Adjusted estimate of the prevalence of hepatitis delta virus in 25 countries and territories

BACKGROUND & AIMS

Hepatitis delta virus (HDV) is a satellite RNA virus that requires the hepatitis B virus (HBV) for assembly and propagation. Individuals infected with HDV progress to advanced liver disease faster than HBV-monoinfected individuals. Recent studies have estimated the global prevalence of anti-HDV antibodies among the HBV-infected population to be 5-15%. This study aimed to better understand HDV prevalence at the population level in 25 countries/territories.

METHODS

We conducted a literature review to determine the prevalence of anti-HDV and HDV RNA in hepatitis B surface antigen (HBsAg)-positive individuals in 25 countries/territories. Virtual meetings were held with experts from each setting to discuss the findings and collect unpublished data. Data were weighted for patient segments and regional heterogeneity to estimate the prevalence in the HBV-infected population. The findings were then combined with The Polaris Observatory HBV data to estimate the anti-HDV and HDV RNA prevalence in each country/territory at the population level.

RESULTS

After adjusting for geographical distribution, disease stage and special populations, the anti-HDV prevalence among the HBsAg+ population changed from the literature estimate in 19 countries. The highest anti-HDV prevalence was 60.1% in Mongolia. Once adjusted for the size of the HBsAg+ population and HDV RNA positivity rate, China had the highest absolute number of HDV RNA+ cases.

CONCLUSIONS

We found substantially lower HDV prevalence than previously reported, as prior meta-analyses primarily focused on studies conducted in groups/regions that have a higher probability of HBV infection: tertiary care centers, specific risk groups or geographical regions. There is large uncertainty in HDV prevalence estimates. The implementation of reflex testing would improve estimates, while also allowing earlier linkage to care for HDV RNA+ individuals. The logistical and economic burden of reflex testing on the health system would be limited, as only HBsAg+ cases would be screened.

IMPACT AND IMPLICATIONS

There is a great deal of uncertainty surrounding the prevalence of hepatitis delta virus among people living with hepatitis B virus at the population level. In this study, we aimed to better understand the burden in 25 countries and territories, to refine techniques that can be used in future analyses. We found a lower prevalence in the majority of places studied than had been previously reported. These data can help inform policy makers on the need to screen people living with hepatitis B virus to find those coinfected with hepatitis delta virus and at high risk of progression, while also highlighting the pitfalls that other researchers have often fallen into.

Assessment of Minimal Hepatic Encephalopathy with Brain MRI and EncephalApp Stroop Test

Background: Minimal hepatic encephalopathy (MHE) consists of subtle cognitive deficits that are not apparent on a standard neurological examination. Minimal hepatic encephalopathy has been reported in up to 80% of cirrhotic patients and is associated with decreased job performance, poor driving performance, impaired quality of life, and poor survival. In parallel, brain magnetic resonance imaging (MRI) abnormalities are known to occur in liver cirrhotic patients in the form of T1 globus pallidus hyperintensities. In recent years, a new psychometric test for diagnosing MHE has been developed as an app for smartphones and tablets (EncephalApp Stroop test). A translated version of the app is available in Romanian language. Aim:To use EncephalApp Stroop test for MHE diagnosis in our cirrhotic patients; to describe the main brain MRI abnormalities encountered in these patients; and to establish if Stroop test results correlate with imaging findings, clinical neurologic findings, and liver function parameters or prognosis. Material and methods:Cross-sectional study over a one-year period, involving 30 adult patients with liver cirrhosis. Subjects were evaluated through a standard neurological examination, psychometric testing using EncephalApp Stroop test, electroencephalogram and brain MRI. In parallel, 40 adult healthy controls were also recruited and evaluated with the EncephalApp Stroop test using the same methodology. Results:Age distribution was similar between the two groups (p=0.6). The mean age of patients was 50±10 years and that of controls 51±12 years. Mean Stroop result was 171±26 seconds for the patient group and 143±20 seconds for the control group (p<0.0001). There was a direct correlation between Stroop test results and age in the control group (R=0.69, p<0.0001) but not also in the patient group (R=0.28, p=0.13). Statistically significant results were obtained by using the Fischer exact test for both cut-off values: 145 seconds in patients < 45-year-old (p<0.001) and 190 seconds in those ≥45 years-old (p=0.03). MRI T1-hyperintensities of the basal ganglia, blood ammonia levels and electroencephalographic changes were not associated with poorer results. Conclusion:Our pilot study, although small, confirmed that patients with liver cirrhosis may have subtle deficits in cognitive areas like attention, concentration or reaction time. This can be assessed easily with the EncephalApp Stroop test which is readily available for use on smartphones or tablets.

Electrocardiographic findings in true acute left main coronary total occlusion a subanalisys from ATOLMA registry

INTRODUCTION

Acute total occlusion of the left main coronary artery (ATOLMA) usually leads to a catastrophic presentation. Prediction of ATOLMA by electrocardiogram (ECG) may contribute to early detection and reperfusion. Limited data have been reported previously. This study aims to identify the admission 12‑leads ECG features that can predict the presence of ATOLMA and in-Hospital mortality in these patients.

METHODS

The admission ECGs findings in 24 patients from the previously reported ATOLMA multicenter registry were compared to the ECGs findings in 15 patients with an acute subtotal occlusion of the left main (ASOLMA) and to 15 patients with anterior ST-elevation myocardial infarction of the proximal left anterior descending (LADp-STEMI).

RESULTS

Some ECG features at presentation can predict an ATOLMA: QRS left axis deviation (-61.17 ± 9 degrees); ST-segment elevation in aVL (1.9 ± 0.65 mm); absence of ST-segment elevation in V1 (0.0 ± 0.6 mm); bifascicular block (58%); fragmented QRS (62.5%); prolongation of QTc interval (465 ± 19 ms) and of QRS interval (136 ± 12 mm). The multivariate analysis found that the independent predictors to distinguish ATOLMA from ASOLMA were aVL ST-segment deviation (OR 5.6(95% CI 1.5-21), p = 0.01) and absence of V1 ST-segment elevation (OR 27(95% CI 1.4-52), p = 0.01); and from LADp-STEMI was QRS width (OR 1.1(95% CI 1.02-1.2), p = 0.02). Fragmented QRS was the only independent predictor of in-hospital mortality in ATOLMA (OR 0.125(95% CI 0.01-0.81), p = 0.03).

CONCLUSIONS

aVL ST-segment elevation, the absence of V1 ST-segment elevation, left axis deviation, the presence of bifascicular block, and prolongation of QRS and QTc interval are predictors of ATOLMA. Fragmented QRS predicts in-hospital mortality in ATOLMA.

Primary Angioplasty in a Catastrophic Presentation: Acute Left Main Coronary Total Occlusion-The ATOLMA Registry

OBJECTIVES

To determine the outcome predictors of in-hospital mortality in acute total occlusion of the left main coronary artery (ATOLMA) patients referred to emergent angioplasty and to describe the clinical presentation and the long-term outcome of these patients.

BACKGROUND

ATOLMA is an uncommon angiographic finding that usually leads to a catastrophic presentation. Limited and inconsistent data have been previously reported regarding true ATOLMA, yet comprehensive knowledge remains scarce.

METHODS

This is a multicenter retrospective cohort that includes patients presenting with myocardial infarction due to a confirmed ATOLMA who underwent emergency percutaneous coronary intervention (PCI).

RESULTS

In the period of the study, 7930 emergent PCI were performed in the five participating centers, and 46 of them had a true ATOLMA (0.58%). At admission, cardiogenic shock was present in 89% of patients, and cardiopulmonary resuscitation was required in 67.4%. All the patients had right dominance. Angiographic success was achieved in 80.4% of the procedures, 13 patients (28.2%) died during the catheterization, and the in-hospital mortality rate was 58.6% (27/46). At one-year and at the final follow-up, 18 patients (39%) were alive, including four cases successfully transplanted. Multivariate analysis showed that postprocedural TIMI flow was the only independent predictor of in-hospital mortality (OR 0.23, (95% CI 0.1-0.36), p < 0.001).

CONCLUSIONS

Our study confirms that the clinical presentation of ATOLMA is catastrophic, presenting a high in-hospital mortality rate; nevertheless, primary angioplasty in this setting is feasible. Postprocedural TIMI flow resulted as the only independent predictor of in-hospital mortality. In-hospital survivors presented an encouraging outcome. ATOLMA and left dominance could be incompatible with life.

Quantification of serum markers of hepatitis B (HBV) and Delta virus (HDV) infections in patients with chronic HDV infection

The interplay between hepatitis B (HBV) and delta (HDV) viruses is complex and not always characterized during chronic HDV infection. We assessed the clinical usefulness of new quantitative assays for HBV and HDV serum markers in a retrospective cross-sectional study. Sera obtained from 122 HDV genotype 1 and HBV genotype D coinfected, anti-HIV-negative patients (71 males; median age 49.8 [21.7-66.9] years), recruited consecutively in two geographical areas (Italy 69 patients, Romania 53 patients) with different HBV and HDV epidemiology, were tested for HBsAg, HBV-DNA, HBcrAg, total anti-HBc, HDV-RNA, IgM and total anti-HDV using quantitative assays. Cirrhosis, which showed comparable prevalence in the two cohorts, was diagnosed in 97 of 122 (79.5%) patients. At multivariate analysis, cirrhosis was associated with lower total anti-HBc/IgM anti-HDV ratio (OR 0.990, 95% CI 0.981-0.999, P = .038), whereas disease activity was associated with higher total anti-HDV (OR 10.105, 95% CI 1.671-61.107, P = .012) and HDV-RNA levels (OR 2.366, 95% CI 1.456-3.844, P = .001). HDV-RNA serum levels showed a positive correlation with HBV-DNA (ρ = 0.276, P = .005), HBsAg (ρ = 0.404, P < .001) and HBcrAg (ρ = 0.332, P < .001). The combined quantitative profiling of HBV and HDV serum markers identifies specific patterns associated with activity and stage of chronic hepatitis D (CHD). HDV pathogenicity depends on the underlying active HBV infection in spite of the inhibition of its replication. HDV-RNA, IgM anti-HDV, total anti-HDV, total anti-HBc, HBsAg and HBcrAg serum levels qualify for prospective studies to predict progressive CHD and identify candidates to antiviral therapy.

Risk of hepatitis B virus reactivation in hepatitis B virus + hepatitis C virus-co-infected patients with compensated liver cirrhosis treated with ombitasvir, paritaprevir/r + dasabuvir + ribavirin

Hepatitis B virus may reactivate in patients with chronic hepatitis C treated with direct-acting antivirals. The aim of this study was to investigate the risk of hepatitis B virus (HBV) reactivation in HBV + hepatitis C virus (HCV)-co-infected patients with compensated liver cirrhosis treated with paritaprevir/ombitasvir/ritonavir, dasabuvir with ribavirin. We reviewed prospectively gathered data from a national cohort of 2070 hepatitis C virus patients with compensated liver cirrhosis who received reimbursed paritaprevir/ombitasvir/r, dasabuvir with ribavirin for 12 weeks from the Romanian National Health Agency during 2015-2016. Twenty-five patients in this cohort were HBs antigen positive (1.2%); 15 untreated with nucleotide analogues agreed to enter the study. These patients were followed up: ALT monthly, serology for HBV and DNA viral load at baseline, EOT and SVR at 12 weeks. Hepatitis B virus (HBV)-co-infected patients were all genotype 1b and 52% females, with a median age of 60 years (51 ÷ 74); 76% were pretreated with peginterferon + ribavirin; 72% were with severe necroinflammatory activity on FibroMax assessment; 40% presented comorbidities; and all were HBe antigen negative. Hepatitis C virus (HCV) SVR response rate was 100%. Hepatitis B virus (HBV)-DNA viral load was undetectable in 7/15 (47%) before therapy, and for the other 8 patients, it varied between below 20 and 867 IU/mL. Five patients (33%) presented virological reactivation (>2 log increase in HBV-DNA levels) during therapy. One patient presented with hepatitis associated with HBV reactivation, and two started anti-HBV therapy with entecavir. Hepatitis B virus (HBV) virological reactivation was present in 33% in our patients. Generally, HBV-DNA elevations were mild (<20 000 IU/mL); however, we report one case of hepatitis associated with HBV reactivation.

Elafibranor, an Agonist of the Peroxisome Proliferator-Activated Receptor-α and -δ, Induces Resolution of Nonalcoholic Steatohepatitis Without Fibrosis Worsening

BACKGROUND & AIMS

Elafibranor is an agonist of the peroxisome proliferator-activated receptor-α and peroxisome proliferator-activated receptor-δ. Elafibranor improves insulin sensitivity, glucose homeostasis, and lipid metabolism and reduces inflammation. We assessed the safety and efficacy of elafibranor in an international, randomized, double-blind placebo-controlled trial of patients with nonalcoholic steatohepatitis (NASH).

METHODS

Patients with NASH without cirrhosis were randomly assigned to groups given elafibranor 80 mg (n = 93), elafibranor 120 mg (n = 91), or placebo (n = 92) each day for 52 weeks at sites in Europe and the United States. Clinical and laboratory evaluations were performed every 2 months during this 1-year period. Liver biopsies were then collected and patients were assessed 3 months later. The primary outcome was resolution of NASH without fibrosis worsening, using protocol-defined and modified definitions. Data from the groups given the different doses of elafibranor were compared with those from the placebo group using step-down logistic regression, adjusting for baseline nonalcoholic fatty liver disease activity score.

RESULTS

In intention-to-treat analysis, there was no significant difference between the elafibranor and placebo groups in the protocol-defined primary outcome. However, NASH resolved without fibrosis worsening in a higher proportion of patients in the 120-mg elafibranor group vs the placebo group (19% vs 12%; odds ratio = 2.31; 95% confidence interval: 1.02-5.24; P = .045), based on a post-hoc analysis for the modified definition. In post-hoc analyses of patients with nonalcoholic fatty liver disease activity score ≥4 (n = 234), elafibranor 120 mg resolved NASH in larger proportions of patients than placebo based on the protocol definition (20% vs 11%; odds ratio = 3.16; 95% confidence interval: 1.22-8.13; P = .018) and the modified definitions (19% vs 9%; odds ratio = 3.52; 95% confidence interval: 1.32-9.40; P = .013). Patients with NASH resolution after receiving elafibranor 120 mg had reduced liver fibrosis stages compared with those without NASH resolution (mean reduction of 0.65 ± 0.61 in responders for the primary outcome vs an increase of 0.10 ± 0.98 in nonresponders; P < .001). Liver enzymes, lipids, glucose profiles, and markers of systemic inflammation were significantly reduced in the elafibranor 120-mg group vs the placebo group. Elafibranor was well tolerated and did not cause weight gain or cardiac events, but did produce a mild, reversible increase in serum creatinine (effect size vs placebo: increase of 4.31 ± 1.19 μmol/L; P < .001).

CONCLUSIONS

A post-hoc analysis of data from trial of patients with NASH showed that elafibranor (120 mg/d for 1 year) resolved NASH without fibrosis worsening, based on a modified definition, in the intention-to-treat analysis and in patients with moderate or severe NASH. However, the predefined end point was not met in the intention to treat population. Elafibranor was well tolerated and improved patients' cardiometabolic risk profile. ClinicalTrials.gov number: NCT01694849.

Adalimumab and Infliximab in Crohn's disease - real life data from a national retrospective cohort study

AIM

to compare the efficacy and safety of Adalimumab(ADA) and Infliximab(IFX), in a large Romanian population and to identify predictors of response. Methods We performed a national retrospective cohort study including 265 patients (136 ADA, 129 IFX) between 2008-2014. Binary logistic regression was performed with the statistical program Minitab.

RESULTS

Patients were half women, with a median age of 36, a median disease duration of 2.5 years, 80% received Azathioprine. Mean therapy duration was 20 months in ADA group and 36 months in IFX group. Complete response to Adalimumab respectively Infliximab was recorded in 77%vs.65%, secondary loss of response in 18%vs.28%, statistically comparable. We failed to identify predictors of response. In 79.2%of patients with secondary loss of response to ADA, the dose was escalated, 12.5% were switched to Infliximab. In 70%of patients that lost response to IFX, the dose was increased, 30% were switched to Adalimumab.

CONCLUSIONS

Adalimumab and Infliximab have similar efficacy, with a complete response rate of~70%. In case of secondary loss of response to IFX, the best solution is to switch to ADA, with 83% response rate, while in case of secondary loss of response to ADA, increasing the dose leads to 84 % response rate.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm - volume 3

The total number, morbidity and mortality attributed to viraemic hepatitis C virus (HCV) infections change over time making it difficult to compare reported estimates from different years. Models were developed for 15 countries to quantify and characterize the viraemic population and forecast the changes in the infected population and the corresponding disease burden from 2014 to 2030. With the exception of Iceland, Iran, Latvia and Pakistan, the total number of viraemic HCV infections is expected to decline from 2014 to 2030, but the associated morbidity and mortality are expected to increase in all countries except for Japan and South Korea. In the latter two countries, mortality due to an ageing population will drive down prevalence, morbidity and mortality. On the other hand, both countries have already experienced a rapid increase in HCV-related mortality and morbidity. HCV-related morbidity and mortality are projected to increase between 2014 and 2030 in all other countries as result of an ageing HCV-infected population. Thus, although the total number of HCV countries is expected to decline in most countries studied, the associated disease burden is expected to increase. The current treatment paradigm is inadequate if large reductions in HCV-related morbidity and mortality are to be achieved.

Strategies to manage hepatitis C virus infection disease burden - volume 3

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 15 countries in Europe, the Middle East and Asia, and the relative impact of two scenarios was considered: increased treatment efficacy while holding the annual number of treated patients constant and increased treatment efficacy and an increased annual number of treated patients. Increasing levels of diagnosis and treatment, in combination with improved treatment efficacy, were critical for achieving substantial reductions in disease burden. A 90% reduction in total HCV infections within 15 years is feasible in most countries studied, but it required a coordinated effort to introduce harm reduction programmes to reduce new infections, screening to identify those already infected and treatment with high cure rate therapies. This suggests that increased capacity for screening and treatment will be critical in many countries. Birth cohort screening is a helpful tool for maximizing resources. Among European countries, the majority of patients were born between 1940 and 1985. A wider range of birth cohorts was seen in the Middle East and Asia (between 1925 and 1995).

Historical epidemiology of hepatitis C virus (HCV) in select countries - volume 3

Detailed, country-specific epidemiological data are needed to characterize the burden of chronic hepatitis C virus (HCV) infection around the world. With new treatment options available, policy makers and public health officials must reconsider national strategies for infection control. In this study of 15 countries, published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates were gathered from the literature and validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Iran and Lebanon to 4.2% in Pakistan. The largest viraemic populations were in Pakistan (7 001 000 cases) and Indonesia (3 187 000 cases). Injection drug use (IDU) and a historically unsafe blood supply were major risk factors in most countries. Diagnosis, treatment and liver transplant rates varied widely between countries. However, comparison across countries was difficult as the number of cases changes over time. Access to reliable data on measures such as these is critical for the development of future strategies to manage the disease burden.

Contrast-enhanced ultrasound (CEUS) for the evaluation of focal liver lesions - a prospective multicenter study of its usefulness in clinical practice

PURPOSE

To assess the value of contrast-enhanced ultrasound (CEUS) for differentiating malignant from benign focal liver lesions (FLLs) and for diagnosing different FLL types.

MATERIAL AND METHODS

CEUS performed in 14 Romanian centers was prospectively collected between February 2011 and June 2012. The inclusion criteria were: age > 18 years; patients diagnosed with 1 - 3 de novo FLLs on B-mode ultrasound; reference method (computed tomography (CT), magnetic resonance imaging (MRI) or biopsy) available; patient's informed consent. FLL lesions were characterized during CEUS according to the European Federation of Societies for Ultrasound in Medicine and Biology guidelines. For statistical analysis, indeterminate FLLs at CEUS were rated as false classifications.

RESULTS

A total number of 536 cases were included in the final analysis, 344 malignant lesions (64.2 %) and 192 benign lesions (35.8 %). The reference method was: CT/MRI - 379 cases (70.7 %), pathological exam - 150 cases (27.9 %) and aspiration of liver abscesses - 7 cases (1.4 %). CEUS was conclusive in 89.3 % and inconclusive in 10.7 % of cases. To differentiate between malignant and benign FLLs, CEUS had 85.7 % sensitivity, 85.9 % specificity, 91.6 % positive predictive value, 77.1 % negative predictive value and 85.8 % accuracy. The CEUS accuracy for differentiation between malignant and benign liver lesions was similar in tumors with diameter ≤ 2 cm and those with diameter > 2 cm.

CONCLUSION

CEUS represents a useful method in clinical practice for differentiating between malignant and benign FLLs detected on standard ultrasonography, and the results of this study are in concordance with previous multicenter studies: DEGUM (Germany) and STIC (France).

Nutritional risk screening and prevalence of malnutrition on admission to gastroenterology departments: a multicentric study

BACKGROUND AND AIMS

There is little awareness and a lack of data on the prevalence of hospital malnutrition in gastro-enterology departments. Since part of these patients are referred for surgical treatment and poor nutritional status is a known risk factor for perioperative morbidity, we conducted a prospective study aimed to screen for the nutritional risk and assess the prevalence and risk factors of malnutrition in gastro-enterology departments in Romania.

METHODS

We included patients consecutively admitted to 8 gastroenterology units over a period of three months in our study. Nutritional risk was evaluated using NRS 2002. Malnutrition was defined using BMI ( 20 kg m2) or and 10% weight loss in the last six months.

RESULTS

3198 patients were evaluated, 51.6% males and 48.4% females, with the mean age of 54.5 Â+- 14.3 years. Overall percentage of patients at nutritional risk was 17.1%, with the highest risk for patients with advanced liver diseases (49.8%), oncologic (31.3%), inflammatory bowel diseases (20.2%), and pancreatic diseases (18.9%). The overall prevalence of malnutrition was of 20.4%, higher for advanced liver diseases (39.4%), inflammatory bowed diseases (30.6%), oncologic (26.8%) and pancreatic diseases (23%). Independent risk factors for malnutrition were younger age (p 0.0001), female gender (p 0.0001), a higher (A ≥ 3) NRS (p 0.0001), presence of neoplasm (p 0.0001), of advanced liver disease (p=0.0003) and a reduction of 25% of dietary intake (p 0.0001).

CONCLUSIONS

One in five patients admitted to gastroenterology units could benefit from prompt nutritional intervention. Correction of nutritional status is mandatory before any surgical procedure. Emphasis on nutritional evaluation at admission and beginning of nutritional therapy where needed are particularly required in patients with advanced liver diseases, digestive neoplasms, inflammatory bowel diseases and pancreatic diseases.

ABBREVIATIONS

NRS= nutritional risk score, BMI = body mass index, IBD = inflammatory bowel diseases.

Outcome of liver transplantation for hepatocellular carcinoma -- a single center experience

BACKGROUND & AIMS

Liver transplantation (LT) is a promising treatment for patients with liver cirrhosis associated with hepatocellular carcinoma (HCC). The aim of our study was to evaluate our experience regarding the clinical and pathological staging of HCC in patients who underwent LT, as well as recurrence free and overall survival.

METHODS

From January 2006 to December 2011, 38 patients with diagnosis of HCC, underwent LT in our Center. Demographic, clinical, imaging and pathologic information were recorded. A Cox proportional hazards survival analysis was performed in order to identify significant predictors of tumor recurrence and patient's death after LT.

RESULTS

Eighteen patients (47.4%) in our study group were within Milan criteria. The mean follow-up was 22 months and the recurrence rate of HCC after LT was 13.2%. The 1, 3- year recurrence free survival rates were 85%, 74.3% respectively. The 1 and 3-year overall survival rates were 83.5% and 63.6% respectively. No significant predictor for HCC recurrence was identified in our study group by survival analysis, taking into account 13 different variables. As independent predictors of patient'ss death after LT for HCC however, the presence of diabetes mellitus (p=0.001), presence of more than 3 HCC nodules (p=0.03) and tumor recurrence after LT (p=0.03) were identified by multivariate Cox proportional hazards survival analysis.

CONCLUSION

In our cohort HCC recurrence rate after LT was 13.2%. Diabetes mellitus, presence of more than 3 HCC nodules and HCC recurrence were significant predictors of poor overall survival after LT.

The MELD score exception for polycystic liver disease

Polycystic Liver Disease (PLD) is a rare progressive disease characterized by increased liver volume due to many cysts, with symptoms related mainly to the size of the liver and the compression on adjacent organs. Most patients who have PLD require no medical or surgical intervention. On the other hand, massive hepatomegaly with severe symptoms which cannot be managed conservatively requires surgical procedures.Liver transplantation (LT) offers the only curative option for the relief of symptoms arising from cyst enlargement and compression of abdominal structures. We presented a rare case of a young man with highly symptomatic isolated PLD due to liver volume - 23,200 cm3, which provokes severe physical and social handicaps and we considered that only total hepatectomy and LT provides a chance of definitive treatment.To our knowledge this is the largest specimen from a PLD patient who was transplanted.

Noninvasive clinical model for the diagnosis of nonalcoholic steatohepatitis in overweight and morbidly obese patients undergoing bariatric surgery

BACKGROUND

Liver biopsy, an invasive method, is the gold standard for differentiate nonalcoholic steatohepatitis (NASH) from other stages of fatty liver disease. A noninvasive test to diagnose NASH and disease severity before surgery and also for monitoring disease status after bariatric surgery (BS) will be an important medical challenge.

AIM

To create a noninvasive biomarkers model for the diagnosis of NASH in overweight, obese and morbidly obese patients (MOP).

PATIENTS AND METHODS

Sixty patients (mean BMI= 47.81kg/m2) were admitted after exclusion of other causes of liver disease. Liver biopsies were obtained at the time of the bariatric surgery or by percutaneous liver biopsy and graded using Kleiner score. Continuous variables were compared using Wilcoxon rank sum test and for prediction of NASH we used logistic regression.

RESULTS

Logistic regression analysis showed that BMI, ALT, AST, alkaline phosphatase (ALP), HOMA-R, hs-CRP, M30, M65, leptine and adiponectine levels remained independent predictors for NASH (p less than 0.02). Using AUC analysis, we established the following cutoff levels being indicative of NASH: BMI ė 47 kg/m2, ALT ė 32 IU/mL, AST ė 25 IU/mL, ALP ė 85 IU/mL, HOMA-IR ė 4, M65 ė 389 U/L. Adiponectine less than 13.5 mg/L. A NASH-score, calculated as the sum of these 7 parameters, at a cutoff level of 4 points, can accurately predict NASH (sensitivity of 90%, specificity of 93.94% and AUC of 0.9576).

CONCLUSIONS

We propose a noninvasive model for NASH diagnosis in MOP that should be validated prospectively. Using this noninvasive score, NASH would be predicted without the risks of liver biopsy.

Pre-liver transplantation, cardiac assessment

Liver transplantation (LT) is a stressful condition for the cardiovascular system of patients with advanced hepatic disease. The underlying hemodynamic and cardiac status of patients with cirrhosis is crucial to determine which patients should became recipients. In addition to advanced age and the presence of comorbidities, there are specific cardiovascular responses in cirrhosis that can be detrimental to the LT candidate. Patients with cirrhosis requiring LT usually demonstrate increased cardiac output, a compromised ventricular response to stress, low systemic vascular resistance and bradycardia. Post-transplant reperfusion may result in cardiac death due to a multitude of causes, including arrhythmia, acute heart failure and myocardial infarction. This review examines screening strategies for transplant candidates and details the prognostic value of common test used to identify ischemic heart disease, heart failure, portopulmonary hypertension. There are discused evidence-based recommendations for their evaluation and management.

[Liver transplantation--indications, surgical technique, results--the analysis of a clinical series of 200 cases]

INTRODUCTION

Initially considered experimental, liver transplantation (LT) has become the treatment of choice for the patients with end-stage liver diseases.

MATERIAL AND METHODS

Between April 2000 and October 2009, 200 LTs (10 reLTs) were performed in 190 patients, this study being retrospective. There were transplanted 110 men and 80 women, 159 adults and 31 children with the age between 1 and 64 years old (mean age--39.9). The main indication in the adult group was represented by viral cirrhosis, while the pediatric series the etiology was mainly glycogenosis and biliary atresia. There were performed 143 whole graft LTs, 46 living donor LTs, 6 split LTs, 4 reduced LTs and one domino LT RESULTS: The postoperative survival was 90% (170 patients). The patient and graft one-year and five-year survivals were 76.9%, 73.6% and 71%, 68.2%, respectively. The early complications occurred in 127 patients (67%). The late complications were recorded in 71 patients (37.3%). The intraoperative and early postoperative mortality rate was 9.5% (18 patients).

CONCLUSIONS

The Romanian liver transplantation program from Fundeni includes all types of current surgical techniques and the results are comparable with those from other international centers.

MELD exceptions and new predictive score of death on long waiting lists for liver transplantation

BACKGROUND

Cirrhosis related complications, considered MELD exceptions, proved to add prognostic value to the MELD score in predicting waiting list mortality.

AIM

To identify the predictive value for death on a long waiting list (WL) for the complications of liver disease.

METHODS

During 2004-2007, 372 consecutive adult patients were listed for liver transplantation (LT). To identify the potential predictors of patient death, univariate and multivariate Cox's proportional hazards regression model was used.

RESULTS

In the univariate survival analysis the following variables were significant: spontaneous bacterial peritonitis, refractory ascites, hyponatremia, hepatic encephalopathy, hepatorenal syndrome, initial and current MELD score, initial and current Child-Pugh score. The independent predictors of death on our WL were: refractory ascites (p=0.002) and hepatorenal syndrome (p=0.002). Based on a logistic regression analysis a new score has been developed: Score = 1/(1+ exp(-(-4.38 + 1.34 x Refractory ascites + 0.9 x Hepatorenal syndrome + 0.15 x Current MELD). The c-statistic for the new score for prediction of death on the WL was 0.85 compared to 0.80 for current MELD score.

CONCLUSION

Refractory ascites and hepatorenal syndrome should add valuable points to the current MELD in order to better prioritize for LT patients included on long WL.

ABBREVIATIONS

Liver transplantation (LT), Model for End-Stage Liver Disease (MELD), waiting list (WL), United Network for Organ Sharing (UNOS), standard deviation (SD), receiver operating characteristic (ROC), hepatitis B virus (HBV), hepatocellular carcinoma (HCC), positive predictive value (PPV), negative predictive value (NPV), Child-Turcotte-Pugh (CTP), hepatic venous pressure gradient (HVPG).

Stem cells therapies for gastrointestinal and liver diseases

Stem cells therapies represent a new field of biomedical science which could provide in the future the cure for diseases until now incurable. The present paper reviews current knowledge on key biological properties of stem cells with focus on hepatic and gastrointestinal stem cells and current applications of stem cells therapies in gastrointestinal and liver diseases. Potential clinical applications for stem cells therapies have been suggested from animal model trials in acute liver failure, inherited metabolic liver disease and endstage liver disease (cirrhosis). Hematopoietic autologous stem cells transplantation has already been successfully performed in patients with severe inflammatory bowel disease or patients with refractory celiac disease with aberrant T cells. Future stem cells therapies for gastrointestinal postoperative or Crohn's disease fistulas are currently under investigation. More research is needed for perfecting stem cells harvesting protocols from different sources, in vitro expansion and differentiation protocols which can be used in phase II and III clinical trials.

Predictors of death on the waiting list for liver transplantation characterized by a long waiting time

The number of patients dying while on the liver transplantation (LT) waiting list (WL) has continued to increase in recent years as a result of severe shortage of organs. Therefore, it is important to evaluate the existing models that predict death on the WL and to determine the independent predictors of death. The study cohort comprised 152 adult patients listed for LT in our centre over a period of 2 years (January 2001 to January 2003). The 12-month survival rate has been calculated by Kaplan-Meier method. The survival analysis performed by Cox proportional hazard model has evaluated the three parameters which compose the model for end-stage liver disease (MELD) score. Forty-four patients (28.9%) died while listed for LT. The survival rate was 92% at 3 months, 80% at 6 months and 69% at 12 months. Median survival was not reached. MELD score was found to be an excellent predictor of death at 12 months on our WL--c-statistic (area under curve) 0.84. In our survival analysis, only international normalized (prothrombin) ratio (INR) and serum creatinine were identified as an independent predictors of death (P < 0.0001). A new simplified version of the MELD score, which does not include serum bilirubin, is proposed and its c-statistic as predictor for death on the WL at 12 months is 0.86, as good as the original MELD score, when evaluated on our list. There is a fourfold increase in mortality on our WL for LT between 3 and 12 months after the inclusion. A simplified version of the MELD score, using only serum creatinine and INR might be taken into account when predicting 12 months mortality on WL with longer waiting time, but it has to be confirmed by other prospective studies.

[Orthotopic liver transplantation in adult patients with cadaveric grafts. Experience of the Fundeni Center of General Surgery and Liver Transplantation]

We analyze the experience of the Center of General Surgery and Liver Transplantation from the Fundeni Clinical Institute (Bucharest, Romania) regarding orthotopic liver transplantation (OLT) in adult recipients, with whole liver grafts from cadaveric donors, between April 2000 (when the first successful LT was performed in Romania) and December 2004. This series includes 37 OLTs in adult recipients (16 women and 21 men, aged between 29-57 years--average 46 years). Other two LT with whole liver cadaveric grafts and two reduced-size LT were performed in children; also, in the same period, due to the acute organ shortage, other methods of LT were performed in 28 patients (21 living donor LT, 6 split LT and one "do mino" LT), that were not included in the present series. The indications for OLT were HBV cirrhosis--10, HBV+HDV cirrhosis--4, HCV cirrhosis--11, HBV+HCV cirrhosis--2, biliary cirrhosis--5, Wilson disease--2, alcoholic cirrhosis--1, non-alcoholic liver disease--1, autoimmune cirrhosis--1. With three exceptions, in which the classical transplantation technique was used, the liver was grafted following the technique described by Belghiti. Local postoperative complications occurred in 15 patients (41%) and general complications in 17 (46%); late complications were registered in 18 patients (49%) and recurrence of the initial disease in 6 patients (16%). Intrao- and postoperative mortality was 8% (3/37). There were two patients (5%) who died because of immunosuppressive drug neurotoxicity at more than 30 days following LT. Four patients (11%) died lately because of PTLD, liver venoocclusive disease, recurrent autoimmune hepatitis and liver venoocclusive disease, myocardial infarction, respectively. Thirty-four patients survived the postoperative period (92%); according to Kaplan-Meier analysis, actuarial patient-survival rate at month 31 was 75%.

Long esophageal stricture in Crohn's disease: a case report

Crohn's disease of the esophagus is rare, and it is very unusual for it to be located only in the esophagus. We report a case of Crohn's disease confined to the esophagus in a 26-year-old female. The patient was admitted because of progressive dysphagia, odynophagia and weight loss. A barium-swallow examination showed an irregular narrowing of the esophagus below the level of the aortic arch which was 15 cm long, with marginal ulcers and a pseudopolypoid appearance of the mucosa; a computed tomographic scan of the thorax revealed a thickened esophageal wall. Esophagoscopy revealed an esophageal stricture 25 cm distal to the incisor teeth, 2 mm in diameter, with "punched out" ulcers and pseudopolypoid mucosa. Endobiopsy specimens showed chronic lymphocytic infiltration into the corion in the absence of neutrophils, basal-cell hyperplasia and elongation of the stromal papillae. The patient underwent an esophagectomy through a combined cervico-abdominal approach followed by a cervical esogastrostomy. The specimen was 18 cm long, the thickness of the wall was 1.7 cm with fibrosis involving all layers of the esophageal wall and a cobblestone appearance of the mucosa. A heavy lymphoplasmocytic infiltrate extended from the mucosa deep into the muscularis, fibrosis and granulomas were found transmurally. Crohn's disease of the esophagus is a rare and specific entity which can present in various ways; strictures resembling those from reflux esophagitis or a tumor are common. Diagnosis may be suggested by the presence of a chronic lymphocytic infiltrate with or without non-caseating granulomas, and no histologic evidence of chronic reflux esophagitis.

Fatal intestinal hemorrhage complicating ileal lymphoma after cyclosporine for unresponsive celiac disease

Unresponsive celiac disease may benefit from immunosuppressive therapy. Malignant small intestinal lymphoma is the most serious complication of celiac disease, also being noted as a complication of immunosuppressive therapy. The diagnosis of small intestinal lymphoma complicating celiac disease is notoriously difficult. Perforation is the most common complication of small intestinal lymphoma, frank hemorrhage being unusual. We report a case of massive, fatal hemorrhage from small intestinal lymphoma complicating unresponsive celiac disease treated with cyclosporine. The patient was presented with severe diarrhea and nutritional deterioration. Unresponsive celiac disease was diagnosed on the basis of clinical and histologic criteria with no response while on a gluten-free diet, corticotherapy and octreotide acetate injections. Cyclosporine therapy was advised. The patient had a remarkable clinical response. After 3 months from the start of the cyclosporine therapy, the patient returned with massive intestinal bleeding. The patient underwent emergency surgery diagnosing an enteropathy-associated lymphoma. We conclude that cyclosporine therapy for unresponsive celiac disease should be considered in select, severely ill patients only after a full-thickness biopsy of the small intestinal wall to disclose a latent super-imposed lymphoma, which course may be accelerated by immunosuppressive therapy.

[The morphological substrate and histogenesis of systemic and ocular atherosclerosis]

The atherosclerosis is an complex pathologic process with thrombosis and vessels obstructions. At the cerebral level, atherosclerosis determines lesions especially at the Willis circle vessels, and his peripheral ramifications (ophthalmic artery). The authors presents the atherosclerotic lesions at the level of ocular vessels, and their consequence at the central retinal artery, and other ocular vessels.