atherosclerosis is a dynamic process in the human body. Many studies have evaluated atherosclerosis and its relationship with other systems in the body. Our perception of its pathogenesis is evolving with the introduction of new players in the game. It is no longer possible to consider the atherosclerosis as an independent process, unaffected by the liver and its function. Although several tasks performed by the liver, such as lipid metabolism, have been implicated in the pathogenesis of atherosclerosis, the role of other disorders of the liver (autoimmune diseases, viral hepatitis, and cirrhosis) are not fully understood. In this review, the most commonly encountered inflammatory liver diseases and their effects on atherosclerosis are discussed.
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Affiliation(s)
- Tugrul Purnak
- Department of Gastroenterology, Ankara Numune Education and Research Hospital, Ankara, Turkey
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Beyazit Y, Koklu S, Tas A, Purnak T, Sayilir A, Kurt M, Turhan T, Celik T, Suvak B, Torun S, Akbal E. Serum adenosine deaminase activity as a predictor of disease severity in ulcerative colitis. J Crohns Colitis 2012; 6:102-7. [PMID: 22261534 DOI: 10.1016/j.crohns.2011.07.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 07/01/2011] [Accepted: 07/15/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM Ulcerative colitis (UC) is a chronic inflammatory disease characterized by recurrent inflammation and ulcerations of colonic mucosa and an inappropriate and delayed healing. Adenosine deaminase (ADA) is a cytoplasmic enzyme involved in the catabolism of purine bases, capable of catalyzing the deamination of adenosine, forming inosine in the result process. Although ADA has been shown to increase in several inflammatory conditions, there are no literature data indicating an alteration in UC. METHODS This study evaluated the activity of total ADA in serum of 43 patients with UC and 18 healthy controls. Patients' age, disease duration, drug intake, and other medical history were all noted for each subject. Complete blood count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were determined for both patients and controls. Correlation analysis was also performed between ADA and other inflammation markers of UC. RESULTS Serum mean ADA levels were 11.12 ± 2.03 and 7.99 ± 2.04 U/l for patients with UC in active state and in remission and 8.55 ± 2.26 U/l in the healthy control group. Mean serum ADA levels were significantly elevated in active UC patients compared with patients with UC in remission and control groups. Overall accuracy of ADA in determination of active UC was 83.7 with sensitivity 83.3%, specificity 84.2%. CONCLUSIONS Serum ADA levels were found to be elevated in UC patients in active state suggesting a partial role of activated T-cell response in the disease pathophysiology. Further randomized controlled studies are warranted to demonstrate the role of ADA in UC patients, with a special interest in specifically targeted therapies against ADA for achieving disease remission.
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Affiliation(s)
- Yavuz Beyazit
- Department of Gastroenterology, Turkiye Yuksek İhtisas Training and Research Hospital, Ankara, Turkey.
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Purnak T, Beyazit Y, Oztas E, Yesil Y, Efe C, Torun S, Celik T, Tenlik I, Kurt M, Ozaslan E. Serum angiotensin-converting enzyme level as a marker of fibrosis in patients with chronic hepatitis B. J Renin Angiotensin Aldosterone Syst 2012; 13:244-9. [PMID: 22277254 DOI: 10.1177/1470320311434241] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND and aims: Hepatitis B virus (HBV) infection is a public health problem and affects nearly 350 million people worldwide. The present study was conducted in order to investigate the role of circulating angiotensin-converting enzyme (ACE) in the context of renin-angiotensin-aldosterone in newly diagnosed chronic hepatitis B infection. Moreover the association between liver fibrosis and serum ACE levels was also investigated. MATERIALS AND METHODS The study was performed on 50 chronic hepatitis B (CHB) patients (24 males, 26 females; median age 39.4 years, range 18-63) and 20 healthy controls. The clinical features of CHB patients including demographics, laboratory and liver biopsy findings were summarized. Serum ACE levels were measured by using commercially available kits. RESULTS Serum median ACE levels were 48.4 (14-83) U/L and 26.2 (12-48) U/L for the CHB patients and controls, respectively. Serum ACE levels were significantly higher in patients with CHB compared with the control group (p<0.001). Twenty-two patients (44%) had advanced liver fibrosis (Ishak score >2) and 28 patients (56%) had mild liver fibrosis (Ishak score ≤ 2). Mean serum levels of ACE were significantly higher among patients with advanced fibrosis as compared with those without advanced fibrosis (60.3±14.2 U/L vs. 39.0±10.5 U/L, p<0.001). Receiver operating characteristic (ROC) curve analysis suggested that the optimum ACE level cut-off point for advanced fibrosis was 52.5 U/L (sensitivity: 81.8%, specificity: 82.1%, PPV 78.3%, NPV 85.2%, accuracy 82%, AUC: 0.890). CONCLUSIONS Our study showed that elevated circulating ACE levels are commonly observed in CHB patients. This finding was more prominent in patients with advanced fibrosis in liver. When evaluating a patient along with other parameters, the inclusion of ACE levels in the evaluation of CHB patients may grant additional prognostic information.
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Affiliation(s)
- Tugrul Purnak
- Department of Gastroenterology, Ankara Numune Education and Research Hospital, Ankara, Turkey.
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Beyazit Y, Kekilli M, Purnak T, Spiegel J. Ear stapling application as an alternative treatment for weight loss. Ear Nose Throat J 2012; 90:294-6. [PMID: 21792793 DOI: 10.1177/014556131109000702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Kayhan B, Olmez S, Ozaslan E, Uner E, Turhan N, Koseoglu T, Purnak T. Dysphagia resolved with vitamin B12 therapy: a case of esophageal parakeratosis. Endoscopy 2011; 43 Suppl 2 UCTN:E231. [PMID: 21773960 DOI: 10.1055/s-0030-1256285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- B Kayhan
- Department of Gastroenterology, Ankara Numune Education and Research Hospital, Ankara, Turkey
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Affiliation(s)
- Tugrul Purnak
- Department of Gastroenterology, Numune Education and Research Hospital, Ankara, Turkey
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Efe C, Ozaslan E, Kav T, Purnak T, Shorbagi A, Ozkayar O, Berlot AH, Sökmensuer C, Muratori P. Liver fibrosis may reduce the efficacy of budesonide in the treatment of autoimmune hepatitis and overlap syndrome. Autoimmun Rev 2011; 11:330-4. [PMID: 22001521 DOI: 10.1016/j.autrev.2011.09.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Accepted: 09/26/2011] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIM The aim of the present study was to assess the efficacy and tolerability of budesonide as an alternative first line treatment option for autoimmune hepatitis (AIH) and the overlap syndrome. METHODS A total of 18 AIH or overlap syndrome patients were evaluated. Outcomes of treatment by the end of the study were defined as treatment failure, partial response, complete response and remission. RESULTS Complete response and remission were achieved in 61.1% (11/18) of patients, while 38.9% (7/18) of patients were considered treatment failures. Liver fibrosis was observed in 55.5% of patients' biopsies. More patients with liver fibrosis failed to respond to treatment compared to patients without fibrosis, a difference bordering on statistical significance (60% vs. 12.5%; p=0.066). Although statistically insignificant, the presence of at least one side effect was observed more frequently in patients with fibrosis compared to those without fibrosis (80% vs. 37.5%; p=0.145). Overall, side effects occurred significantly more commonly in non-responders than responders (100% vs. 36%; p=0.013). CONCLUSIONS Budesonide is an effective treatment option for the management of AIH, with a low incidence of side effects in patients without findings of advanced liver disease. The presence of liver fibrosis may increase the likelihood of treatment failure as well as the risk of developing side effects. Our study findings suggest that budesonide may be effective in a select group of AIH patients. Further studies are needed to determine its exact place for the treatment of AIH and overlap syndrome.
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Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Hacettepe University Faculty of Medicine, Ankara, Turkey.
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Efe C, Ozaslan E, Purnak T. Outcome of pregnancy in patients with autoimmune hepatitis/primary biliary cirrhosis overlap syndrome: a report of two cases. Clin Res Hepatol Gastroenterol 2011; 35:687-9. [PMID: 21784721 DOI: 10.1016/j.clinre.2011.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 06/01/2011] [Indexed: 02/04/2023]
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Affiliation(s)
- Ersan Ozaslan
- Ankara Numune Education and Research Hospital, Department of Gastroenterology, Ankara, Turkey
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