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Kishimoto K, Kakisaka K, Abe T, Ito A, Yusa K, Suzuki A, Endo K, Yoshida Y, Oikawa T, Miyasaka A, Sato A, Nishiya M, Yanagawa N, Kuroda H, Matsumoto T. Autoimmune Hepatitis Complicated by Undiagnosed Factor VII Deficiency: A Pitfall of Coagulopathy. Intern Med 2024; 63:2011-2014. [PMID: 37981301 PMCID: PMC11309871 DOI: 10.2169/internalmedicine.2854-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/05/2023] [Indexed: 11/21/2023] Open
Abstract
Prothrombin time (PT) is a key parameter for assessing the severity of liver disease. We present the case of a 37-year-old woman with severe acute liver injury due to autoimmune hepatitis. Although prednisolone drastically improved her hepatocyte function, her PT did not recover to the reference range. A review of her medical records revealed that the patient had normal transaminase levels and prolonged PT 2 years previously. Further examinations of her coagulopathy revealed that she had low factor VII activity, suggesting a diagnosis of factor VII deficiency. Our experience suggests that altered coagulopathy should be considered in cases of liver injury with an extraordinary PT.
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Affiliation(s)
- Kotaro Kishimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Japan
| | - Keisuke Kakisaka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Japan
| | - Tamami Abe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Japan
| | - Asami Ito
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Japan
| | - Kenji Yusa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Japan
| | - Akiko Suzuki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Japan
| | - Kei Endo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Japan
| | - Yuichi Yoshida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Japan
| | - Takayoshi Oikawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Japan
| | - Akio Miyasaka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Japan
| | - Ayaka Sato
- Department of Molecular Diagnostic Pathology, School of Medicine, Iwate Medical University, Japan
| | - Masao Nishiya
- Department of Molecular Diagnostic Pathology, School of Medicine, Iwate Medical University, Japan
| | - Naoki Yanagawa
- Department of Molecular Diagnostic Pathology, School of Medicine, Iwate Medical University, Japan
| | - Hidekatsu Kuroda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Japan
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Biswas S, Shalimar. Liver Transplantation for Acute Liver Failure- Indication, Prioritization, Timing, and Referral. J Clin Exp Hepatol 2023; 13:820-834. [PMID: 37693253 PMCID: PMC10483009 DOI: 10.1016/j.jceh.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/17/2023] [Indexed: 09/12/2023] Open
Abstract
Acute liver failure (ALF) is a major success story in gastroenterology, with improvements in critical care and liver transplant resulting in significant improvements in patient outcomes in the current era compared to the dismal survival rates in the pretransplant era. However, the ever-increasing list of transplant candidates and limited organ pool makes judicious patient selection and organ use mandatory to achieve good patient outcomes and prevent organ wastage. Several scoring systems exist to facilitate the identification of patients who need a liver transplant and would therefore need an early referral to a specialized liver unit. The timing of the liver transplant is also crucial as transplanting a patient too early would lead to those who would recover spontaneously receiving an organ (wastage), and a late decision might result in the patient becoming unfit for transplant (delisted) or have an advanced disease which would result in poor post-transplant outcomes. The current article reviews the indications and contraindications of liver transplant in ALF patients, the various prognostic scoring systems, etiology-specific outcomes, prioritization and timing of referral.
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Affiliation(s)
- Sagnik Biswas
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences New Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences New Delhi, India
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3
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Chen J, Luo S, Tang F, Han M, Zheng J, Deng M, Luo G. Development and validation of a practical prognostic nomogram for evaluating inpatient mortality of cirrhotic patients with acute variceal hemorrhage. Ann Hepatol 2023; 28:101086. [PMID: 36889674 DOI: 10.1016/j.aohep.2023.101086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/20/2023] [Accepted: 01/25/2023] [Indexed: 03/10/2023]
Abstract
INTRODUCTION AND OBJECTIVES Cirrhotic patients with acute variceal hemorrhage (AVH) have high short-term mortality. Established prognostic scores are seldom applicable clinically, partially because they need external validation or contain subjective variables. We aimed to develop and validate a practical prognostic nomogram based on objective predictors to predict prognosis for cirrhotic patients with AVH. PATIENTS AND METHODS We enrolled 308 AVH patients with cirrhosis from our center as the derivation cohort to develop a new nomogram using logistic regression and validated it in cohorts of patients from Medical Information Mart for Intensive Care (MIMIC) III (n = 247) and IV (n = 302). RESULTS International normalized ratio (INR), albumin (ALB) and estimated glomerular filtration rate (eGFR) were identified as predictors for inpatient mortality and a nomogram was constructed based on them. The nomogram discriminated well in both derivation and MIMIC-III/-IV validation cohorts with the area under the receiver operating characteristic curves (AUROCs) of 0.846 and 0.859/0.833, respectively and showed a better agreement between expected and observed outcomes (Hosmer-Lemeshow tests, all comparisons, P > 0.05) than other scores in all cohorts. Our nomogram had the lowest Brier scores (0.082/0.114/0.119 in training/MIMIC-III/MIMIC-IV) and highest R2 (0.367/0.393/0.346 in training/MIMIC-III/MIMIC-IV) compared to the recalibrated model for end-stage liver disease (MELD), MELD-hepatic encephalopathy (MELD-HE) and cirrhosis acute gastrointestinal bleeding (CAGIB) scores in all cohorts. CONCLUSIONS We developed a practical prognostic nomogram using easily verified indicators available in initial patient evaluation, which may serve as a reliable tool to accurately predict inpatient mortality for cirrhotic patients with AVH.
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Affiliation(s)
- Jie Chen
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Sha Luo
- Department of Laboratory Medicine, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Feng Tang
- Department of Gastroenterology, Third People's Hospital of Chengdu, Chengdu, Sichuan, China
| | - Ming Han
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Jie Zheng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Mingming Deng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China.
| | - Gang Luo
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China.
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4
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Kakisaka K, Nakayama N, Kumagai K, Hisanaga T, Kondo T, Setsu T, Sato S, Kooka Y, Endo K, Yoshida Y, Oikawa T, Kuroda H, Miyasaka A, Abe R, Nakada TA, Ikura Y, Harada K, Genda T, Terai S, Kato N, Takami T, Ido A, Mochida S, Matsumoto T, Tanaka A. Distinction of Drug-Induced Liver Injury From Autoimmune Hepatitis in Patients With Acute Liver Injury: Proposal of a Combination of Diagnostic Scores. GASTRO HEP ADVANCES 2023; 2:497-504. [PMID: 39132042 PMCID: PMC11307899 DOI: 10.1016/j.gastha.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 02/02/2023] [Indexed: 08/13/2024]
Abstract
Background and Aims Acute liver injury (ALI) due to autoimmune hepatitis (AIH) can be treated by immunosuppression. In contrast, idiosyncratic drug-induced liver injury (DILI) had a poor prognosis. DILI thus needs to be distinguished from non-DILI. Methods Twenty-nine patients with DILI and 77 with non-DILI (42 of AIH and 35 with undetermined cause) diagnosed during 2005-2017 comprised the derivation cohort. 110 patients with ALI due to either AIH, DILI, or obscure causes at 6 liver centers during 2010-2015 were the validation cohort. Revised international AIH group scores (IAIHGs) and the Roussel-Uclaf Causality Assessment Method (RUCAM) were modified to calculate results using medical interviews and laboratory data without chronological changes. Diagnostic accuracy for the distinction of DILI and non-DILI was evaluated by receiver operating characteristic analysis and results were expressed as the area under the curve (AUC). This study received institutional institutional review board approval (MH2020-205). Results The AUCs of modified IAIHGs and RUCAM scores for the diagnosis of DILI were 0.96 and 1.00 when cut-off values were set at 3 for the modified RUCAM and 5 for the modified IAIHGs in the derivation cohort. In the validation cohort, the AUCs of modified IAIHGs and RUCAM scores for the diagnosis of DILI were 0.95 and 0.97, respectively. The accuracy of the combination of the modified scores was 81% (89/110). Conclusion Modified diagnostic scores based on detailed medical interviews and routine laboratory data can distinguish DILI from non-DILI in patients with ALI.
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Affiliation(s)
- Keisuke Kakisaka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Yahaba, Japan
| | - Nobuaki Nakayama
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Moroyama, Japan
| | - Kotaro Kumagai
- Department of Digestive and Lifestyle Related Disease, Health Research Course, Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Takuro Hisanaga
- Department of Gastroenterology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Takayuki Kondo
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Toru Setsu
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Shunsuke Sato
- Department of Gastroenterology, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
| | - Yohei Kooka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Yahaba, Japan
| | - Kei Endo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Yahaba, Japan
| | - Yuichi Yoshida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Yahaba, Japan
| | - Takayoshi Oikawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Yahaba, Japan
| | - Hidekatsu Kuroda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Yahaba, Japan
| | - Akio Miyasaka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Yahaba, Japan
| | - Ryuzo Abe
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Taka-aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshihiro Ikura
- Department of Pathology, Aijinkai Takatsuki General Hospital, Takatsuki, Japan
| | - Kenichi Harada
- Department of Human Pathology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Takuya Genda
- Department of Gastroenterology, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Taro Takami
- Department of Gastroenterology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Akio Ido
- Department of Digestive and Lifestyle Related Disease, Health Research Course, Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Satoshi Mochida
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Moroyama, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Yahaba, Japan
| | - Atsushi Tanaka
- Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
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Kakisaka K, Suzuki Y, Takahashi F, Takikawa Y. Referral system has a diminished difference in the risk for hepatic encephalopathy development among each etiology in patients with acute liver injury. Hepatol Res 2022; 52:401-410. [PMID: 34989069 DOI: 10.1111/hepr.13744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/25/2021] [Accepted: 01/03/2022] [Indexed: 02/08/2023]
Abstract
AIM Hepatic encephalopathy (HE) development is crucial in liver transplantation for patients with acute liver injury (ALI) and failure (ALF); to predict HE development, the Japan Hepatic Encephalopathy Prediction (JHEP) model, calculated using age, etiology, prothrombin time (PT), and total bilirubin, was established in 2004, and a referral system to the liver center was implemented using the JHEP model from April 2004. METHODS The JHEP model's ability to predict HE development in 460 consecutive patients with ALI between April 2004 and January 2021 using data from the referral system was evaluated, and the JHEP model was revised. RESULTS During the observation period, 7.8% patients developed HE. There was no difference in the proportion of HE development among the etiologies. In the Hosmer-Lemeshow test for HE development prediction, the JHEP model, revised JHEP (rJHEP) model, which was calculated without etiology data, and the modified JHEP model, which used the PT international ratio instead of PT in the rJHEP model, were good fitting models. Upon 30% random sampling from the total patients 60 times, the receiver operating curve analysis of both JHEP and rJHEP models for HE development was performed in all the datasets. The area under the curve of the JHEP model was subtracted from that of the rJHEP model (95% confidential interval, 0.000516-0.01793). CONCLUSIONS The referral system using the JHEP model reduced the difference in the risk for HE development among each etiology; the rJHEP model had a better prediction ability for HE development than the JHEP model.
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Affiliation(s)
- Keisuke Kakisaka
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Yuji Suzuki
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Yahaba, Japan
| | - Fumiaki Takahashi
- Center for Liberal Arts and Science, Iwate Medical University, Yahaba, Japan
| | - Yasuhiro Takikawa
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Yahaba, Japan
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Ikura A, Chu PS, Nakamoto N, Ojiro K, Taniki N, Yoshida A, Shinoda M, Morikawa R, Yamataka K, Noguchi F, Hoshi H, Usui S, Ebinuma H, Kitagawa Y, Saito H, Kanai T. CLIF-C Organ Failure Score and Liver Volume Predict Prognosis in Steroid-Treated Severe Acute Autoimmune Hepatitis. Hepatol Commun 2020; 4:1019-1033. [PMID: 32626834 PMCID: PMC7327221 DOI: 10.1002/hep4.1521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/11/2020] [Accepted: 04/02/2020] [Indexed: 12/19/2022] Open
Abstract
Controversies and debates remain regarding the best management of severe acute‐onset autoimmune hepatitis (SA‐AIH) due to the lack of useful outcome or complication prediction systems. We conducted this clinical practice‐based observational study to clarify whether Chronic Liver Failure Consortium Organ Failure scores (CLIF‐C OFs) and the computed tomography–derived liver volume to standard liver volume (CTLV/SLV) ratio at admission to a tertiary transplant center can predict outcomes and complications due to infection. Thirty‐four consecutive corticosteroid‐treated patients with SA‐AIH from 2007 to 2018 were included. Severe hepatitis was defined as an international normalized ratio (of prothrombin time) over 1.3 any time before admission. Of the 34 corticosteroid‐treated patients with SA‐AIH inclusive of 25 (73.5%) acute liver failure cases, transplant‐free survival was observed in 24 patients (70.6%). Any infection was noticed in 10 patients (29.4%). CLIF‐C OFs, at the cutoff of 9, significantly predicted survival (P = 0.0002, log‐rank test), outperformed the Model for End‐stage Liver Disease system in predicting outcome (P = 0.0325), and significantly discriminated between liver transplant and death in a competing risk analysis. SA‐AIH was characterized as having decreased CTLV/SLV, which was also predictive of survival (P < 0.0001). Interestingly, CLIF‐C OFs, especially the subscores for respiratory dysfunction, also predicted infection (P = 0.007). Conclusion: In corticosteroid‐treated patients with SA‐AIH, CLIF‐C OFs and CTLV/SLV ratios predicted both survival outcome and complications due to infection. Further investigation is warranted to determine whether making decisions based on CLIF‐C OFs or CTLV/SLV ratios is useful.
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Affiliation(s)
- Akihiko Ikura
- Division of Gastroenterology and Hepatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Po-Sung Chu
- Division of Gastroenterology and Hepatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Nobuhiro Nakamoto
- Division of Gastroenterology and Hepatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Keisuke Ojiro
- Division of Gastroenterology and Hepatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan.,Department of Gastroenterology and Hepatology Tokyo Dental College Ichikawa General Hospital Ichikawa City Japan
| | - Nobuhito Taniki
- Division of Gastroenterology and Hepatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Aya Yoshida
- Division of Gastroenterology and Hepatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Masahiro Shinoda
- Department of Surgery Keio University School of Medicine Tokyo Japan
| | - Rei Morikawa
- Division of Gastroenterology and Hepatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Karin Yamataka
- Division of Gastroenterology and Hepatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Fumie Noguchi
- Division of Gastroenterology and Hepatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Hitomi Hoshi
- Division of Gastroenterology and Hepatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Shingo Usui
- Division of Gastroenterology and Hepatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan.,Department of Gastroenterology and Hepatology National Hospital Organization Saitama Hospital Wako City Japan
| | - Hirotoshi Ebinuma
- Division of Gastroenterology and Hepatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan.,Department of Gastroenterology International University of Health and Welfare School of Medicine Narita City Japan
| | - Yuko Kitagawa
- Department of Surgery Keio University School of Medicine Tokyo Japan
| | - Hidetsugu Saito
- Division of Gastroenterology and Hepatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan.,Division of Pharmacotherapeutics Keio University School of Pharmacy Tokyo Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan
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Motoi S, Toyoda H, Obara T, Ohta E, Arita Y, Negishi K, Moriya K, Kuboi Y, Soejima M, Imai T, Ido A, Tsubouchi H, Kawano T. Anti-Apoptotic Effects of Recombinant Human Hepatocyte Growth Factor on Hepatocytes Were Associated with Intrahepatic Hemorrhage Suppression Indicated by the Preservation of Prothrombin Time. Int J Mol Sci 2019; 20:ijms20081821. [PMID: 31013780 PMCID: PMC6514566 DOI: 10.3390/ijms20081821] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 11/16/2022] Open
Abstract
Hepatocyte growth factor (HGF) is an endogenously expressed bioactive substance that has a strong anti-apoptotic effect. In this study, we biochemically and histologically characterized the effects of rh-HGF on in vitro human hepatocyte injury and mouse acute liver failure (ALF) models, both of which were induced by antibody-mediated Fas signaling. rh-HGF inhibited intracellular caspase-3/7 activation and cytokeratin 18 (CK-18) fragment release in both models. Histologically, rh-HGF dramatically suppressed parenchymal damage and intrahepatic hemorrhage. Among the laboratory parameters, prothrombin time (PT) was strongly preserved by rh-HGF, and PT was well correlated with the degree of intrahepatic hemorrhage. These results showed that the anti-apoptotic effect of rh-HGF on hepatocytes coincided strikingly with the suppression of intrahepatic hemorrhage. PT was considered to be the best parameter that correlated with the intrahepatic hemorrhages associated with hepatocellular damage. The action of rh-HGF might derive not only from its anti-apoptosis effects on liver parenchymal cells but also from its stabilization of structural and vasculature integrity.
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Affiliation(s)
- Sotaro Motoi
- Eisai Co., Ltd., KAN Product Creation Unit, Eisai Product Creation Systems, 5-1-3 Tokodai, Tsukuba, Ibaraki 3002635, Japan.
- KAN Research Institute, Inc., 6-8-2 Minatojima-Minamimachi, Chuo-Ku, Kobe, Hyogo 6500047, Japan.
| | - Hiroko Toyoda
- Eisai Co., Ltd., KAN Product Creation Unit, Eisai Product Creation Systems, 5-1-3 Tokodai, Tsukuba, Ibaraki 3002635, Japan.
| | - Takashi Obara
- Eisai Co., Ltd., KAN Product Creation Unit, Eisai Product Creation Systems, 5-1-3 Tokodai, Tsukuba, Ibaraki 3002635, Japan.
| | - Etsuko Ohta
- Eisai Co., Ltd., KAN Product Creation Unit, Eisai Product Creation Systems, 5-1-3 Tokodai, Tsukuba, Ibaraki 3002635, Japan.
| | - Yoshihisa Arita
- KAN Research Institute, Inc., 6-8-2 Minatojima-Minamimachi, Chuo-Ku, Kobe, Hyogo 6500047, Japan.
| | - Kana Negishi
- KAN Research Institute, Inc., 6-8-2 Minatojima-Minamimachi, Chuo-Ku, Kobe, Hyogo 6500047, Japan.
| | - Katsuhiro Moriya
- Eisai Co., Ltd., KAN Product Creation Unit, Eisai Product Creation Systems, 5-1-3 Tokodai, Tsukuba, Ibaraki 3002635, Japan.
| | - Yoshikazu Kuboi
- Eisai Co., Ltd., KAN Product Creation Unit, Eisai Product Creation Systems, 5-1-3 Tokodai, Tsukuba, Ibaraki 3002635, Japan.
- KAN Research Institute, Inc., 6-8-2 Minatojima-Minamimachi, Chuo-Ku, Kobe, Hyogo 6500047, Japan.
| | - Motohiro Soejima
- Eisai Co., Ltd., KAN Product Creation Unit, Eisai Product Creation Systems, 5-1-3 Tokodai, Tsukuba, Ibaraki 3002635, Japan.
- KAN Research Institute, Inc., 6-8-2 Minatojima-Minamimachi, Chuo-Ku, Kobe, Hyogo 6500047, Japan.
| | - Toshio Imai
- KAN Research Institute, Inc., 6-8-2 Minatojima-Minamimachi, Chuo-Ku, Kobe, Hyogo 6500047, Japan.
| | - Akio Ido
- Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 8908544, Japan.
- Department of HGF Tissue Repair and Regenerative Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 8908544, Japan.
| | - Hirohito Tsubouchi
- Department of Gastroenterology and Hepatology, Kagoshima City Hospital, 37-1 Uearata-cho, Kagoshima 8908760, Japan.
| | - Tetsu Kawano
- KAN Research Institute, Inc., 6-8-2 Minatojima-Minamimachi, Chuo-Ku, Kobe, Hyogo 6500047, Japan.
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