Clinical trial watch: reports from the AASLD Liver Meeting®, Boston, November 2014

Progress in clinical and basic research of fuzheng Huayu formula for the treatment of liver fibrosis

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Chinese medicine has great potential and advantages in the treatment of liver fibrosis, with Fuzheng Huayu formula (FZHY) serving as a prime example due to its remarkable efficacy in delaying and reversing liver fibrosis while simultaneously improving clinical symptoms for patients.

AIM OF THE REVIEW

In this paper, we present a comprehensive review of recent studies on the therapeutic potential of FZHY and its components/ingredients in the treatment of liver fibrosis and cirrhosis, with the aim of providing insights for future research endeavors.

MATERIALS AND METHODS

A comprehensive literature search was conducted on FZHY, TCM319, traditional Chinese medicine 319, liver fibrosis and cirrhosis using multiple internationally recognized databases including PubMed, Embase, Springer, Web of science, SciVerse ScienceDirect, Clinical Trails. Gov, CNKI, Wanfang, and VIP.

RESULTS

FZHY is widely used clinically for liver fibrosis and cirrhosis caused by various chronic liver diseases, with the effects of improving serum liver function, liver pathological histology, serological indices related to liver fibrosis, decreasing liver stiffness values and portal hypertension, as well as reducing the incidence of hepatocellular carcinoma and morbidity/mortality in patients with cirrhosis. Numerous in vivo and in vitro experiments have demonstrated that FZHY possesses anti-fibrotic effects by inhibiting hepatic stellate cell activation, reducing inflammation, protecting hepatocytes, inhibiting hepatic sinusoidal capillarization and angiogenesis, promoting extracellular matrix degradation, and facilitating liver regeneration. In recent years, there has been a growing focus on investigating the primary active components/ingredients of FZHY, and significant strides have been made in comprehending their synergistic mechanisms that enhance efficacy.

CONCLUSION

FZHY is a safe and effective drug for treating liver fibrosis. Future research on FZHY should focus on its active components/ingredients and their synergistic effects, as well as the development of modern cocktail drugs based on its components/ingredients. This will facilitate a more comprehensive understanding of the molecular mechanisms and targets of FZHY in treating liver fibrosis, thereby further guide clinical applications and drug development.

Ciclopirox Olamine Induces Proliferation Inhibition and Protective Autophagy in Hepatocellular Carcinoma

Hepatocellular carcinoma is one of the most common fatal malignancies worldwide. Thus far, the hepatocellular carcinoma prognosis has been bleak due to deficiencies in the identification and diagnosis of early hepatocellular carcinoma. Ciclopirox olamine (CPX) is a synthetic antifungal agent and has been considered as an anti-cancer candidate drug recently, though the detailed mechanisms related to its anti-cancer effect in hepatocellular carcinoma have not yet been revealed. Here, we found that CPX could inhibit proliferation in HCC cells but not in intrahepatic cholangiocarcinoma cells by arresting the cell cycle. Moreover, the anti-cancer effects of CPX in HCC cells were also attributed to CPX-triggered ROS accumulation and DJ-1 downregulation. Additionally, CPX could promote complete autophagic flux, which alleviated the anti-cancer effect of CPX in HCC cells, whereas the ROS scavenger (NAC) would attenuate CPX-induced protective autophagy. Interestingly, CPX could also induce glycogen clustering in HCC cells. Altogether, this study provides a new insight into the detailed molecular mechanisms of CPX as an anti-cancer therapy and a strategy for treating hepatocellular carcinoma.

CCT6A expression in hepatocellular carcinoma and its correlation with clinical characteristics, liver function indexes, tumor markers and prognosis

BACKGROUND

Chaperonin-containing tailless complex polypeptide 1 subunit 6A (CCT6A) plays roles in cancer progression, but its clinical implication in hepatocellular carcinoma (HCC) management needs further exploration. This study aimed to explore the correlation of CCT6A with clinical characteristics, liver function indexes, tumor markers and prognosis in HCC patients.

METHODS

240 HCC patients were retrospectively enrolled. 240 pairs of cancer and adjacent specimens were used to evaluate CCT6A protein expression by immunohistochemistry assay; among which 184 pairs were used to assess CCT6A mRNA expression by reverse transcription-quantitative polymerase chain reaction.

RESULTS

Both CCT6A protein expression and CCT6A mRNA expression were higher in HCC tumor tissue than in adjacent tissue (P < 0.001). The receiver operating characteristic (ROC) curve showed that CCT6A had certain potential in discriminating tumor tissues from adjacent tissues. In addition, CCT6A protein expression was positively correlated with multifocal tumor nodule (P = 0.001), ≥ 5.0 cm tumor size (P = 0.028), BCLC stage (P = 0.002) and abnormal AFP (P = 0.021). Besides, CCT6A mRNA expression was associated with multifocal tumor nodule (P = 0.025), ≥ 5.0 cm tumor size (P = 0.018), higher BCLC stage (P = 0.036), abnormal CA199 (P = 0.027) and abnormal AFP (P = 0.008). However, no correlation was found in CCT6A with liver function indexes (all P ≥ 0.05). Moreover, CCT6A protein and mRNA high expressions were both correlated with poor accumulating overall survival (OS) (P = 0.004, P = 0.002, respectively). Furthermore, CCT6A protein high expression (vs. low) independently predicted shorter OS (P = 0.027).

CONCLUSIONS

CCT6A serves as a possible biomarker reflecting tumor features and prognostication in HCC patients.

Drug-eluting bead transarterial chemoembolization (TACE) exhibits superior efficacy and equal tolerance to conventional TACE in hepatocellular carcinoma patients with conventional TACE history

OBJECTIVE

Multiple conventional transarterial chemoembolization (cTACE) procedures would cause treatment resistance in hepatocellular carcinoma (HCC) patients, whether drug-eluting bead transarterial chemoembolization (DEB-TACE) would resolve this issue is a necessary topic. Thus, this study aimed to compare the efficacy and safety between DEB-TACE and cTACE in HCC patients with cTACE treatment history.

METHODS

Totally, 134 HCC patients with cTACE treatment history were retrospectively reviewed. They were categorized into DEB-TACE group (N = 70) and cTACE group (N = 64) based on the current treatment they received.

RESULTS

After 1-month treatment, DEB-TACE group exhibited an elevated objective response rate (ORR) (71.9% vs. 47.3%, P = 0.008) while similar disease control rate (DCR) (93.0% vs. 81.8%, P = 0.074) compared to cTACE group. Besides, after 3-month treatment, DEB-TACE group also displayed higher ORR (68.4% vs. 44.1%, P = 0.038) and DCR (81.6% vs. 58.8%, P = 0.034) compared to cTACE group. Furthermore, the median progression-free survival (PFS) (11.5 months vs. 6.5 months P = 0.014) and overall survival (OS) (18.5 months vs. 13.0 months, P = 0.025) were longer in DEB-TACE group compared to cTACE group. Moreover, DEB-TACE (vs. cTACE) independently correlated with prolonged PFS (P = 0.021) and OS (P = 0.017) after adjustment by multivariate Cox's regression. Besides, most of liver function indexes were similar before and after treatment between these two groups. Also, the commonly observed adverse events were pain, fever, nausea/vomiting and blood pressure elevation with similar incidence between these two groups (all P > 0.050).

CONCLUSION

DEB-TACE exhibits superiority over cTACE in HCC patients with cTACE treatment history.

Transglutaminase 3 expression in hepatocellular carcinoma patients: Correlation with tumor features and survival profile

BACKGROUND

Transglutaminase 3 (TGM3) regulates multiple oncogene pathways (GSK-3β/β-catenin pathway, Akt/ERK pathway, etc.) to promote hepatocellular carcinoma (HCC) cell proliferation, migration and invasion, however, its clinical value for HCC management is still limited. Therefore, we conducted this study to compare the TGM3 expression between tumor tissue and paired adjacent noncancerous tissue, aiming to explore the clinical application of TGM3 in HCC patients.

METHODS

Totally, 208 HCC patients were enrolled and their clinicopathological features were collected. Then, 208 pairs of HCC specimens and adjacent noncancerous specimens were used to detect TGM3 protein expression by IHC assay and assessed by a semi-quantitative scoring method. Besides, 157 pairs were proposed to detect TGM3 mRNA expression by RT-qPCR.

RESULTS

Both TGM3 protein (P<0.001) and mRNA (P<0.001) levels were increased in HCC specimens compared to adjacent noncancerous specimens. Besides, TGM3 high protein expression correlated with multifocal tumor nodules (P<0.001), advanced Barcelona Clinic Liver Cancer (BCLC) stage (P = 0.006), higher carcinoembryonic antigen (P = 0.038) and alpha-fetoprotein (AFP) (P<0.001). While TGM3 high mRNA expression correlated with multifocal tumor nodules (P = 0.025), largest tumor size ≥ 5.0 cm (P = 0.042) and higher AFP (P = 0.019). Furthermore, both TGM3 protein (P = 0.002) and mRNA (P = 0.028) high expressions correlated with shorter overall survival (OS). While after adjustment by multivariant Cox's regression, TGM3 protein high expression (vs. low) independently predicted worse OS (P = 0.004).

CONCLUSIONS

TMG3 expression is increased in tumor tissue, also its high expression correlates with multiple tumor nodules, higher BCLC stage, abnormal AFP and reduced OS in HCC patients.

The Timing of Liver Transplantation Following Downstaging: Wait of Not to Wait?

PURPOSE

HCC is a complex disease that is diagnosed in advanced stage and on the background of cirrhosis. Locoregional therapies provide sufficient downstaging to enable patients suitable for radical procedures such liver transplantation. However, the interval between locoregional therapies and definitive therapy is still controversial. We performed a review of literature to evaluate the role of waiting period between locoregional therapies and liver transplantation or resection from the perspective of cure and recurrence rates.

METHODS

Thorough literature search was performed to evaluate the role of locoregional therapy and the interval to definitive therapies for the treatment of hepatocellular cancer.

RESULTS

Usually, small tumors with lower tumor burden, in other words, tumors within Milan criteria, can be transplanted with an acceptable overall and disease-free survival. However, treating patients with locally advanced tumors is currently a matter of extensive research. Currently, locoregional therapies are applied to downstage the patients. However, the duration of waiting is a crucial point that needs further research. There is a consensus that the waiting interval between down-staging and transplantation should be no less than 3 months. This is important for selection of favorable tumor biology as well as from the point of antitumor immune response.

CONCLUSION

Currently, there are no surrogate markers for surveillance of response to locoregional therapies as well as the antitumor immune response that develops as a result of down-staging.

Inhibition of TRPM7 blocks MRTF/SRF-dependent transcriptional and tumorigenic activity

Myocardin-related transcription factors A and B (MRTFs) are coactivators of Serum Response Factor (SRF) that mediates the expression of genes involved in cell proliferation, migration and differentiation. There is mounting evidence that MRTFs and SRF represent promising targets for hepatocellular carcinoma (HCC) growth. Since MRTF-A nuclear localization is a prerequisite for its transcriptional activity and oncogenic properties, we searched for pharmacologically active compounds able to redistribute MRTF-A to the cytoplasm. We identified NS8593, a negative gating modulator of the transient receptor potential cation channel TRPM7, as a novel inhibitor of MRTF-A nuclear localization and transcriptional activity. Using a pharmacological approach and targeted genome editing, we investigated the functional contribution of TRPM7, a unique ion channel containing a serine-threonine kinase domain, to MRTF transcriptional and tumorigenic activity. We found that TRPM7 function regulates RhoA activity and subsequently actin polymerization, MRTF-A-Filamin A complex formation and MRTF-A/SRF target gene expression. Mechanistically, TRPM7 signaling relies on TRPM7 channel-mediated Mg²⁺ influx and phosphorylation of RhoA by TRPM7 kinase. Pharmacological blockade of TRPM7 results in oncogene-induced senescence of hepatocellular carcinoma (HCC) cells in vitro and in vivo in HCC xenografts. Hence, inhibition of the TRPM7/MRTF axis emerges as a promising strategy to curb HCC growth.

Reappraisal of Failures in Downstaging Treatment of Hepatocellular Carcinoma Prior to Liver Transplant-Preliminary Report on the Impact of Underestimations of Tumor Numbers and Tumor Sizes as Measured From Imaging Before Transplant

Downstaging treatment of hepatocellular carcinoma (HCC) prior to liver transplant (LT) is an accepted strategy to meet the Milan criteria. However, after transplant surgery, a reality is noted that the number or/and the size of some HCCs measured from the liver explants is different from that measured from the pre-LT imaging. If tumor number or tumor size measured from the liver explants was beyond that measured from pre-LT imaging, we define it as "failed downstaging." Among 27 patients who received downstaging therapies, there are 11 "number reduction failures" and 6 "size reduction failures." We attribute the discrepancy to 2 possible reasons; one is that the pre-LT imaging after downstaging could not completely detect all the HCC; the other is that the time interval between the downstaging and LT is long enough to develop new HCCs. After follow-up, 6 patients developed HCC recurrence. The significant factors affecting recurrence include tumor size from postdownstaging imaging (P = .048), tumor number ≥ 2 (P = .007), multiple sessions of downstaging (P = .03), ratio of neutrophil to lymphocyte (P = .047), and tumor number from liver explant (borderline P = .05). Tumor recurrence after LT is significantly higher in those with "size reduction failure" (P = .048). The interval between LT and tumor recurrence is significantly shorter in those with "size reduction failure" (P = .04). To decrease underestimations of HCC, combining various imaging studies including the computed tomographic scan, magnetic resonance imaging, and contrast ultrasonography is needed to increase the accuracy before LT. Repeated imaging studies at short intervals of no more than 3 months are necessary during a long wait. How to minimize the underestimations of HCC to determine the appropriate candidacy for LT is an important goal for transplantation surgeons.

The Role of Fibrosis and Liver-Associated Fibroblasts in the Pathogenesis of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the most aggressive types of cancer and lacks effective therapeutic approaches. Most HCC develops in the setting of chronic liver injury, hepatic inflammation, and fibrosis. Hepatic stellate cells (HSCs) and cancer-associated fibroblasts (CAFs) are key players in liver fibrogenesis and hepatocarcinogenesis, respectively. CAFs, which probably derive from HSCs, activate into extracellular matrix (ECM)-producing myofibroblasts and crosstalk with cancer cells to affect tumor growth and invasion. In this review, we describe the different components which form the HCC premalignant microenvironment (PME) and the tumor microenvironment (TME), focusing on the liver fibrosis process and the biology of CAFs. We will describe the CAF-dependent mechanisms which have been suggested to promote hepatocarcinogenesis, such as the alteration of ECM, CAF-dependent production of cytokines and angiogenic factors, CAF-dependent reduction of immuno-surveillance, and CAF-dependent promotion of epithelial-mesenchymal transition (EMT). New knowledge of the fibrosis process and the role of CAFs in HCC may pave the way for new therapeutic strategies for liver cancer.

The Role of Fibrosis and Liver-Associated Fibroblasts in the Pathogenesis of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the most aggressive types of cancer and lacks effective therapeutic approaches. Most HCC develops in the setting of chronic liver injury, hepatic inflammation, and fibrosis. Hepatic stellate cells (HSCs) and cancer-associated fibroblasts (CAFs) are key players in liver fibrogenesis and hepatocarcinogenesis, respectively. CAFs, which probably derive from HSCs, activate into extracellular matrix (ECM)-producing myofibroblasts and crosstalk with cancer cells to affect tumor growth and invasion. In this review, we describe the different components which form the HCC premalignant microenvironment (PME) and the tumor microenvironment (TME), focusing on the liver fibrosis process and the biology of CAFs. We will describe the CAF-dependent mechanisms which have been suggested to promote hepatocarcinogenesis, such as the alteration of ECM, CAF-dependent production of cytokines and angiogenic factors, CAF-dependent reduction of immuno-surveillance, and CAF-dependent promotion of epithelial-mesenchymal transition (EMT). New knowledge of the fibrosis process and the role of CAFs in HCC may pave the way for new therapeutic strategies for liver cancer.

Hepatic stellate cells limit hepatocellular carcinoma progression through the orphan receptor endosialin

Hepatocellular carcinoma (HCC) is among the most common and deadliest cancers worldwide. A major contributor to HCC progression is the cross talk between tumor cells and the surrounding stroma including activated hepatic stellate cells (HSC). Activation of HSC during liver damage leads to upregulation of the orphan receptor endosialin (CD248), which contributes to regulating the balance of liver regeneration and fibrosis. Based on the established role of endosialin in regulating HSC/hepatocyte cross talk, we hypothesized that HSC‐expressed endosialin might similarly affect cell proliferation during hepatocarcinogenesis. Indeed, the histological analysis of human HCC samples revealed an inverse correlation between tumor cell proliferation and stromal endosialin expression. Correspondingly, global genetic inactivation of endosialin resulted in accelerated tumor growth in an inducible mouse HCC model. A candidate‐based screen of tumor lysates and differential protein arrays of cultured HSC identified several established hepatotropic cytokines, including IGF2, RBP4, DKK1, and CCL5 as being negatively regulated by endosialin. Taken together, the experiments identify endosialin‐expressing HSC as a negative regulator of HCC progression.

Fe3O4 nanoparticles and cryoablation enhance ice crystal formation to improve the efficiency of killing breast cancer cells

The key problem of cryoablation is that only freezing is often unable to kill the capillaries at tumor edges, leading to a high rate of recurrence. Here, we found that Fe₃O₄ nanoparticles were highly useful to improve the freezing capability of cryosurgery due to their ability to alter intracellular ice formation (IIF) and growth in tumor cells. The killing efficiency of cryoablation for MCF-7 breast cancer cells can be expected to be enhanced as the Fe₃O₄ nanoparticles concentration increased, it was mainly because that more IIF was induced by the participation of Fe₃O₄ nanoparticles during freezing, recrystallization and thawing. Furthermore, our results also showed that recrystallization contributed to the formation of extracellular embryonic crystals, which was capable of enhancing the efficiency of killing MCF-7 cells. This research is to develop an understanding of the mechanism of the cryoablation enhancing the killing efficiency in the presence of the Fe₃O₄ nanoparticles, and to promote their further application in tumor therapy.

Long-term survival of hepatocellular carcinoma after percutaneous radiofrequency ablation guided by ultrasound

Background

The risk factors for recurrence and death after radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) remain poorly known. This study was aimed to study the 10-year overall survival (OS) of HCC treated by ultrasound (US)-guided RFA and the risk factors for recurrence and death.

Methods

Between June 2005 and June 2016, 1000 patients with HCC treated by US-guided RFA at 4 hospitals in China; among them, 525 patients met the criteria for radical ablation and 410 had high AFP levels before RFA treatment. Clinical and biochemical factors were tested for association with recurrence and survival. Patients were divided into the recurrence (n = 348) and no recurrence groups (n = 62).

Results

The 5- and 10-year survival rates were 66 and 35%, respectively. Tumor size (HR = 1.36, 95% CI 1.12–1.65), albumin levels (HR = 0.76, 95% CI 0.65–0.91), prothrombin time (HR = 2.18, 95% CI 1.54–3.10), and α-fetoprotein levels (HR = 1.13, 95% CI 1.00–1.26) were independently associated with mortality after RFA for HCC. Tumor size (HR = 1.27, 95% CI: 1.15–1.40), HBV-DNA (HR = 7.70, 95% CI 3.57–16.63), AFP levels before treatment (HR = 2.172, 95% CI 1.256–3.756, P = 0.006), and AFP response (HR = 4.722, 95% CI 1.053–21.184, P = 0.0427) were independently associated with the risk of recurrence of HCC after RFA. The median survival of the patients with and without recurrence after RFA was 54 (95% CI 45–58) and 62 (95% CI 48–80) months, respectively (log-rank, P = 0.04).

Conclusions

Tumor size, albumin, prothrombin time, and α-fetoprotein levels were independently associated with mortality after US-guided RFA for HCC, while tumor size and HBV-DNA were independently associated with recurrence. Patients with recurrence had a poorer survival compared with those without.

Hepatic stellate cells secreting WFA+ -M2BP: Its role in biological interactions with Kupffer cells

BACKGROUND AND AIM

Hepatic stellate cells (HSCs) play a central role in hepatic fibrosis and are regulated by Kupffer cells (KCs). Wisteria floribunda agglutinin-positive Mac-2 binding protein (WFA⁺ -M2BP) was recently identified as a serum marker for hepatic fibrosis. Although WFA⁺ -M2BP was identified as a ligand of Mac-2, the function of WFA⁺ -M2BP in hepatic fibrosis remains unclear.

METHODS

Liver specimens were obtained from five patients with cirrhosis, five with chronic hepatitis, and five without hepatic fibrosis. WFA⁺ -M2BP kinetics were evaluated histologically and in subpopulations of liver cells such as HSCs, KCs, endothelial cells, biliary epithelial cells, and hepatocytes in in vitro culture. The function of WFA⁺ -M2BP in activated HSCs was evaluated using immunoblot analysis.

RESULTS

Numbers of WFA⁺ -M2BP-positive cells in liver tissues increased with fibrosis stage. There were significant differences in WFA⁺ -M2BP levels between fibrosis stages F0 and F1-2 (P = 0.012) and between fibrosis stages F1-2 and F3-4 (P < 0.001). HSCs were the source of WFA⁺ -M2BP secretion in in vitro cultures of liver cells, as determined by sandwich immunoassay. Cells of the human HSC line LX-2 also secreted WFA⁺ -M2BP. Histologically, tissue sections showed that WFA⁺ -M2BP was located in Mac-2-expressing KCs. In vitro assays showed that exogenous WFA⁺ -M2BP stimulation enhanced Mac-2 expression in KCs and that HSCs co-cultured with KCs increased α-smooth muscle actin expression. Finally, Mac-2-depleted KCs with short interfering RNA had reduced α-smooth muscle actin expression following co-culturing with HSCs.

CONCLUSIONS

WFA⁺ -M2BP from HSCs induces Mac-2 expression in KCs, which in turn activates HSCs to be fibrogenic.

Terlipressin plus albumin for treatment of type 1 hepatorenal syndrome: A meta-analysis

AIM

to assess the efficacy of terlipressin plus albumin in the treatment of hepatorenal syndrome (HRS).

METHODS

Cochrane strategy was used to identify randomized controlled trials published before July 2016 by searching PubMed, The Cochrane Library, Web of Science and LILACS, Medline, EMBASE, Chinese Biomedical Literature Database, Chongqing VIP Information Co., Ltd, China National Knowledge Internet Database, and Wanfang Data.

RESULTS

Six randomized controlled trials involving 542 cases were selected for this meta-analysis. The HRS remission rate and the survival rate were increased by terlipressin plus albumin, with OR = 5.25 (95%CI: 2.77-6.52) and 2.33 (95%CI: 1.11-4.88) compared with albumin alone, respectively. Blood creatinine was decreased by the combination treatment, and mean arterial pressure was increased significantly, while there was no difference in urine output. Side effects due to systemic circulation congestion and peripheral vasoconstriction were reported, such as stomach ache and extremity cyanosis. No fatal side effect was reported.

CONCLUSION

compared with albumin alone, terlipressin plus albumin is effective in the treatment of HRS, as demonstrated by increased remission rate and survival rate and no occurrence of fatal side effect.

Hyponatraemia induced by terlipressin: a case report and literature review

WHAT IS KNOWN AND OBJECTIVE

Terlipressin is widely used to treat variceal bleeding and hepatorenal syndrome. We report one case of stubborn hyponatraemia induced by long-term (up to 21 days) therapy with terlipressin and review the side effects of this agent.

CASE SUMMARY

A 41-year-old man with variceal rebleeding experienced a course of stubborn hyponatraemia during a long-term (up to 21 days) therapy with terlipressin. The hyponatraemia could not be corrected until withdrawal of terlipressin. The adverse event is likely due to the stimulation of V1 receptors in the splanchnic area and V2 receptors in the collecting duct.

WHAT IS NEW AND CONCLUSION

Given that this reaction has rarely been reported, we discuss the present case with a review of other similar cases. Serum sodium should be monitored intensively to avoid misdiagnosis whenever terlipressin treatment is employed for either gastrointestinal haemorrhage or hepatorenal syndrome.

Hepatorenal Acute Kidney Injury and the Importance of Raising Mean Arterial Pressure

BACKGROUND

The efficacy of vasoconstrictors in hepatorenal syndrome (HRS) is variable. We hypothesized that the effectiveness of vasoconstrictor therapy in improving kidney function ultimately relates to the magnitude of the achieved mean arterial pressure (MAP) increase.

METHODS

A retrospective study was conducted to identify cirrhotic individuals treated with vasoconstrictors for acute kidney injury (AKI) presumably caused by HRS to examine the relationship between change in MAP and change in serum creatinine (sCr) using multivariate mixed linear regression.

RESULTS

Among 73 patients treated with midodrine/octreotide, change in MAP inversely correlated with change in sCr (p = 0.0005). The quartile with the greatest increase in MAP (+15.9 to +29.4 mm Hg) was associated with a subsequent absolute decrease in sCr. The strength of the correlation increased when the analysis was restricted to those who met the HRS criteria (n = 27, p = 0.002), where the third (+5.3 to +15.6 mm Hg) and fourth (+15.9 to +20.9 mm Hg) quartiles of MAP change were associated with a decrease in sCr. A similar but stronger correlation was found among 14 patients treated with norepinephrine either after failing midodrine/octreotide (n = 10) or de novo (n = 4; p = 0.002), where a rise in MAP of +19.2 to 25 mm Hg was associated with a larger reduction in sCr. Associations remained significant after adjustment for baseline parameters.

CONCLUSIONS

The magnitude of MAP rise during HRS therapy with midodrine/octreotide or norepinephrine correlated with a reduction in sCr concentration. Our results suggest that achieving a pre-specified target of MAP increase might improve renal outcomes in hepatorenal AKI.

Nonalcoholic fatty liver disease - current status and future directions

Nonalcoholic fatty liver disease (NAFLD) has emerged as the most common chronic liver disease worldwide with a reported prevalence ranging 6-33%, depending on the studied populations. It encompasses a spectrum of liver manifestations ranging from simple steatosis (also known as nonalcoholic fatty liver, NAFL) to nonalcoholic steatohepatitis (NASH), fibrosis and cirrhosis, which may ultimately progress to hepatocellular carcinoma. NAFLD is strongly associated with the components of metabolic syndrome, mainly obesity and type 2 diabetes mellitus. NAFLD patients are at increased risk of liver-related as well as cardiovascular mortality. Current paradigm suggests a benign course for NAFL whereas NASH is considered to be the progressive phenotype. Although previously under-recognized accumulating evidence suggests that NAFL may also progress, suggesting a higher number of patients at risk than previously appreciated. Liver biopsy remains the gold standard for definitive diagnosis, but the majority of patients can be diagnosed accurately by noninvasive methods. Approved therapies for NAFLD are still lacking and lifestyle modifications aiming at weight loss remain the mainstay of NAFLD treatment. Intensive research could identify insulin resistance, lipotoxicity and dysbiosis of the gut microbiota as major pathophysiological mechanisms, leading to the development of promising targeted therapies which are currently investigated in clinical trials. In this review we summarized the current knowledge of NAFLD epidemiology, natural history, diagnosis, pathogenesis and treatment and considered future directions.

Antiviral treatment with sofosbuvir and simeprevir in a kidney transplant recipient with HCV-decompensated cirrhosis: viral eradication and removal from the liver transplant waiting list

Hepatitis C positive kidney transplant (KT) recipients are a difficult-to-treat subpopulation. Interferon-based therapies are contraindicated (or at least not used) in KT patients, due to the risk of allograft rejection, its poor tolerability and the low rates of sustained virological response (SVR) achieved with these therapies. Nevertheless, the use of direct-acting antiviral drugs (DAAs) will certainly provide new opportunities for hepatitis C treatment in the KT setting. Here, we report the case of a KT recipient with decompensated cirrhosis who received antiviral therapy with sofosbuvir, simeprevir, and ribavirin during 24 weeks while awaiting liver transplantation. Hepatitis C was eradicated, and the patient was removed from the transplant list. Although there is no safety and efficacy data regarding the use of DAAs in the KT setting, this case suggests that KT recipients may benefit from the use of new antiviral drugs with high SVR rates and an excellent safety profile.

Kupffer cells and liver transplantation

Nowadays, liver transplantation is globally considered the most effective treatment for end-stage liver diseases. Ischemia-reperfusion (I/R) injury and immune rejection response (IRR) are the two major imperfections which severely affect the recipients' prognosis and survival rate without satisfactory clinical management strategies. Therefore, exploring effective methods to improve I/R injury and IRR have important clinical significance under circumstances of shortage of donor livers. Kupffer cells (KCs) are the largest population of antigen representing cells (APCs) which settle in the liver. As the first defensive line of the live, KCs exhibit various biological effects. However, the exact mechanisms responsible for the role of KCs in I/R injury and IRR remain elusive. We hereby review the current finding about the role of KCs in I/R injury and IRR.

Activins and Follistatin in Chronic Hepatitis C and Its Treatment with Pegylated-Interferon-α Based Therapy

Pegylated-interferon-α based therapy for the treatment of chronic hepatitis C (CHC) is considered suboptimal as not all patients respond to the treatment and it is associated with several side effects that could lead to dose reduction and/or termination of therapy. The currently used markers to monitor the response to treatment are based on viral kinetics and their performance in the prediction of treatment outcome is moderate and does not combine accuracy and their values have several limitations. Hence, the development of new sensitive and specific predictor markers could provide a useful tool for the clinicians and healthcare providers, especially in the new era of interferon-free therapy, for the classification of patients according to their response to the standard therapy and only subscribing the novel directly acting antiviral drugs to those who are anticipated not to respond to the conventional therapy and/or have absolute contraindications for its use. The importance of activins and follistatin in the regulation of immune system, liver biology, and pathology has recently emerged. This review appraises the up-to-date knowledge regarding the role of activins and follistatin in liver biology and immune system and their role in the pathophysiology of CHC.