Real-world efficacy and safety of Ledipasvir + Sofosbuvir and Ombitasvir/Paritaprevir/Ritonavir ± Dasabuvir combination therapies for chronic hepatitis C: A Turkish experience

BACKGROUND/AIMS

This study aimed to evaluate the real-life efficacy and tolerability of direct-acting antiviral treatments for patients with chronic hepatitis C (CHC) with/without cirrhosis in the Turkish population.

MATERIAL AND METHODS

A total of 4,352 patients with CHC from 36 different institutions in Turkey were enrolled. They received ledipasvir (LDV) and sofosbuvir (SOF)±ribavirin (RBV) orombitasvir/paritaprevir/ritonavir±dasabuvir (PrOD)±RBV for 12 or 24 weeks. Sustained virologic response (SVR) rates, factors affecting SVR, safety profile, and hepatocellular cancer (HCC) occurrence were analyzed.

RESULTS

SVR12 was achieved in 92.8% of the patients (4,040/4,352) according to intention-to-treat and in 98.3% of the patients (4,040/4,108) according to per-protocol analysis. The SVR12 rates were similar between the treatment regimens (97.2%-100%) and genotypes (95.6%-100%). Patients achieving SVR showed a significant decrease in the mean serum alanine transaminase (ALT) levels (50.90±54.60 U/L to 17.00±14.50 U/L) and model for end-stage liver disease (MELD) scores (7.51±4.54 to 7.32±3.40) (p<0.05). Of the patients, 2 were diagnosed with HCC during the treatment and 14 were diagnosed with HCC 37.0±16.0 weeks post-treatment. Higher initial MELD score (odds ratio [OR]: 1.92, 95% confidence interval [CI]: 1.22-2.38; p=0.023]), higher hepatitis C virus (HCV) RNA levels (OR: 1.44, 95% CI: 1.31-2.28; p=0.038), and higher serum ALT levels (OR: 1.38, 95% CI: 1.21-1.83; p=0.042) were associated with poor SVR12. The most common adverse events were fatigue (12.6%), pruritis (7.3%), increased serum ALT (4.7%) and bilirubin (3.8%) levels, and anemia (3.1%).

CONCLUSION

LDV/SOF or PrOD±RBV were effective and tolerable treatments for patients with CHC and with or without advanced liver disease before and after liver transplantation. Although HCV eradication improves the liver function, there is a risk of developing HCC.

NSAID, antiaggregant, and/or anticoagulant-related upper gastrointestinal bleeding: Is there any change in prophylaxis rate after a 10-year period?

BACKGROUND/AIMS

Using proton-pump inhibitor (PPI) is a protective option for patients who require long-term non-steroidal anti-inflammatory drugs (NSAIDs) and antiaggregants. In our previous study, the rate of PPI use in prophylaxis was found to be 2%. Here we aimed to investigate whether there is a change in PPI use in prophylaxis in a similar patient group after 10 years.

MATERIALS AND METHODS

The patients who followed up with upper gastrointestinal (GI) bleeding diagnosis between January 01, 2016 and December 31, 2017 were retrospectively evaluated. Patients who had malignancy or variceal hemorrhage were excluded. Ninety-six patients, who had taken NSAIDs, antiaggregants, or anticoagulants that were considered as the possible cause of bleeding, were included in the study. Risk groups for NSAID GI toxicity and PPI use rates in these patients were evaluated.

RESULTS

Twenty (21%) of all patients with upper GI bleeding were using PPI. According to the pre-bleeding risk factor assessment, 86% of the patients were found to have moderate to high risk for NSAID-related GI bleeding, and 81% of these patients were not using PPI. PPI prophylaxis was not provided to 15 (75%) of the 20 patients with previous history of peptic ulcer bleeding.

CONCLUSION

Despite many studies and recommendations on risk factors and prophylaxis for NSAID-related bleeding, prophylactic PPI use is still largely ignored by physicians. The rate of PPI use in the patient group of this study was found still quite insufficient.

Genes of major histocompatibility complex class II influence chronic C hepatitis treatment with interferon in hemodialysis patients

The prevalence of anti-HCV among patients on hemodialysis is consistently higher than in the general population, indicating that patients on hemodialysis programs are at risk of acquiring HCV infection. The response to interferon alpha 2b (IFN -α 2b) therapy in chronic C hepatitis depends on viral and host factors. We treated 22 chronic C hepatitis uremic patients with IFN- α 2b (3 MU three times a week) and compared interferon responsive and unresponsive patients with regard to HLA II genes. HLA II genes were investigated by PCR-SSP low resolution, anti-HCV with ELISA II and HCV-RNA with reverse transcriptase “nested” PCR. Findings: HLA DRB1*13 is 50% positive in the non-responder group (four women, four men, mean age; 28.8±11.9 years) and 7% in the responder group (five women, nine men, mean age; 32.2±7.8 years) (p<0.05). There was no difference with respect to HLA genes between controls (six women, eight men, mean age; 29.5 ± 12.8 years) and patients (nine women, 13 men, mean age; 31.0 ± 9.3 years) (HLA DRB1*13 is 28% and 22% positive, respectively). We conclude that major histocompatibility complex class II genes influence the outcome of chronic C hepatitis treatment with IFN -α 2b.

Factors affecting the success of endoscopic bougia dilatation of radiation-induced esophageal stricture

AIMS

The purpose of this retrospective study was to assess clinical outcomes of endoscopic bougie dilation of esophageal strictures after radiation therapy for head and neck cancer, and to assess the risk factors which affect the treatment success.

METHODS

Thirty-one patients with esophageal stricture due to radiation therapy were treated with endoscopic bougie dilation. The following parameters were evaluated; age, gender, primary site of the tumor, initial treatment of the tumor, prescribed dose of radiation, the time to onset of esophageal stricture after radiation therapy, grade of esophageal stricture according to clinical and endoscopic findings, number of dilatations, recurrence of esophageal stricture, and the result of the therapy.

RESULTS

The average follow-up was 26 months with a range of 1-84 months. Successful endoscopic bougie dilation was achieved in 26 of 31 patients. The median time to onset of esophageal stricture after radiation therapy was significantly shorter in patients who did not respond to endoscopic bougie dilation.

CONCLUSION

Endoscopic bougie dilation is a safe and effective procedure for the management of radiation-induced esophageal stricture. Time to onset of esophageal stricture is the most important factor for the treatment success. In addition, the total prescribed dosage of radiation has minimal effects on the result of endoscopic bougie dilation.

Technetium-99m hexamethyl propylene amine oxime-labeled leukocyte scintigraphy at three different times in active ulcerative colitis: comparison with colonoscopy and clinico-biochemical parameters in the assessment of disease extension and severity

OBJECTIVE

In this study, our objective was to define the usefulness of technetium-99m hexamethyl propylene amine oxime (Tc-99m HMPAO)-labeled leukocyte scintigraphy at three different time points in the assessment of disease extension and severity in patients with active ulcerative colitis (UC).

METHODS

Twenty-one consecutive patients (10 women, 11 men; mean age 42.4 +/- 12 years) with active UC were prospectively studied. All patients were diagnosed by colonoscopy and histopathology prior to inclusion. Scintigraphy was performed at 1 h, 2 h, and 4 h after Tc-99m HMPAO-labeled leukocyte injection. Clinic-biochemical activity score, total colonoscopic activity score, and total scintigraphic activity score at 1 h, 2 h, and 4 h were calculated for each patient.

RESULTS

Sensitivity, specificity, and accuracy values of Tc-99m HMPAO-labeled leukocyte scintigraphy were calculated as follows, respectively: 1 h imaging 86%, 73%, and 83%; 2 h imaging 89%, 74%, and 86%; 4 h imaging 90%, 58%, and 83% in the detection of active inflammatory segments. Even though no statistically significant difference was found between 1 h, 2 h, and 4 h imaging with respect to the sensitivity, specificity of labeled leukocyte scintigraphy, the largest area under the curve value was found for 2 h imaging.

CONCLUSIONS

Tc-99m HMPAO-labeled leukocyte scintigraphy has been found to be correlated well with colonoscopy in the assessment of both the extension and severity of UC. We recommend 2 h scintigraphic imaging because it provides the largest area under the curve value and decreases the number of false-positive results.

Hepatic epithelioid hemangioendothelioma treated with orthotopic liver transplantation: a case report

Hepatic epithelioid hemangiendothelioma is a rare vascular tumor. The clinical course is unpredictable and different treatment modalities are offered depending on the patients condition. Orthotopic liver tranplantation is the choice of treatment in diffuse cases without metastases. A 32 year old woman was admitted to hospital with multiple mass lesions diagnosed by ultrasonography of the liver. Physical examination was normal except for a painless hepatomegaly, and her biochemical tests were within the normal range. Computed tomographic scanning showed the presence of multiple lesions in both lobes, some of which were accompanied by a small degree of calcification. Although these findings were suggestive of hepatic epithelioid hemangioendothelioma, ultrasonographic guided fine needle aspiration biopsy failed to diagnose the exact nature of the lesions. The diagnosis of hepatic epithelioid hemangioendothelioma was confirmed by diagnostic laparotomy and immunohistochemical examination of the specimen by FVIII-RAg, CD34 and CD 31 markers. The patient was treated by orthotopic liver transplantation and had no evidence of tumor 18 months after transplantation. The problems in differential diagnosis and treatment options are discussed in this report of the first case of this rare tumor, treated by orthotopic liver transplantation in Turkey.

Alverine induced toxic hepatitis: a case report

Drug-induced hepatotoxicity is an important cause of hepatocellular injury. Hepatic necrosis may range from asymptomatic elevations in transaminases to fulminant hepatic failure and death. Alverine is an antispasmodic drug which is especially used in patients with irritable bowel syndrome. Only a few cases of alverine associated hepatotoxicity have been reported previously. We present the case of a patient with alverine induced hepatotoxicity and cholestasis, which has only seldomly been reported in the literature.

The prevalence of manifest and latent celiac disease in type 1 diabetes mellitus

BACKGROUND/AIMS

Celiac disease and type 1 diabetes mellitus are both autoimmune diseases which have a common genetic predisposition. The aim of this study was to determine the prevalence of manifest and latent celiac disease in type 1 diabetic patients.

METHODS

Anti-endomysium IgA was tested by indirect immunofluorescence using sections of human umbilical cord for screening in 100 adult patients with type 1 diabetes mellitus and in 80 age and sex matched controls with no known disease. Distal duodenal biopsy, human leukocyte antigen typing, urinary D-xylose excretion test, stool analysis, biochemistry profile, blood counts, serum ferritin level and small intestinal radiography were performed in anti-endomysium IgA positive cases. Small bowel biopsy specimens consistent with celiac disease were defined as manifest celiac disease, while positive antiendomysium IgA and normal intestinal histology with the presence of human leukocyte antigen class II antigens consistent with the disease were defined as latent celiac disease.

RESULTS

Anti-endomysium IgA was positive in eight diabetic patients, while it was negative in all controls. Celiac disease was found in a total of six (6%) patients, four with manifest and two with latent disease. Only one patient had symptoms.

CONCLUSIONS

The prevalence of celiac disease is increased in patients with type 1 diabetes mellitus. Since many patients may be asymptomatic, it is suggested that all diabetic patients should be screened for this disease.

Helicobacter pylori eradication lowers esophageal sphincter pressures in functional dyspepsia patients

BACKGROUND/AIMS

Helicobacter pylori infection is the most common cause of gastroduodenal diseases. The role H. pylori eradication in functional dyspepsia patients is contradictory. We performed this study to determine the effects of H. pylori eradication in functional dyspepsia patients with respect to physiological and histological parameters including esophageal sphincter functions.

METHODOLOGY

We studied 20 functional dyspepsia patients, whose H. pylori infection was confirmed by histology and urease test. We also confirmed eradication using the same methods after three months. We performed 24-hour esophageal pH monitoring, esophageal manometry, meal stimulated gastrin release test and measured dyspepsia severity score and gastric emptying time before and three months after eradication. Eradication regimen consisted of omeprazol 20 mg b.i.d., clarithromycin 500 mg b.i.d. and metranidazol 500 mg b.i.d., for two weeks. Gastric inflammation and H. pylori density within biopsy samples from the antrum (n = 4), corpus (n = 4), cardia (n = 2), fundus (n = 2), duodenum (n = 2) and distal esophagus (n = 1) were assessed.

RESULTS

Dyspepsia severity score (P < 0.001), meal stimulated gastrin levels, upper (P = 0.01) and lower (P = 0.06) sphincter pressures were decreased after eradication irrespective of gastric histology; but gastric emptying times (P = 0.87) and pH < 4.5% reflux (P = 0.91) were not changed significantly.

CONCLUSIONS

H. pylori eradication results in decreased esophageal sphincter pressures irrespective of gastric histology in functional dyspepsia patients. These decreases are not associated with increased objective reflux or reflux symptomatology. The clinical significance of these finding deserves further evaluations.

Persistently normal alanine transaminase levels in chronic C hepatitis: what does it tell us?

BACKGROUND/AIMS

We evaluated the demographic, clinical, histological and serological characteristics of chronic hepatitis C infection with persistently normal serum alanine transaminase levels and compared the results with those obtained in a group of chronic hepatitis C infection with serum alanine transaminase levels above normal.

METHODOLOGY

Twenty-one patients who had chronic hepatitis C infection with normal alanine transaminase during the follow-up period and 34 patients who had chronic C infection with serum alanine transaminase levels above normal were included in this study. Demographic, clinical, histological and serological parameters of these two groups were evaluated.

RESULTS

There were no significant differences in age, gender, known route of infection, viral load and genotype distribution between the two groups (P > 0.05). The gamma-glutamyltransferase and gamma-globulin levels were significantly higher in the serum alanine transaminase levels above normal group (P < 0.01 and P < 0.05). Among the patients with normal alanine transaminase, liver biopsy findings were normal in eight patients (38%). None of the patients with serum alanine transaminase levels above normal had normal liver biopsy findings. Histologic activity index was significantly higher in serum alanine transaminase levels above normal group (9.7 +/- 2.2 vs. 6.4 +/- 1.9; P < 0.001). Histologic activity index and alanine transaminase levels correlate with the stage of the disease (P < 0.05).

CONCLUSIONS

For a definite diagnosis in patients with HCV-RNA+ and normal alanine transaminase liver biopsy is necessary and significant liver disease may be present in such patients irrespective of viral load, genotype and alanine transaminase levels.

Genes of major histocompatibility complex class II influence chronic C hepatitis treatment with interferon in hemodialysis patients

The prevalence of anti-HCV among patients on hemodialysis is consistently higher than in the general population, indicating that patients on hemodialysis programs are at risk of acquiring HCV infection. The response to interferon alpha 2b (IFN -alpha 2b) therapy in chronic C hepatitis depends on viral and host factors. We treated 22 chronic C hepatitis uremic patients with IFN -alpha 2b (3 MU three times a week) and compared interferon responsive and unresponsive patients with regard to HLA II genes. HLA II genes were investigated by PCR-SSP low resolution, anti-HCV with ELISA II and HCV-RNA with reverse transcriptase "nested" PCR.

FINDINGS

HLA DRB1*13 is 50% positive in the non-responder group (four women, four men, mean age; 28.8+/-11.9 years) and 7% in the responder group (five women, nine men, mean age; 32.2+/-7.8 years) (p<0.05). There was no difference with respect to HLA genes between controls (six women, eight men, mean age; 29.5+/-12.8 years) and patients (nine women, 13 men, mean age; 31.0+/-9.3 years) (HLA DRB1*13 is 28% and 22% positive, respectively). We conclude that major histocompatibility complex class II genes influence the outcome of chronic C hepatitis treatment with IFN -alpha 2b.

The effects of chronic L-arginine treatment on vascular responsiveness of streptozotocin-diabetic rats

In this study, the protective effects of L-arginine treatment in vivo on vascular reactivity of streptozotocin (STZ)-induced 12-week-old diabetic rats were examined. Loss of weight, polydipsia, polyphagia, hyperglycemia, hypoinsulinemia, and elevated levels of plasma cholesterol and triglyceride were observed in diabetic rats. L-arginine treatment (1 mg/mL in drinking water) did not significantly affect these metabolic and biochemical abnormalities. Plasma malondialdehyde (MDA) levels in untreated diabetic rats were also significantly higher than untreated controls. However, L-arginine treatment prevented the increase in MDA level of plasma of diabetic rats. Contractile responses, but not sensitivity to noradrenaline (NA), were significantly increased in diabetic rats compared to controls. Treatment of diabetic rats with L-arginine completely prevented the increase in NA responses. Relaxation response to acetylcholine (ACh), but not to sodium nitroprusside (SNP), in diabetic aorta has been found to be significantly decreased as compared with controls. However, there were no significant differences in pD2 values of acetylcholine in either of the groups. L-arginine treatment increased the ACh responses to the control level. All effects of L-arginine on vascular reactivity were found to be specific for diabetic rats and not controls. These results suggest that functional abnormalities occurred in aorta from diabetic rat might at least in part result from L-arginine deficiency, and the lipid peroxidation-lowering effect of L-arginine may account for its protective effect on vascular reactivity of diabetic rats.

The effect of selenium and vitamin E on microvascular permeability of rat organs

The effects of dietary sodium selenite and vitamin E on the microvascular permeability of rat organs such as heart, brain, kidney, liver and eye were investigated by using the Evans blue leakage method. Combined deficiency of selenium and vitamin E caused an increase in the permeability of the heart and eye with respect to their controls while it had no considerable effect on the permeability of other organs. On the other hand, toxic levels of selenium (4.2 mg/kg) in diet decreased the permeabilities in kidney, liver, and eye whereas this parameter of brain increased in the same animal group. These results suggested that low or high sodium selenite and vitamin E contents in diet could alter the microvascular permeability of different organs in different manners. It might be important to give reasonable explanations for the pathophysiology of some diseases that are characterized with organ damage and/or disfunction originated from selenium deficiency or toxicity.