Toll-like receptor signaling inhibits hepatitis B virus replication in vivo

Toll-like receptors (TLR) play a key role in innate immunity. To examine the ability of diverse TLRs to modulate hepatitis B virus (HBV) replication, HBV transgenic mice received a single intravenous injection of ligands specific for TLR2, TLR3, TLR4, TLR5, TLR7, and TLR9. All of the ligands except for TLR2 inhibited HBV replication in the liver noncytopathically within 24 h in a alpha/beta interferon-dependent manner. The ability of these TLR ligands to induce antiviral cytokines at the site of HBV replication suggests that TLR activation could represent a powerful and novel therapeutic strategy for the treatment of chronic HBV infection.

Oscillating CD8(+) T cell effector functions after antigen recognition in the liver

When hepatitis B virus (HBV)-specific CD8(+) cytotoxic T lymphocytes (CTLs) are adoptively transferred into HBV transgenic mice, they enter the liver, recognize antigen, secrete interferon gamma (IFNgamma), inhibit viral replication, and kill their target cells, causing hepatitis. In the current study, we examined the impact of antigen recognition on the evolution of the activation phenotype, antiviral effector functions, expansion and contraction kinetics, and compartmentalization of the transferred CTLs. The results reveal that noncytolytic and cytolytic effector functions and expansion-contraction kinetics of the CTLs are regulated asynchronously and in an oscillatory manner as a consequence of antigen recognition in the liver and in association with PD-1 upregulation. We suggest that such oscillations maximize viral clearance and minimize tissue injury during HBV infection and that poor coordination of these events could lead to viral persistence and chronic liver disease.

Viscoelasticity Measurement in Rat Livers Using Shear-Wave US Elastography

To investigate the usefulness of shear-wave speed and dispersion slope measurements obtained, using an ultrasound elastography system in rat livers with various degrees of necroinflammation and fibrosis. A total of 25 male Sprague Dawley rats were randomly divided into 5 groups of 5 rats each: G0 (control), G1 (CCl4 injected twice a week for 1 wk), G2 (CCl4 injected four times a wk for 1 wk), G3 (CCl4 injected twice a wk for 6 wk) and G4 (CCl4 injected twice a wk for 10 wk). The shear-wave speed (m/s) and the dispersion slope ([m/s]/kHz) were measured. Histologic features (inflammation, necrosis and fibrosis) were used as reference standards. In multivariable analysis with histologic features as independent variables, the fibrosis grade was significantly related to shear-wave speed (p < 0.05) and the necrosis grade was significantly related to dispersion slope (p < 0.05). Dispersion slope is more useful than shear-wave speed for predicting the degree of necroinflammation.

Noninvasive diagnostic method for idiopathic portal hypertension based on measurements of liver and spleen stiffness by ARFI elastography

BACKGROUND

Acoustic radiation force impulse (ARFI) elastography is an ultrasound technique that is capable of measuring tissue stiffness noninvasively. It is difficult to differentiate idiopathic portal hypertension (IPH) from liver cirrhosis (LC) or chronic hepatitis (CH), and liver biopsy is essential. We investigated whether it would be possible to noninvasively diagnose IPH by measuring the stiffness of the liver and spleen by ARFI.

METHODS

The subjects were 17 IPH patients, 25 LC patients, 20 CH patients, and 20 normal controls (NC). We measured liver stiffness, spleen stiffness, and the spleen/liver stiffness ratio, and plotted ROC curves.

RESULTS

The median value of liver stiffness in the IPH group was lower than that in the LC group (p = 0.00077) and about the same as in the CH group (p = 0.79). The median value of spleen stiffness was highest in the IPH group (IPH vs. LC group, p = 0.003; IPH vs. CH group, p < 0.00001). The spleen/liver stiffness ratio was lower in the LC group and in the CH group, and higher in the IPH group (p < 0.001, respectively). When an ROC curve of spleen/liver stiffness ratios was plotted to differentiate between the IPH group and the combined group of patients with other liver diseases (LC + CH group), when a cutoff value of 1.71 was used, the AUROC was 0.933 sensitivity 0.941, specificity 0.800, and accuracy 0.839.

CONCLUSION

Measuring the spleen/liver stiffness ratio by ARFI made it possible to noninvasively, specifically, and accurately diagnose IPH.

Hepatocellular carcinoma treated with sorafenib: early detection of treatment response and major adverse events by contrast-enhanced US

BACKGROUND & AIMS

Early prediction of tumour response and major adverse events (AEs), especially liver failure, in patients with hepatocellular carcinoma (HCC) is essential for maximizing the clinical benefits of sorafenib. To evaluate the usefulness of dynamic contrast-enhanced ultrasound (DCE-US) for the early prediction of tumour response and major AEs in HCC patients.

METHODS

Thirty-seven HCC patients were started on a reduced dosage of sorafenib, subsequently increased to the standard dosage. Tumour response at 1 month was assessed by CT using the Response Evaluation Criteria in Solid Tumors (RECIST). Major AEs were defined as grade 3 or higher. DCE-US was performed before treatment (day 0) and on days 7, 14 and 28. Changes in perfusion parameters in the tumour and liver parenchyma between day 0 and later time points were compared between treatment responders and nonresponders based on RECIST and between patients who experienced major AEs and those who did not. Tumour results were also compared with progression-free survival (PFS) and overall survival (OS).

RESULTS

Tumour perfusion parameters based on the area under the time-intensity curve (AUC) were statistically significant, with AUC during washin on day 14, the most relevant for tumour response (P = 0.0016) and AUC during washin on day 7, the most relevant for both PFS (P = 0.009) and OS (P = 0.037). A decrease in total AUC between days 0 and 7 in the liver parenchyma was strongly correlated with major AEs (P = 0.0002).

CONCLUSION

DCE-US may be useful for the early prediction of tumour response and major AEs in patients with HCC.

Depletion of CD25+CD4+T cells (Tregs) enhances the HBV-specific CD8+ T cell response primed by DNA immunization

AIM

Persistent hepatitis B virus (HBV) infection is characterized by a weak CD8(+) T cell response to HBV. Immunotherapeutic strategies that overcome tolerance and boost these suboptimal responses may facilitate viral clearance in chronically infected individuals. Therefore, we examined whether CD25(+)CD4(+) regulatory T (Treg) cells might be involved in a inhibition of CD8(+) T cell priming or in the modulation of the magnitude of the 'peak' antiviral CD8(+) T cell response primed by DNA immunization.

METHODS

B10.D2 mice were immunized once with plasmid pCMV-S. Mice received 500 microg of anti-CD25 mAb injected intraperitoneally 3 d before DNA immunization to deplete CD25(+) cells. Induction of HBV-specific CD8(+) T cells in peripheral blood mononuclear cells (PBMCs) was measured by S28-39 peptide loaded DimerX staining and their function was analyzed by intracellular IFN-gamma staining.

RESULTS

DNA immunization induced HBV-specific CD8(+) T cells. At the peak T cell response (d 10), 7.1+/-2.0% of CD8(+) T cells were HBV-specific after DNA immunization, whereas 12.7+/-3.2% of CD8(+) T cells were HBV-specific in Treg-depleted mice, suggesting that DNA immunization induced more antigen-specific CD8(+) T cells in the absence of CD25(+) Treg cells (n = 6, P<0.05). Similarly, fewer HBV-specific memory T cells were detected in the presence of these cells (1.3+/-0.4%) in comparison to Treg-depleted mice (2.6+/-0.9%) on d 30 after DNA immunization (n = 6, P<0.01). Both IFN-gamma production and the avidity of the HBV-specific CD8(+) T cell response to antigen were higher in HBV-specific CD8(+) T cells induced in the absence of Treg cells.

CONCLUSION

CD25(+) Treg cells suppress priming and/or expansion of antigen-specific CD8(+) T cells during DNA immunization and the peak CD8(+) T cell response is enhanced by depleting this cell population. Furthermore, Treg cells appear to be involved in the contraction phase of the CD8(+) T cell response and may affect the quality of memory T cell pools. The elimination of Treg cells or their inhibition may be important in immunotherapeutic strategies to control HBV infection by inducing virus-specific cytotoxic T lymphocyte responses in chronically infected subjects.

Irreversible electroporation for nonthermal tumor ablation in patients with hepatocellular carcinoma: initial clinical experience in Japan

PURPOSE

This clinical study was conducted to evaluate the safety and short-term outcomes of irreversible electroporation (IRE) for the treatment of patients with hepatocellular carcinoma (HCC) in Japan.

MATERIALS AND METHODS

The study was designed in a prospective setting. Five patients (3 men and 2 women; mean age, 66.6 ± 5.8 years) with 6 HCCs were enrolled and treated using percutaneous ultrasound (US)-guided IRE. Safety was assessed based on adverse events and laboratory values. Local control was assessed using contrast-enhanced US with a perflubutane microbubble contrast agent, contrast-enhanced multiphase CT, and gadoxetic acid-enhanced MRI (EOB-MRI) at designated points.

RESULTS

The tumors ranged in diameter from 11 to 28 mm (mean diameter, 17.5 ± 6.3 mm). Five of the 6 tumors (83 %) were successfully treated, with no local recurrence to date (mean follow-up 244 ± 55 days). In 1 lesion located in liver segment 1, residual tumor was diagnosed at 7 days after intervention by follow-up EOB-MRI. No serious complications related to the IRE procedure were observed.

CONCLUSION

The results of this study suggest that image-guided percutaneous IRE can achieve satisfactory local disease control, particularly for small HCCs, and is well tolerated by patients.

Liver fibrosis: noninvasive assessment using supersonic shear imaging and FIB4 index in patients with non-alcoholic fatty liver disease

PURPOSE

Shear wave elastography (SWE) has been validated in chronic hepatitis C and B; however, limited data are available in non-alcoholic fatty liver disease (NAFLD). This study aimed to evaluate the accuracy of SWE and FIB4 index for the diagnosis of fibrosis in a cohort of consecutive patients with biopsy-proven NAFLD, and to evaluate the effects of other histologic parameters on SWE measurement.

METHODS

Written informed consent was obtained from all patients, and this study was approved by our internal review board and ethics committee. Seventy-one patients with histologically proven NAFLD (mean age 50.8 years ± 15.7) were examined. All patients underwent SWE (Aixplorer™; SuperSonic Imagine) and FIB4 index (based on age, aspartate aminotransferase and alanine aminotransferase levels, and platelet counts) measurements. SWE measurements were compared with the histologic features based on the NAFLD activity score and FIB4 index.

RESULTS

The area under the ROC curve for the diagnosis of hepatic fibrosis stage 3 or higher was 0.821 (optimal cut-off value 13.1 kPa, sensitivity 62.5%, specificity 57.4%) for SWE and 0.822 (optimal cut-off value 1.41, sensitivity 71.9%, specificity 53.9%) for FIB4 index. The median liver stiffness values measured using SWE showed a stepwise increase with increasing hepatic fibrosis stage (P < 0.001), inflammation score (P = 0.018), and ballooning score (P < 0.001), and showed a stepwise decrease with increasing hepatic steatosis stage (P = 0.046).

CONCLUSIONS

SWE and FIB4 index are useful noninvasive tools for estimating the severity of fibrosis in NAFLD patients. However, the presence of severe steatosis may affect the liver stiffness measurement, resulting in underestimations of liver fibrosis.

Dual red imaging (novel advanced endoscopy) can increase visibility and can predict the depth in diagnosing esophageal varices

BACKGROUND

Dual red imaging (DRI) is a new technology that can increase the visibility of deeper veins compared with narrow band imaging (NBI). As esophageal varices (EVs) are a vascular disease occurring in the submucosal layer, their visibility might be increased by DRI. We prospectively clarified whether the visibility of EVs with red color sign (RCS) can be increased by DRI, and clarified the relation between the visibility scores and the obtained endoscopic ultrasound (EUS) images.

METHODS

Forty patients were enrolled. The visibility of the EVs on DRI and NBI endoscopic images was evaluated by five observers in a blinded manner and was compared with a white light image (bad, 0; equal, 1; good, 2). The diameter of the lumen and the depth of the EVs and RCS from the epithelium were measured by EUS. The relation between the visibility scores and the EUS findings was investigated.

RESULTS

The DRI scores were 1.66 ± 0.34 for the EV substance and 1.79 ± 0.28 for the RCS, whereas the NBI scores were 0.68 ± 0.38 and 0.41 ± 0.28, respectively. A significant negative correlation was found between the depth and the visibility score (r = -0.505, p = 0.001 for EVs; r = -0.458, p = 0.003 for RCS).

CONCLUSIONS

DRI increased the visibility of the EVs and RCS. The visibility of the EVs or RCS in the shallower position was more enhanced by DRI. Visual recognition of the changing degrees of visibility by DRI enables the prediction of the depth of EVs.

Predictive factors for hepatocellular carcinoma occurrence or recurrence after direct-acting antiviral agents in patients with chronic hepatitis C

BACKGROUND AND AIMS

Direct-acting antiviral agents (DAAs) and the risk of hepatocellular carcinoma (HCC) is controversially reported in the literature. The primary endpoints of this study were to clarify the cumulative incidence and recurrence rate of HCC after DAA treatment. The secondary endpoints were to identify the factors associated with the occurrence or recurrence of HCC after DAAs treatment.

METHODS

Of 234 HCV patients, 211 with no history of HCC (no-HCC-history group) and 23 with previous treated HCC history (HCC-history group) were treated with DAAs and followed for more than 24 weeks to determine the incidence of HCC. Platelet count, albumin, α-fetoprotein (AFP) level, L3%, the FIB-4 index and APRI scores were analyzed as possible factors associated with HCC occurrence and recurrence. An intergroup comparison was made of the cumulative incidence of HCC. Cox proportional hazards regression was used to determine associations between blood test values and risk of HCC.

RESULTS

The median observation period was 21 months. Cumulative incidence of HCC was higher in the HCC-history group than in the no-HCC-history group (p < 0.0001, 19.0 and 0.52 per 100 patient-years, respectively). Univariate analysis revealed platelet count, albumin, α-fetoprotein (AFP) level, AFP-L3%, and FIB-4 index and APRI scores at the end of DAA treatment as being significantly associated with occurrence/recurrence of HCC. Multivariate analysis revealed that AFP levels before and after the administration of DAAs and AFP-L3% after DAA were independently associated with the occurrence/recurrence of HCC (p = 0.045, 0.043, 0.005, respectively).

CONCLUSION

The HCC occurrence rate after DAA treatment was very low, and the recurrence rate lower than that in previous interferon reports. The AFP level and AFP-L3% were identified as important factors in predicting occurrence/recurrence of HCC. Careful observation is needed when increased levels of AFP or AFP-L3% after DAAs treatment are observed.

Relationship between liver tissue stiffness and histopathological findings analyzed by shear wave elastography and compression testing in rats with non-alcoholic steatohepatitis

PURPOSE

The aim of the present study was to investigate two methods of determining liver stiffness in rats with various degrees of non-alcoholic steatohepatitis induced by a methionine- and choline-deficient (MCD) diet by comparing each finding with reference to histopathological liver findings.

METHODS

Twenty male Wister rats were fed an MCD diet for up to 32 weeks, and four were fed a normal diet. Ultrasound-based shear wave elastography (SWE) and mechanical compression testing using an Instron Universal Testing machine were performed on each rat at designated time points. After each examination, liver histopathology was analyzed to evaluate the degrees of steatosis, inflammation, and fibrosis based on non-alcoholic fatty liver disease (NAFLD) activity score, and each finding was compared with reference to liver histopathologic findings.

RESULTS

Median liver stiffness values measured using SWE showed a stepwise increase with increasing histological inflammation score (P = 0.002), hepatic fibrosis stage (P = 0.029), ballooning score (P = 0.012), and steatosis grade (P = 0.030). Median liver stiffness measured using an Instron machine showed a stepwise increase only with increasing histological fibrosis stage (P = 0.033).

CONCLUSIONS

Degree of liver stiffness measured by SWE and the Instron machine differed. SWE reflected mainly inflammation, whereas Instron machine-derived values primarily reflected fibrosis. This is the main source of discrepancies between measurements made with these two modalities.

Japanese periodical nationwide epidemiologic survey of aberrant portal hemodynamics

AIM

Idiopathic portal hypertension (IPH), extrahepatic portal obstruction (EHO), and Budd-Chiari syndrome (BCS) are characterized by aberrant portal hemodynamics of unknown etiology. The aim of this study was to explore trends in the descriptive epidemiology of these diseases through periodical nationwide surveys.

METHODS

Nationwide epidemiologic surveys were undertaken in 1999, 2005, and 2015 using the same protocol. The survey targets were selected from all departments of gastrointestinal medicine, surgery, pediatrics, and pediatric surgery in Japan by stratified random sampling according to the number of beds. We asked each department to complete a mail-back questionnaire on the annual numbers of patients with IPH, EHO, and BCS during the preceding year.

RESULTS

The estimated number of BCS patients increased from 280 (95% confidence interval, 200-360) in 1999 survey to 410 (300-530) in 2015 survey, whereas the number of IPH and EHO patients has remained largely unchanged during the 15 years (IPH was approximately 1000; EHO was approximately 770 in 2015 survey). The mean age at symptom onset was approximately 45 years for IPH, 30 years for EHO, and 40 years for BCS over the past 15 years. Those who described disease aggravation from the time of diagnosis accounted for approximately 10% of IPH, 15% of EHO, and 20% of BCS patients in each of the three surveys.

CONCLUSIONS

In Japan, the prevalence of BCS is increasing, while those of IPH and EHO appear to be stable. Clinical characteristics, including prognoses, have remained largely unchanged in the past 15 years.

Focal nodular hyperplasia-like lesion of the liver with focal adenoma features associated with idiopathic portal hypertension

Great progress has been made in the diagnosis of focal nodular hyperplasia (FNH) and hepatocellular adenoma (HCA) in the last few years due to the use of molecular criteria. This has allowed us to identify a new type of hepatic nodule. In this case report, we present a male patient with a hepatic nodule associated with idiopathic portal hypertension (IPH) pathologically exhibiting not only the morphological features of FNH, such as ductular reactions, dilated sinusoids, major vascular abnormalities and an immunohistochemical "map-like" pattern of glutamine synthetase (GS), but also the immunohistological features of focal HCA, such as strong expression of serum amyloid A and C-reactive protein and weak expression of GS. As the final diagnosis, the nodule was identified as an FNH-like lesion with focal inflammatory hepatocellular adenoma.

Usefulness of autotaxin for the complications of liver cirrhosis

BACKGROUND

Autotaxin (ATX) has been reported as a direct biomarker for estimating the evaluation of liver fibrosis. But available data on ATX as a useful biomarker for the complications of liver cirrhosis (LC) are scant.

AIM

To assess the clinical usefulness of ATX for assessing the complications of LC.

METHODS

This multicenter, retrospective study was conducted at six locations in Japan. We include patients with LC, n = 400. The ATX level was evaluated separately in men and women because of its high level in female patients. To assess the clinical usefulness of ATX for the complications of LC, the area under the curve (AUC) of ATX assessing for the severe complications was analyzed in comparison with the model for end-stage liver disease score, albumin-bilirubin (ALBI) score, fibrosis-4 index, and aspartate aminotransferase-to-platelet ratio index.

RESULTS

The mean age was 68.4 ± 11.4 years, 240 patients (60.0%) were male. A total of 213 (53.3%) and 187 (46.8%) patients were compensated and decompensated, respectively. The numbers of patients with varix rupture, hepatic ascites, and hepatic encephalopathy were 35 (8.8%), 131 (32.8%), and 103 (25.8%), respectively. The AUCs of ATX in men for hepatic encephalopathy, hepatic ascites, and varix ruptures were 0.853, 0.816, and 0.706, respectively. The AUCs of ATX in women for hepatic encephalopathy, hepatic ascites, and varix rupture were 0.759, 0.717, and 0.697, respectively. The AUCs of ATX in men were higher than those in women, as were all the other biomarkers used to detect encephalopathy and varix ruptures. However, for detecting ascites, the AUC of ALBI in men was more effective than using ATX.

CONCLUSION

ATX in men was more effective than any other biomarkers for detecting hepatic encephalopathy and varix ruptures.

Case study to assess the safety of irreversible electroporation near the heart

INTRODUCTION

Irreversible electroporation (IRE) is a promising technique for the focal treatment of soft tissue tumors. Even though the local application of an excessive electric field is a potential cause of cardiac arrhythmias, initial clinical studies have shown that IRE is generally safe when cardiac gating is employed.

CASE DESCRIPTION

In this case report, we observed an episode of ventricular extrasystoles without hemodynamic changes during which time the synchronization device failed to operate properly, with pulses delivered not in the absolute refractory period but in the relative refractory period.

DISCUSSION AND EVALUATION

At present, persons performing IRE must keep in mind that there is a small but real risk of synchronization failure even when a cardiac synchronization device is used.

CONCLUSION

It is advisable to err on the side of caution when treating lesions near the heart.

Role of dual red imaging to guide intravariceal sclerotherapy injection of esophageal varices (with videos)

BACKGROUND AND AIMS

Dual red imaging (DRI) is a novel image-enhanced endoscopy technique that can increase the visibility and predict the depth of esophageal varices (EVs). The recurrence rate of EVs after endoscopic injection sclerotherapy (EIS) reportedly decreases by intravariceal injection of a sclerosant. We evaluated prospectively whether the EIS success rate was increased by DRI compared with the white-light imaging (WLI) mode.

METHODS

A total of 79 patients with EVs were randomly divided into the DRI (n = 40) and WLI (n = 39) groups. The primary endpoint was the success rate of intravariceal injection on the first EIS puncture. The secondary endpoint was the recurrence rate. A variable puncture needle was used, and the length was adjusted according to the EV visibility change by DRI. In the WLI group, DRI was not used.

RESULTS

The success rate of the first puncture was significantly higher in the DRI group than in the WLI group (80.0% vs 46.2%; P = .0018). The cumulative recurrence rate was significantly lower in the DRI group (P = .031). The sum of the depth and luminal diameter of EVs was investigated by EUS. The Pearson correlation coefficient between this value and the needle length was higher in the DRI group than in the WLI group (r = 0.878 vs 0.603).

CONCLUSIONS

DRI increased the EIS success rate and decreased the recurrence rate. This resulted from the puncture needle adjustment to the appropriate length via EV depth prediction by DRI.

Restoration of natural killer cell activity by interferon-free direct-acting antiviral combination therapy in chronic hepatitis C patients

AIM

Interferon-free direct-acting antiviral (DAA) therapy is an effective treatment for chronic hepatitis C (CH(C)) patients. Activity of natural killer (NK) cells was reported to be impaired in patients with hepatitis C virus infection. The aim of this study was to examine whether DAA therapy could restore NK activity in patients with CH(C).

METHODS

Direct-acting antiviral therapy was given to 31 CH(C) patients as asunaprevir/daclatasvir (ASV/DCV) (n = 15), ledipasvir/sofosbuvir (n = 7), ombitasvir/paritaprevir/ritonavir (n = 6), or elbasvir/grazoprevir (n = 3). Prior to therapy (0M), at the completion of the therapy (EOT), and at 24 weeks after completion (AFTER), NK activity and the frequency of CD56dim NK and CD56bright NK cells in peripheral blood were estimated by Cr release assay and flow cytometry. Statistical analysis was carried out by anova and the Mann-Whitney U-test.

RESULTS

In one of the ASV/DCV-treated patients, treatment was stopped 12 weeks after initiation of therapy because of viral breakthrough. The anova showed that NK activity significantly improved at EOT (vs. 0M, P < 0.01) and at AFTER (vs. 0M, P < 0.001) in 30 patients with sustained virologic response. It also showed that the frequency of CD56dim NK cells was significantly increased at EOT and at AFTER (vs. 0M, P < 0.05). In addition, the NK activity ratio (AFTER/0M) had no significant difference between patient groups with higher and lower Fibrosis-4 scores.

CONCLUSION

Direct-acting antiviral therapy in CH(C) patients could improve NK activity by increasing the frequency of CD56dim NK cells. Additionally, our results might imply that DAAs therapy could reduce the risk of hepatocarcinogenesis by restoring innate immune responses.

Memory Th1 cells augment tumor-specific CTL following transcutaneous peptide immunization

Targeting dendritic cells in vivo by transcutaneous peptide immunization (TCI) represents an efficient immunization strategy to induce tumor-specific CTL because it reflects the physiologic conditions occurring during pathogen infection. Here we show that including a Th1 peptide in TCI can activate preexisting memory Th1 (mTh1) responses and thereby enhance the CTL response. For this purpose, peptide-25, a major Th1 epitope of Ag85B from Mycobacterium tuberculosis, was selected. We adoptively transferred peptide-25-specific mTh1 cells and hgp100-specific naive CTL (pmel-1 TCR transgenic) into C57BL/6 mice. Subsequently, mice were transcutaneously immunized with CTL peptide (hgp100) and Th1 peptide (peptide-25). Five days after TCI, the frequency and function of pmel-1 cells was monitored by intracellular IFN-gamma staining, ELISPOT, and in vivo cytotoxicity assays. TCI efficiently expanded hgp100-specific, IFN-gamma-producing, strongly cytotoxic CD8(+) T cells. Concurrent activation of mTh1 cells by peptide-25 induced a 1.5-fold increase in the number of hgp100-specific CTL with enhanced effector functions. Furthermore, TCI elicited not only prophylactic but also therapeutic antitumor responses that were augmented by peptide-25. These results show that TCI facilitates peptide-specific activation of CD4(+) T cells, responsible for the augmenting effect of peptide-25 on the hgp100-specific CTL response. Because a significant proportion of the Japanese population has been vaccinated with Bacillus Calmette-Guerin, they are likely to possess Ag85B- or peptide-25-specific mTh1 cells. Therefore, concomitant activation of Ag85B- or peptide-25-specific mTh1 cells together with tumor-specific CTL by TCI might augment antitumor immune responses in a sizeable fraction of patients.

Branched-chain amino acid-enriched nutrient increases blood platelet count in patients after endoscopic injection sclerotherapy

AIM

Protein and energy malnutrition is a severe problem for patients with liver cirrhosis (LC) and fasting often induces starvation which is a vitally important outcome. Dietary restriction is essential for endoscopic injection sclerotherapy (EIS) in patients with risky esophageal varices, thereby creating the possible exacerbation of nutritional state and inducing liver dysfunction. Whether EIS induces nutritional deficiency in LC patients and the effects of branched-chain amino acid (BCAA)-enriched nutrient are prospectively investigated.

METHODS

A total of 61 LC patients were randomly divided into an EIS monotherapy group (non-BCAA group, n = 31) and an EIS combined with BCAA therapy group (n = 30). Platelet count, blood chemistry and somatometry values were prospectively measured at five time points.

RESULTS

The platelet counts before treatment were at the same level in both groups (P = 0.72). Three months after treatment, the counts decreased in the non-BCAA group; however, they increased in the BCAA group (P = 0.019). Body mass index, triceps skin fold thickness and arm muscle circumference significantly decreased in both groups. The BCAA and tyrosine ratio value increased only in the BCAA group (P < 0.01). The skeletal muscle volume measured by InBody720 significantly decreased in the non-BCAA group (P < 0.001).

CONCLUSION

EIS induced protein-energy malnutrition, however, skeletal muscle volume was maintained by taking BCAA. Administration of BCAA had some effect in maintaining the nutritional state, and may improve the platelet count. Taking a greater amount of nutrients and shorter dietary restriction period or hospitalization was desirable.

Thrombopoietin receptor agonist is more effective than platelet transfusion for chronic liver disease with thrombocytopenia, shown by propensity score matching

AIM

The thrombopoietin receptor agonist, lusutrombopag, was recently adapted for treatment of thrombocytopenia in chronic liver disease. However, no studies have compared the effects of lusutorombopag and platelet transfusion. Therefore, we aimed to clarify the efficacy and proportion of responders of lusutrombopag compared with platelet transfusion, by propensity score matching.

METHODS

A total of 200 patients (90 lusutrombopag, 110 platelet transfusion) with thrombocytopenia were enrolled, and matched for age, liver function, renal function, platelet count, peripheral blood count, and spleen size, using the propensity score-matching method. Finally, 52 patients (26 lusutrombopag, 26 platelet transfusion) were included. The primary end-point was an increase in platelet count. Secondary end-points were the proportion of responders, duration of the sustained effect, incidence of adverse events, and predictors associated with an increase in platelet count.

RESULTS

The median increase in platelets from baseline was 48 × 103 /μL versus 9.5 × 103 /μL (lusutrombopag vs. transfusion, P < 0.0001). The proportion of responders (increase of >10 × 103 /μL) was 100% versus 50.0% (P < 0.0001). Median duration of the sustained effect (increase of >50 × 103 /μL) was 10 versus 2 days (P < 0.0001). The incidence of adverse events was 7.7% versus 50.0% (P = 0.036). Predictors associated with an increase in platelets were hemoglobin and spleen size by multiple regression analysis.

CONCLUSION

Lusutrombopag was more effective in chronic liver disease patients than platelet transfusion. The proportion of responders, effect duration, and non-incidence rate of adverse events were higher in the lusutrombopag group.

The Risk of Cirrhosis and Its Complications Based on PNPLA3 rs738409 G Allele Frequency

BACKGROUND

Data regarding the influence of patatin-like phospholipase domain-containing 3 (PNPLA3) polymorphism for patients with liver cirrhosis (LC) are scarce.

OBJECTIVE

This study assesses the role of the PNPLA3 polymorphism for the development of LC and its complications by the findings of genetic examinations.

METHODS

Patients with LC caused by virus (n = 157), alcohol (n = 104), nonalcoholic fatty liver disease (NAFLD) (n = 106), or autoimmune disease (n = 33) and without LC (n = 128) were enrolled. LC was composed of the presence and absence of complications, such as variceal bleeding, hepatic ascites, and hepatic encephalopathy. To assess the role of the PNPLA3 polymorphism, odds ratio (OR) for the rs738409 variant was calculated for the patients between (i) with LC and without LC in the entire cohort and (ii) the presence and absence of complications in the patients with LC.

RESULTS

There was a significant difference among the patients without LC and those with alcohol, NAFLD-related LC in the frequency of G alleles (p < 0.001, both). According to complications of LC, the OR for NAFLD-related cirrhosis significantly increased in the presence of the two mutated alleles (OR = 3.165; p = 0.046) when the wild type was used as the reference. However, there were no significant risks for the complications in the virus and alcohol-related cirrhosis unless there was a presence of G alleles.

CONCLUSION

The PNPLA3 polymorphism was associated with the risk of NAFLD-related LC and its complications.

Prognostic and recurrence factors after endoscopic injection sclerotherapy for esophageal varices: Multivariate analysis with the propensity score matching: Multivariate analysis with propensity score matching

BACKGROUND

Peri-esophageal collateral veins have been reported to be associated with the recurrence of esophageal varices (EVs). In this study, we retrospectively analyzed whether endoscopic ultrasonography (EUS) findings obtained just before endoscopic injection sclerotherapy (EIS) are associated with the success rate of intravariceal injection, recurrence rate of EVs, and overall survival rate (OS) of patients. Furthermore, we investigated the independent predictors associated with these factors by multivariate analysis.

METHODS

A total of 91 patients with risky EVs treated by EIS were analyzed. The primary endpoint was to identify independent predictors associated with the success rate of intravariceal injection, recurrence rate, and OS by multivariate analysis, to confirm the usefulness of EUS examination. The secondary endpoint was to clarify differences in recurrence rate and OS between patients who underwent additional argon plasma coagulation (APC) and those who did not, by the propensity score matching method.

RESULTS

Luminal diameter of EVs and F factor were predictors of the success rate of intravariceal injection. APC was predictor of OS and recurrence of EVs. EUS findings were not associated with these factors. Propensity score matching (APC, 23; without APC, 23) showed that recurrence rate was significantly improved in the APC group (P = 0.050) and that OS had the tendency to be higher in the APC group (P = 0.068).

CONCLUSION

Endoscopic ultrasonography findings before EIS were associated with successful intravariceal injection but were not associated with recurrence rate or OS. Additional APC could improve OS and reduce the recurrence of EVs.

Morphological study of the gastrointestinal tract around the ligament of Treitz using upper gastrointestinal radiography: Fundamental data for EUS-guided gastrojejunostomy

BACKGROUND/PURPOSE

We developed EUS-guided double-balloon occluded gastrojejunostomy (EPASS) for gastric drainage tract obstruction. The success of EPASS depends on the proximity of the stomach and the gastrointestinal (GI) tract near the ligament of Treitz. The aim of this study is to clarify the GI anatomy near the ligament of Treitz.

METHODS

One thousand and sixteen cases imaged upper GI radiography using barium were retrospectively evaluated. Morphologically, the GI tract running near the ligament of Treitz was divided in three types: Type I: The 4th portion of the duodenum (D4) approaches the stomach; Type II: D4 does not approach the stomach; Type III: D4 forms a loop to the jejunum. The minimum distance between the stomach and the GI tract near the ligament of Treitz was measured.

RESULTS

Based on the morphological classification, 74.6% in the study group was classified in Type I, 22.0% in Type II, and 3.3% in Type III, respectively. The median minimum distance in Type II/III group were significantly longer, compared with the Type I (P < .01).

CONCLUSIONS

The GI anatomy near the ligament of Treitz was clarified using upper GI radiography. It is divided into three patterns, and one-fourth of cases may have difficulty in EUS-guided gastrojejunostomy.

Experimental study of a physician-controlled electrocautery-enhanced delivery system incorporating a newly developed lumen-apposing metal stent for interventional endoscopic ultrasound (with videos)

BACKGROUND/PURPOSE

Although the lumen-apposing metal stent (LAMS) is useful for interventional endoscopic ultrasound (EUS) procedures, there has been some concern about the potential for stent-induced adverse events because of the high lumen-apposing force. A newly designed LAMS with less lumen-apposing force has been developed for use with a physician-controlled electrocautery-enhanced delivery system. The aim of this animal study was to evaluate the feasibility of performing interventional EUS using this newly designed LAMS system.

METHODS

Endoscopic ultrasound-guided cystogastrostomy was performed using the novel LAMS three times in a wet simulation model. EUS-guided gastroenterostomy and EUS-guided gallbladder drainage were then performed using the system in four pigs.

RESULTS

The LAMS was successfully placed in all three EUS-guided cystogastrostomy procedures using the wet simulation model and in all four EUS-guided gastroenterostomy and gallbladder drainage procedures in the animal model. In the 3 weeks following the procedure, eating behavior was normal in all animals and there were no adverse events. The stents remained patent during this time and were removed without difficulty. The fistula was mature in all cases and a standard upper gastrointestinal endoscope was easily advanced via the fistula to observe the afferent and efferent loops or the lumen of the gallbladder. Necropsy confirmed complete adhesion between the stomach and the wall of the jejunum or gallbladder.

CONCLUSIONS

Our study findings demonstrate the feasibility of this new LAMS system and its potential clinical value for interventional EUS.