The profile of bile acids and their sulfate metabolites in human urine and serum

The role of sulfation in ameliorating the hepatotoxicity of bile acids (BAs) in humans remains unknown due to the lack of proper analytical methods to quantify individual BAs and their sulfate metabolites in biological tissues and fluids. To this end, a simple and sensitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was developed and validated to characterize the detailed BA profile in human urine and serum. The limit of quantification was 1ng/mL and baseline separation of all analytes was achieved within in a run time of 32min. The method was validated over the dynamic range of 1-1000ng/mL. The LC-MS/MS method was more accurate, precise, and selective than the commercially available kits for the quantification of sulfated and unsulfated BAs, and the indirect quantification of individual sulfated BAs after solvolysis. The LC-MS/MS method was applied to characterize the BA profile in urine and serum of healthy subjects. Thirty three percent of serum BAs were sulfated, whereas 89% of urinary BAs existed in the sulfate form, indicating the role of sulfation in enhancing the urinary excretion of BAs. The percentage of sulfation of individual BAs increased with the decrease in the number of hydroxyl groups indicating the role of sulfation in the detoxification of the more hydrophobic and toxic BA species. Eighty percent of urinary BAs and 55% of serum BAs were present in the glycine-amidated form, whereas 8% of urinary BAs and 13% of serum BAs existed in the taurine-amidated form.

Pilot study of pegylated interferon alfa-2b and ribavirin for recurrent hepatitis C after liver transplantation

Recurrent hepatitis C is often treated with an interferon and ribavirin combination therapy, but the results have been disappointing. Given the promising results reported with pegylated interferon and ribavirin for hepatitis C, we were interested in evaluating the effectiveness of this treatment in liver transplant recipients with recurrent hepatitis C (HCV).

METHODS

Between November 2001 and September 2002, patients with recurrent HCV were screened to determine if they were eligible for treatment. Liver function tests, HCV-RNA, and liver biopsies were performed on all patients prior to treatment. HCV-RNA was repeated at 3 months, the end of treatment (EOT), and 6 months after EOT for patients who were HCV-RNA negative at EOT. Patients were prospectively followed after starting weekly pegylated interferon alfa-2b 1.5 mcg/kg per week and ribavirin 800 mg per day (Schering-Plough, Kenilworth, NJ, USA) with folic acid 1 mg per day.

RESULTS

Thirty-nine patients eligible for treatment displayed a median age of 50.4 years. Eighteen patients completed treatment, 4 remain on treatment, and 17 were intolerant. Sustained HCV-RNA eradication occurred in 66.7% of patients who completed treatment. Side effects led to treatment withdrawal in 17 patients (43.6%) In an intention-to treat analysis, sustained HCV-RNA eradication occurred in 30.8% of patients.

CONCLUSION

Side effects are an important limiting factor in the treatment of recurrent HCV with pegylated interferon and ribavirin. However, these results are encouraging as sustained HCV eradication occurred in at least 66.7% of patients who completed treatment. Prospective randomized trials are required to assess the effectiveness of this treatment and its impact on quality of life and histology.

Urinary bile acids as biomarkers for liver diseases I. Stability of the baseline profile in healthy subjects

The role of bile acids (BAs) as biomarkers for liver injury has been proposed for decades. However, the large inter- and intra-individual variability of the BA profile has prevented its clinical application. To this end, we investigated the effect of covariates such as food, gender, age, BMI, and moderate alcohol consumption on the BA profile in healthy human subjects. The BA profile was characterized by the calculation of indices that describe the composition, sulfation, and amidation of total and individual BAs. Both inter- and intra-individual variabilities of BA indices were low in serum and even lower in urine compared with those of absolute concentrations of BAs. Serum BA concentrations increased with consumption of food, whereas urinary BA concentrations were mildly affected by food. Gender differences in the urinary and serum BA profile were minimal. The serum and urinary BA profiles were also not affected by age. BMI showed minimal effect on the urine and serum BA profile. Moderate alcohol consumption did not have a significant effect on the BA profile in both urine and serum. When the effect of the type of alcohol was studied, the results indicate that moderate drinking of beer does not affect BA concentrations and has minimal effect on BA indices, whereas moderate wine consumption slightly increases BA concentrations without affecting the BA indices. In summary, urinary BA indices showed lower variability and higher stability than absolute BA concentrations in serum and showed minimal changes to covariate effects suggesting their utility as biomarkers in clinic.

Outcomes of liver transplantation for cryptogenic cirrhosis: a single-center study of 71 patients

Cryptogenic cirrhosis (CC) is emerging as an important indication for orthotoptic liver transplantation (OLT) in the United States. Our aim was to identify risk factors associated with nonalcoholic steatohepatitis (NASH) in patients with CC and to evaluate outcomes following OLT.

PATIENTS AND METHODS

A chart review was performed on patients transplanted for CC at the University of Nebraska Medical Center between October 1993 and May 2003.

RESULTS

Seventy-one patients were identified (37 were men and 34 women). Average age was 53.5 years. Mean cholesterol and triglyceride levels increased from 174.8 to 222.3 mg/dL (P <.05) and from 162.60 to 279.66 mg/dL (P <.05), respectively. The prevalence of diabetes mellitus also increased from 37.14% to 54.93% (P <.05). Incidental hepatocellular carcinoma was present in six patients and high-grade dysplasia in one patient. Steatohepatitis developed in eight patients and recurrent cryptogenic disease in four, of whom one required retransplantation for decompensated liver disease. Rejection occurred in 24 patients. Cumulative incidence of graft failure at 1 year was 4% (95% CI 0% to 10%) and at 5 years was 7% (95% CI 0% to 18%). Survival at 1 year was 85% (95% CI 77% to 94%) and at 5 years was 73% (95% CI between 61% to 86%).

CONCLUSIONS

Cryptogenic liver disease is an important cause of decompensated cirrhosis; NASH appears to be an intermediate stage in the development of this disease in a subset of patients. Short-term and 5-year survival rates in this series appear comparable to other liver transplant recipients, supporting liver transplantation as an acceptable treatment for CC.

Value of dobutamine stress myocardial contrast perfusion echocardiography in patients with advanced liver disease

Although dobutamine stress echocardiography has been used for the preoperative evaluation of patients with advanced liver disease (ALD), no data exist regarding the value of myocardial perfusion imaging (MPI) with real-time myocardial contrast echocardiography (RTMCE) in this patient population. We sought to determine the value of MPI during dobutamine stress RTMCE for predicting prognosis in patients with ALD. We examined both wall motion and MPI in 230 patients with ALD who underwent dobutamine stress RTMCE using intravenous commercially available contrast agents (Optison, GE-Amersham, Princeton, NJ; or Definity, Bristol-Myers Squibb Medical Imaging, North Billerica, MA). The prognostic value of clinical variables, including the Model for End-Stage Liver Disease (MELD) score, and echocardiographic data were examined using a Cox Hazard model. The primary endpoint was mortality of all causes. Among the 85 patients who underwent orthotopic liver transplantation, 4 had abnormal MPI and 81 had normal perfusion. The hospital mortality rate was 50% (2/4) in patients with abnormal MPI and 2% (2/81) in patients with normal MPI (P = 0.01). Among patients with abnormal MPI, 1 died from myocardial infarction in the first postoperative day and the second 1 from hemorrhagic shock. During a median follow-up of 15 months, 53 (23%) patients died. The independent predictors of death were an age of > or = 65 yr (RR = 2.2; 95% confidence interval (CI) = 1.1-4.4; P = 0.03), MELD score of > or = 25 (RR = 3.2; 95% CI = 1.8-5.5; P < 0.0001), and abnormal MPI (RR = 2.4; 95% CI = 1.1-5.2; P = 0.02). The 2-yr mortality was 24% for patients with normal MPI and 45% for those with inducible MPI abnormalities (P = 0.003). In conclusion, MPI obtained by RTMCE appears to be a useful tool in predicting mortality in patients with ALD. Further studies are required to verify its independent value.

Pegylated interferon for recurrent hepatitis C in liver transplant recipients with renal failure: a prospective cohort study

BACKGROUND

Hepatitis C (HCV) universally recurs following orthotopic liver transplantation (OLT), representing an important cause for retransplantation. Although it is often treated with interferon and ribavirin, ribavirin is contraindicated in the presence of renal failure. In this setting of renal failure, pegylated-interferon monotherapy may be useful for recurrent HCV in liver transplant patients.

METHODS

Between June 2001 and November 2002, patients with recurrent HCV were screened to determine if they were eligible for treatment. Renal failure was defined as serum creatinine greater than 1.8 mg/dL. HCVRNA and liver biopsies were performed prior to treatment, end of treatment (EOT) and 6 months after EOT for those who were HCV-RNA negative at EOT. Patients were followed prospectively after starting weekly pegylated-interferon alpha 2b 1.0 microg/kg (Schering-Plough, Kenilworth, NJ, USA).

RESULTS

Among the 45 patients with recurrent HCV screened, 9 were eligible, including 8 men and 1 woman of average age 55 years. Eight patients were intolerant to the treatment requiring discontinuation within the first 3 months. Two patients developed a sustained response to HCV eradication. One patient who completed treatment has normal liver tests but is still viremic.

CONCLUSIONS

Pegylated-interferon alpha 2b is poorly tolerated in liver transplant recipients with recurrent HCV and chronic renal failure. Larger, prospective studies are required to determine the optimum duration of treatment and the impact of treatment on histology and quality of life.

Urinary bile acids as biomarkers for liver diseases II. Signature profiles in patients

Hepatobiliary diseases result in the accumulation of bile acids (BAs) in the liver, systemic blood, and other tissues leading to an unfavorable prognosis. The BA profile was characterized by the calculation of indices that describe the composition, sulfation, and amidation of total and individual BAs. Comparison of the urinary BA profiles between healthy subjects and patients with hepatobiliary diseases demonstrated significantly higher absolute concentrations of individual and total BAs in patients. The percentage sulfation of some individual BAs were different between the two groups. The percentage amidation of overall and most individual BAs was higher in patients than controls. The percentage of primary BAs (CDCA and CA) was higher in patients, whereas the percentage of secondary BAs (DCA and LCA) was lower in patients. BA indices belonging to percentage amidation and percentage composition were better associated with the severity of the liver disease as determined by the model for end-stage liver disease (MELD) score and disease compensation status compared with the absolute concentrations of individual and total BAs. In addition, BA indices corresponding to percentage amidation and percentage composition of certain BAs demonstrated the highest area under the receiver operating characteristic (ROC) curve suggesting their utility as diagnostic biomarkers in clinic. Furthermore, significant increase in the risk of having liver diseases was associated with changes in BA indices.

Impact of pegylated interferon alpha-2B and ribavirin on hepatic fibrosis in liver transplant patients with recurrent hepatitis C: an open-label series

BACKGROUND

Patients with recurrent hepatitis C virus (HCV) are often treated with interferon-based therapy in an attempt to eradicate HCV and prevent cirrhosis requiring retransplantation. We describe our experience with pegylated interferon and ribavirin and the impact of this therapy on hepatic fibrosis.

METHODS

Patients were treated with pegylated interferon alpha-2b 1.5 mcg/kg/week and ribavirin 800 mg/day for 6-12 months according to genotype. HCV ribonucleic acid (HCV RNA) was repeated at 3 months, end of treatment (EOT) and 6 months after EOT for patients HCV RNA negative at EOT. Liver biopsies were performed prior to treatment and at EOT.

RESULTS

Thirty nine patients were eligible. Twenty two completed treatment and 17 (43.6%) were intolerant. Eleven of 22 (50%) patients who completed treatment developed sustained viral response (SVR). Two patients intolerant to treatment also developed SVR. Serial biopsies were performed in 17 patients and refused in five. Improved fibrosis scores were present in four patients (non-responders, n = 2), unchanged in 10 (non-responders, n = 4), and worse in three (all non-responders).

CONCLUSIONS

Side effects are an important limiting factor in recurrent HCV treatment with SVR only 33.3% in an intention-to-treat analysis. However, improved or stable fibrosis scores were also demonstrated in 66.7% of non-responders. This suggests failure to eradicate HCV should not necessarily lead to treatment discontinuation as a subgroup of patients may benefit from maintenance therapy.

Diarrhea associated with lansoprazole

Lansoprazole is a proton pump inhibitor widely prescribed for gastroesophageal reflux and benign peptic ulcer disease. According to the manufacturer's package insert (TAP Pharmaceuticals, Lake Forest, IL, USA), the most common side-effects are diarrhea, headache and abdominal pain, which occur in approximately 3% of patients and are reversible with drug discontinuation. An unusual case of microscopic colitis is reported in a previously asymptomatic patient who developed new-onset diarrhea after initiation of lansoprazole. The case is reviewed and possible mechanisms of diarrhea secondary to proton pump inhibitors are discussed.

Mild donor liver steatosis has no impact on hepatitis C virus fibrosis progression following liver transplantation

BACKGROUND

This study examines the impact of donor liver macrovesicular steatosis on recurrence of hepatitis C virus (HCV) disease after liver transplantation.

METHODS

Between 1998 and 2004, 113 patients underwent liver transplantation for HCV-related cirrhosis. Time to histologic recurrence (fibrosis score >or=2) was the primary endpoint of the study. Recurrence was graded according to the system of Ludwig and Batts. A Cox's proportional hazard regression model was used to analyse the association between donor liver steatosis and HCV recurrence.

RESULTS

Recurrence-free survival for patients who received steatotic grafts was 82% and 47% at 1 and 4 years, respectively, and 81% and 52% for patients who received a non-steatotic liver. Donor macrovesicular steatosis (5-45%) was found to have no impact on HCV recurrence (P=0.47). Donor age (P=0.02) and cold ischaemia time (P=0.01) were found to increase the relative risk of HCV recurrence. The estimated risk of HCV recurrence increased by 23% for every 10-year increase in donor age. Similarly the risk of recurrence increased by 13% for every 1-h increase in cold ischaemia time.

CONCLUSION

Mild-moderate donor liver macrovesicular steatosis has no impact on HCV recurrence after liver transplantation for HCV-related cirrhosis. Cold ischaemia time and donor age increased the likelihood of HCV recurrence.

Controversies in liver transplantation for hepatitis C

Hepatitis C is one of the most common indications for liver transplantation in the United States, accounting for approximately 40%-45% of all liver transplants. Unfortunately, recurrent disease is universal in patients who are viremic before transplantation. This can lead to cirrhosis in at least 25% of patients 5 years after liver transplantation, and recurrent hepatitis C is now emerging as an important but occasionally contentious indication for retransplantation. Several attempts have been undertaken to identify patients at high risk for severe recurrent disease who may benefit from treatment, but unfortunately antiviral therapy frequently is ineffective and often is associated with numerous side effects. Although we have made significant strides in understanding the natural history of this disease in nontransplant patients, this does not hold true for the transplant population in which several uncertainties covering virtually the entire spectrum of liver transplantation persist. Despite these concerns, on a more practical level, it is usually only in the postoperative setting that clinicians truly can assess the impact of their interventions on the natural history of recurrent hepatitis C, for example, by adjusting immunosuppression or prescribing antiviral therapy. Preoperative and perioperative (including donor) factors often are outside the control of hepatologists and transplant surgeons. This review is not an inclusive review of the literature but summarizes what we believe are the more controversial topics of this disease.

Managing post-transplant lymphoproliferative disorders in solid-organ transplant recipients: a review of immunosuppressant regimens

Post-transplant lymphoproliferative disorders (PTLD) are a heterogeneous group of potentially life-threatening complications that occur after solid organ and bone marrow transplantation. Risk factors for acquiring PTLD are type of organ transplanted, age, intensity of immunosuppression, viral infections such as Epstein-Barr virus (EBV) and time after transplantation. Due to a dearth of well designed prospective trials, treatment for PTLD is often empirical, with reduction in immunosuppression accepted as the first step. Rituximab, a monoclonal antibody directed against the CD20 antigen of immature B cells, is often used as monotherapy after reduction in immunosuppression, although this is associated with a high risk of relapse if patients have at least one of the following risk factors: age greater than 60 years, elevated lactate dehydrogenase levels and Eastern Cooperative Oncology Group Score between 2 and 4. For such patients, rituximab should be considered in combination with CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone), particularly if high-grade PTLD is present. Although widely prescribed, the use of ganciclovir for PTLD remains controversial as EBV-transformed cells lack the thymidine kinase necessary for ganciclovir activation. Newer antivirals that combine ganciclovir with activators of cellular thymidine kinase have shown promising results in preclinical studies. In the absence of controlled trials, surgery may be indicated for localized disease and radiotherapy for patients with impending spinal cord compression or disease localized to the central nervous system or orbit. Future interventions may include adoptive immunotherapy, intravenous immunoglobulin, mammalian target of rapamycin inhibitors, monoclonal antibodies to interleukin-6 and galectin-1, and even EBV vaccination. Although several trials are in progress, it is necessary to wait for the long-term outcome of these studies on risk of PTLD relapse.

Pegylated interferon alfa-2a and ribavirin for recurrent hepatitis C after liver transplantation

BACKGROUND

Recurrent hepatitis C virus (HCV) is often treated with interferon and ribavirin combination therapy but results have been disappointing. Given the promising results reported with pegylated interferon and ribavirin for hepatitis C, this combination is now preferred for the treatment of recurrent HCV. This article reports a transplantation program's experience with antiviral therapy treatment for liver transplant recipients with recurrent HCV.

METHODS

Between October 2002 and June 2004, patients with recurrent HCV were screened to determine if they were eligible for treatment. Liver function tests, HCVRNA, and liver biopsies were done on all patients prior to treatment. HCVRNA was repeated at 3 months, end of treatment (EOT), and 6 months after EOT for patients HCVRNA-negative at EOT. Patients were prospectively followed up after starting weekly pegylated interferon alfa-2a 180 mcg/wk and ribavirin 1000-1200 mg/d (Roche, Nutley, NJ, United States) with folic acid 1 mg/d.

RESULTS

Thirty-two patients were eligible for treatment with a median age of 49.2 years. Twenty-one patients have completed treatment, 6 remain on treatment, and 5 were intolerant. In an intention-to-treat analysis, sustained HCVRNA eradication occurred in at least 40.6% of patients. Side effects led to treatment withdrawal in 5 patients (15.6%).

CONCLUSION

Pegylated interferon alfa-2a and ribavirin appear promising for the treatment of recurrent HCV. Side effects were an infrequent cause of treatment discontinuation, unlike previous combinations of interferon-based therapy. Randomized, prospective trials incorporating serial liver biopsies with appropriate quality of life analyses are required to manage this silent epidemic.

Interferon alpha 2b and ribavirin for the treatment of recurrent hepatitis C after liver transplantation: cohort study of 38 patients

AIM

Recurrent hepatitis C virus (HCV) is universal following liver transplantation. Patients are often treated with interferon and ribavirin in an attempt to eradicate the virus. We describe our experience with 38 patients with recurrent HCV from a single liver transplant program.

METHODS

Between October 2000 and November 2001, 38 patients with recurrent HCV were treated with interferon alpha 2b 3 million units three times a week and ribavirin 1000-1200 mg per day. HCV RNA and liver biopsies were performed before treatment at the end of treatment (EOT), and 6 months after EOT in patients who were HCV RNA negative at EOT.

RESULTS

There were 29 males and nine females. Median age was 49 years. In total, 34 patients were genotype 1 and two each were genotype 3 and 4. Six patients received HCV positive donors and 24 patients (63%) completed treatment. The most common indication for discontinuation of treatment was severe fatigue in 14 patients (37%). On intention to treat analysis, a sustained biochemical and virological response occurred in 10 patients (26%). Unchanged or improved fibrosis scores were present in 37% of patients, of whom 71% were non-responders to therapy.

CONCLUSIONS

Interferon alpha 2b and ribavirin were poorly tolerated in this series of recurrent HCV patients, with sustained HCV eradication occurring in only 26% of patients. However, the majority of non-responders demonstrated unchanged or improved fibrosis scores, suggesting that a subset of patients may benefit from maintenance antiviral therapy to prevent the development of cirrhosis.

Immunosuppression in liver transplantation

Calcineurin inhibitors remain the mainstay of immunosuppression in liver transplantation but are associated with important side effects such as diabetes, hypertension and nephrotoxicity which can influence quality of life and survival rates. A variety of non-calcineurin inhibitors have been used in liver transplantation, either during induction immunosuppression in an attempt to delay the introduction of calcineurin inhibitors or during maintenance immunosuppression with reduced dose calcineurin inhibitors to minimize calcineurin inhibitor toxicity while preserving hepatic allograft function. With few exceptions, single agent immunosuppression with non- calcineurin inhibitors has not been universally practiced outside of clinical trials due to unacceptably high rates of hepatic allograft rejection. Although several single center studies have reported encouraging results with these new agents when used with reduced dose calcineurin inhibitors, large, randomized studies are eagerly awaited. Furthermore, as the impact of these newer agents on the recurrence of hepatitis C continues to evolve, clinicians need to be prudent with their use until data from controlled studies is available. This article will review currently used immunosuppressants in liver transplantation, novel therapies in development and the impact of these medications of the recurrence of hepatitis C after liver transplantation.

Major hereditary gastrointestinal cancer syndromes: a narrative review

Gastrointestinal cancer is one of the major causes of death worldwide. Hereditary gastrointestinal cancer syndromes constitute about 5-10% of all cancers. About 20-25% of undiagnosed cases have a possible hereditary component, which is not yet established. In the last few decades, the advance in genomics has led to the discovery of multiple cancer predisposition genes in gastrointestinal cancer. Physicians should be aware of these syndromes to identify high-risk patients and offer genetic testing to prevent cancer death. In this review, we describe clinical manifestations, genetic testing and its challenges, diagnosis and management of the major hereditary gastrointestinal cancer syndromes.

Current status of liver transplantation for cholangiocarcinoma

Cholangiocarcinoma (CCA) is the second most common liver cancer with a median survival of 12-24 mo without treatment. It is further classified based on its location into intrahepatic CCA (iCCA), perihilar CCA (pCCA), and distal CCA. Surgical resection is the mainstay of treatment, but up to 70% of these tumors are inoperable at the time of diagnosis. CCA was previously an absolute contraindication for liver transplantation (LT) due to poor outcomes primary due to early recurrent disease. However, improvement in patient selection criteria and neoadjuvant treatment protocols have improved outcomes for inoperable pCCA patients with recent studies reporting LT may improve survival in iCCA. Future advances in the treatment of CCA should include refining patient selection criteria and organ allocation for all subtypes of CCA, determining effective immunotherapies and the evolving role of personalized medicine in patients ineligible for surgical resection or LT. Our article reviews the current status of LT in CCA, along with future directions in managing patients with CCA.

Betaine and nonalcoholic steatohepatitis: back to the future?

Nonalcoholic steatohepatitis (NASH) is an important indication for liver transplantation in many Western countries. Obesity and insulin resistance are the two most common risk factors for NASH, which can lead to recurrent NASH after liver transplantation. There is currently no approved therapy for NASH, and treatment is directed at risk factor modification and lifestyle changes. Betaine has been used for NASH, with mixed results, and may show promise in conjunction with other agents in clinical trials.

Fatal liver disease despite sustained eradication of recurrent hepatitis C virus requiring liver retransplantation

Liver retransplantation for recurrent hepatitis C is usually not recommended for patients with early, severe disease. As it is difficult to predict which patients are at risk, interferon-based therapies are often used after histological confirmation of recurrent disease. Unfortunately, this treatment is poorly tolerated, costly and often unsuccessful. Three patients are described who developed decompensated cirrhosis requiring retransplantation despite sustained viral eradication. With the exception of one patient who developed post transplant nonalcoholic steatohepatitis, no etiology was identified in the others. All were retransplanted and remain hepatitis C negative at a mean follow-up of 25.6 months. Despite a lack of alternatives, the reflexive urge to use interferon-based therapy for recurrent hepatitis C in an attempt to prevent retransplantation at all costs should be resisted, particularly as recent studies suggest onset of recurrent disease after initial transplant does not predict onset of recurrence following retransplantation.

De novo cryptogenic hepatitis after sustained eradication of hepatitis C following liver transplantation

Patients with recurrent hepatitis C (HCV) after liver transplantation (OLT) are often treated with interferon and ribavirin in an attempt to eradicate HCV and prevent cirrhosis. We report four patients who developed de novo cryptogenic hepatitis following sustained eradication of recurrent HCV, which led to decompensated liver disease in two patients, both of whom required listing for retransplantation. Between September 2000 and October 2001, 38 consecutive patients with recurrent HCV were treated with interferon alpha 2b and ribavirin, of whom eight patients (21%) developed a sustained response to HCV eradication. Four of these patients developed cryptogenic hepatitis, which led to decompensated cirrhosis in two patients. Both patients were listed for retransplantation but died on the waiting list. No etiology for liver disease was identified despite extensive investigations in all four patients including postmortem analysis in the two patients. We hypothesize that these individuals developed an aberrant immune response leading to allograft injury whose severity may be determined by underlying haplotype, degree of immunosuppression, presence/absence of HCV, and duration of treatment. We have not found any similar reports in the literature but anticipate more cases to be reported given the universal use of antiviral therapy for recurrent HCV.

Role of betaine in liver disease-worth revisiting or has the die been cast?

Nonalcoholic steatohepatitis (NASH) is an important indication for liver transplantation in many Western countries due to the epidemic of obesity and insulin resistance. Unfortunately, no medication is approved for NASH and risk factor modification is often advised. Over the last decade, several clinical trials on NASH have been conducted with several ongoing and the future looks promising. Although betaine (trimethyl glycine) was evaluated for NASH, results were mixed in the clinical trials in large part due to the quality of the studies. It seems reasonable to re-evaluate betaine in clinical trials for NASH and alcoholic liver disease due to its low cost, tolerability and mechanism of action.