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Yu Y, Kass MA, Zhang M, Youssef N, Freije CA, Brock KP, Aguado LC, Seifert LL, Venkittu S, Hong X, Shlomai A, de Jong YP, Marks DS, Rice CM, Schneider WM. Deep mutational scanning of hepatitis B virus reveals a mechanism for cis-preferential reverse transcription. Cell 2024; 187:2735-2745.e12. [PMID: 38723628 DOI: 10.1016/j.cell.2024.04.008] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 02/12/2024] [Accepted: 04/10/2024] [Indexed: 05/22/2024]
Abstract
Hepatitis B virus (HBV) is a small double-stranded DNA virus that chronically infects 296 million people. Over half of its compact genome encodes proteins in two overlapping reading frames, and during evolution, multiple selective pressures can act on shared nucleotides. This study combines an RNA-based HBV cell culture system with deep mutational scanning (DMS) to uncouple cis- and trans-acting sequence requirements in the HBV genome. The results support a leaky ribosome scanning model for polymerase translation, provide a fitness map of the HBV polymerase at single-nucleotide resolution, and identify conserved prolines adjacent to the HBV polymerase termination codon that stall ribosomes. Further experiments indicated that stalled ribosomes tether the nascent polymerase to its template RNA, ensuring cis-preferential RNA packaging and reverse transcription of the HBV genome.
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Affiliation(s)
- Yingpu Yu
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Maximilian A Kass
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA; Department of Infectious Diseases, Molecular Virology, Heidelberg University, Medical Faculty Heidelberg, Heidelberg, Germany
| | - Mengyin Zhang
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Noor Youssef
- Department of Systems Biology, Harvard Medical School, Boston, MA 02115, USA; Department of Organismic and Evolutionary Biology, Broad Institute of MIT and Harvard, Harvard University, Cambridge, MA 02138, USA
| | - Catherine A Freije
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Kelly P Brock
- Department of Systems Biology, Harvard Medical School, Boston, MA 02115, USA; Department of Organismic and Evolutionary Biology, Broad Institute of MIT and Harvard, Harvard University, Cambridge, MA 02138, USA
| | - Lauren C Aguado
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Leon L Seifert
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA; Center for Clinical and Translational Science, The Rockefeller University, New York, NY 10065, USA
| | - Sanjana Venkittu
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Xupeng Hong
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Amir Shlomai
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Ype P de Jong
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA; Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Debora S Marks
- Department of Systems Biology, Harvard Medical School, Boston, MA 02115, USA; Department of Organismic and Evolutionary Biology, Broad Institute of MIT and Harvard, Harvard University, Cambridge, MA 02138, USA
| | - Charles M Rice
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA.
| | - William M Schneider
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA.
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2
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Ofri I, Peleg N, Leshno M, Shlomai A. A decision-making model for prediction of a stable disease course in chronic hepatitis B patients. Sci Rep 2023; 13:23051. [PMID: 38155298 PMCID: PMC10754935 DOI: 10.1038/s41598-023-50460-2] [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] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023] Open
Abstract
Patients with chronic hepatitis B (CHB) are regularly monitored for HBV DNA and liver enzymes in order to assess disease progression and the need for antiviral therapy. Identifying patients with a stable course of disease can potentially prolong the intervals between visits, withhold unnecessary tests and save money. Accordingly, we aimed to find predictors for a stable disease course in patients with CHB. 579 patients with CHB, who were followed in a tertiary referral center between January 2004-December 2018, were retrospectively analyzed. Patients with low and steady viral load titer (< 2000 IU/ml) and normal ALT levels (< 40 IU/ml) in 6 consecutive clinic encounters were considered to have a stable course of CHB. A stepwise multivariate logistic regression analysis and a decision tree model were used to identify predictors of a stable disease course. Following exclusion of ineligible patients, a total of 220 patients were included in the final analysis. 64/220 patients had a stable disease course. Patients with a stable disease were older (62.99 ± 12.36 Vs. 54.07 ± 13.64, p < 0.001) with a higher percentage of women (53% vs. 38%) and had lower baseline levels of AST, ALT and viral load (VL). In a multivariate analysis, age (OR 0.94, 95% CI 0.91-0.98), baseline ALT (OR 1.06, 95% CI 1.01-1.1) and VL (OR 1.05 95% CI 1.02-1.08), were significantly associated with a stable disease. In a decision tree model, patients 46-67 years old, with baseline VL < 149 IU/mL and ALT < 40 IU/mL had the best probability (91%) for a stable disease course over 4.4 ± 2.2 years. We conclude that integrating patients' age with baseline VL and ALT can predict a stable disease course in patients with CHB off treatment.
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Affiliation(s)
- Imri Ofri
- Department of Medicine D and the Laboratory of Liver Research, Rabin Medical Center, Beilinson Hospital, 39 Jabotinsky Street, Petah-Tikva, Israel
- The Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Noam Peleg
- The Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- The Institute of Gastroenterology, Beilinson Hospital, Petah-Tikva, Israel
| | - Moshe Leshno
- The Coller Faculty of Management, Tel-Aviv University, Tel-Aviv, Israel
| | - Amir Shlomai
- Department of Medicine D and the Laboratory of Liver Research, Rabin Medical Center, Beilinson Hospital, 39 Jabotinsky Street, Petah-Tikva, Israel.
- The Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
- The Liver Institute, Beilinson Hospital, Petah-Tikva, Israel.
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3
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Yu Y, Schneider WM, Kass MA, Michailidis E, Acevedo A, Pamplona Mosimann AL, Bordignon J, Koenig A, Livingston CM, van Gijzel H, Ni Y, Ambrose PM, Freije CA, Zhang M, Zou C, Kabbani M, Quirk C, Jahan C, Wu X, Urban S, You S, Shlomai A, de Jong YP, Rice CM. An RNA-based system to study hepatitis B virus replication and evaluate antivirals. Sci Adv 2023; 9:eadg6265. [PMID: 37043562 PMCID: PMC10096565 DOI: 10.1126/sciadv.adg6265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/08/2023] [Indexed: 06/19/2023]
Abstract
Hepatitis B virus (HBV) chronically infects an estimated 300 million people, and standard treatments are rarely curative. Infection increases the risk of liver cirrhosis and hepatocellular carcinoma, and consequently, nearly 1 million people die each year from chronic hepatitis B. Tools and approaches that bring insights into HBV biology and facilitate the discovery and evaluation of antiviral drugs are in demand. Here, we describe a method to initiate the replication of HBV, a DNA virus, using synthetic RNA. This approach eliminates contaminating background signals from input virus or plasmid DNA that plagues existing systems and can be used to study multiple stages of HBV replication. We further demonstrate that this method can be uniquely applied to identify sequence variants that confer resistance to antiviral drugs.
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Affiliation(s)
- Yingpu Yu
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - William M. Schneider
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Maximilian A. Kass
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
- Department of Infectious Diseases, Molecular Virology, University Hospital Heidelberg, Heidelberg, Germany
| | - Eleftherios Michailidis
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Ashley Acevedo
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Ana L. Pamplona Mosimann
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Juliano Bordignon
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Alexander Koenig
- Infectious Diseases Research Unit, GSK, Upper Providence, PA 19426, USA
| | | | | | - Yi Ni
- German Center for Infection Research (DZIF), Partner Site Heidelberg, Heidelberg, Germany
| | - Pradeep M. Ambrose
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
- Department of Physiology, Biophysics, and Systems Biology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Catherine A. Freije
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Mengyin Zhang
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Chenhui Zou
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Mohammad Kabbani
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Corrine Quirk
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Cyprien Jahan
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Xianfang Wu
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Stephan Urban
- Department of Infectious Diseases, Molecular Virology, University Hospital Heidelberg, Heidelberg, Germany
- German Center for Infection Research (DZIF), Partner Site Heidelberg, Heidelberg, Germany
| | - Shihyun You
- Infectious Diseases Research Unit, GSK, Upper Providence, PA 19426, USA
| | - Amir Shlomai
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
| | - Ype P. de Jong
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Charles M. Rice
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY 10065, USA
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4
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Shostak Y, Kramer MR, Edni O, Glusman Bendersky A, Shafran N, Bakal I, Heching M, Rosengarten D, Shitenberg D, Amor SM, Ben Zvi H, Pertzov B, Cohen H, Rotem S, Elia U, Chitlaru T, Erez N, Peysakhovich Y, D. Barac Y, Shlomai A, Bar-Haim E, Shtraichman O. Immunogenicity of a Third Dose of BNT162b2 Vaccine among Lung Transplant Recipients—A Prospective Cohort Study. Vaccines (Basel) 2023; 11:vaccines11040799. [PMID: 37112711 PMCID: PMC10141618 DOI: 10.3390/vaccines11040799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/08/2023] Open
Abstract
Two doses of mRNA SARS-CoV-2 vaccines elicit an attenuated humoral immune response among immunocompromised patients. Our study aimed to assess the immunogenicity of a third dose of the BNT162b2 vaccine among lung transplant recipients (LTRs). We prospectively evaluated the humoral response by measuring anti-spike SARS-CoV-2 and neutralizing antibodies in 139 vaccinated LTRs ~4–6 weeks following the third vaccine dose. The t-cell response was evaluated by IFNγ assay. The primary outcome was the seropositivity rate following the third vaccine dose. Secondary outcomes included: positive neutralizing antibody and cellular immune response rate, adverse events, and COVID-19 infections. Results were compared to a control group of 41 healthcare workers. Among LTRs, 42.4% had a seropositive antibody titer, and 17.2% had a positive t-cell response. Seropositivity was associated with younger age (t = 3.736, p < 0.001), higher GFR (t = 2.355, p = 0.011), and longer duration from transplantation (t = −1.992, p = 0.024). Antibody titer positively correlated with neutralizing antibodies (r = 0.955, p < 0.001). The current study may suggest the enhancement of immunogenicity by using booster doses. Since monoclonal antibodies have limited effectiveness against prevalent sub-variants and LTRs are prone to severe COVID-19 morbidity, vaccination remains crucial for this vulnerable population.
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Affiliation(s)
- Yael Shostak
- Department of Medicine D, Beilinson Hospital, Petah Tikva 4941492, Israel
- Pulmonary Institute, Rabin Medical Center, Petach Tikva 4941492, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Mordechai R. Kramer
- Pulmonary Institute, Rabin Medical Center, Petach Tikva 4941492, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Omer Edni
- Department of Medicine D, Beilinson Hospital, Petah Tikva 4941492, Israel
| | | | - Noa Shafran
- Department of Medicine D, Beilinson Hospital, Petah Tikva 4941492, Israel
| | - Ilana Bakal
- Pulmonary Institute, Rabin Medical Center, Petach Tikva 4941492, Israel
| | - Moshe Heching
- Pulmonary Institute, Rabin Medical Center, Petach Tikva 4941492, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Dror Rosengarten
- Pulmonary Institute, Rabin Medical Center, Petach Tikva 4941492, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Dorit Shitenberg
- Pulmonary Institute, Rabin Medical Center, Petach Tikva 4941492, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Shay M. Amor
- Pulmonary Institute, Rabin Medical Center, Petach Tikva 4941492, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Haim Ben Zvi
- Clinical Microbiology Laboratory, Beilinson Hospital, Petah Tikva 4941492, Israel
| | - Barak Pertzov
- Pulmonary Institute, Rabin Medical Center, Petach Tikva 4941492, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Hila Cohen
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness Ziona 7410001, Israel
| | - Shahar Rotem
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness Ziona 7410001, Israel
| | - Uri Elia
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness Ziona 7410001, Israel
| | - Theodor Chitlaru
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness Ziona 7410001, Israel
| | - Noam Erez
- Department of Infectious Diseases, Israel Institute for Biological Research, Ness Ziona 7410001, Israel
| | - Yuri Peysakhovich
- Cardiothoracic Surgery Department, Rabin Medical Center, Petach Tikva 4941492, Israel
| | - Yaron D. Barac
- Cardiothoracic Surgery Department, Rabin Medical Center, Petach Tikva 4941492, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Amir Shlomai
- Department of Medicine D, Beilinson Hospital, Petah Tikva 4941492, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Erez Bar-Haim
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness Ziona 7410001, Israel
| | - Osnat Shtraichman
- Pulmonary Institute, Rabin Medical Center, Petach Tikva 4941492, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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5
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Siman-Tov R, Shalabi R, Shlomai A, Goldberg E, Essa W, Shusterman E, Ablin JN, Caspi M, Rosin-Arbesfeld R, Sklan EH. Elevated Serum Amyloid A Levels Contribute to Increased Platelet Adhesion in COVID-19 Patients. Int J Mol Sci 2022; 23:ijms232214243. [PMID: 36430724 PMCID: PMC9692251 DOI: 10.3390/ijms232214243] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/10/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022] Open
Abstract
Coronavirus disease-19 (COVID-19) patients are prone to thrombotic complications that may increase morbidity and mortality. These complications are thought to be driven by endothelial activation and tissue damage promoted by the systemic hyperinflammation associated with COVID-19. However, the exact mechanisms contributing to these complications are still unknown. To identify additional mechanisms contributing to the aberrant clotting observed in COVID-19 patients, we analyzed platelets from COVID-19 patients compared to those from controls using mass spectrometry. We identified increased serum amyloid A (SAA) levels, an acute-phase protein, on COVID-19 patients' platelets. In addition, using an in vitro adhesion assay, we showed that healthy platelets adhered more strongly to wells coated with COVID-19 patient serum than to wells coated with control serum. Furthermore, inhibitors of integrin aIIbβ3 receptors, a mediator of platelet-SAA binding, reduced platelet adhesion to recombinant SAA and to wells coated with COVID-19 patient serum. Our results suggest that SAA may contribute to the increased platelet adhesion observed in serum from COVID-19 patients. Thus, reducing SAA levels by decreasing inflammation or inhibiting SAA platelet-binding activity might be a valid approach to abrogate COVID-19-associated thrombotic complications.
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Affiliation(s)
- Ronen Siman-Tov
- Department of Clinical Microbiology and Immunology, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Rulla Shalabi
- Department of Medicine F, Rabin Medical Center, Beilinson Hospital, Petah Tikva 4941492, Israel
| | - Amir Shlomai
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah Tikva 4941492, Israel
| | - Elad Goldberg
- Department of Medicine F, Rabin Medical Center, Beilinson Hospital, Petah Tikva 4941492, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Wesam Essa
- Department of Medicine F, Rabin Medical Center, Beilinson Hospital, Petah Tikva 4941492, Israel
| | - Eden Shusterman
- Department of Internal Medicine H, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
| | - Jacob N. Ablin
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Internal Medicine H, Tel Aviv Medical Center, Tel Aviv 6423906, Israel
| | - Michal Caspi
- Department of Clinical Microbiology and Immunology, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Rina Rosin-Arbesfeld
- Department of Clinical Microbiology and Immunology, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Ella H. Sklan
- Department of Clinical Microbiology and Immunology, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Correspondence: ; Tel.: +972-3-6408197
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6
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Mao X, Cheung KS, Peng C, Mak LY, Cheng HM, Fung J, Peleg N, Leung HHW, Kumar R, Lee JH, Shlomai A, Yuen MF, Seto WK. Steatosis, HBV-related HCC, cirrhosis, and HBsAg seroclearance: A systematic review and meta-analysis. Hepatology 2022; 77:1735-1745. [PMID: 36111362 DOI: 10.1002/hep.32792] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 05/20/2022] [Revised: 08/22/2022] [Accepted: 09/13/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND AIMS NAFLD and chronic hepatitis B (CHB) infection are common etiologies of HCC. The impact of hepatic steatosis on HCC in CHB, as well as its relationship with the development of cirrhosis, fibrosis, and HBsAg seroclearance, remains controversial. APPROACH AND RESULTS Data from observational studies were collected through PubMed, EMBASE, and the Cochrane Library from inception to February 1, 2022. Outcomes of interest included the association of hepatic steatosis with HCC, cirrhosis, advanced fibrosis, and HBsAg seroclearance, expressed in terms of pooled ORs. Additional subgroup and sensitivity analyses were performed to validate the robustness of findings. A total of 34 studies with 68,268 patients with CHB were included. Hepatic steatosis was associated with higher odds of HCC (OR, 1.59; 95% CI, 1.12-2.26; I2 = 72.5%), with the association remaining consistent in Asia (OR, 1.56; 95% CI, 1.08-2.25), studies with a median follow-up duration of ≥5 years (OR, 2.82; 95% CI, 1.57-5.08), exclusion of alcohol use (OR, 1.71; 95% CI, 1.01-2.91), and biopsy-proven steatosis (OR, 2.86; 95% CI, 1.61-5.06), although no significant association was noted among nucleos(t)ide analogue-treated patients (OR, 1.05; 95% CI, 0.62-1.77). Steatosis was associated with the development of cirrhosis (OR, 1.52; 95% CI, 1.07-2.16; I2 = 0%) and HBsAg seroclearance (OR, 2.22; 95% CI, 1.58-3.10; I2 = 49.0%). CONCLUSIONS Hepatic steatosis was associated with an increased risk of HCC and cirrhosis among patients with CHB but with a higher chance of achieving a functional cure, highlighting the importance of identifying concomitant steatosis in CHB.
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Affiliation(s)
- Xianhua Mao
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Ka Shing Cheung
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong.,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Chengzhi Peng
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Lung-Yi Mak
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Ho Ming Cheng
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - James Fung
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Noam Peleg
- Division of Gastroenterology, Rabin Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Howard H-W Leung
- Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong, Hong Kong
| | - Rajneesh Kumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Graduate Medical School, Singapore
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Amir Shlomai
- Department of Medicine D and The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong.,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
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7
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Goyal A, Churkin A, Barash D, Cotler SJ, Shlomai A, Etzion O, Dahari H. Modeling-Based Response-Guided DAA Therapy for Chronic Hepatitis C to Identify Individuals for Shortening Treatment Duration. Open Forum Infect Dis 2022; 9:ofac157. [PMID: 35493122 PMCID: PMC9045946 DOI: 10.1093/ofid/ofac157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/18/2022] [Indexed: 01/04/2023] Open
Abstract
Shortening duration of direct-acting antiviral therapy for chronic hepatitis C could provide cost savings, reduce medication exposure, and foster adherence and treatment completion in special populations. The current analysis indicates that measuring hepatitis C virus at baseline and on days 7 and 14 of therapy can identify patients for shortening therapy duration.
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Affiliation(s)
- Ashish Goyal
- The Program for Experimental and Theoretical Modeling, Division of Hepatology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA,Current affiliation: Medicine Design, Pharmacokinetics, Dynamics, & Metabolism, Pfizer Worldwide R&D, Cambridge, Massachusetts, USA
| | - Alex Churkin
- Department of Software Engineering, Sami Shamoon College of Engineering, Beer-Sheba, Israel
| | - Danny Barash
- Department of Computer Science, Ben-Gurion University, Beer-Sheba, Israel
| | - Scott J Cotler
- The Program for Experimental and Theoretical Modeling, Division of Hepatology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Amir Shlomai
- Department of Medicine D and The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ohad Etzion
- Soroka University Medical Center, Beer-Sheba, Israel,The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheba, Israel
| | - Harel Dahari
- The Program for Experimental and Theoretical Modeling, Division of Hepatology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA,Correspondence: Harel Dahari, PhD, Division of Hepatology, Stritch School of Medicine, Loyola University Chicago, 2160 S. First Ave, Maywood, IL 60153 ()
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8
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Sofer S, Lamkiewicz K, Armoza Eilat S, Partouche S, Marz M, Moskovits N, Stemmer SM, Shlomai A, Sklan EH. A genome-wide CRISPR activation screen reveals Hexokinase 1 as a critical factor in promoting resistance to multi-kinase inhibitors in hepatocellular carcinoma cells. FASEB J 2022; 36:e22191. [PMID: 35147243 DOI: 10.1096/fj.202101507rr] [Citation(s) in RCA: 9] [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] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/27/2021] [Accepted: 01/20/2022] [Indexed: 01/05/2023]
Abstract
Hepatocellular carcinoma (HCC) is often diagnosed at an advanced stage and is, therefore, treated with systemic drugs, such as tyrosine-kinase inhibitors (TKIs). These drugs, however, offer only modest survival benefits due to the rapid development of drug resistance. To identify genes implicated in TKI resistance, a cluster of regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated protein 9 activation screen was performed in hepatoma cells treated with regorafenib, a TKI used as second-line therapy for advanced HCC. The screen results show that Hexokinase 1 (HK1), catalyzing the first step in glucose metabolism, is a top candidate for conferring TKI resistance. Compatible with this, HK1 was upregulated in regorafenib-resistant cells. Using several experimental approaches, both in vitro and in vivo, we show that TKI resistance correlates with HK1 expression. Furthermore, an HK inhibitor resensitized resistant cells to TKI treatment. Together, our data indicate that HK1 may function as a critical factor modulating TKI resistance in hepatoma cells and, therefore, may serve as a biomarker for treatment success.
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Affiliation(s)
- Summer Sofer
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kevin Lamkiewicz
- RNA Bioinformatics and High-Throughput Analysis, Friedrich Schiller University, Jena, Germany.,European Virus Bioinformatics Center, Jena, Germany
| | - Shir Armoza Eilat
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shirly Partouche
- Felsenstein Medical Research Center, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Manja Marz
- RNA Bioinformatics and High-Throughput Analysis, Friedrich Schiller University, Jena, Germany.,European Virus Bioinformatics Center, Jena, Germany.,Leibniz Institute for Age Research-Fritz Lipmann Institute, Jena, Germany
| | - Neta Moskovits
- PDX Laboratory, Felsenstein Medical Research Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Salomon M Stemmer
- PDX Laboratory, Felsenstein Medical Research Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah-Tikva, Israel
| | - Amir Shlomai
- Felsenstein Medical Research Center and the Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Ella H Sklan
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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9
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Churkin A, Kriss S, Uziel A, Goyal A, Zakh R, Cotler SJ, Etzion O, Shlomai A, Rotstein HG, Dahari H, Barash D. Machine learning for mathematical models of HCV kinetics during antiviral therapy. Math Biosci 2022; 343:108756. [PMID: 34883104 PMCID: PMC8792269 DOI: 10.1016/j.mbs.2021.108756] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 11/04/2021] [Accepted: 11/04/2021] [Indexed: 01/03/2023]
Abstract
Mathematical models for hepatitis C virus (HCV) dynamics have provided a means for evaluating the antiviral effectiveness of therapy and estimating treatment outcomes such as the time to cure. Recently, a mathematical modeling approach was used in the first proof-of-concept clinical trial assessing in real-time the utility of response-guided therapy with direct-acting antivirals (DAAs) in chronic HCV-infected patients. Several retrospective studies have shown that mathematical modeling of viral kinetics predicts time to cure of less than 12 weeks in the majority of individuals treated with sofosbuvir-based as well as other DAA regimens. A database of these studies was built, and machine learning methods were evaluated for their ability to estimate the time to cure for each patient to facilitate real-time modeling studies. Data from these studies exploring mathematical modeling of HCV kinetics under DAAs in 266 chronic HCV-infected patients were gathered. Different learning methods were applied and trained on part of the dataset ('train' set), to predict time to cure on the untrained part ('test' set). Our results show that this machine learning approach provides a means for establishing an accurate time to cure prediction that will support the implementation of individualized treatment.
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Affiliation(s)
- Alexander Churkin
- Department of Software Engineering, Sami Shamoon College of Engineering, Beer-Sheba, Israel
| | - Stephanie Kriss
- Program for Experimental and Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Asher Uziel
- Program for Experimental and Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Ashish Goyal
- Program for Experimental and Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Rami Zakh
- Department of Computer Science, Ben-Gurion University, Israel
| | - Scott J Cotler
- Program for Experimental and Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Ohad Etzion
- Soroka University Medical Center, Beer-Sheba, Israel
| | - Amir Shlomai
- Department of Medicine D and The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Horacio G Rotstein
- Federated Department of Biological Sciences, New Jersey Institute of Technology and Rutgers University, Newark, NJ, USA; Institute for Future Technologies, New Jersey Institute of Technology, Newark, NJ, USA
| | - Harel Dahari
- Program for Experimental and Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA.
| | - Danny Barash
- Department of Computer Science, Ben-Gurion University, Israel.
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10
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Leibovici-Weissman Y, Anchel N, Nesher E, Leshno M, Shlomai A. Early post-liver transplantation infections and their effect on long-term survival. Transpl Infect Dis 2021; 23:e13673. [PMID: 34153169 DOI: 10.1111/tid.13673] [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] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 05/18/2021] [Accepted: 06/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Infections post-liver transplantation are major drivers for morbidity and mortality. However, the impact of infections within 180 days post-liver transplantation on long-term survival is not clear. METHODS We present a retrospective cohort of 317 liver transplant patients for whom all infectious episodes were prospectively collected during a mean follow-up of 4.4 years. RESULTS A total of 143/317 (45%) of patients suffered from any infectious episode during the first 6 months following liver transplantation. Patients with surgical site infections have a reduced survival compared to those with no infection (HR 0.33, 95% CI 0.172-0.636, P = .001), whereas infections from other sources, including pneumonia, UTI, and line-related infections, were not associated with increased mortality. Furthermore, even though the presence of any infection within 30 days or 6 months post-transplantation did not affect survival, more than a single infectious episode per patient was significantly associated with increased mortality (HR 1.70, CI 1.12-2.60, P = .013). In a multivariate analysis, the number of infectious episodes remained statistically significant (HR 1.58, 95% CI 1.03-2.43, P = .035) upon adjustment for other major variables associated with comorbidities and infection risk. CONCLUSIONS Surgical site infections and the number of infectious episodes within 180 days post-liver transplantation are major determinants of long-term survival among these patients.
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Affiliation(s)
- Yaara Leibovici-Weissman
- Department of Medicine D, Rabin Medical Center, Liver Institute, Beilinson Hospital, Petah-Tikva, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Noa Anchel
- The Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Eviatar Nesher
- The Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Department of Organ Transplantation, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Moshe Leshno
- The Coller School of Management, Tel Aviv University, Ramat Aviv, Israel
| | - Amir Shlomai
- Department of Medicine D, Rabin Medical Center, Liver Institute, Beilinson Hospital, Petah-Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
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11
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Shafran N, Shafran I, Ben-Zvi H, Sofer S, Sheena L, Krause I, Shlomai A, Goldberg E, Sklan EH. Secondary bacterial infection in COVID-19 patients is a stronger predictor for death compared to influenza patients. Sci Rep 2021; 11:12703. [PMID: 34135459 PMCID: PMC8209102 DOI: 10.1038/s41598-021-92220-0] [Citation(s) in RCA: 122] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/01/2021] [Indexed: 01/22/2023] Open
Abstract
Secondary bacterial infections are a potentially fatal complication of influenza infection. We aimed to define the impact of secondary bacterial infections on the clinical course and mortality in coronavirus disease 2019 (COVID-19) patients by comparison with influenza patients. COVID-19 (n = 642) and influenza (n = 742) patients, admitted to a large tertiary center in Israel and for whom blood or sputum culture had been taken were selected for this study. Bacterial culture results, clinical parameters, and death rates were compared. COVID-19 patients had higher rates of bacterial infections than influenza patients (12.6% vs. 8.7%). Notably, the time from admission to bacterial growth was longer in COVID-19 compared to influenza patients (4 (1-8) vs. 1 (1-3) days). Late infections (> 48 h after admission) with gram-positive bacteria were more common in COVID-19 patients (28% vs. 9.5%). Secondary infection was associated with a higher risk of death in both patient groups 2.7-fold (1.22-5.83) for COVID-19, and 3.09-fold (1.11-7.38) for Influenza). The association with death remained significant upon adjustment to age and clinical parameters in COVID-19 but not in influenza infection. Secondary bacterial infection is a notable complication associated with worse outcomes in COVID-19 than influenza patients. Careful surveillance and prompt antibiotic treatment may benefit selected patients.
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Affiliation(s)
- Noa Shafran
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Inbal Shafran
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Haim Ben-Zvi
- Microbiology Laboratory, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Summer Sofer
- Department of Clinical Microbiology and Immunology, The Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Liron Sheena
- Department of Medicine F, Rabin Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Krause
- Department of Medicine F, Rabin Medicine, Tel Aviv University, Tel Aviv, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Shlomai
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elad Goldberg
- Department of Medicine F, Rabin Medicine, Tel Aviv University, Tel Aviv, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ella H Sklan
- Department of Clinical Microbiology and Immunology, The Sackler Faculty of Medicine, Tel Aviv University, 6997801, Tel Aviv, Israel.
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12
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Shlomai A, Leshno A, Sklan EH, Leshno M. Modeling Social Distancing Strategies to Prevent SARS-CoV-2 Spread in Israel: A Cost-Effectiveness Analysis. Value Health 2021; 24:607-614. [PMID: 33933228 PMCID: PMC7833124 DOI: 10.1016/j.jval.2020.09.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/21/2020] [Accepted: 09/27/2020] [Indexed: 05/11/2023]
Abstract
OBJECTIVES While highly effective in preventing SARS-CoV-2 spread, national lockdowns come with an enormous economic price. Few countries have adopted an alternative "testing, tracing, and isolation" approach to selectively isolate people at high exposure risk, thereby minimizing the economic impact. To assist policy makers, we performed a cost-effectiveness analysis of these 2 strategies. METHODS A modified Susceptible, Exposed, Infectious, Recovered, and Deceased (SEIRD) model was employed to assess the situation in Israel, a small country with ∼9 million people. The incremental cost-effectiveness ratio (ICER) of these strategies as well as the expected number of infected individuals and deaths were calculated. RESULTS A nationwide lockdown is expected to save, on average, 274 (median 124, interquartile range: 71-221) lives compared to the "testing, tracing, and isolation" approach. However, the ICER will be, on average, $45 104 156 (median $49.6 million, interquartile range: 22.7-220.1) to prevent 1 case of death. CONCLUSION A national lockdown has a moderate advantage in saving lives with tremendous costs and possible overwhelming economic effects. These findings should assist decision makers dealing with additional waves of this pandemic.
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Affiliation(s)
- Amir Shlomai
- Department of Medicine D and The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel and The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ari Leshno
- Goldschleger Eye Institute, Sheba Medical Center, Ramat Gan, Israel and The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ella H Sklan
- Department of Clinical Microbiology and Immunology, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Moshe Leshno
- The Coller School of Management, Tel Aviv University, Tel Aviv, Israel
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13
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Dahari H, Shlomai A, Cotler SJ. Early HBV RNA kinetics under NA treatment may reveal new insights into HBV RNA dynamics and NA mode of action-more detailed kinetic studies are needed. J Viral Hepat 2021; 28:687-688. [PMID: 33386635 PMCID: PMC7946716 DOI: 10.1111/jvh.13463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 10/23/2020] [Accepted: 11/30/2020] [Indexed: 01/04/2023]
Affiliation(s)
- Harel Dahari
- The Program for Experimental & Theoretical Modeling,
Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola
University Chicago, Maywood, IL, USA,Corresponding author:
| | - Amir Shlomai
- Department of Medicine D and The Liver Institute, Rabin
Medical Center, Beilinson Hospital, Petah-Tikva and the Sackler Faculty of Medicine,
Tel Aviv University, Tel Aviv, Israel
| | - Scott J. Cotler
- The Program for Experimental & Theoretical Modeling,
Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola
University Chicago, Maywood, IL, USA
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14
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Goldberg E, Ben Zvi H, Sheena L, Sofer S, Krause I, Sklan EH, Shlomai A. A real-life setting evaluation of the effect of remdesivir on viral load in COVID-19 patients admitted to a large tertiary centre in Israel. Clin Microbiol Infect 2021; 27:917.e1-917.e4. [PMID: 33705849 PMCID: PMC7939997 DOI: 10.1016/j.cmi.2021.02.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/24/2021] [Accepted: 02/27/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The effectiveness of remdesivir, a Food and Drug Administration-approved drug for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has been repeatedly questioned during the current coronavirus disease 2019 (COVID-19) pandemic. Most of the recently reported studies were randomized controlled multicentre clinical trials. Our goal was to test the efficiency of remdesivir in reducing nasopharyngeal viral load and hospitalization length in a real-life setting in patients admitted to a large tertiary centre in Israel. METHODS A total of 142 COVID-19 patients found to have at least three reported SARS-CoV-2 quantitative RT-PCR tests during hospitalization were selected for this study. Of these, 29 patients received remdesivir, while the remaining non-treated 113 patients served as controls. RESULTS Among the tested parameters, the control and remdesivir groups differed significantly only in the intubation rates. Remdesivir treatment did not significantly affect nasopharyngeal viral load, as determined by comparing the differences between the first and last cycle threshold values of the SARS-CoV-2 quantitative RT-PCR tests performed during hospitalization (cycle threshold 7.07 ± 6.85 vs. 7.08 ± 7.27, p 0.977 in the control and treated groups, respectively). Remdesivir treatment shortened hospitalization length by less than a day compared with non-treated controls and by 3.1 days when non-intubated patients from both groups were compared. These differences, however, were not statistically significant, possibly because of the small size of the remdesivir group. DISCUSSION Remdesivir was not associated with nasopharyngeal viral load changes, but our study had a significant disease severity baseline imbalance and was not powered to detect viral load or clinical differences.
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Affiliation(s)
- Elad Goldberg
- Department of Medicine F, Rabin Medicine, Tel Aviv University, Tel Aviv, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Ben Zvi
- Microbiology Laboratory, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Liron Sheena
- Department of Medicine F, Rabin Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Summer Sofer
- Department of Clinical Microbiology and Immunology, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Krause
- Department of Medicine F, Rabin Medicine, Tel Aviv University, Tel Aviv, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ella H Sklan
- Department of Clinical Microbiology and Immunology, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Amir Shlomai
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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15
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Shafran N, Issachar A, Shochat T, Shafran IH, Bursztyn M, Shlomai A. Abnormal liver tests in patients with SARS-CoV-2 or influenza - prognostic similarities and temporal disparities. JHEP Rep 2021; 3:100258. [PMID: 33644724 PMCID: PMC7902222 DOI: 10.1016/j.jhepr.2021.100258] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/25/2021] [Accepted: 02/15/2021] [Indexed: 02/08/2023] Open
Abstract
Background & Aims Abnormal liver tests are common in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, but a possible direct role of the virus in liver injury and its association with short-term outcomes are controversial. Therefore, we aimed to compare the pattern of abnormal liver tests in patients with SARS-CoV-2 with those of patients infected with influenza, a non-hepatotropic respiratory virus, and their association with worse outcomes during hospitalisation. Methods We performed a retrospective cohort study of 1,737 hospitalised patients (865 with influenza and 872 with SARS-CoV-2) in a tertiary medical centre. We defined abnormal liver tests as alanine transaminase or aspartate transaminase ≥40 IU/ml at any time-point during hospitalisation. Results Abnormal liver tests were mild to moderate in most patients regardless of infection type, but the majority of patients with influenza had a transaminase peak earlier during hospitalisation compared with patients with SARS-CoV-2. Abnormal liver tests correlated with markers of severe disease in either influenza or SARS-CoV-2 infections, and were associated with death, occurring mainly in patients with severe liver test abnormalities (>200 IU/L) (38.7% and 60% of patients with influenza or SARS-CoV-2, respectively). In multivariate analysis, controlling for age, sex, lymphopaenia, and C-reactive protein, liver test abnormalities remained significantly associated with death for influenza (odds ratio 4.344; 95% CI 2.218-8.508) and SARS-CoV-2 (odds ratio 3.898; 95% CI 2.203-6.896). These results were confirmed upon propensity score matching. Conclusions Abnormal liver tests during hospitalisation with SARS-CoV-2 or influenza infections are common, may differ in their time course, and reflect disease severity. They are associated with worse outcomes, mainly in patients with severe liver test abnormalities, regardless of infection type. Lay summary Coronavirus disease 2019 (COVID-19) is a serious global health pandemic, the causative agent of which is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Abnormal liver tests are common among SARS-CoV-2 infected patients and are often associated with worse outcomes. Herein, we compare the pattern of abnormal liver tests and their association with disease severity between 2 major non-hepatotropic respiratory viruses: SARS-CoV-2 and influenza. We show that abnormal liver tests are common in both infections, may slightly differ in their kinetics, and are associated with worse outcomes, especially in patients with severe liver test abnormalities. These results strongly suggest that abnormal liver tests in SARS-CoV-2 patients reflect disease severity, rather than a virus-mediated direct liver injury, and should be closely followed in admitted patients.
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Key Words
- ALKP, alkaline phosphatase
- ALT, alanine transaminase
- AST, aspartate transaminase
- BOSmin, minimal blood oxygen saturation
- COVID-19
- COVID-19, coronavirus disease 2019
- CRP, C-reactive protein
- GGT, gamma-glutamyl transferase
- Liver injury
- Respiratory tract infections
- SARS-CoV-2, severe acute respiratory syndrome coronavirus 2
- SBPmin, minimal systolic blood pressure
- WBC count, white blood cell count
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Affiliation(s)
- Noa Shafran
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Assaf Issachar
- The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Tzippy Shochat
- Bio-Statistical Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Inbal Haya Shafran
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Michael Bursztyn
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,Hadassah-Hebrew University Medical Center, Mount-Scopus, Jerusalem, Israel
| | - Amir Shlomai
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,The Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
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16
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Etzion O, Dahari H, Yardeni D, Issachar A, Nevo-Shor A, Cohen-Naftaly M, Ashur Y, Uprichard SL, Arbib OS, Munteanu D, Braun M, Cotler SJ, Abufreha N, Keren-Naus A, Shemer-Avni Y, Mor O, Murad J, Novack V, Shlomai A. Response guided therapy for reducing duration of direct acting antivirals in chronic hepatitis C infected patients: a Pilot study. Sci Rep 2020; 10:17820. [PMID: 33082372 PMCID: PMC7575564 DOI: 10.1038/s41598-020-74568-x] [Citation(s) in RCA: 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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/30/2020] [Indexed: 02/06/2023] Open
Abstract
The advent of direct-acting antivirals (DAAs) has transformed the landscape of hepatitis C virus (HCV) management. We aimed to prospectively (real-time) evaluate the feasibility of using a response-guided therapy approach, based on mathematical modeling of early viral kinetics, to reduce the duration of DAAs therapy. Patients were treated with DAAs according to the physicians' preference. HCV was measured at baseline and at day 2 and weeks 1, 2 and 4 after treatment initiation. The primary endpoint was the proportion of patients with sustained-virological response (SVR) at 12 and/or 24 weeks post-treatment. Twenty-nine patients (mean age 54 ± 16, 44% females, 73% with HCV genotype 1), were enrolled and all completed therapy. Treatment duration was shortened in 11 of the 29 patients (38%). SVR was achieved in 28 of the 29 patients (97%). Relapse occurred post treatment in a single case of a non-cirrhotic male with genotype 3, who was treated with sofosbuvir/velpatasvir for 6 weeks. Virus sequencing did not identify baseline or treatment emergent resistance associated substitutions. Real-time mathematical modeling of early HCV kinetics can be utilized for shortening DAAs duration in approximately 40% of patients without compromising treatment efficacy.Clinical trial registration: ClinicalTrials.gov Identifier: NCT03603327.
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Affiliation(s)
- Ohad Etzion
- grid.412686.f0000 0004 0470 8989Department of Gastroenterology and Liver Diseases, Soroka University Medical Center, 151 Rager Yitzhak Blvd, 84171 Beer-Sheva, Israel ,grid.7489.20000 0004 1937 0511Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Harel Dahari
- grid.164971.c0000 0001 1089 6558The Program for Experimental and Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Chicago, 2160 S. First Ave, Maywood, IL 60153 USA
| | - David Yardeni
- grid.412686.f0000 0004 0470 8989Department of Gastroenterology and Liver Diseases, Soroka University Medical Center, 151 Rager Yitzhak Blvd, 84171 Beer-Sheva, Israel ,grid.7489.20000 0004 1937 0511Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Assaf Issachar
- grid.413156.40000 0004 0575 344XDepartment of Medicine D and The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Anat Nevo-Shor
- grid.412686.f0000 0004 0470 8989Department of Gastroenterology and Liver Diseases, Soroka University Medical Center, 151 Rager Yitzhak Blvd, 84171 Beer-Sheva, Israel ,grid.7489.20000 0004 1937 0511Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Michal Cohen-Naftaly
- grid.413156.40000 0004 0575 344XDepartment of Medicine D and The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yaffa Ashur
- grid.412686.f0000 0004 0470 8989Medical Management Unit, Soroka University Medical Center, Beer-Sheva, Israel
| | - Susan L. Uprichard
- grid.164971.c0000 0001 1089 6558The Program for Experimental and Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Chicago, 2160 S. First Ave, Maywood, IL 60153 USA
| | - Orly Sneh Arbib
- grid.413156.40000 0004 0575 344XDepartment of Medicine D and The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Daniela Munteanu
- grid.412686.f0000 0004 0470 8989Department of Gastroenterology and Liver Diseases, Soroka University Medical Center, 151 Rager Yitzhak Blvd, 84171 Beer-Sheva, Israel ,grid.7489.20000 0004 1937 0511Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Marius Braun
- grid.413156.40000 0004 0575 344XDepartment of Medicine D and The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Scott J. Cotler
- grid.164971.c0000 0001 1089 6558The Program for Experimental and Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Chicago, 2160 S. First Ave, Maywood, IL 60153 USA
| | - Naim Abufreha
- grid.412686.f0000 0004 0470 8989Department of Gastroenterology and Liver Diseases, Soroka University Medical Center, 151 Rager Yitzhak Blvd, 84171 Beer-Sheva, Israel ,grid.7489.20000 0004 1937 0511Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ayelet Keren-Naus
- grid.412686.f0000 0004 0470 8989Laboratory of Clinical Virology, Soroka University Medical Center, Beer-Sheva, Israel
| | - Yonat Shemer-Avni
- grid.412686.f0000 0004 0470 8989Laboratory of Clinical Virology, Soroka University Medical Center, Beer-Sheva, Israel
| | - Orna Mor
- grid.413795.d0000 0001 2107 2845Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat Gan, Israel
| | - Jayanah Murad
- grid.412686.f0000 0004 0470 8989Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - Victor Novack
- grid.412686.f0000 0004 0470 8989Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - Amir Shlomai
- grid.413156.40000 0004 0575 344XDepartment of Medicine D and The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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17
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Shlomai A, Ben-Zvi H, Glusman Bendersky A, Shafran N, Goldberg E, Sklan EH. Nasopharyngeal viral load predicts hypoxemia and disease outcome in admitted COVID-19 patients. Crit Care 2020; 24:539. [PMID: 32873316 PMCID: PMC7459243 DOI: 10.1186/s13054-020-03244-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 08/12/2020] [Indexed: 12/20/2022] Open
Affiliation(s)
- Amir Shlomai
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Ben-Zvi
- Microbiology Laboratory, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Ahinoam Glusman Bendersky
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Shafran
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elad Goldberg
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Department of Medicine F, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.
| | - Ella H Sklan
- Department of Clinical Microbiology and Immunology, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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18
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Gozlan Y, Bucris E, Shirazi R, Rakovsky A, Ben-Ari Z, Davidov Y, Veizman E, Saadi T, Braun M, Cohen-Naftaly M, Shlomai A, Shibolet O, Zigmond E, Katchman H, Menachem Y, Safadi R, Galun E, Zuckerman E, Nimer A, Hazzan R, Maor Y, Saif AM, Etzion O, Lurie Y, Mendelson E, Mor O. High frequency of multiclass HCV resistance-associated mutations in patients failing direct-acting antivirals: real-life data. Antivir Ther 2020; 24:221-228. [PMID: 30880684 DOI: 10.3851/imp3301] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Direct-acting antiviral (DAA) therapy has dramatically increased sustained virological response rates in HCV-infected patients. However, resistance-associated substitutions (RAS) interfering with NS3- and NS5A-targeted therapy, still emerge. This real-life study analysed the type and frequency of RAS in rare cases of patients failing DAA regimens in 12 clinical centres in Israel. METHODS Blood samples and clinical data from 49 patients who failed various DAAs were collected. RAS identified in the NS3 and NS5A regions by population (Sanger) and next-generation sequencing (NGS) were compared by treatment regimen and HCV subtypes. RESULTS The majority (71.4%, 35/49) of patients were infected with the genotype (GT)1b strain, while 12.2% (6/49) carried GT1a and 14.3% GT3a/b (7), GT4a (1) and GT1b/GT3a. RAS were identified in 85.7% (42/49) of failures, of which 90.5% (38/42) were clinically relevant RAS (known to be associated with a specific GT and DAA in patients failing therapy or those with more than twofold change in in vitro replicon assays). The most abundant RAS were 168A/E/Q/G/N/V (32.6%, 16/49) identified in NS3, and 93H/N (61.2%, 30/49), 31I/M/V (34.7%, 17/49) and 30R/H/K (12.2%, 6/49), identified in NS5A. Significantly more clinically relevant RAS were identified in NS5A (82.2%, 37/45) than in NS3 (35.7%, 10/28; P<0.01). While RAS were identified in all GT1a, GT3b and GT4a failures (100%, 10/10), only 71.8% (28/39) of GT1b or GT3a failures had RAS (P=0.09). In four cases, NGS identified additional clinically relevant RAS and in one patient, NGS deciphered coexistence of GT3a and GT1b infections. CONCLUSIONS Our findings, together with additional real-life data, will contribute to the optimization of retreatment in DAA failure, when cost-related and suboptimal regimens must be employed.
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Affiliation(s)
- Yael Gozlan
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat Gan, Israel
| | - Efrat Bucris
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat Gan, Israel
| | - Rachel Shirazi
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat Gan, Israel
| | - Avia Rakovsky
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat Gan, Israel
| | - Ziv Ben-Ari
- Liver Disease Center, Sheba Medical Center, Ramat Gan, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yana Davidov
- Liver Disease Center, Sheba Medical Center, Ramat Gan, Israel
| | - Ella Veizman
- Liver Unit, Rambam Medical Center, Haifa, Israel
| | - Tarek Saadi
- Liver Unit, Rambam Medical Center, Haifa, Israel
| | - Marius Braun
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Michal Cohen-Naftaly
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Amir Shlomai
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Oren Shibolet
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Ehud Zigmond
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Helena Katchman
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Yoram Menachem
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Tel Aviv Medical Center, Tel Aviv, Israel
| | | | - Eitan Galun
- Liver Unit, Hadassah Medical Center, Jerusalem, Israel
| | | | - Assy Nimer
- Faculty of Medicine in the Galilee, Bar-Ilan University, Ramat Gan, Israel.,Internal Medicine Department, Galilee Medical Center, Nahariya, Israel
| | - Rawi Hazzan
- Liver Unit, Haemek Medical Center, Afula, Israel
| | - Yaakov Maor
- The Institute of Gastroenterology and Hepatology, Kaplan Medical Center, Rehovot, Israel.,The Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Abu Moch Saif
- Liver Unit, Hillel Yaffe Medical Center, Hadera, Israel
| | - Ohad Etzion
- Department of Gastroenterology & Liver Diseases, Soroka University Medical Center, Beer Sheva, Israel
| | - Yoav Lurie
- Liver Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Ella Mendelson
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat Gan, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orna Mor
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat Gan, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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19
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Taylor RS, Taylor RJ, Bayliss S, Hagström H, Nasr P, Schattenberg JM, Ishigami M, Toyoda H, Wai-Sun Wong V, Peleg N, Shlomai A, Sebastiani G, Seko Y, Bhala N, Younossi ZM, Anstee QM, McPherson S, Newsome PN. Association Between Fibrosis Stage and Outcomes of Patients With Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-Analysis. Gastroenterology 2020; 158:1611-1625.e12. [PMID: 32027911 DOI: 10.1053/j.gastro.2020.01.043] [Citation(s) in RCA: 550] [Impact Index Per Article: 137.5] [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: 08/29/2019] [Revised: 01/19/2020] [Accepted: 01/22/2020] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Biopsy-confirmed liver fibrosis is a prognostic factor for patients with nonalcoholic fatty liver disease (NAFLD). We performed a systematic review to quantify the prognostic value of fibrosis stage in patients with NAFLD and the subgroup of patients with nonalcoholic steatohepatitis (NASH) and to assess the evidence that change in fibrosis stage is a surrogate endpoint. METHODS We searched the MEDLINE, Embase, Cochrane Library, and trial registry databases through August 2018 for prospective or retrospective cohort studies of liver-related clinical events and outcomes in adults with NAFLD or NASH. We collected data on mortality (all cause and liver related) and morbidity (cirrhosis, liver cancer, and all liver-related events) by stage of fibrosis, determined by biopsy, for patients with NAFLD or NASH. Using fibrosis stage 0 as a reference population, we calculated fibrosis stage-specific relative risk (RR) and 95% confidence interval (CI) values for mortality and morbidities. We performed fixed-effect and random-effect model meta-analyses. Metaregression was used to examine associations among study design (prospective vs retrospective cohort), overall risk of bias (medium or high), and mean duration of follow-up (in years). RESULTS Our meta-analysis included 13 studies, comprising 4428 patients with NAFLD; 2875 of these were reported to have NASH. Compared with no fibrosis (stage 0), unadjusted risk increased with increasing stage of fibrosis (stage 0 vs 4): all-cause mortality RR, 3.42 (95% CI, 2.63-4.46); liver-related mortality RR, 11.13 (95% CI, 4.15-29.84); liver transplant RR, 5.42 (95% CI, 1.05-27.89); and liver-related events RR, 12.78 (95% CI, 6.85-23.85). The magnitude of RR did not differ significantly after adjustment for confounders, including age or sex in the subgroup of NAFLD patients with NASH. Three studies examined the effects of increasing fibrosis on quality of life had inconsistent findings. CONCLUSIONS In a systematic review and meta-analysis, we found biopsy-confirmed fibrosis to be associated with risk of mortality and liver-related morbidity in patients with NAFLD, with and without adjustment for confounding factors and in patients with reported NASH. Further studies are needed to assess the association between fibrosis stage and patient quality of life and establish that change in liver fibrosis stage is a valid endpoint for use in clinical trials.
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Affiliation(s)
- Rod S Taylor
- Institute of Health and Well Being, University of Glasgow, United Kingdom.
| | | | - Sue Bayliss
- Institute of Applied Health Research, University of Birmingham, United Kingdom
| | - Hannes Hagström
- Unit of Hepatology, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Patrik Nasr
- Department of Gastroenterology and Hepatology, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Jorn M Schattenberg
- University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidenori Toyoda
- Department of Gastroenterology and Hepatology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Noam Peleg
- Department of Gastroenterology and Hepatology, Rabin Medical Center, Beilinson Hospital, Petach-Tikva Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medicine D, Rabin Medical Center, Beilinson hospital, Petach-Tikva
| | - Amir Shlomai
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Giada Sebastiani
- Department of Medicine, McGill University Health Centre, Montréal, Quebec, Canada
| | - Yuya Seko
- Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Neeraj Bhala
- Institute of Applied Health Research, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, United Kingdom
| | - Zobair M Younossi
- Department of Medicine, Inova Fairfax Hospital, Falls Church, Virginia
| | - Quentin M Anstee
- Institute of Clinical and Translational Research, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, United Kingdom; Newcastle National Institute of Health Research Biomedical Research Centre and Liver Transplant Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, United Kingdom
| | - Stuart McPherson
- Liver Transplant Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust; Institute of Clinical and Translational Research, Newcastle University, Newcastle-upon-Tyne, United Kingdom; Newcastle National Institute of Health Research Biomedical Research Centre, Newcastle-upon-Tyne, United Kingdom
| | - Philip N Newsome
- National Institute for Health Research Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, United Kingdom; Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom; Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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20
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Peleg N, Issachar A, Sneh Arbib O, Cohen-Naftaly M, Harif Y, Oxtrud E, Braun M, Leshno M, Barsheshet A, Shlomai A. Liver steatosis is a major predictor of poor outcomes in chronic hepatitis C patients with sustained virological response. J Viral Hepat 2019; 26:1257-1265. [PMID: 31243878 DOI: 10.1111/jvh.13167] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 05/10/2019] [Accepted: 05/28/2019] [Indexed: 12/24/2022]
Abstract
Sustained virological response (SVR) results in reduced incidence of hepatocellular carcinoma (HCC) and mortality among chronic hepatitis C (CHC) patients with advanced fibrosis. Since both advanced fibrosis and liver steatosis (LS) may coexist in CHC patients, we evaluated their individual effects on a composite outcome of all-cause mortality and HCC in CHC patients with SVR following direct-acting antivirals (DAA) treatment. We retrospectively evaluated inception cohort of 515 CHC patients who achieved SVR following treatment with DAA, with a mean follow-up of 24 months. Baseline liver fibrosis was assessed by transient elastography, and LS was validated by at least three independent ultrasonographic examinations. 211 of 515 patients (41%) had baseline LS. Patients with LS had a higher cumulative rate of all-cause mortality and HCC at 2 years of follow-up compared to patients without LS (15.75% and 2.79%, respectively, P < 0.001), although they did not have increased incidence of advanced fibrosis or cirrhosis. Consistently, multivariate analysis showed that LS was associated with a significant 7.5-fold increased risk of all-cause mortality and HCC (HR 7.51, 95% C.I 3.61-13.36, P < 0.001) even upon adjustment to components of the metabolic syndrome, whereas advanced fibrosis showed only a trend towards statistical significance (HR 2.32, 95% C.I 0.97-6.59, P = 0.06). In conclusion, LS is a major predictor of all-cause mortality and HCC in patients who achieved SVR following DAA treatment regardless of fibrosis stage. These patients should be rigorously screened for HCC.
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Affiliation(s)
- Noam Peleg
- The Division of Gastroenterology and Hepatology, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | - Assaf Issachar
- The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Sneh Arbib
- The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | - Michal Cohen-Naftaly
- The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Harif
- The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | - Evelin Oxtrud
- The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | - Marius Braun
- The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Leshno
- Coller School of Management, Tel Aviv University, Tel Aviv, Israel
| | - Alon Barsheshet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Amir Shlomai
- The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
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21
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Shlomai A, Leshno M, Goldstein DA. Cabozantinib for patients with advanced hepatocellular carcinoma: a cost-effectiveness analysis. Therap Adv Gastroenterol 2019; 12:1756284819878304. [PMID: 31579104 PMCID: PMC6759721 DOI: 10.1177/1756284819878304] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 09/04/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS The multi-kinase inhibitor sorafenib is a first-line drug for patients with advanced hepatocellular carcinoma (HCC). Treatment options for patients whose disease has progressed on sorafenib are limited. In a recent randomized controlled trial (CELESTIAL trial), patients with advanced HCC who had failed prior systemic therapy had moderate progression-free survival and overall survival advantages when treated with the multi-kinase inhibitor cabozantinib. However, since this treatment is costly and is accompanied by significant adverse events in a large proportion of patients, its cost-effectiveness in these patients should be determined. METHODS We developed a Markov model incorporating health outcomes, measured by life-years and quality-adjusted life-years (QALYs) to evaluate the cost-effectiveness of cabozantinib compared with placebo in patients who have failed prior systemic therapy. RESULTS Treatment with cabozantinib results in a mean gain of 11.6 weeks of life (0.22 life-years) as compared with placebo. When quality of life was incorporated, treatment with cabozantinib produced a gain of 0.16 QALYs. The total mean incremental cost of cabozantinib was US$76,406 per patient. The incremental cost-effectiveness ratio for cabozantinib compared with best supportive care was US$469,374/QALY using the recommended dose of 60 mg cabozantinib daily. CONCLUSION Our results suggest that the use of cabozantinib in patients with advanced HCC who have progressed on prior treatment, results in a modest incremental benefit with high incremental costs, suggesting that it is not cost-effective at conventional willingness to pay thresholds.
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Affiliation(s)
| | - Moshe Leshno
- Coller School of Management, Tel Aviv University, Tel Aviv, Israel
| | - Daniel A. Goldstein
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach-Tikva, Israel,The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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22
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Peleg N, Issachar A, Sneh Arbib O, Cohen-Naftaly M, Braun M, Leshno M, Barsheshet A, Shlomai A. Liver steatosis is a strong predictor of mortality and cancer in chronic hepatitis B regardless of viral load. JHEP Rep 2019; 1:9-16. [PMID: 32039349 PMCID: PMC7001543 DOI: 10.1016/j.jhepr.2019.02.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 02/09/2023] Open
Abstract
Liver steatosis may occur concomitantly in patients with chronic hepatitis B infection (CHB) and is implicated in increased morbidity and mortality. Hepatitis B virus (HBV) viral load is a marker for disease progression and long-term outcomes in CHB. We investigated the association between liver steatosis and HBV viral load and their individual effects on all-cause mortality and the development of cancer in patients with CHB and liver steatosis. Methods This retrospective study included 524 treatment-naïve patients with CHB, with a mean follow-up of 6 years. Liver biopsy was available for 170 patients and liver steatosis was validated by at least 3 ultrasonographic examinations. Results A total of 241/524 (46%) patients with CHB had liver steatosis, with a strong correlation between the degree of liver steatosis as assessed by ultrasonography or by liver biopsy (r = 0.9, p < 0.001). Although liver steatosis was not significantly associated with advanced fibrosis, a multivariate analysis showed that liver steatosis was associated with a 4-fold increased risk of all-cause mortality and cancer (hazard ratio 4.35; 95% CI 1.69–8.99; p < 0.001), irrespective of other major metabolic factors. However, baseline HBV viral load was not significantly associated with this composite outcome (hazard ratio 1.65; p = 0.29). In addition, liver steatosis was inversely associated with HBV viral load. Conclusion Patients with CHB and liver steatosis have an increased risk of all-cause mortality and cancer development compared to patients with CHB without liver steatosis, regardless of their baseline HBV viral load. Although tending to have a lower baseline viral load, patients with CHB and liver steatosis should be closely monitored irrespective of viral load. Lay summary Patients with chronic hepatitis B infection (CHB) may have liver steatosis at the same time. Here we show that in patients with CHB, liver steatosis is significantly associated with all-cause mortality and cancer, irrespective of other major metabolic factors, and the effect of liver steatosis on mortality and cancer is stronger than the effect of hepatitis B viral load on these outcomes. Thus, patients with CHB and liver steatosis should be closely monitored, irrespective of their viral load. HBV viral load is an important predictor of adverse outcomes in patients with chronic HBV (CHB). Liver steatosis may co-occur with CHB but its effect on all-cause mortality and cancer has not been determined. Liver steatosis is significantly associated with all-cause mortality and cancer in patients with CHB. The effect of liver steatosis on mortality and cancer is stronger than the effect of HBV viral load. Patients with CHB and liver steatosis should be closely monitored, irrespective of their viral load.
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Affiliation(s)
- Noam Peleg
- Department of Medicine D, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
| | - Assaf Issachar
- Department of Medicine D, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel.,The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Sneh Arbib
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
| | - Michal Cohen-Naftaly
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
| | - Marius Braun
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Leshno
- Coller School of Management, Tel Aviv University, Tel Aviv, Israel
| | - Alon Barsheshet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Amir Shlomai
- Department of Medicine D, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel.,The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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23
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Nesher E, Braun M, Eizner S, Issachar A, Cohen M, Shlomai A, Gurevich M, Tur-Kaspa R, Mor E. Transplantation of Livers from Old Donors: Pushing the Envelope Beyond the Seventh Decade. Isr Med Assoc J 2018; 20:765-769. [PMID: 30550007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The lack of organs for liver transplantation has prompted transplant professionals to study potential solutions, such as the use of livers from donors older than 70 years. This strategy is not widely accepted because potential risks of vascular and biliary complications and recurrence of hepatitis C. OBJECTIVES To examine the efficacy and safety of liver grafts from older donors for transplantation. METHODS A retrospective analysis of data on 310 adults who underwent deceased donor liver transplantation between 2005 and 2015 was conducted. We compared graft and recipient survival, as well as major complications, of transplants performed with grafts from donors younger than 70 years (n=265, control group) and those older than 70 years (n=45, older-donor group), followed by multivariate analysis, to identify risk factors. RESULTS There was no significant difference between the control and older-donor group at 1, 5, and 10 years of recipient survival (79.5% vs. 73.3%, 68.3% vs. 73.3%, 59.2% vs. 66.7%, respectively) or graft survival (74.0% vs. 71.0%, 62.7% vs. 71.0%, 54.8% vs. 64.5%, respectively). The rate of biliary and vascular complications was similar in both groups. Significant risk factors for graft failure were hepatitis C (hazard ratio [HR] = 1.92, 95% confidence interval [95%CI] 1.16-2.63), older donor age (HR = 1.02, 95%CI 1.007-1.031), and male gender of the recipient (HR = 1.65, 95%CI 1.06-2.55). CONCLUSIONS Donor age affects liver graft survival. However, grafts from donors older than 70 years may be equally safe if cold ischemia is maintained for less than 8 hours.
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Affiliation(s)
- Eviatar Nesher
- Department of Transplantation, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marius Braun
- Liver Diseases Institute, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sigal Eizner
- Department of Transplantation, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assaf Issachar
- Liver Diseases Institute, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Cohen
- Liver Diseases Institute, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Shlomai
- Liver Diseases Institute, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Gurevich
- Department of Transplantation, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Tur-Kaspa
- Liver Diseases Institute, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eytan Mor
- Department of Transplantation, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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24
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Shlomai A, Leshno M, Goldstein DA. Regorafenib treatment for patients with hepatocellular carcinoma who progressed on sorafenib-A cost-effectiveness analysis. PLoS One 2018; 13:e0207132. [PMID: 30408106 PMCID: PMC6224101 DOI: 10.1371/journal.pone.0207132] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 10/24/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND AND AIMS Hepatocellular carcinoma (HCC) is one of the leading causes of cancer related deaths. Patients with advanced HCC are treated with sorafenib. A recent randomized controlled trial demonstrated a survival benefit for regorafenib treatment in patients with advanced HCC who had progressed on sorafenib. We aimed to evaluate the cost-effectiveness of this approach. METHODS To evaluate the cost effectiveness of regorafenib, we used a Markov model that incorporates health outcomes, measured by life-years and quality-adjusted life-years (QALYs). Drug costs were based on 2017 discounted prices. Model robustness was validated by probabilistic sensitivity analyses using Monte Carlo simulations. RESULTS The use of regorafenib results in a gain of 19.76 weeks of life (0.38 Life Years) as compared to placebo. When adjusted for quality of life, using regorafenib produced a gain of 0.25 quality adjusted life years (QALYs). The incremental cost-effectiveness ratio for regorafenib compared with best supportive care was between $201,797 and $268,506 per QALY. CONCLUSION The modest incremental benefit at a relatively high incremental cost of regorafenib treatment suggests that it is not cost-effective at commonly accepted willingness to pay thresholds.
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Affiliation(s)
- Amir Shlomai
- Department of Medicine D and the Liver Institute, Rabin Medical Center, Petach-Tikva, Israel
- The Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Moshe Leshno
- Coller School of Management, Tel Aviv University, Tel Aviv, Israel
| | - Daniel A. Goldstein
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petach-Tikva, Israel
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States of America
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25
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van Dijk TY, Rahamimov R, Chagnac A, van Dijk DJ, Mor E, Shlomai A, Rozen-Zvi B. The effect of cause, timing, kidney function recovery, and recurrent events on the prognosis of acute kidney injury in kidney transplant recipients. Clin Transplant 2018; 32:e13398. [DOI: 10.1111/ctr.13398] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/09/2018] [Accepted: 08/27/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Tuvya Y. van Dijk
- Department of Internal Medicine D; Rabin Medical Center; Petah-Tikva Israel
- Sackler Faculty of Medicine; Tel- Aviv University; Tel-Aviv Israel
| | - Ruth Rahamimov
- Sackler Faculty of Medicine; Tel- Aviv University; Tel-Aviv Israel
- Department of Nephrology and Hypertension; Rabin Medical Center; Petah-Tikva Israel
- Department of Transplantation; Rabin Medical Center; Petah- Tikva Israel
| | - Avry Chagnac
- Sackler Faculty of Medicine; Tel- Aviv University; Tel-Aviv Israel
- Department of Nephrology and Hypertension; Rabin Medical Center; Petah-Tikva Israel
| | - David J. van Dijk
- Sackler Faculty of Medicine; Tel- Aviv University; Tel-Aviv Israel
- Department of Nephrology and Hypertension; Rabin Medical Center; Petah-Tikva Israel
| | - Eytan Mor
- Sackler Faculty of Medicine; Tel- Aviv University; Tel-Aviv Israel
- Department of Transplantation; Rabin Medical Center; Petah- Tikva Israel
| | - Amir Shlomai
- Department of Internal Medicine D; Rabin Medical Center; Petah-Tikva Israel
- Sackler Faculty of Medicine; Tel- Aviv University; Tel-Aviv Israel
- The Liver Institute; Rabin Medical Center; Petah-Tikva Israel
| | - Benaya Rozen-Zvi
- Sackler Faculty of Medicine; Tel- Aviv University; Tel-Aviv Israel
- Department of Nephrology and Hypertension; Rabin Medical Center; Petah-Tikva Israel
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26
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Peleg N, Sneh Arbib O, Issachar A, Cohen-Naftaly M, Braun M, Shlomai A. Noninvasive scoring systems predict hepatic and extra-hepatic cancers in patients with nonalcoholic fatty liver disease. PLoS One 2018; 13:e0202393. [PMID: 30106985 PMCID: PMC6091950 DOI: 10.1371/journal.pone.0202393] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 08/02/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Liver fibrosis predicts liver-related morbidity and mortality in patients with non-alcoholic fatty liver disease (NAFLD). Non-invasive scores correlate with the degree of liver fibrosis in these patients. AIMS AND METHODS To investigate the accuracy of noninvasive scoring systems in predicting long-term outcomes and cancer incidence of patients with NAFLD, we performed a single-center retrospective study of patients with biopsy proven NAFLD. Mean follow up period was 100 months. Outcomes included liver-related complications, hospitalizations, overall mortality and the development of any malignancies. RESULTS 32 patients had advanced fibrosis (F3-F4) per biopsy at baseline and 121 patients had mild to moderate fibrosis (F0-F2). Both advanced histologic fibrosis stage as well as higher non-invasive scores predicted repeated hospitalizations and longer hospitalization stays. In a multivariate analysis, liver fibrosis (p = 0.002), FIB-4 score (p<0.001), NFS (p<0.001) but not APRI score (p = 0.07) were predictors of overall mortality, and the occurrence of malignancies was associated with higher APRI (p<0.001), FIB-4 (p<0.001) and NFS (p = 0.008) scores, but not with advanced fibrosis, as determined by liver biopsy (p = 0.105). CONCLUSIONS In NAFLD patients, noninvasive scoring systems are good predictors of morbidity and mortality and may have an additive value in predicting the development of hepatic and extra-hepatic cancers.
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Affiliation(s)
- Noam Peleg
- Department of Medicine D, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
| | - Orly Sneh Arbib
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
| | - Assaf Issachar
- Department of Medicine D, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Cohen-Naftaly
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
| | - Marius Braun
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Shlomai
- Department of Medicine D, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petach-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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27
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Shirin D, Peleg N, Sneh-Arbib O, Cohen-Naftaly M, Braun M, Shochat T, Issachar A, Shlomai A. The Pattern of Elevated Liver Function Tests in Nonalcoholic Fatty Liver Disease Predicts Fibrosis Stage and Metabolic-Associated Comorbidities. Dig Dis 2018; 37:69-76. [PMID: 30016799 DOI: 10.1159/000491428] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 06/21/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patients with nonalcoholic fatty liver disease (NAFLD) and with abnormal liver function tests (LFTs) most commonly present with elevated hepatocellular enzymes (H pattern), but a subset of patients is found to have elevated cholestatic enzymes (C pattern) or a mixed (M) pattern. AIMS AND METHODS To determine whether the epidemiologic background and comorbidities, as well as the degree of liver fibrosis, differ between NAFLD patients with different patterns of elevated LFTs by retrospectively analyzing data of 106 patients with a biopsy-proven diagnosis of NAFLD. The pattern of elevated LFTs was determined by adopting the "R-Ratio" formula commonly used for drug-induced liver injury. RESULTS Advanced fibrosis (F > 2) was found in 15 out of 48 (31.3%) patients with a C pattern of elevated LFTs as compared to 2 out of 44 (4.5%) in M patients and 2 out of 11 (18.2%) in H patients (p = 0.004). Group C patients are older and also had a higher prevalence of diabetes, a higher mean hemoglobin A1c, and a higher prevalence of hypertension, as well as a trend for a higher prevalence of hypertriglyceridemia. CONCLUSIONS Using a simple formula incorporating routine LFTs can help to categorize NAFLD patients as low or high risk for advanced fibrosis stage and metabolic-associated comorbidities.
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Affiliation(s)
- Dor Shirin
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Noam Peleg
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,The Liver Institute, Rabin Medical Center, Beilinson hospital, Petah-Tikva, Israel
| | - Orly Sneh-Arbib
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petah-Tikva, Israel
| | - Michal Cohen-Naftaly
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petah-Tikva, Israel
| | - Marius Braun
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Petah-Tikva, Israel.,The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tzipora Shochat
- Biostatistics Core, Rabin Medical Center, Petah-Tikva, Israel
| | - Assaf Issachar
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.,The Liver Institute, Rabin Medical Center, Beilinson hospital, Petah-Tikva, Israel
| | - Amir Shlomai
- Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, .,The Liver Institute, Rabin Medical Center, Beilinson hospital, Petah-Tikva, .,The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv,
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28
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Dukhovny A, Shlomai A, Sklan EH. The antiviral protein Viperin suppresses T7 promoter dependent RNA synthesis-possible implications for its antiviral activity. Sci Rep 2018; 8:8100. [PMID: 29802323 PMCID: PMC5970183 DOI: 10.1038/s41598-018-26516-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 05/11/2018] [Indexed: 12/28/2022] Open
Abstract
Viperin is a multifunctional interferon-inducible broad-spectrum antiviral protein. Viperin belongs to the S-Adenosylmethionine (SAM) superfamily of enzymes known to catalyze a wide variety of radical-mediated reactions. However, the exact mechanism by which viperin exerts its functions is still unclear. Interestingly, for many RNA viruses viperin was shown to inhibit viral RNA accumulation by interacting with different viral non-structural proteins. Here, we show that viperin inhibits RNA synthesis by bacteriophage T7 polymerase in mammalian cells. This inhibition is specific and occurs at the RNA level. Viperin expression significantly reduced T7-mediated cytoplasmic RNA levels. The data showing that viperin inhibits the bacteriophage T7 polymerase supports the conservation of viperin’s antiviral activity between species. These results highlight the possibility that viperin might utilize a broader mechanism of inhibition. Accordingly, our results suggest a novel mechanism involving polymerase inhibition and provides a tractable system for future mechanistic studies of viperin.
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Affiliation(s)
- Anna Dukhovny
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
| | - Amir Shlomai
- Department of Medicine D and the Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ella H Sklan
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel.
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29
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Abstract
Hepatitis B virus (HBV) targets the liver and is a major driver for liver cancer. Clinical data suggest that HBV infection is associated with reduced response to treatment with the multi-kinase inhibitor sorafenib, the first available molecularly targeted anti-hepatocellular carcinoma (HCC) drug. Given that Raf is one of the major targets of sorafenib, we investigated the activation state of the Raf-Mek-Erk pathway in the presence of HBV and in response to sorafenib. Here we show that hepatoma cells with replicating HBV are less susceptible to sorafenib inhibitory effect as compared to cells in which HBV expression is suppressed. However, although HBV replication is associated with increased level of pErk, its blockade only modestly augments sorafenib effect. In contrast, the phosphorylated form of the pro-oncogenic Mitogen-Activated Protein Kinase 14 (pMAPK14), a protein kinase that was recently linked to sorafenib resistance, is induced in sorafenib-treated hepatoma cells in association with HBV X protein expression. Knocking down pMAPK14 results in augmentation of the therapeutic efficacy of sorafenib and largely alleviates resistance to sorafenib in the presence of HBV. Thus, this study suggests that HBV promotes HCC resistance to sorafenib. Combining pMAPK14 inhibitors with sorafenib may be beneficial in patients with HBV-associated HCC.
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Affiliation(s)
- Dvora Witt-Kehati
- Felsenstein Medical Research Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Alexandra Fridkin
- Department of Medicine D, Beilinson hospital Rabin Medical Center, Petah-Tikva, Israel
| | - Maya Bitton Alaluf
- Felsenstein Medical Research Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Department of Medicine D, Beilinson hospital Rabin Medical Center, Petah-Tikva, Israel
| | - Romy Zemel
- Felsenstein Medical Research Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amir Shlomai
- Felsenstein Medical Research Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Department of Medicine D, Beilinson hospital Rabin Medical Center, Petah-Tikva, Israel; The Liver Institute, Beilinson Hospital Rabin Medical Center, Petah-Tikva, Israel.
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30
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Shirazi R, Ram D, Rakovsky A, Bucris E, Gozlan Y, Lustig Y, Shaked-Mishan P, Picard O, Shemer-Avni Y, Ben-Zvi H, Halutz O, Lurie Y, Veizman E, Carlebach M, Braun M, Naftaly MC, Shlomai A, Safadi R, Mendelson E, Sklan EH, Ben-Ari Z, Mor O. Characterization of hepatitis B and delta coinfection in Israel. BMC Infect Dis 2018; 18:97. [PMID: 29486716 PMCID: PMC6389180 DOI: 10.1186/s12879-018-3008-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 02/21/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Characteristics of hepatitis B (HBV) and delta (HDV) coinfection in various geographical regions, including Israel, remain unclear. Here we studied HDV seroprevalence in Israel, assessed HDV/HBV viral loads, circulating genotypes and hepatitis delta antigen (HDAg) conservation. METHODS Serological anti HDV IgG results from 8969 HBsAg positive individuals tested in 2010-2015 were retrospectively analyzed to determine HDV seroprevalence. In a cohort of HBV/HDV coinfected (n=58) and HBV monoinfected (n=27) patients, quantitative real-time PCR (qRT-PCR) and sequencing were performed to determine viral loads, genotypes and hepatitis delta antigen (HDAg) protein sequence. RESULTS 6.5% (587/8969) of the HBsAg positive patients were positive for anti HDV antibodies. HDV viral load was >2 log copies/ml higher than HBV viral load in most of the coinfected patients with detectable HDV RNA (86%, 50/58). HDV genotype 1 was identified in all patients, most of whom did not express HBV. While 66.6% (4/6) of the HBV/HDV co-expressing patients carried HBV-D2 only 18.5% (5/27) of the HBV monoinfections had HBV-D2 (p=0.03). Higher genetic variability in the HDAg protein sequence was associated with higher HDV viral load. CONCLUSIONS The overall significant prevalence of HDV (6.5%) mandates HDV RNA testing for all coinfected patients. Patients positive for HDV RNA (characterized by low HBV DNA blood levels) carried HDV genotype 1. Taken together, the significant HDV seroprevalence and the lack of effective anti-HDV therapy, necessitates strict clinical surveillance especially in patients with higher HDV viral loads and increased viral evolution.
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Affiliation(s)
- Rachel Shirazi
- Central Virology Laboratory, Ministry of Health, Chaim Sheba Medical Center, Tel - Hashomer, 52621, Ramat Gan, Israel
| | - Daniela Ram
- Central Virology Laboratory, Ministry of Health, Chaim Sheba Medical Center, Tel - Hashomer, 52621, Ramat Gan, Israel
| | - Aviya Rakovsky
- Central Virology Laboratory, Ministry of Health, Chaim Sheba Medical Center, Tel - Hashomer, 52621, Ramat Gan, Israel
| | - Efrat Bucris
- Central Virology Laboratory, Ministry of Health, Chaim Sheba Medical Center, Tel - Hashomer, 52621, Ramat Gan, Israel
| | - Yael Gozlan
- Central Virology Laboratory, Ministry of Health, Chaim Sheba Medical Center, Tel - Hashomer, 52621, Ramat Gan, Israel
| | - Yaniv Lustig
- Central Virology Laboratory, Ministry of Health, Chaim Sheba Medical Center, Tel - Hashomer, 52621, Ramat Gan, Israel
| | | | - Orit Picard
- Gastroenterology Laboratory, Sheba Medical Center, Ramat Gan, Israel
| | - Yonat Shemer-Avni
- Laboratory of Clinical Virology, Soroka University Medical Center, Beer Sheva, Israel
| | - Haim Ben-Zvi
- Microbiology Laboratory, Rabin Medical Center, Petach Tikva, Israel
| | - Ora Halutz
- Microbiology Laboratory, Sorasky Medical Center, Tel Aviv, Israel
| | - Yoav Lurie
- Liver Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Ella Veizman
- Liver Unit, Rambam Medical Center, Haifa, Israel
| | | | - Marius Braun
- Liver Institute, Rabin Medical Center, Petah-Tikva, Israel
| | | | - Amir Shlomai
- Liver Institute, Rabin Medical Center, Petah-Tikva, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rifaat Safadi
- Liver Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Ella Mendelson
- Central Virology Laboratory, Ministry of Health, Chaim Sheba Medical Center, Tel - Hashomer, 52621, Ramat Gan, Israel.,School of Public Health, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ella H Sklan
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ziv Ben-Ari
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Disease Center, Sheba Medical Center, Ramat Gan, Israel
| | - Orna Mor
- Central Virology Laboratory, Ministry of Health, Chaim Sheba Medical Center, Tel - Hashomer, 52621, Ramat Gan, Israel. .,School of Public Health, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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31
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Michailidis E, Pabon J, Xiang K, Park P, Ramanan V, Hoffmann HH, Schneider WM, Bhatia SN, de Jong YP, Shlomai A, Rice CM. A robust cell culture system supporting the complete life cycle of hepatitis B virus. Sci Rep 2017; 7:16616. [PMID: 29192196 PMCID: PMC5709435 DOI: 10.1038/s41598-017-16882-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 11/17/2017] [Indexed: 12/18/2022] Open
Abstract
The discovery of sodium taurocholate cotransporting polypeptide (NTCP) as the hepatitis B virus (HBV) receptor enabled researchers to create hepatoma cell lines susceptible to HBV infection. Infection in current systems, however, is inefficient and virus fails to spread. Infection efficiency is enhanced by treating cells with polyethylene glycol 8000 (PEG) during infection. However, this alone does not promote virus spread. Here we show that maintaining PEG in culture medium increases the rate of infection by at least one order of magnitude, and, most importantly, promotes virus spread. To demonstrate the utility of this system, we show that two interferon-stimulated genes (ISGs), ISG20 and tetherin, restrict HBV spread in NTCP-expressing hepatoma cells. Thus, this protocol can be easily applied to existing cell culture systems to study the complete HBV life cycle, including virus spread.
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Affiliation(s)
- Eleftherios Michailidis
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA
| | - Jonathan Pabon
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA
| | - Kuanhui Xiang
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA.,Department of Microbiology and Center of Infectious Disease, School of Basic Medical Sciences, Peking University Health Science Center, Beijing, China
| | - Paul Park
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA
| | - Vyas Ramanan
- Department of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Hans-Heinrich Hoffmann
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA
| | - William M Schneider
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA
| | - Sangeeta N Bhatia
- Institute for Medical Engineering and Science, David H. Koch Institute for Integrative Cancer Research, Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA.,Howard Hughes Medical Institute, Cambridge, MA, USA
| | - Ype P de Jong
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA.,Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Amir Shlomai
- Department of Medicine D and the Liver Institute, Rabin Medical Center, Belinson Hospital, Petach-Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Charles M Rice
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA.
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32
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Peleg N, Issachar A, Sneh-Arbib O, Shlomai A. AST to Platelet Ratio Index and fibrosis 4 calculator scores for non-invasive assessment of hepatic fibrosis in patients with non-alcoholic fatty liver disease. Dig Liver Dis 2017; 49:1133-1138. [PMID: 28572039 DOI: 10.1016/j.dld.2017.05.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [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: 02/20/2017] [Revised: 04/26/2017] [Accepted: 05/01/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Liver fibrosis is the single most important prognostic factor in patients with non-alcoholic fatty liver disease (NAFLD). The predictive value of the AST to Platelet Ratio Index (APRI) score, originally developed for fibrosis assessment in hepatitis C virus (HCV) patients, is much less known in the context of NAFLD patients. METHODS We retrospectively compared the performance of APRI and fibrosis 4 calculator (FIB-4) scores in NAFLD patients with documented liver biopsies, to their performance in chronic HCV patients. RESULTS 153 patients with biopsy-proven NAFLD and 297 patients with biopsy-proven chronic HCV infection were included. The APRI score was a good predictor for advanced fibrosis in NAFLD patients (area under the ROC curve 0.8307) although it was modestly inferior as compared to the well-validated FIB-4 score (area under the ROC curve 0.8959). The predictive value of APRI score in NALFD patients was inferior as compared to its predictive value in HCV patients (area under the ROC curve of 0.8307 versus 0.9965). In contrast to FIB-4, APRI score was not a good discriminator between intermediate stages of fibrosis in NAFLD patients. CONCLUSIONS APRI and Fib-4 scores are reasonable tools to allocate NAFLD patients with advanced fibrosis. FIB-4 may better discriminate between intermediate fibrosis stages.
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Affiliation(s)
- Noam Peleg
- Department of Medicine D and the Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | - Assaf Issachar
- Department of Medicine D and the Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Sneh-Arbib
- Department of Medicine D and the Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | - Amir Shlomai
- Department of Medicine D and the Liver Institute, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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33
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Leibovici-Weissman Y, Mor E, Leshno M, Shlomai A. Patients' Age Rather Than Model of End-Stage Liver Disease Score Predicts Survival After Liver Transplantation. Dig Dis Sci 2017; 62:801-807. [PMID: 28054162 DOI: 10.1007/s10620-016-4423-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 12/16/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND The model of end-stage liver disease (MELD) score is the standard tool for prioritizing patients awaiting liver transplantation. There is currently no definite high cutoff score reflecting disease severity that might exclude patients from transplantation. Furthermore, the age limit that used to disqualify patients from eligibility to transplantation was recently withdrawn in several countries. AIMS The aims of this study were to assess the effects of MELD score and age at time of transplantation on patients' short- and long-term survival. METHODS We conducted a retrospective single-center study on a cohort of patients transplanted for the first time due to non-fulminant liver failure. RESULTS Four hundred and seventeen patients (mean age 50.2 years, 63% males) who underwent liver transplantation for the first time were included. Both higher patients' and donors' age were significantly associated with increased long-term mortality (p = 0.007, 95% CI 1.006-1.038 for patient age, p = 0.02, 95% CI 1.002-1.023 for donor age). Patients' age remained significantly associated with survival at 1 year post-transplantation, as well. We found no association between higher MELD score at transplantation and long-term mortality (p = 0.189, 95% CI 0.99-1.051) irrespective of patients' age. Specifically, when patients were divided according to their MELD score at transplantation (MELD < 15, MELD 15-25 and MELD > 25), no significant differences in long-term survival were detected between these three subgroups. Results did not differ significantly in a subgroup analysis of patients without hepatocellular carcinoma at the time of transplantation. CONCLUSIONS Patients' and donors' age rather than patients' MELD score at transplantation determine survival following liver transplantation.
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Affiliation(s)
- Yaara Leibovici-Weissman
- Department of Internal Medicine D, Rabin Medical Center, Beilinson Hospital, 39 Jabotinsky Street, Petah-Tikva, 49100, Israel. .,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Eytan Mor
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Department of Transplantation, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Moshe Leshno
- Tel-Aviv University School of Management, Tel-Aviv University, Tel Aviv, Israel
| | - Amir Shlomai
- Department of Internal Medicine D, Rabin Medical Center, Beilinson Hospital, 39 Jabotinsky Street, Petah-Tikva, 49100, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.,The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
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Gozlan Y, Ben-Ari Z, Moscona R, Shirazi R, Rakovsky A, Kabat A, Veizman E, Berdichevski T, Weiss P, Cohen-Ezra O, Lurie Y, Gafanovich I, Braun M, Cohen-Naftaly M, Shlomai A, Shibolet O, Zigmond E, Zuckerman E, Carmiel-Haggai M, Nimer A, Hazzan R, Maor Y, Kitay-Cohen Y, Shemer-Avni Y, Kra-Oz Z, Schreiber L, Peleg O, Sierra S, Harrigan PR, Mendelson E, Mor O. HCV genotype-1 subtypes and resistance-associated substitutions in drug-naive and in direct-acting antiviral treatment failure patients. Antivir Ther 2017; 22:431-441. [PMID: 28067632 DOI: 10.3851/imp3123] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Direct-acting antiviral (DAA) treatment regimens and response rates of patients with HCV genotype-1 (GT1) are currently considered subtype-dependent. Identification of clinically relevant resistance-associated substitutions (RASs) in the NS3 and NS5A proteins at baseline and in DAA failures, may also impact clinical decisions. METHODS In a multicentre cohort study (n=308), NS3 or NS5B sequencing (n=248) was used to discriminate between GT1 subtypes. The correlation between baseline NS3 and NS5A RASs on the 12-week sustained virological response (SVR12) rates of 160 of the patients treated with second-generation DAAs was also assessed. Post-treatment resistance analysis was performed on samples from 58 patients exhibiting DAA virological failure. RESULTS GT1a, GT1b and GT1d subtypes were identified in 23.0%, 75.4% and 1.2% of tested samples. GT1b was most prevalent (97.7%, 128/131) among patients born in the former Soviet Union. The Q80K NS3 RAS was identified in 17.5% (10/57) of the GT1a carriers, most of whom were Israeli-born. NS3 and NS5A baseline RASs showed a negligible correlation with SVR12 rates. Treatment-emergent RASs were observed among 8.9% (4/45) and 76.9% (10/13) of first- and second-generation DAA failures, respectively, with D168V/E (NS3), Y93H and L31M (NS5A) being the most prevalent mutations. CONCLUSIONS NS3 sequencing analysis can successfully discriminate between GT1 subtypes and identify NS3 amino acid substitutions. While pre-treatment NS3 and NS5A RASs marginally affect second-generation DAA SVR12 rates, post-treatment resistance analysis should be considered prior to re-therapy.
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Affiliation(s)
- Yael Gozlan
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat-Gan, Israel
| | - Ziv Ben-Ari
- Liver Disease Center, Sheba Medical Center, Ramat-Gan, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roy Moscona
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat-Gan, Israel
| | - Rachel Shirazi
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat-Gan, Israel
| | - Aviya Rakovsky
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat-Gan, Israel
| | - Arij Kabat
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat-Gan, Israel
| | - Ella Veizman
- Liver Disease Center, Sheba Medical Center, Ramat-Gan, Israel
| | | | - Peretz Weiss
- Liver Disease Center, Sheba Medical Center, Ramat-Gan, Israel
| | | | - Yoav Lurie
- Liver Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Marius Braun
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah-Tikva, Israel
| | - Michal Cohen-Naftaly
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah-Tikva, Israel
| | - Amir Shlomai
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah-Tikva, Israel
| | - Oren Shibolet
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Tel-Aviv Medical Center, Tel Aviv, Israel
| | - Ehud Zigmond
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Gastroenterology, Tel-Aviv Medical Center, Tel Aviv, Israel
| | | | - Michal Carmiel-Haggai
- Liver Unit, Galilee Medical Center, Naharya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Ramat-Gan, Israel
| | - Assy Nimer
- Faculty of Medicine in the Galilee, Bar-Ilan University, Ramat-Gan, Israel.,Internal Medicine Department, Galilee Medical Center, Naharya, Israel
| | - Rawi Hazzan
- Liver Unit, Haemek Medical Center, Afula, Israel
| | - Yaakov Maor
- Division of Gastroenterology, Kaplan Health Sciences Centre, Department of Medicine, Faculty of Medicine, Hebrew University, Rehovot, Israel
| | - Yona Kitay-Cohen
- Gastroenterology and Hepatology Institute, Meir Medical Center, Kfar Saba, Israel
| | | | - Zipi Kra-Oz
- Virology Laboratory, Rambam Medical Center, Haifa, Israel
| | | | | | - Saleta Sierra
- Institute of Virology, University of Cologne, Cologne, Germany
| | | | - Ella Mendelson
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat-Gan, Israel.,School of Public Health, Tel Aviv University, Tel Aviv, Israel
| | - Orna Mor
- Central Virology Laboratory, Ministry of Health, Sheba Medical Center, Ramat-Gan, Israel
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35
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Scheel TKH, Luna JM, Liniger M, Nishiuchi E, Rozen-Gagnon K, Shlomai A, Auray G, Gerber M, Fak J, Keller I, Bruggmann R, Darnell RB, Ruggli N, Rice CM. A Broad RNA Virus Survey Reveals Both miRNA Dependence and Functional Sequestration. Cell Host Microbe 2016; 19:409-23. [PMID: 26962949 DOI: 10.1016/j.chom.2016.02.007] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 01/25/2016] [Accepted: 02/18/2016] [Indexed: 12/19/2022]
Abstract
Small non-coding RNAs have emerged as key modulators of viral infection. However, with the exception of hepatitis C virus, which requires the liver-specific microRNA (miRNA)-122, the interactions of RNA viruses with host miRNAs remain poorly characterized. Here, we used crosslinking immunoprecipitation (CLIP) of the Argonaute (AGO) proteins to characterize strengths and specificities of miRNA interactions in the context of 15 different RNA virus infections, including several clinically relevant pathogens. Notably, replication of pestiviruses, a major threat to milk and meat industries, critically depended on the interaction of cellular miR-17 and let-7 with the viral 3' UTR. Unlike canonical miRNA interactions, miR-17 and let-7 binding enhanced pestivirus translation and RNA stability. miR-17 sequestration by pestiviruses conferred reduced AGO binding and functional de-repression of cellular miR-17 targets, thereby altering the host transcriptome. These findings generalize the concept of RNA virus dependence on cellular miRNAs and connect virus-induced miRNA sequestration to host transcriptome regulation.
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Affiliation(s)
- Troels K H Scheel
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY 10065, USA; Copenhagen Hepatitis C Program, Department of Infectious Diseases and Clinical Research Centre, Copenhagen University Hospital, 2650 Hvidovre, Denmark; Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
| | - Joseph M Luna
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY 10065, USA; Laboratory of Molecular Neuro-Oncology, and Howard Hughes Medical Institute, The Rockefeller University, New York, NY 10065, USA
| | - Matthias Liniger
- Department of Virology, Institute of Virology and Immunology IVI, 3147 Mittelhäusern, Switzerland; Department of Infectious Diseases and Pathobiology, University of Bern, 3012 Bern, Switzerland
| | - Eiko Nishiuchi
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY 10065, USA
| | - Kathryn Rozen-Gagnon
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY 10065, USA
| | - Amir Shlomai
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY 10065, USA
| | - Gaël Auray
- Department of Virology, Institute of Virology and Immunology IVI, 3147 Mittelhäusern, Switzerland; Department of Infectious Diseases and Pathobiology, University of Bern, 3012 Bern, Switzerland
| | - Markus Gerber
- Department of Virology, Institute of Virology and Immunology IVI, 3147 Mittelhäusern, Switzerland; Department of Infectious Diseases and Pathobiology, University of Bern, 3012 Bern, Switzerland
| | - John Fak
- Laboratory of Molecular Neuro-Oncology, and Howard Hughes Medical Institute, The Rockefeller University, New York, NY 10065, USA
| | - Irene Keller
- Interfaculty Bioinformatics Unit and Swiss Institute of Bioinformatics, University of Bern, 3012 Bern, Switzerland
| | - Rémy Bruggmann
- Interfaculty Bioinformatics Unit and Swiss Institute of Bioinformatics, University of Bern, 3012 Bern, Switzerland
| | - Robert B Darnell
- Laboratory of Molecular Neuro-Oncology, and Howard Hughes Medical Institute, The Rockefeller University, New York, NY 10065, USA; New York Genome Center, New York, NY 10013, USA
| | - Nicolas Ruggli
- Department of Virology, Institute of Virology and Immunology IVI, 3147 Mittelhäusern, Switzerland; Department of Infectious Diseases and Pathobiology, University of Bern, 3012 Bern, Switzerland
| | - Charles M Rice
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY 10065, USA.
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36
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Billerbeck E, Mommersteeg MC, Shlomai A, Xiao JW, Andrus L, Bhatta A, Vercauteren K, Michailidis E, Dorner M, Krishnan A, Charlton MR, Chiriboga L, Rice CM, de Jong YP. Humanized mice efficiently engrafted with fetal hepatoblasts and syngeneic immune cells develop human monocytes and NK cells. J Hepatol 2016; 65:334-43. [PMID: 27151182 PMCID: PMC4955758 DOI: 10.1016/j.jhep.2016.04.022] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 03/31/2016] [Accepted: 04/04/2016] [Indexed: 12/04/2022]
Abstract
BACKGROUND & AIMS Human liver chimeric mice are useful models of human hepatitis virus infection, including hepatitis B and C virus infections. Independently, immunodeficient mice reconstituted with CD34(+) hematopoietic stem cells (HSC) derived from fetal liver reliably develop human T and B lymphocytes. Combining these systems has long been hampered by inefficient liver reconstitution of human fetal hepatoblasts. Our study aimed to enhance hepatoblast engraftment in order to create a mouse model with syngeneic human liver and immune cells. METHODS The effects of human oncostatin-M administration on fetal hepatoblast engraftment into immunodeficient fah(-/-) mice was tested. Mice were then transplanted with syngeneic human hepatoblasts and HSC after which human leukocyte chimerism and functionality were analyzed by flow cytometry, and mice were challenged with HBV. RESULTS Addition of human oncostatin-M enhanced human hepatoblast engraftment in immunodeficient fah(-/-) mice by 5-100 fold. In contrast to mice singly engrafted with HSC, which predominantly developed human T and B lymphocytes, mice co-transplanted with syngeneic hepatoblasts also contained physiological levels of human monocytes and natural killer cells. Upon infection with HBV, these mice displayed rapid and sustained viremia. CONCLUSIONS Our study provides a new mouse model with improved human fetal hepatoblast engraftment and an expanded human immune cell repertoire. With further improvements, this model may become useful for studying human immunity against viral hepatitis. LAY SUMMARY Important human pathogens such as hepatitis B virus, hepatitis C virus and human immunodeficiency virus only infect human cells which complicates the development of mouse models for the study of these pathogens. One way to make mice permissive for human pathogens is the transplantation of human cells into immune-compromised mice. For instance, the transplantation of human liver cells will allow the infection of these so-called "liver chimeric mice" with hepatitis B virus and hepatitis C virus. The co-transplantation of human immune cells into liver chimeric mice will further allow the study of human immune responses to hepatitis B virus or hepatitis C virus. However, for immunological studies it will be crucial that the transplanted human liver and immune cells are derived from the same human donor. In our study we describe the efficient engraftment of human fetal liver cells and immune cells derived from the same donor into mice. We show that liver co-engraftment resulted in an expanded human immune cell repertoire, including monocytes and natural killer cells in the liver. We further demonstrate that these mice could be infected with hepatitis B virus, which lead to an expansion of natural killer cells. In conclusion we have developed a new mouse model that could be useful to study human immune responses to human liver pathogens.
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Affiliation(s)
- Eva Billerbeck
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA
| | - Michiel C. Mommersteeg
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA
| | - Amir Shlomai
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA
| | - Jing W. Xiao
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA
| | - Linda Andrus
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA
| | - Ankit Bhatta
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA
| | - Koen Vercauteren
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA
| | - Eleftherios Michailidis
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA
| | - Marcus Dorner
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA
| | - Anuradha Krishnan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Michael R. Charlton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Luis Chiriboga
- Department of Pathology, New York University Medical Center, New York, NY, USA
| | - Charles M. Rice
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA,Corresponding authors. Address: The Rockefeller University, Laboratory of Virology and Infectious Disease, 1230 York Avenue, Box 64, New York, NY 10065, USA. Tel.: +1 212 327 7009; fax: +1 212 327 7048. (C.M. Rice), (Y.P. de Jong)
| | - Ype P. de Jong
- Laboratory of Virology and Infectious Disease, The Rockefeller University, New York, NY, USA,Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA,Corresponding authors. Address: The Rockefeller University, Laboratory of Virology and Infectious Disease, 1230 York Avenue, Box 64, New York, NY 10065, USA. Tel.: +1 212 327 7009; fax: +1 212 327 7048. (C.M. Rice), (Y.P. de Jong)
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37
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Hasin Y, Shteingart S, Dahari H, Gafanovich I, Floru S, Braun M, Shlomai A, Verstandig A, Dery I, Uprichard SL, Cotler SJ, Lurie Y. Hepatitis C virus cures after direct acting antiviral-related drug-induced liver injury: Case report. World J Hepatol 2016; 8:858-862. [PMID: 27458506 PMCID: PMC4945506 DOI: 10.4254/wjh.v8.i20.858] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 04/28/2016] [Accepted: 06/29/2016] [Indexed: 02/06/2023] Open
Abstract
The United States Food and Drug Administration recently warned that the direct acting antiviral (DAA) combination hepatitis C virus (HCV) treatment of Paritaprevir, Ombitasvir, Dasabuvir, Ritonavir, and Ribavirin (PODr + R) can cause severe liver injury in patients with advanced liver disease. Drug induced liver injury was observed in a small number of patients with decompensated cirrhosis treated with other DAAs, but has not been reported in patients with compensated cirrhosis. We report a case of a 74-year-old woman with chronic HCV and Child-Pugh class A cirrhosis (compensated cirrhosis) treated with PODr + R. The patient presented on day 14 of PODr + R therapy with jaundice and new-onset ascites. Her total bilirubin level increased to 23 mg/dL and international normalized ratio rose to 1.65, while aminotransferase levels remained relatively stable. Hepatitis C treatment was discontinued on day 24 and she gradually recovered. Follow-up testing showed that she achieved a sustained virologic response. In conclusion, hepatic decompensation developed within two weeks of starting treatment with PODr + R in a patient with Child-Pugh class A cirrhosis and was characterized by jaundice and ascites with stable aminotransferase levels. Careful monitoring is warranted in patients with HCV-related cirrhosis treated with PODr + R.
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38
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Abstract
Approximately 350 million people worldwide are chronically infected with hepatitis B virus (HBV), representing a significant public health challenge. Nucleos/tide analogues (NUCs) and interferon alpha (IFNα), the current standard of care for chronic infection, aim at preventing progression of the disease to cirrhosis, hepatocellular carcinoma (HCC) and death. However, in contrast to the case of hepatitis C virus infection, in which novel antiviral drugs cure the vast majority of treated patients, in regard to HBV, cure is rare due to the unusual persistence of viral DNA in the form of covalently closed circular DNA (cccDNA) within the nucleus of infected cells. Available therapies for HBV require lifelong treatment and surveillance, as reactivation frequently occurs following medication cessation and the occurrence of HCC is decreased but not eliminated, even after years of successful viral suppression. Progress has been made in the development of new therapeutics, and it is likely that only a combination of immune modulators, inhibitors of gene expression and replication and cccDNA-targeting drugs will eradicate chronic infection. This review aims to summarize the state of the art in HBV drug research highlighting those agents with the greatest potential for success based on in vitro as well as on data from clinical studies.
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Affiliation(s)
- Maya Bitton Alaluf
- Department of Medicine D, Beilinson Hospital Rabin Medical Center, Petah Tikva, Israel
| | - Amir Shlomai
- Department of Medicine D, Beilinson Hospital Rabin Medical Center, Petah Tikva, Israel.,The Liver Institute, Beilinson Hospital Rabin Medical Center, Petah Tikva, Israel.,The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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39
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Witt-Kehati D, Bitton Alaluf M, Shlomai A. Advances and Challenges in Studying Hepatitis B Virus In Vitro. Viruses 2016; 8:v8010021. [PMID: 26784218 PMCID: PMC4728581 DOI: 10.3390/v8010021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 11/30/2015] [Accepted: 01/06/2016] [Indexed: 12/17/2022] Open
Abstract
Hepatitis B virus (HBV) is a small DNA virus that infects the liver. Current anti-HBV drugs efficiently suppress viral replication but do not eradicate the virus due to the persistence of its episomal DNA. Efforts to develop reliable in vitro systems to model HBV infection, an imperative tool for studying HBV biology and its interactions with the host, have been hampered by major limitations at the level of the virus, the host and infection readouts. This review summarizes major milestones in the development of in vitro systems to study HBV. Recent advances in our understanding of HBV biology, such as the discovery of the bile-acid pump sodium-taurocholate cotransporting polypeptide (NTCP) as a receptor for HBV, enabled the establishment of NTCP expressing hepatoma cell lines permissive for HBV infection. Furthermore, advanced tissue engineering techniques facilitate now the establishment of HBV infection systems based on primary human hepatocytes that maintain their phenotype and permissiveness for infection over time. The ability to differentiate inducible pluripotent stem cells into hepatocyte-like cells opens the door for studying HBV in a more isogenic background, as well. Thus, the recent advances in in vitro models for HBV infection holds promise for a better understanding of virus-host interactions and for future development of more definitive anti-viral drugs.
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Affiliation(s)
- Dvora Witt-Kehati
- The Liver Institute, Rabin Medical Center Beilinson Hospital, Petah-Tikva, Israel.
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Maya Bitton Alaluf
- Department of Medicine D, Rabin Medical Center Beilinson Hospital, Petah-Tikva, Israel.
| | - Amir Shlomai
- The Liver Institute, Rabin Medical Center Beilinson Hospital, Petah-Tikva, Israel.
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
- Department of Medicine D, Rabin Medical Center Beilinson Hospital, Petah-Tikva, Israel.
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40
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March S, Ramanan V, Trehan K, Ng S, Galstian A, Gural N, Scull MA, Shlomai A, Mota MM, Fleming HE, Khetani SR, Rice CM, Bhatia SN. Micropatterned coculture of primary human hepatocytes and supportive cells for the study of hepatotropic pathogens. Nat Protoc 2015; 10:2027-53. [PMID: 26584444 PMCID: PMC5867906 DOI: 10.1038/nprot.2015.128] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The development of therapies and vaccines for human hepatropic pathogens requires robust model systems that enable the study of host-pathogen interactions. However, in vitro liver models of infection typically use either hepatoma cell lines that exhibit aberrant physiology or primary human hepatocytes in culture conditions in which they rapidly lose their hepatic phenotype. To achieve stable and robust in vitro primary human hepatocyte models, we developed micropatterned cocultures (MPCCs), which consist of primary human hepatocytes organized into 2D islands that are surrounded by supportive fibroblast cells. By using this system, which can be established over a period of days, and maintained over multiple weeks, we demonstrate how to recapitulate in vitro hepatic life cycles for the hepatitis B and C viruses and the Plasmodium pathogens P. falciparum and P. vivax. The MPCC platform can be used to uncover aspects of host-pathogen interactions, and it has the potential to be used for drug and vaccine development.
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Affiliation(s)
- Sandra March
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Department of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Vyas Ramanan
- Department of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Kartik Trehan
- Department of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Shengyong Ng
- Department of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Ani Galstian
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Department of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Nil Gural
- Department of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Margaret A Scull
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, New York, USA
| | - Amir Shlomai
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, New York, USA
| | - Maria M Mota
- Unidade de Malaria, Instituto de Medicina Molecular, Universidade de Lisboa, Lisboa, Portugal
| | - Heather E Fleming
- Department of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Salman R Khetani
- Department of Mechanical Engineering, School of Biomedical Engineering, Colorado State University, Fort Collins, Colorado, USA
| | - Charles M Rice
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, New York, USA
| | - Sangeeta N Bhatia
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Department of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Howard Hughes Medical Institute, Cambridge, Massachusetts, USA
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
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41
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Shlomai A, Tobar A, Benjaminov O. Multiple liver lesions after oxaliplatin-based chemotherapy for colorectal cancer. Gastroenterology 2015; 149:e1-3. [PMID: 26433107 DOI: 10.1053/j.gastro.2015.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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: 12/16/2014] [Revised: 01/06/2015] [Accepted: 02/10/2015] [Indexed: 01/13/2023]
Affiliation(s)
- Amir Shlomai
- The Liver Institute, Rabin Medical Center, Beilinson hospital, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ana Tobar
- Department of Pathology, Rabin Medical Center, Beilinson hospital, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ofer Benjaminov
- Department of Radiology, Rabin Medical Center, Beilinson hospital, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Shlomai A. Hepatitis C virus addiction to liver miR-122 takes its Toll on the host. Hepatology 2015; 62:1633-5. [PMID: 26096908 DOI: 10.1002/hep.27947] [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] [Indexed: 12/07/2022]
Affiliation(s)
- Amir Shlomai
- The Liver Institute, Beilinson Hospital Rabin Medical Center, Petah-Tikva, Israel, The Sackler Faculty of Medicine Tel-Aviv University Tel-Aviv, Israel
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Ricardo-Lax I, Ramanan V, Michailidis E, Shamia T, Reuven N, Rice CM, Shlomai A, Shaul Y. Hepatitis B virus induces RNR-R2 expression via DNA damage response activation. J Hepatol 2015; 63:789-96. [PMID: 26026873 DOI: 10.1016/j.jhep.2015.05.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [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: 07/25/2014] [Revised: 04/21/2015] [Accepted: 05/19/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Hepatitis B virus (HBV) infects and replicates in quiescent hepatocytes, which are deficient in dNTPs, the critical precursors of HBV replication. Most tumor viruses promote dNTP production in host cells by inducing cell proliferation. Although HBV is known as a major cause of hepatocellular carcinoma, it does not lead to cellular proliferation. Instead, HBV acquires dNTPs by activating the expression of the R2 subunit of the Ribonucleotide Reductase (RNR) holoenzyme, the cell cycle gene that is rate-limiting for generation of dNTPs, without inducing the cell cycle. We wished to elucidate the molecular basis of HBV-dependent R2 expression in quiescent cells. METHODS Quiescent HepG2 cells were transduced with an HBV-containing lentiviral vector, and primary human hepatocytes were infected with HBV. DNA damage response and RNR-R2 gene expression were monitored under this condition. RESULTS We report here that HBV-induced R2 expression is mediated by the E2F1 transcription factor, and that HBV induces E2F1 accumulation, modification and binding to the R2 promoter. We found that Chk1, a known E2F1 kinase that functions in response to DNA damage, was activated by HBV. In cells where Chk1 was pharmacologically inhibited, or depleted by shRNA-mediated knockdown, HBV-mediated R2 expression was severely attenuated. Furthermore, we found that HBV attenuates DNA repair, thus reducing cellular dNTP consumption. CONCLUSIONS Our findings demonstrate that HBV exploits the Chk1-E2F1 axis of the DNA damage response pathway to induce R2 expression in a cell cycle-independent manner. This suggests that inhibition of this pathway may have a therapeutic value for HBV carriers.
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Affiliation(s)
- Inna Ricardo-Lax
- Department of Molecular Genetics, Weizmann Institute of Science, Rehovot 76100, Israel
| | - Vyas Ramanan
- Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA 02139, United States
| | - Eleftherios Michailidis
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY 10065, United States
| | - Tal Shamia
- Department of Molecular Genetics, Weizmann Institute of Science, Rehovot 76100, Israel
| | - Nina Reuven
- Department of Molecular Genetics, Weizmann Institute of Science, Rehovot 76100, Israel
| | - Charles M Rice
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY 10065, United States
| | - Amir Shlomai
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY 10065, United States.
| | - Yosef Shaul
- Department of Molecular Genetics, Weizmann Institute of Science, Rehovot 76100, Israel.
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Ramanan V, Shlomai A, Cox DB, Schwartz RE, Michailidis E, Bhatta A, Scott DA, Zhang F, Rice CM, Bhatia SN. CRISPR/Cas9 cleavage of viral DNA efficiently suppresses hepatitis B virus. Sci Rep 2015; 5:10833. [PMID: 26035283 PMCID: PMC4649911 DOI: 10.1038/srep10833] [Citation(s) in RCA: 219] [Impact Index Per Article: 24.3] [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] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 04/29/2015] [Indexed: 02/07/2023] Open
Abstract
Chronic hepatitis B virus (HBV) infection is prevalent, deadly, and seldom cured due to the persistence of viral episomal DNA (cccDNA) in infected cells. Newly developed genome engineering tools may offer the ability to directly cleave viral DNA, thereby promoting viral clearance. Here, we show that the CRISPR/Cas9 system can specifically target and cleave conserved regions in the HBV genome, resulting in robust suppression of viral gene expression and replication. Upon sustained expression of Cas9 and appropriately chosen guide RNAs, we demonstrate cleavage of cccDNA by Cas9 and a dramatic reduction in both cccDNA and other parameters of viral gene expression and replication. Thus, we show that directly targeting viral episomal DNA is a novel therapeutic approach to control the virus and possibly cure patients.
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Affiliation(s)
- Vyas Ramanan
- Department of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Amir Shlomai
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY 10065, USA
| | - David B.T. Cox
- Department of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Broad Institute, Cambridge, MA 02139, USA
- Department of Biology, Massachusetts Institute of Technology, Cambridge, MA 02139
| | - Robert E. Schwartz
- Department of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY 10065, USA
| | - Eleftherios Michailidis
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY 10065, USA
| | - Ankit Bhatta
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY 10065, USA
| | - David A. Scott
- Broad Institute, Cambridge, MA 02139, USA
- McGovern Institute for Brain Research, Massachusetts Institute of Technology, Cambridge, MA 02139
| | - Feng Zhang
- Department of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Broad Institute, Cambridge, MA 02139, USA
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA 02139
- McGovern Institute for Brain Research, Massachusetts Institute of Technology, Cambridge, MA 02139
| | - Charles M. Rice
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY 10065, USA
| | - Sangeeta N. Bhatia
- Department of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Broad Institute, Cambridge, MA 02139, USA
- Howard Hughes Medical Institute, Cambridge, MA 02139, USA
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
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Affiliation(s)
- Amir Shlomai
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, 1230 York Avenue, New York, NY 10065, USA
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Shlomai A, de Jong YP, Rice CM. Virus associated malignancies: the role of viral hepatitis in hepatocellular carcinoma. Semin Cancer Biol 2014; 26:78-88. [PMID: 24457013 DOI: 10.1016/j.semcancer.2014.01.004] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Revised: 12/29/2013] [Accepted: 01/09/2014] [Indexed: 02/06/2023]
Abstract
Hepatocellular carcinoma (HCC) is the third leading fatal cancer worldwide and its incidence continues to increase. Chronic viral hepatitis involving either hepatitis B virus (HBV) or hepatitis C virus (HCV) infection is the leading etiology for HCC, making HCC prevention a major goal of antiviral therapy. While recent clinical observations and translational research have enhanced our understanding of the molecular mechanisms driving the initiation and progression of HCC, much remains unknown. Current data indicates that HCC tumors are highly complex and heterogeneous resulting from the aberrant function of multiple molecular pathways. This complex biology is responsible, at least in part, for the absence of highly efficient target-directed therapies for this deadly cancer. Additionally, the direct or indirect effect of HBV and HCV infection on the development of HCC is still a contentious issue. Thus, the question remains whether viral hepatitis-associated HCC stems from virus-specific factors, and/or from a general mechanism involving inflammation and tissue regeneration. In this review we summarize general mechanisms implicated in HCC, emphasizing data generated by new technologies available today. We also highlight specific pathways by which HBV and HCV could be involved in HCC pathogenesis. However, improvements to current in vitro and in vivo systems for both viruses will be needed to rigorously define the temporal sequence and specific pathway dysregulations that drive the strong clinical link between chronic hepatitis virus infection and HCC.
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Affiliation(s)
- Amir Shlomai
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY, USA.
| | - Ype P de Jong
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY, USA; Division of Gastroenterology and Hepatology, Center for the Study of Hepatitis C, Weill Cornell Medical College, New York, NY, USA
| | - Charles M Rice
- Laboratory of Virology and Infectious Disease, Center for the Study of Hepatitis C, The Rockefeller University, New York, NY, USA.
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Ben-Shlomo S, Zvibel I, Varol C, Spektor L, Shlomai A, Santo EM, Halpern Z, Oren R, Fishman S. Role of glucose-dependent insulinotropic polypeptide in adipose tissue inflammation of dipeptidylpeptidase 4-deficient rats. Obesity (Silver Spring) 2013; 21:2331-41. [PMID: 23408696 DOI: 10.1002/oby.20340] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [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: 08/05/2012] [Accepted: 12/11/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Dipeptidyl peptidase 4 (DPP4) inhibitors, used in obese diabetic patients, reduce inflammation in several models. The role of chronic DPP4-deficiency (DPP4-) in diet-induced obesity with respect to insulin sensitivity and adipose tissue inflammation was investigated. DESIGN AND METHODS Insulin resistance was induced by 2 months high fat diet (HFD). In vitro effects of glucose-dependent insulinotropic polypeptide (GIP) were assessed in adipose tissue explants and stromal vascular fraction (SVF). RESULTS HFD-fed DPP4-rats gained significantly more weight and visceral fat mass, yet were more insulin sensitive. Adipose tissue of DPP4- rats demonstrated increased adipocyte maturation and increased expression of enzymes involved in triglyceride uptake and synthesis, yet increased adiponectin mRNA, reduced mRNA of proinflammatory cytokines and reduced vascular adhesion molecules, suggesting reduced inflammation. In vitro and in vivo experiments explored the role of GIP in inducing this phenotype. Indeed, we demonstrated that GIP directly enhanced adiponectin expression in rat and human adipose tissue explants and in SVF. Lastly, GIP administration to normal or HFD-fed rats elevated serum adiponectin and improved their glucose tolerance test. CONCLUSION In a HFD model, DPP4-rats exhibited reduced adipose tissue inflammation and improved insulin resistance, which may be mediated in part by GIP induction of adiponectin.
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Affiliation(s)
- Shani Ben-Shlomo
- The Research Center for Digestive Tract and Liver Diseases, The Department of Gastroenterology and Liver diseases, Tel-Aviv Sourasky Medical Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Shlomai A, Halfon P, Goldiner I, Zelber-Sagi S, Halpern Z, Oren R, Bruck R. Serum bile acid levels as a predictor for the severity of liver fibrosis in patients with chronic hepatitis C. J Viral Hepat 2013; 20:95-102. [PMID: 23301544 DOI: 10.1111/j.1365-2893.2012.01628.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [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: 01/20/2023]
Abstract
Serum bile acids (SBAs) are commonly elevated in cholestatic liver diseases, but it is unclear if SBA levels are also elevated in noncholestatic chronic liver diseases and whether those levels correlate with disease severity. We analysed SBA levels of 135 consecutive patients with chronic hepatitis C virus infection and correlated these levels with the degree of liver fibrosis as determined by liver biopsy. In addition, we assessed the accuracy of SBA levels as a noninvasive predictor for liver fibrosis by its comparison to the patients' FibroTest scores. Two-thirds (90/135 patients, 67%) of the study patients had nonsevere liver fibrosis (Metavir F0-F2), and the others (45/135, 33%) had severe fibrosis or cirrhosis (Metavir F3-F4). The SBA levels were significantly higher in patients with severe fibrosis as compared to nonsevere fibrosis (11.46 ± 10.01 vs 6.37 ± 4.69, P < 0.0001). Furthermore, a receiver operator characteristics curve based on a model that included serum bile acids, age, body mass index, serum AST, glucose and cholesterol levels suggested that this combination reliably predicts the degree of liver fibrosis and is not inferior to the current noninvasive FibroTest score (areas under the curve of 0.837 vs 0.83, respectively, P = 0.87). We conclude that measurement of SBA levels may have a clinical role as a simple noninvasive tool to assess the severity of HCV-induced liver disease. Combined with widely available laboratory parameters, SBA levels can predict disease severity with a high degree of accuracy.
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Affiliation(s)
- A Shlomai
- Institute of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Mouler Rechtman M, Burdelova EO, Bar-Yishay I, Ben-Yehoyada M, Fishman S, Halpern Z, Shlomai A. The metabolic regulator PGC-1α links anti-cancer cytotoxic chemotherapy to reactivation of hepatitis B virus. J Viral Hepat 2013; 20:34-41. [PMID: 23231082 DOI: 10.1111/j.1365-2893.2012.01622.x] [Citation(s) in RCA: 9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Patients with chronic hepatitis B virus (HBV) infection are at an increased risk for a severe and a potentially fatal viral reactivation following anti-cancer therapy. The molecular mechanism for this induction of HBV expression is still unclear. Here, we show that treating hepatoma cell line expressing HBV with various anti-cancer cytotoxic agents results in a significant up-regulation of HBV expression. This HBV induction is at the transcriptional level and is time dependent. Interestingly, treating hepatoma cells with anti-cancer cytotoxic agents results in a robust induction of peroxisome proliferator-activated receptor-gamma coactivator-1α (PGC-1α), a metabolic and energy regulator that is normally induced in the liver under starvation conditions and that has been previously shown to strongly coactivate HBV transcription. Most importantly, HBV up-regulation following anti-cancer therapy depends on PGC-1α induction, because PGC-1α knock-down abolishes HBV induction. Finally, pretreatment of HBV-expressing cells with the antioxidant agent N-acetylcysteine attenuates the induction of both PGC-1α and HBV in response to anti-cancer treatment, suggesting that chemotherapy-associated PGC-1α induction is mediated by cellular oxidative stress that ultimately leads to HBV up-regulation. We conclude that cytotoxic anti-cancer chemotherapy has a direct and an immune system-independent effect on HBV gene expression, which is mediated by PGC-1α. Our results attribute to this metabolic regulator an unexpected role in linking anti-cancer treatment to HBV reactivation and make PGC-1α a potential target for future anti-HBV therapy, especially under conditions in which it is robustly induced, such as following anti-cancer treatment.
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Affiliation(s)
- M Mouler Rechtman
- The Research Center for Digestive Tract and Liver Diseases, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Shlomai A. Targeting late SV40 factor: Is the achilles heel of hepatocarcinogenesis revealed? World J Gastroenterol 2012; 18:6709-11. [PMID: 23239907 PMCID: PMC3520158 DOI: 10.3748/wjg.v18.i46.6709] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 05/29/2012] [Accepted: 06/07/2012] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is a dreadful cancer and a major cause of death among patients with chronic liver disease and cirrhosis. The apparent alterations in a diversity of intracellular pathways found in HCC has set the rational for developing molecular-directed drugs that simultaneously inhibit multiple pathways, such as the multi-kinase inhibitor Sorafenib. However, recently this concept has been challenged by showing that HCC is heavily dependent on a single oncogene designated late SV-40 factor (LSF), a transcription factor that is over-expressed in liver cancer cells and that its expression is strongly correlated with tumor grade and aggressiveness. Furthermore, using an intensive screening for drugs that inhibit LSF activity, Grant et al have found a molecule designated factor quinolinone inhibitor 1 that can specifically block the ability of LSF to bind its target promoters, resulting in a massive death of HCC cells both in vitro and in vivo. The innovative findings of HCC representing “oncogene addiction” to LSF and the ability of a single molecule to block the activity of this oncogene resulting in tumor abolishment are encouraging and provide us with the hope that the “Achilles heel” of HCC has been found.
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