Relevance of chronic hepatitis E in liver transplant recipients: a real-life setting

The chronic course of hepatitis E virus (HEV) infections in orthotopic liver transplant (OLT) recipients has been described previously, but prospectively collected data are rare. We aimed to study the role of chronic hepatitis E in OLT in a real-life setting. Therefore, 287 adult OLT recipients (169 male [59%], median age 56 years) were prospectively tested by HEV polymerase chain reaction assay (lower level of detection = 10 IU/mL), irrespective of their level of liver enzymes. In 4 patients (1.4%), chronic HEV infection was diagnosed. All 4 patients were male, and their age (median 48.5 years), the time since transplantation (median 45.5 months), and bilirubin level (median 0.6 mg/dL) did not differ significantly from the total cohort. However, alanine transaminase and aspartame transaminase levels were significantly higher in HEV-infected patients (75-646 U/L, median 216 U/L and 68-317 U/L, median 108 U/L) than in non-infected patients (6-617 U/L, median 41 and 6-355 U/L, median 36; P = 0.004 and 0.040, Mann-Whitney test). In 3 patients, liver biopsy was performed and revealed signs of inflammation and chronic liver disease, as enlarged densely infiltrated portal tracts with mild-to-moderate interface hepatitis. All infected patients were treated with ribavirin with the starting dose adjusted to renal function (400-800 mg/day). In 2 patients, dose reduction was necessary. Transaminases normalized in all 4 patients, and all patients cleared their infection within 3 months of ribavirin treatment. However, 1 patient experienced viral relapse 12 weeks after discontinuation. Ribavirin medication was re-started and viral clearance occurred within 8 weeks and persisted. Sequence analysis of the HEV genome of this patient revealed that he was infected with an HEV variant, which recently has been shown to have a reduced response to ribavirin in cell culture. The risk of chronic HEV infections in OLT recipients in low-endemic countries should not be overestimated. No case of chronic hepatitis E was observed in patients with normal liver enzymes, indicating that general screening of all OLT recipients is not necessary. However, if chronic hepatitis E develops, it can be treated efficiently with ribavirin.

Comparison of autochthonous and imported cases of hepatitis A or hepatitis E

BACKGROUND

Hepatitis A and hepatitis E are not limited to tropical countries but are also present in industrialized countries. Both infections share similar clinical features. There is no comparative study evaluating the clinical parameters of autochthonous and imported hepatitis A virus and hepatitis E virus infections.

AIMS

The aim of this study was to determine differences between autochthonous and imported hepatitis A virus (HAV) and hepatitis E virus (HEV) infections.

METHODS

Medical charts of all patients at our center with acute HAV and HEV infections were analyzed retrospectively (n = 50, study period 01/2009 - 08/2013).

RESULTS

Peak bilirubin (median 8.6 vs. 4.4 mg/dL, p = 0.008) and ALT levels (median 2998 vs. 1666 IU/mL, p = 0.04) were higher in patients with hepatitis A compared to hepatitis E. In comparison to autochthones hepatitis E cases, patients with imported infections had significantly higher peak values for AST, ALT, bilirubin and INR (p = 0.009, p = 0.002, p = 0.04 and p = 0.049, respectively). In HAV infection, AST levels tended to be higher in imported infections (p = 0.08).

CONCLUSIONS

(i) It is not possible to differentiate certainly between acute HAV and HEV infections by clinical or biochemical parameters, however, HAV infections might be associated with more cholestasis and higher ALT values. (ii) Imported HEV infections are associated with higher transaminases, INR and bilirubin levels compared to autochthonous cases and (iii) imported HAV infections tend to be associated with higher transaminases in comparison to autochthonous cases.

Clinical Course of acute-on-chronic liver failure syndrome and effects on prognosis

Acute-on-chronic liver failure (ACLF) is characterized by acute decompensation (AD) of cirrhosis, organ failure(s), and high 28-day mortality. We investigated whether assessments of patients at specific time points predicted their need for liver transplantation (LT) or the potential futility of their care. We assessed clinical courses of 388 patients who had ACLF at enrollment, from February through September 2011, or during early (28-day) follow-up of the prospective multicenter European Chronic Liver Failure (CLIF) ACLF in Cirrhosis study. We assessed ACLF grades at different time points to define disease resolution, improvement, worsening, or steady or fluctuating course. ACLF resolved or improved in 49.2%, had a steady or fluctuating course in 30.4%, and worsened in 20.4%. The 28-day transplant-free mortality was low-to-moderate (6%-18%) in patients with nonsevere early course (final no ACLF or ACLF-1) and high-to-very high (42%-92%) in those with severe early course (final ACLF-2 or -3) independently of initial grades. Independent predictors of course severity were CLIF Consortium ACLF score (CLIF-C ACLFs) and presence of liver failure (total bilirubin ≥12 mg/dL) at ACLF diagnosis. Eighty-one percent had their final ACLF grade at 1 week, resulting in accurate prediction of short- (28-day) and mid-term (90-day) mortality by ACLF grade at 3-7 days. Among patients that underwent early LT, 75% survived for at least 1 year. Among patients with ≥4 organ failures, or CLIF-C ACLFs >64 at days 3-7 days, and did not undergo LT, mortality was 100% by 28 days.

CONCLUSIONS

Assessment of ACLF patients at 3-7 days of the syndrome provides a tool to define the emergency of LT and a rational basis for intensive care discontinuation owing to futility.

[Economic burden of Clostridium difficile enterocolitis in German hospitals based on routine DRG data]

BACKGROUND

Clostridium difficile associated diarrhea (CDAD) is not only a increasing medical but also economical problem.

METHODS

Data from the DRG project group of the German society for digestive and metabolic diseases (DGVS) were analyzed for CDAD. Out of 430,875 cases from 37 German hospitals 2,767 cases were grouped by having CDAD either as primary (PD) or secondary diagnosis (SD; likely to be from a hospital source) in an initial or recurring hospital stay (RD). For comparison non-CDAD cases from the same hospitals from that year where matched using propensity score matching. As endpoints we defined LOS (length of stay), difference of LOS to national average LOS, total costs per case and difference between costs and revenue for all three groups.

RESULTS

Patients from the PD group (n = 817) showed a mean LOS of 11.2 days compared to 8.5 days for the control group, 4,132 € mean cost per case (536 € more than control) and a mean loss of -1,064 € per case compared to -636 €. In the SD group (n = 1,840) patients stayed in the hospital for 28.8 days (control: 18.1 days), had costs of 19,381 € (control: 13,082 €) and a loss of -3,442 € compared to -849 € in the control group. Recurring cases (RD; n = 110) showed a LOS of 37.3 days (control: 21.3 days), had even higher costs (20.755 € vs. 13,101 €) and higher losses (-4,196 € vs. -1,109 €).

CONCLUSION

By extrapolating these findings CDAD not only harms patients but generates a yearly cost burden of 464 million € for the German healthcare system including a loss of 197 million € for German hospitals. To the authors' opinion sufficient measures against CDAD should include pre hospital risk reduction programs, introduction of effective therapeutic and hygienic strategies in hospitals as well as improvements in documentation for these cases to support further developments of the German DRG system.

Quality of life one year post-Shiga toxin-producing Escherichia coli O104 infection--a prospective cohort study

BACKGROUND

In 2011, a major outbreak of hemolytic-uremic syndrome (HUS) and bloody diarrhea related to infections from Shiga toxin-producing Escherichia coli O104 (STEC) occurred in Germany. While previous research has focused on the medical components of this disease, we aimed to investigate the course of health-related quality of life (HrQoL) over 12 months including somatic and psychosocial risk factors. Furthermore, the influence of chronic fatigue (CF) on HrQoL was examined.

METHODS

A prospective cohort study with n = 389 patients completing self-report scales at baseline, after 6 months (participation rate: 79%) and after 12 months (participation rate: 77%). The courses of physical and mental HrQoL over the 12 month period were calculated by employing general linear mixed models.

KEY RESULTS

While the physical component score of HrQoL reached a score comparable to the general population, the mental component score remained below average 12 months after STEC infection. Female gender, prior psychiatric disorder, and prior traumatic events were risk factors for a worse HrQoL course after 12 months, while social support was identified to be protective. CF was associated with low HrQoL. In addition, the somatic symptom burden remained persistently high.

CONCLUSIONS & INFERENCES

Our results show high somatic and psychosocial burden in patients 12 months after STEC infection. We recommend considering the risk factors and protective factors of poor HrQoL early in the treatment of STEC or similar diseases. Patients who are suffering from persisting somatic symptoms, CF, and impaired HrQoL may require specific aftercare.

Gemcitabine plus sorafenib versus gemcitabine alone in advanced biliary tract cancer: a double-blind placebo-controlled multicentre phase II AIO study with biomarker and serum programme

BACKGROUND

Since sorafenib has shown activity in different tumour types and gemcitabine regimens improved the outcome for biliary tract cancer (BTC) patients, we evaluated first-line gemcitabine plus sorafenib in a double-blind phase II study.

PATIENTS AND METHODS

102 unresectable or metastatic BTC patients with histologically proven adenocarcinoma of gallbladder or intrahepatic bile ducts, Eastern Cooperative Oncology Group (ECOG) 0-2 were randomised to gemcitabine (1000 mg/m2 once weekly, first 7-weeks+1-week rest followed by once 3-weeks+1-week rest) plus sorafenib (400 mg twice daily) or placebo. Treatment continued until progression or unacceptable toxicity. Tumour samples were prospectively stained for sorafenib targets and potential biomarkers. Serum samples (first two cycles) were measured for vascular endothelial growth factors (VEGFs), vascular endothelial growth factor receptor 2 (VEGFR-2) and stromal cell-derived factor 1 (SDF1)α by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Gemcitabine plus sorafenib was generally well tolerated. Four and three patients achieved partial responses in the sorafenib and placebo groups, respectively. There was no difference in the primary end-point, median progression-free survival (PFS) for gemcitabine plus sorafenib versus gemcitabine plus placebo (3.0 versus 4.9 months, P=0.859), and no difference for median overall survival (OS) (8.4 versus 11.2 months, P=0.775). Patients with liver metastasis after resection of primary BTC survived longer with sorafenib (P=0.019) compared to placebo. Patients who developed hand-foot syndrome (HFS) showed longer PFS and OS than patients without HFS. Two sorafenib targets, VEGFR-2 and c-kit, were not expressed in BTC samples. VEGFR-3 and Hif1α were associated with lymph node metastases and T stage. Absence of PDGFRβ expression correlated with longer PFS.

CONCLUSION

The addition of sorafenib to gemcitabine did not demonstrate improved efficacy in advanced BTC patients. Biomarker subgroup analysis suggested that some patients might benefit from combined treatment.

[Development of gastrointestinal infectious diseases between 2000 and 2012]

BACKGROUND

Infectious gastroenterological diseases are of increasing medical and health-economic significance.

METHOD

To evaluate the development of gastroenterolgical infections (GI) over the past 10 years, we have analysed the published data of the German Federal Statistics Office on GI hospital admissions between 2001 and 2011 and the data on cases of infection reported to the Robert-Koch Institute between 2001 and 2012.

RESULTS

In 2011 520795 patients with infectious diarrhoea (ICD 10 A00-A09) required hospital admission. The number of coded main diagnoses alone has more than doubled from 127867 to 282199 cases per year. The increase in the group of over 65-year-old patients was particularly high. The highest increase among hospitalised patients was seen for Clostridium difficile infections (99779 cases in 2011) together with noro- and rotavirus infections, whereas the number of cases with salmonella declined. The number of hospital deaths related to infectious gastrointestinal diseases (major clinical diagnosis) rose from 401 in 2000 to 4152 in 2011. Particularly frequent were deaths coded under the ICD 10 diagnosis A04, which includes Clostridium difficile infections (CDI).

DISCUSSION

In spite of the limitations due to differing data sources, reporting and recording rules, the analysed data do allow conclusions as to the development of the last 10 years. Gastrointestinal infections have not only markedly increased but also required increasing hospital capacities in gastroenterological departments. Since, with the exception of rotavirus infections, no vaccination strategies are available, these developments will have to be combatted above all by improved infectiological training for gastroenterologists.

[A 44-year-old woman with hereditary nonpolyposis colon carcinoma: screening examinations for non-colonic tumors]

A 44-year-old woman presented in March 2010 for surveillance esophagogastroduodenoscopy (EGD). In October 2004, rectal cancer had been diagnosed and treated by resection of the rectum with adjuvant chemotherapy. A diagnosis of hereditary nonpolyposis colon carcinoma (HNPCC) was established on the basis of the Amsterdam II criteria. Due to a lack of clear guidelines we decided to perform annual systematic surveillance examinations of the stomach and the most frequent tumor manifestations. Until 2009, extracolonic tumors were not observed in the patient. In March 2010, EGD showed a discrete erosive lesion in the gastric antrum, which was biopsied. Most notably, the histopathological examination revealed a poorly differentiated mucinous adenocarcinoma. Due to the poor differentiation, we decided against technically possible, endoscopic resection. The patient underwent subtotal gastrectomy and is still doing fine 28 months after surgery. This case prompted us to evaluate our surveillance approach in HNPCC patients and to review the literature.

Autoimmune hepatitis 2013 and beyond

Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease leading to cirrhosis and its complications if left untreated. Clinical features include elevated transaminases, elevated immunoglobulin G and the presence of autoantibodies. A liver biopsy is necessary for the establishment of the diagnosis. If treated properly and timely, prognosis of AIH is excellent. Standard treatment today consists of azathioprine and prednisolone and leads to remission in the vast majority of patients. Intolerance to standard treatment or incomplete remission as well as special patient groups such as pregnant patients or elderly patients require second- or sometimes even third-line treatments. For those patients, a number of effective drugs are available off-label and induction of remission will be possible in the vast majority of patients. Choice of drug regimen is important as drug-drug-interactions, concomitant diseases, age and gender of the patients have to be taken into account to achieve a tolerable side effect profile and good quality of life in patients. Mycophenolate mofetil is the drug of first choice in azathioprine intolerance. Other treatments may include the use of cyclosporine, tacrolimus, cyclophosphamide or biologicals such as rituximab or infliximab. Close monitoring of the patients will be necessary as side effects may occur.

Acute Liver Failure Following Minocycline Treatment – A Case Report and Review of the Literature

We present the case of a 23-year-old female patient with acute liver failure following intake of minocycline. This patient had severe hypereosinophilia and massively increased IgE levels. Experimental studies in this case revealed elevated IFN-γ-, as well as TNF-α-producing CD4+ and CD8+ T-cells after in vitro stimulation with minocycline, indicating a type I/IgE-mediated as well as type II/cytotoxic reaction in the pathogenesis of minocycline-induced liver failure. Although mild forms of liver involvement are well known side effects of minocycline, only 8 cases with acute liver failure have been reported, and we present a review of all cases.

[Pyogenic liver abscess: a retrospective patient study]

INTRODUCTION

Pyogenic liver abscess (PLA) is a disease with changing origins as well as diagnostic and therapeutic options in the last decades.

MATERIALS AND METHODS

A retrospective study of the last 20 patients treated at a gastroenterological department of a university clinic for the major diagnosis of PLA was conducted. Epidemiological, clinical, microbiological and therapeutic aspects were recorded.

RESULTS

75 % of the patients were male. The mean age was 51.7 ± 16.6 years. Most of PLA (70 %) had a hepatobiliary origin. Diabetes mellitus (25 %) and cholangiocarcinoma (20 %) were the major risk factors for PLA. Crohn's disease was a possible cause in at least one patient. Fever (70 %) and tachycardia (50 %) were the most common symptoms. The C-reactive protein was elevated in all patients. Enterococci (> 40 %) and anaerobes (> 20 %) were the most frequent organisms in abscess cultures, Escherichia coli (25 %) was the most frequent organism in blood cultures.

DISCUSSION

The clinical presentation of PLA is usually non-specific. Therefore especially with patients having typical risk factors the differential diagnosis of PLA should be considered. Particularly patients suffering from PLA without any pre-existing illness should be examined for an underlying disease.

[Lack of data relevant for German transplantation medicine]

Collection of data in transplantation medicine is required to define ethical standards, to assess indications and contra-indications and to determine rules for organ allocation. Similarly, assessment of quality of the transplantation process and practice of transplantation centres requires relevant data in transplantation medicine. Apart from data in quality reports, Eurotransplant and organ procurement, any form of data collection is lacking in Germany. In this article the problems caused by this shortcoming are described.

[A rare cause of variceal bleeding]

BACKGROUND

Agnogenic myeloid metaplasia (AMM) is a clonal stem cell disease, which is characterized by myelofibrosis, osteosclerosis and pancytopenia. Affected patients frequently develop portal hypertension secondary to extramedullary hematopoiesis, which rarely becomes clinically relevant.

CASE REPORT

We here report on a 63-year-old patient with a first presentation of variceal bleeding. The patient was diagnosed with portal hypertension and due to marked splenomegaly, liver cirrhosis was suspected. Subsequently, an extramedullary hematopoiesis and AMM could be diagnosed. The variceal bleeding was initially treated endoscopically. The patient has received cytoreductive therapy and a splenorenal shunt, which has led to remission and long-term survival.

CONCLUSION

Agnogenic myeloid metaplasia is a rare cause of portal hypertension and may present with variceal bleeding. Clinicians should be aware of this rare cause of portal hypertension, as treatment of the underlying disease with cytoreductive therapy and appropriate management of portal hypertension may lead to long-term survival.

[Knowledge about HBV, prevention behaviour and treatment adherence of patients with chronic hepatitis B in a large referral centre in Germany]

BACKGROUND

The incidence of chronic hepatitis B in Germany is approximately 0.5 %. Data regarding knowledge about HBV, prevention behaviour and treatment adherence in patients with chronic HBV are scarce.

METHODS

In this prospective study 201 consecutive patients with CHB infection were studied from a large urban academic outpatient clinic at the University Medical Centre in Hamburg. Patients were interviewed with a questionnaire that contained 47 questions covering social demographic dates, knowledge about HBV, treatment adherence and prevention. The success rate of interviews was 100 % with free translation service offered.

RESULTS

20.4 % of the CHB patients were born in Germany, but the majority of the patients were immigrants (80.6 %). 51 % of the patients had a good, 34 % a moderate and 15 % a poor knowledge about HBV. 89 % of the patients knew that HBV can be transmitted through blood contacts, but 34 % believed that inadequate hygienic conditions and 24 % that food products may transmit the virus. 96 % of the patients had knowledge about the existence of an HBV vaccine. Furthermore, 82 % considered a vaccination of all persons in the household important. Despite the knowledge of the existence and importance of a vaccine, only 61,7 % of the 300 affected children/siblings of HBV-positive family members were vaccinated. However, the child vaccination rate was significantly higher among patients with knowledge about the protective effect of the vaccine (p < 0.001), the free of charge vaccination program for children up to 18 years (p < 0.001) and higher school education (p < 0.001). Migrants with poor German language skills had lower knowledge scores (p < 0.001) and showed lower vaccination rates (p = 0.016) compared to immigrants with good German language skills. 43 % of all patients were treated with nucleot(s)ide analogues with a median treatment duration of 2 - 5 years. 65 % of these patients declared to never have missed a dose and 27 % missed less than one dose per month. 90 % of the patients tolerated the antiviral drugs very well and between patients with or without side effects there was no significant difference in quality of life.

CONCLUSION

Chronic hepatitis B in Germany is characterised by awareness problems and language barriers. More attention is needed for HBV-infected immigrants in the form of multilingual information about CHB and awareness campaigns.

Terlipressin in 30 patients with hepatorenal syndrome: results of a retrospective study

Terlipressin is known to improve renal function in patients with liver cirrhosis and hepatorenal syndrome (HRS). This study investigated effects of duration and dose of terlipressin therapy and predictive factors for positive response to treatment. The clinical charts of 30 consecutive patients with HRS who received terlipressin and albumin based on a determined therapeutic scheme, were retrospectively studied. In 25 (66 %) of 38 treatment episodes complete response was achieved (Kaplan-Meier survival method). Predictive for positive response to treatment were duration of treatment and cumulative terlipressin dosis (p < 0.01, 95 % CI 0.31 - 0.59 and p < 0.01, 95 % CI 0.93 - 0.98, respectively) as well as a low level of serum creatinine and MELD score at inclusion (p = 0.01, 95 % CI 0.3 - 9.85 and p < 0.01, 95 % CI 0.87 - 0.98 respectively) and HRS type II (p = 0.04, 95 % CI 1.04 - 9.93). The median duration of therapy was 6 days +/- 4.9 (SD) vs. 8 days +/- 6.3 in the nonresponder group. The median dose of terlipressin in the responder group was 3.9 mg +/- 1.3 per day vs. 3.4 mg +/- 1.4 in the nonresponder group (p = n. s.). The probability that complete response was obtained at day 17 of treatment was 84 % (95 % CI 0.64 - 0.96), whereas at day 7 it was just 52 % (95 % CI 0.36 - 0.7). In conclusion, these data confirm that terlipressin plus albumin is effective in two-thirds of patients with HRS. Prolongation of treatment beyond 7 days up to 20 days is capable of increasing the response rates. Whether outcome can be predicted depending on parameters like type of HRS and base-level of serum creatinine needs to be confirmed in further studies, especially with regard on the previously revised criteria of HRS.

Adalimumab could suppress the activity of non alcoholic steatohepatitis (NASH)

The prevalence of non-alcoholic steatohepatitis (NASH) is increasing. NASH confers an increased risk of liver-related morbidity and mortality with a substantial risk of developing liver cirrhosis. At present, there is no established medical treatment for NASH. The pathogenesis of NASH is incompletely understood. Several lines of evidence suggest that TNF-alpha may be involved in the pathogenesis of NASH by promoting liver inflammation, insulin resistance and hepatocyte apoptosis. Anti-TNF-alpha therapy has not been evaluated for the treatment of NASH. We report here on a patient with NASH who has experienced rapid normalization of liver biochemistry during treatment of an associated rheumatoid arthritis with the humanized anti-TNF-alpha antibody adalimumab. This observation suggests that pilot studies may be warranted to evaluate the role of adalimumab for the treatment of NASH.

[Autoimmune pancreatitis with normal IgG4-Levels: 4 case reports and review of the literature]

We report four cases of autoimmune pancreatitis in an 18-, a 22- and a 26-year-old male patient and a 20-year-old female patient. The 20-year-old female patient was admitted to the hospital with upper abdominal pain and jaundice, the 18-year-old patient with recurrent acute pancreatitis and cholestasis, the 26-year-old patient with right upper abdominal pain for four weeks and laboratory findings suggesting an acute pancreatitis. The 22-year-old patient presented with painless jaundice. EUS-guided fine needle aspiration was performed in all patients. The cytological findings and the EUS were decisive for the diagnosis of autoimmune pancreatitis in all four cases. In contrast, no patient showed elevated IgG4, or antibodies for carboanhydrase-II, for lactoferrin, or rheumatoid factor, serum markers reported to be positive in autoimmune pancreatitis. All patients were treated successfully with steroids, one patient relapsed after discontinuing the steroid medication and required renewed therapy. These case reports demonstrate that autoimmune pancreatitis should be considered in the differential diagnosis in cases of pancreatitis and/or jaundice also in western countries. As demonstrated, the diagnosis should not be based solely on the elevation of IgG4 or autoantibodies.