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Ye L, Ziesch A, Schneider JS, Ofner A, Nieß H, Denk G, Hohenester S, Mayr D, Mahajan UM, Munker S, Khaled NB, Wimmer R, Gerbes AL, Mayerle J, He Y, Geier A, Toni END, Zhang C, Reiter FP. The inhibition of YAP Signaling Prevents Chronic Biliary Fibrosis in the Abcb4 -/- Model by Modulation of Hepatic Stellate Cell and Bile Duct Epithelium Cell Pathophysiology. Aging Dis 2024; 15:338-356. [PMID: 37307826 PMCID: PMC10796084 DOI: 10.14336/ad.2023.0602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 06/02/2023] [Indexed: 06/14/2023] Open
Abstract
Primary sclerosing cholangitis (PSC) represents a chronic liver disease characterized by poor prognosis and lacking causal treatment options. Yes-associated protein (YAP) functions as a critical mediator of fibrogenesis; however, its therapeutic potential in chronic biliary diseases such as PSC remains unestablished. The objective of this study is to elucidate the possible significance of YAP inhibition in biliary fibrosis by examining the pathophysiology of hepatic stellate cells (HSC) and biliary epithelial cells (BEC). Human liver tissue samples from PSC patients were analyzed to assess the expression of YAP/connective tissue growth factor (CTGF) relative to non-fibrotic control samples. The pathophysiological relevance of YAP/CTGF in HSC and BEC was investigated in primary human HSC (phHSC), LX-2, H69, and TFK-1 cell lines through siRNA or pharmacological inhibition utilizing verteporfin (VP) and metformin (MF). The Abcb4-/- mouse model was employed to evaluate the protective effects of pharmacological YAP inhibition. Hanging droplet and 3D matrigel culture techniques were utilized to investigate YAP expression and activation status of phHSC under various physical conditions. YAP/CTGF upregulation was observed in PSC patients. Silencing YAP/CTGF led to inhibition of phHSC activation and reduced contractility of LX-2 cells, as well as suppression of epithelial-mesenchymal transition (EMT) in H69 cells and proliferation of TFK-1 cells. Pharmacological inhibition of YAP mitigated chronic liver fibrosis in vivo and diminished ductular reaction and EMT. YAP expression in phHSC was effectively modulated by altering extracellular stiffness, highlighting YAP's role as a mechanotransducer. In conclusion, YAP regulates the activation of HSC and EMT in BEC, thereby functioning as a checkpoint of fibrogenesis in chronic cholestasis. Both VP and MF demonstrate effectiveness as YAP inhibitors, capable of inhibiting biliary fibrosis. These findings suggest that VP and MF warrant further investigation as potential therapeutic options for the treatment of PSC.
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Affiliation(s)
- Liangtao Ye
- Digestive Diseases Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China.
- Department of Medicine II, University Hospital, LMU Munich, Germany.
| | - Andreas Ziesch
- Department of Medicine II, University Hospital, LMU Munich, Germany.
| | | | - Andrea Ofner
- Department of Medicine II, University Hospital, LMU Munich, Germany.
| | - Hanno Nieß
- Biobank of the Department of General, Visceral and Transplantion Surgery, University Hospital, LMU Munich, Germany.
| | - Gerald Denk
- Department of Medicine II, University Hospital, LMU Munich, Germany.
| | - Simon Hohenester
- Department of Medicine II, University Hospital, LMU Munich, Germany.
| | - Doris Mayr
- Institute of Pathology, Faculty of Medicine, LMU Munich, Germany.
| | - Ujjwal M. Mahajan
- Department of Medicine II, University Hospital, LMU Munich, Germany.
| | - Stefan Munker
- Department of Medicine II, University Hospital, LMU Munich, Germany.
| | - Najib Ben Khaled
- Department of Medicine II, University Hospital, LMU Munich, Germany.
| | - Ralf Wimmer
- Department of Medicine II, University Hospital, LMU Munich, Germany.
| | | | - Julia Mayerle
- Department of Medicine II, University Hospital, LMU Munich, Germany.
| | - Yulong He
- Digestive Diseases Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China.
| | - Andreas Geier
- Division of Hepatology, Department of Medicine II, University Hospital Würzburg, Würzburg, Germany.
| | - Enrico N. De Toni
- Department of Medicine II, University Hospital, LMU Munich, Germany.
| | - Changhua Zhang
- Digestive Diseases Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China.
| | - Florian P. Reiter
- Department of Medicine II, University Hospital, LMU Munich, Germany.
- Division of Hepatology, Department of Medicine II, University Hospital Würzburg, Würzburg, Germany.
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Payani E, Koliogiannis D, Schoenberg MB, Koch D, Eser-Valeri D, Denk G, Rehm M, Schäfer S, Ehmer U, Kremer AE, Meiser B, Werner J, Guba M, Börner N. Frequent Follow-Up of Delisted Liver Transplant Candidates Is Necessary: An Observational Study about Characteristics and Outcomes of Delisted Liver Transplant Candidates. J Clin Med 2023; 12:5880. [PMID: 37762820 PMCID: PMC10532245 DOI: 10.3390/jcm12185880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/27/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
This observational study focuses on the characteristics and survival of patients taken off of the liver transplant waiting list. Assessment of post-delisting survival and a frequent follow-up of patients after delisting are important keys to improve the survival rate of patients with liver failure after being delisted. Within this study, delisted liver transplant candidates were divided into the following groups: (1) "too good" (54%) or (2) "too sick" (22%) for transplantation, (3) adherence issues (12%) or (4) therapy goal changed (11%). The 5-year survival after delisting within these groups was 84%, 9%, 50%, and 68%, respectively. Less than 3% of the delisted patients had to be relisted again. The clinical expert decision of the multidisciplinary transplant team was sufficiently accurate to differentiate between patients requiring liver transplantation and those who were delisted after a stable recovery of liver function. The assessment of post-delisting survival may serve as a complementary metric to assess differences in center practices and to estimate cumulative post-delisting mortality risk.
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Affiliation(s)
- Elnaz Payani
- Department of General-, Visceral- and Transplant Surgery, LMU University Hospital, 81377 Munich, Germany; (E.P.); (N.B.)
- Transplant Center Munich, LMU University Hospital, 81377 Munich, Germany (B.M.)
| | - Dionysios Koliogiannis
- Department of General-, Visceral- and Transplant Surgery, LMU University Hospital, 81377 Munich, Germany; (E.P.); (N.B.)
- Transplant Center Munich, LMU University Hospital, 81377 Munich, Germany (B.M.)
| | | | - Dominik Koch
- Department of General-, Visceral- and Transplant Surgery, LMU University Hospital, 81377 Munich, Germany; (E.P.); (N.B.)
- Transplant Center Munich, LMU University Hospital, 81377 Munich, Germany (B.M.)
| | | | - Gerald Denk
- Transplant Center Munich, LMU University Hospital, 81377 Munich, Germany (B.M.)
- Department of Medicine II, LMU University Hospital, 81377 Munich, Germany
| | - Markus Rehm
- Department of Anesthesiology, LMU University Hospital, 81377 Munich, Germany
| | - Simon Schäfer
- Department of Anesthesiology, LMU University Hospital, 81377 Munich, Germany
- Department of Anesthesiology, Carl von Ossietzky University Oldenburg, 26121 Oldenburg, Germany
| | - Ursula Ehmer
- Department of Medicine II, Technical University (TU) Munich Klinikum Rechts der Isar, 81675 Munich, Germany
| | - Andreas E. Kremer
- Department of Medicine I, Friedrich-Alexander University Erlangen-Nürnberg, 91054 Erlangen, Germany
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Bruno Meiser
- Transplant Center Munich, LMU University Hospital, 81377 Munich, Germany (B.M.)
| | - Jens Werner
- Department of General-, Visceral- and Transplant Surgery, LMU University Hospital, 81377 Munich, Germany; (E.P.); (N.B.)
- Transplant Center Munich, LMU University Hospital, 81377 Munich, Germany (B.M.)
| | - Markus Guba
- Department of General-, Visceral- and Transplant Surgery, LMU University Hospital, 81377 Munich, Germany; (E.P.); (N.B.)
- Transplant Center Munich, LMU University Hospital, 81377 Munich, Germany (B.M.)
| | - Nikolaus Börner
- Department of General-, Visceral- and Transplant Surgery, LMU University Hospital, 81377 Munich, Germany; (E.P.); (N.B.)
- Transplant Center Munich, LMU University Hospital, 81377 Munich, Germany (B.M.)
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Zimny S, Bourhis H, Weber S, Reiter FP, Hohenester S, Kraft E, Mohr I, Merle U, Weiss KH, Denk G. Medical care of patients with Wilson disease in Germany: a multidisciplinary survey among university centers. Orphanet J Rare Dis 2023; 18:122. [PMID: 37226184 DOI: 10.1186/s13023-023-02731-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 05/14/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Wilson disease (WD) is a rare, hereditary disorder of copper metabolism. Due to its variable symptoms and manifestations, diagnosis remains challenging. Affected patients must obtain lifelong medical treatment, as the disease is fatal if untreated. Patients require continuous monitoring, but little is known about the care of these patients in Germany. Therefore, we analyzed the medical care of WD patients at German university centers. We sent a questionnaire containing 20 questions to a total of 108 departments of pediatrics, neurology and gastroenterology in 36 university hospitals. Our questions referred to the characteristics of WD patients at the different sites and internal procedures regarding diagnosis, therapy and follow-up. A descriptive statistical analysis was performed. RESULTS Sixty-three departments (58%) returned our questionnaire. In total, approximately one-third of the estimated WD patients in Germany are seen annually in the outpatient clinics of these departments (approx. 950 patients). There are only a few departments which treat patients in a multidisciplinary setting (12%). Our survey revealed that for diagnosis, 51% of all departments used an algorithm based on the Leipzig score as recommended by international guidelines. Most departments apply essential parameters recommended by WD guidelines. Routine monitoring is performed at least biannually by 84% of the departments, and standard investigations for monitoring are regularly applied. A routine family screening is performed by 84% of all departments. A reduction in medical therapy during pregnancy is recommended by 46% of the departments. Only 14% suggested that WD patients should not breastfeed. Liver transplantation (LT) due to WD is a rare but repeatedly occurring event. Most departments of gastroenterology (72%) reported at least one patient with LT within the last decade. CONCLUSIONS Medical care of WD patients at German university centers follows the recommendations set forth by international guidelines, but only a few centers treat significant numbers of patients. The surveillance of patients does not follow specified standards, but most departments adhere to the accepted guidelines. The formation of central units and networks in a multidisciplinary setting should be evaluated to improve the care of WD patients.
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Affiliation(s)
- Sebastian Zimny
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.
| | - Hélène Bourhis
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Sabine Weber
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Florian Paul Reiter
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
- Department of Medicine II, University Hospital Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Simon Hohenester
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Eduard Kraft
- Department of Physical Medicine and Rehabilitation, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Isabelle Mohr
- Department of Internal Medicine IV, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Uta Merle
- Department of Internal Medicine IV, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Karl Heinz Weiss
- Internal Medicine, Salem Medical Center, Zeppelinstraße 11 - 33, 69121, Heidelberg, Germany
| | - Gerald Denk
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
- Transplant Center, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
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Payani E, Börner N, Kolliogiannis D, Brunner S, Klein I, Ehmer U, Denk G, Lange CM, Ograja K, Dietrich P, Werner J, Guba M. Regional transplant rates depend more on physician-dependent variables than on proximity to transplant center. Langenbecks Arch Surg 2023; 408:191. [PMID: 37171640 PMCID: PMC10181954 DOI: 10.1007/s00423-023-02874-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/30/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE The objective of this work was to uncover inequalities in access to liver transplantation in Bavaria, Germany. METHODS For this purpose, the annual transplantation rate per 1 million inhabitants for the respective districts was determined from the aggregated postal codes of the place of residence of transplanted patients. The variables examined were proximity and travel time to the nearest transplant center, as well as the care category of the regional hospital. In addition, we assessed whether the head of gastroenterology at the regional hospital through which liver transplant candidates are referred was trained at a liver transplant center. RESULTS We could not demonstrate a direct relationship between proximity or travel time to the nearest transplant center and access to liver transplantation. Multivariate regression analysis shows that liver transplant training (p < 0.0001) of the chief physician (gastroenterologist) of the regional hospital was the most decisive independent factor for access to liver transplantation within a district. CONCLUSION We show that the transplant training experience of the head of gastroenterology at a regional hospital is an independent factor for the regional transplantation rate. Therefore, it appears important to maintain some liver transplant expertise outside the transplant centers in order to properly identify and assign potential transplant candidates for transplantation.
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Affiliation(s)
- Elnaz Payani
- Department of General, Visceral and Transplant Surgery, LMU Klinikum Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany
| | - Nikolaus Börner
- Department of General, Visceral and Transplant Surgery, LMU Klinikum Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany
| | - Dionysios Kolliogiannis
- Department of General, Visceral and Transplant Surgery, LMU Klinikum Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany
| | - Stefan Brunner
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Ingo Klein
- Department of Surgery, University of Würzburg, Würzburg, Germany
| | - Ursula Ehmer
- Internal Medicine II, Klinikum Rechts Der Isar, Technical University Munich, Munich, Germany
| | | | | | | | - Peter Dietrich
- Transplant Center Erlangen-Nürnberg, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Jens Werner
- Department of General, Visceral and Transplant Surgery, LMU Klinikum Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany
| | - Markus Guba
- Department of General, Visceral and Transplant Surgery, LMU Klinikum Campus Grosshadern, Marchioninistrasse 15, 81377, Munich, Germany.
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Dietz-Fricke C, Tacke F, Zöllner C, Demir M, Schmidt HH, Schramm C, Willuweit K, Lange CM, Weber S, Denk G, Berg CP, Grottenthaler JM, Merle U, Olkus A, Zeuzem S, Sprinzl K, Berg T, van Bömmel F, Wiegand J, Herta T, Seufferlein T, Zizer E, Dikopoulos N, Thimme R, Neumann-Haefelin C, Galle PR, Sprinzl M, Lohse AW, Schulze zur Wiesch J, Kempski J, Geier A, Reiter FP, Schlevogt B, Gödiker J, Hofmann WP, Buggisch P, Kahlhöfer J, Port K, Maasoumy B, Cornberg M, Wedemeyer H, Deterding K. Treating hepatitis D with bulevirtide - Real-world experience from 114 patients. JHEP Rep 2023; 5:100686. [PMID: 37025462 PMCID: PMC10071092 DOI: 10.1016/j.jhepr.2023.100686] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/13/2022] [Accepted: 12/23/2022] [Indexed: 04/08/2023] Open
Abstract
Background & Aims Bulevirtide is a first-in-class entry inhibitor of hepatitis B surface antigen. In July 2020, bulevirtide was conditionally approved for the treatment of hepatitis D, the most severe form of viral hepatitis, which frequently causes end-stage liver disease and hepatocellular carcinoma. Herein, we report the first data from a large multicenter real-world cohort of patients with hepatitis D treated with bulevirtide at a daily dose of 2 mg without additional interferon. Methods In a joint effort with 16 hepatological centers, we collected anonymized retrospective data from patients treated with bulevirtide for chronic hepatitis D. Results Our analysis is based on data from 114 patients, including 59 (52%) with cirrhosis, receiving a total of 4,289 weeks of bulevirtide treatment. A virologic response defined as an HDV RNA decline of at least 2 log or undetectable HDV RNA was observed in 87/114 (76%) cases with a mean time to virologic response of 23 weeks. In 11 cases, a virologic breakthrough (>1 log-increase in HDV RNA after virologic response) was observed. After 24 weeks of treatment, 19/33 patients (58%) had a virologic response, while three patients (9%) did not achieve a 1 log HDV RNA decline. No patient lost hepatitis B surface antigen. Alanine aminotransferase levels improved even in patients not achieving a virologic response, including five patients who had decompensated cirrhosis at the start of treatment. Treatment was well tolerated and there were no reports of drug-related serious adverse events. Conclusions In conclusion, we confirm the safety and efficacy of bulevirtide monotherapy in a large real-world cohort of patients with hepatitis D treated in Germany. Future studies need to explore the long-term benefits and optimal duration of bulevirtide treatment. Impact and implications Clinical trials proved the efficacy of bulevirtide for chronic hepatitis D and led to conditional approval by the European Medical Agency. Now it is of great interest to investigate the effects of bulevirtide treatment in a real-world setting. In this work, we included data from 114 patients with chronic hepatitis D who were treated with bulevirtide at 16 German centers. A virologic response was seen in 87/114 cases. After 24 weeks of treatment, only a small proportion of patients did not respond to treatment. At the same time, signs of liver inflammation improved. This observation was independent from changes in hepatitis D viral load. The treatment was generally well tolerated. In the future, it will be of interest to investigate the long-term effects of this new treatment.
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Affiliation(s)
- Christopher Dietz-Fricke
- Department of Gastroenterology, Hepatology and Endocrinology at Hannover Medical School, Hannover, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum (CVK) and Campus Charité Mitte (CCM), Berlin, Germany
| | - Caroline Zöllner
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum (CVK) and Campus Charité Mitte (CCM), Berlin, Germany
| | - Münevver Demir
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum (CVK) and Campus Charité Mitte (CCM), Berlin, Germany
| | - Hartmut H. Schmidt
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - Christoph Schramm
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - Katharina Willuweit
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Essen, Germany
| | - Christian M. Lange
- Department of Medicine II, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Sabine Weber
- Department of Medicine II, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Gerald Denk
- Department of Medicine II, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Christoph P. Berg
- Department of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology, and Geriatrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Julia M. Grottenthaler
- Department of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology, and Geriatrics, University Hospital Tuebingen, Tuebingen, Germany
| | - Uta Merle
- Department of Internal Medicine IV, University of Heidelberg, Heidelberg, Germany
| | - Alexander Olkus
- Department of Internal Medicine IV, University of Heidelberg, Heidelberg, Germany
| | - Stefan Zeuzem
- Internal Medicine Department, Goethe University Hospital, Frankfurt, Germany
| | - Kathrin Sprinzl
- Internal Medicine Department, Goethe University Hospital, Frankfurt, Germany
| | - Thomas Berg
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Florian van Bömmel
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Johannes Wiegand
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Toni Herta
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | | | - Eugen Zizer
- Department of Internal Medicine I, University of Ulm, Ulm, Germany
| | | | - Robert Thimme
- Department of Medicine II, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Neumann-Haefelin
- Department of Medicine II, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter R. Galle
- Department of Medicine I, University Medical Center of the Johannes-Gutenberg University, Mainz, Germany
| | - Martin Sprinzl
- Department of Medicine I, University Medical Center of the Johannes-Gutenberg University, Mainz, Germany
| | - Ansgar W. Lohse
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Schulze zur Wiesch
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Infection Research (DZIF), Partner Site Hamburg - Lübeck - Borstel - Riems, Hamburg, Germany
| | - Jan Kempski
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Mildred Scheel Cancer Career Center HaTriCS, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Geier
- University Hospital Würzburg, Division of Hepatology, Dept. of Medicine II, Würzburg, Germany
| | - Florian P. Reiter
- University Hospital Würzburg, Division of Hepatology, Dept. of Medicine II, Würzburg, Germany
| | | | - Juliana Gödiker
- Department of Medicine B, University Hospital Münster, Münster, Germany
| | | | - Peter Buggisch
- Ifi-Institute for Interdisciplinary Medicine, Hamburg, Germany
| | - Julia Kahlhöfer
- Department of Gastroenterology, Hepatology and Endocrinology at Hannover Medical School, Hannover, Germany
| | - Kerstin Port
- Department of Gastroenterology, Hepatology and Endocrinology at Hannover Medical School, Hannover, Germany
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and Endocrinology at Hannover Medical School, Hannover, Germany
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology at Hannover Medical School, Hannover, Germany
- D-SOLVE consortium, a EU Horizon Europe funded project (No 101057917)
- Centre for Individualised Infection Medicine (CiiM), a Joint Venture Between the Helmholtz Centre for Infection Research (HZI) and Hannover Medical School (MHH), Hannover, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology at Hannover Medical School, Hannover, Germany
- Excellence Cluster Resist, Hannover Medical School, Germany
- German Centre for Infection Research (DZIF), Hannover-Braunschweig, Germany
- D-SOLVE consortium, a EU Horizon Europe funded project (No 101057917)
| | - Katja Deterding
- Department of Gastroenterology, Hepatology and Endocrinology at Hannover Medical School, Hannover, Germany
- Corresponding author. Address: Department of Gastroenterology, Hepatology and Endocrinology at Hannover Medical School, Hannover, Germany.
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Mohr I, Bourhis H, Woimant F, Obadia MA, Morgil M, Morvan E, Merle U, Denk G, Poujois A, Weiss KH. Experience on switching trientine formulations in Wilson disease: Efficacy and safety after initiation of TETA 4HCl as substitute for TETA 2HCl. J Gastroenterol Hepatol 2023; 38:219-224. [PMID: 36331262 DOI: 10.1111/jgh.16050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 09/27/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND AIM This retrospective, multicenter study aims to assess the efficacy and safety in Wilson disease (WD) patients treated with trientine tetrahydrochloride (TETA 4HCl) after switch from trientine dihydrochloride (TETA 2HCl). METHODS In total, 68 WD patients with stable copper metabolism were identified to receive TETA 4HCl (Cuprior™) after previous treatment with TETA 2HCl. We analyzed biochemical markers such as urinary copper, serum copper, non-coeruloplasmin bound copper (NCC), and transaminases as well as clinical scores (APRI; FIB-4 score) at baseline with a follow-up (FU) of 12 months. Safety of TETA 4HCl treatment was based on reported adverse events (AEs). RESULTS The study cohort reflects a common WD cohort with a mean age of 20.3 years at diagnosis and 38.3 years at baseline. There are no significant differences concerning serum copper, NCC, transaminases, APRI, and FIB-4 score in the 3-month FU. Six-month FU revealed a decreased AST (P = 0.008), APRI (P = 0.042), and FIB-4 score (P = 0.039). GGT varied only borderline significantly in the 3-month, but not in the 6-month FU. Comparison of urinary copper within the subsets did not reveal a difference to baseline in all FUs, suggesting stable control of copper metabolism. Few AEs during TETA 4HCl treatment were reported, most commonly gastrointestinal discomfort. Only three treatments with TETA 4HCl were discontinued. CONCLUSION Copper parameters and liver function were stable after treatment switch to TETA 4HCl. Treatment with TETA 4HCl was generally well tolerated. This study indicates that the switch from TETA 2HCl to TETA 4HCl is safe and viable.
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Affiliation(s)
- Isabelle Mohr
- Department of Internal Medicine IV, Department of Gastroenterology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hélène Bourhis
- Medizinische Klinik und Poliklinik II, Hospital of the Ludwig-Maximilians University Munich, Munich, Germany
| | - France Woimant
- Department of Neurology, Hôpital Lariboisière, Paris, France
| | - Mickael Alexandre Obadia
- Department of Neurology, Rothschild Foundation Hospital, National reference center for Wilson disease, Paris, France
| | - Müzeyyen Morgil
- Department of Internal Medicine, Salem Hospital Heidelberg, Heidelberg, Germany
| | - Erwan Morvan
- Department of Neurology, Rothschild Foundation Hospital, National reference center for Wilson disease, Paris, France
| | - Uta Merle
- Department of Internal Medicine IV, Department of Gastroenterology, University Hospital Heidelberg, Heidelberg, Germany
| | - Gerald Denk
- Medizinische Klinik und Poliklinik II, Hospital of the Ludwig-Maximilians University Munich, Munich, Germany
| | - Aurelia Poujois
- Department of Neurology, Rothschild Foundation Hospital, National reference center for Wilson disease, Paris, France
| | - Karl Heinz Weiss
- Department of Internal Medicine, Salem Hospital Heidelberg, Heidelberg, Germany
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Langer MM, Bauschen A, Guckenbiehl S, Klauss S, Lutz T, Denk G, Zwanziger D, Moeller LC, Lange CM. Evolution of non-thyroidal illness syndrome in acute decompensation of liver cirrhosis and acute-on-chronic liver failure. Front Endocrinol (Lausanne) 2023; 14:1104388. [PMID: 36755907 PMCID: PMC9899974 DOI: 10.3389/fendo.2023.1104388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/06/2023] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND AND AIMS Non-thyroidal illness syndrome (NTIS) is frequent in critically ill patients and associated with adverse outcomes. We aimed to characterize the evolution of NTIS in patients with acute decompensation (AD) of cirrhosis and acute-on-chronic liver failure (ACLF), since NTIS is not well described in these newly defined syndromes. METHODS Thyroid hormones (TH) were quantified at baseline in consecutive patients with cirrhosis. In addition, 76 inflammatory mediators were quantified by proximity extension analysis assay in a subgroup of patients. Associations between TH, cirrhosis stage, mortality and inflammation were assessed. RESULTS Overall, 437 patients were included, of whom 165 (37.8%), 211 (48.3%), and 61 (14%) had compensated cirrhosis (CC), AD, and ACLF. FT3 concentrations were lower in AD versus CC, and further decreased in ACLF. Importantly, NTIS was present in 83 (39.3%) patients with AD and in 44 (72.1%) patients with ACLF (P<0.001). Yet, TSH and TSH-based indexes (TSH/FT3-ratio, thyroid index) showed an U-shaped evolution during progression of cirrhosis, suggesting a partially preserved responsiveness of the hypothalamus and pituitary in AD. Infections were associated with lower FT3 concentrations in AD, but not in ACLF. Low FT3 concentrations correlated significantly with 90-day mortality. Both, AD/ACLF and NTIS, were associated with signatures of inflammatory mediators, which were partially non-overlapping. CONCLUSION NTIS is frequent already in AD and therefore precedes critically illness in a subgroup of patients with decompensated cirrhosis. This might constitute a new paradigm of TH signaling in cirrhosis, offering opportunities to explore preventive effects of TH in AD.
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Affiliation(s)
- Mona-May Langer
- Department for Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- Department of Internal Medicine II, Ludwig-Maximilians University (LMU) University Hospital Munich, Munich, Germany
| | - Alina Bauschen
- Department for Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Sabrina Guckenbiehl
- Department for Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Sarah Klauss
- Department of Internal Medicine II, Ludwig-Maximilians University (LMU) University Hospital Munich, Munich, Germany
| | - Teresa Lutz
- Department of Internal Medicine II, Ludwig-Maximilians University (LMU) University Hospital Munich, Munich, Germany
| | - Gerald Denk
- Department of Internal Medicine II, Ludwig-Maximilians University (LMU) University Hospital Munich, Munich, Germany
| | - Denise Zwanziger
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Lars C. Moeller
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Christian M. Lange
- Department for Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- Department of Internal Medicine II, Ludwig-Maximilians University (LMU) University Hospital Munich, Munich, Germany
- *Correspondence: Christian M. Lange,
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8
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Schilsky ML, Czlonkowska A, Zuin M, Cassiman D, Twardowschy C, Poujois A, Gondim FDAA, Denk G, Cury RG, Ott P, Moore J, Ala A, D'Inca R, Couchonnal-Bedoya E, D'Hollander K, Dubois N, Kamlin COF, Weiss KH. Trientine tetrahydrochloride versus penicillamine for maintenance therapy in Wilson disease (CHELATE): a randomised, open-label, non-inferiority, phase 3 trial. Lancet Gastroenterol Hepatol 2022; 7:1092-1102. [PMID: 36183738 DOI: 10.1016/s2468-1253(22)00270-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Wilson disease is an inherited disorder of copper transport. Whereas penicillamine is used therapeutically to re-establish copper balance, trientine is indicated for patients with penicillamine intolerance. We aimed to compare penicillamine with trientine tetrahydrochloride (TETA4) for maintenance therapy in patients with Wilson disease. METHODS We conducted a randomised, open-label, non-inferiority, phase 3 trial at 15 health-care centres across nine countries (patients were recruited from 13 of these health-care centres across Brazil, Europe, and the USA). We enrolled patients aged 18-75 years with stable Wilson disease who were treated for at least 1 year with penicillamine. Patients entered a 12-week period to determine stability through clinical assessment by site investigators and predefined thresholds for serum non-caeruloplasmin-bound copper (NCC; by an exchangeable copper assay; 25-150 μg/L), 24 h urinary copper excretion (100-900 μg/24 h), and alanine aminotransferase (ALT; <2 × upper limit of normal). Stable patients were randomly assigned (1:1) to continue receiving the maintenance twice daily dose of oral penicillamine or switched mg-for-mg to oral TETA4 centrally with a web-based system using minimisation. The primary endpoint, assessed 24 weeks after randomisation, was NCC by speciation assay. The non-inferiority margin of mean difference in NCC by speciation assay was -50 μg/L, as estimated by a general linear model for repeated visits, adjusted for baseline values. Further data on safety and efficacy were collected during a 24-week extension period. Data were analysed using an intention-to-treat approach. Safety was assessed in all patients who received at least one dose of study treatment. This study is registered with ClinicalTrials.gov, NCT03539952 (active, not recruiting). FINDINGS Between June 4, 2018, and March 10, 2020, 77 patients were screened. 53 patients were randomly assigned (27 to the penicillamine group and 26 to the TETA4 group). After 24 weeks, the mean difference in serum NCC by speciation assay between the penicillamine group and TETA4 group was -9·1 μg/L (95% CI -24·2 to 6·1), with the lower limit of the 95% CI within the defined non-inferiority margin. At 24 weeks, urinary copper excretion was lower with TETA4 than with penicillamine (mean difference 237·5 μg/24 h (99% CI 115·6 to 359·4). At 48 weeks, TETA4 remained non-inferior to penicillamine in terms of NCC by speciation assay (mean difference NCC -15·5 μg/L [95% CI -34·5 to 3·6]). Urinary copper excretion at 48 weeks remained in the expected range for well treated patients in both study groups, and the mean difference (124·8 μg/24 h [99% CI -37·6 to 287·1]) was not significantly different. At 24 weeks and 48 weeks, masked clinical adjudication of stability assessed by three independent clinicians confirmed clinical stability (100%) of all participants, in agreement with the stability seen with the NCC by speciation assay. There were no notable changes in either the Clinical Global Impression of Change or Unified Wilson Disease Rating Scale (neurological assessment) from baseline (pre-randomisation) at weeks 24 and 48. The mean change in serum total copper from baseline to 24 weeks was 17·6 μg/L (99% CI -9·5 to 44·7) with penicillamine and -6·3 μg/L (-34·7 to 22·1) with TETA4, and the mean change in serum total caeruloplasmin from baseline to 24 weeks was 1·8 mg/L (-19·2 to 22·8) with penicillamine and -2·2 mg/L (-6·1 to 1·7) with TETA4. All liver enzymes were similar at 24 weeks and 48 weeks, with the exception of elevated ALT concentration at 48 weeks for patients in the TETA4 group. Penicillamine was associated with three post-randomisation serious adverse events (leukopenia, cholangiocarcinoma, and hepatocellular cancer); none were reported for TETA4. The most common treatment-emergent adverse events were headache for penicillamine (five [19%] of 27 patients vs two [8%] of 26) and abdominal pain for TETA4 (one [4%] vs four [15%]); all treatment-emergent adverse events resolved and were mild to moderate. One patient developed a rash with TETA4 that resolved on discontinuation of therapy. INTERPRETATION The efficacy of TETA4 as oral maintenance therapy was non-inferior to penicillamine and well tolerated in adults with Wilson disease. FUNDING Orphalan.
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Affiliation(s)
- Michael L Schilsky
- Department of Medicine, Section of Digestive Diseases, and Department of Surgery, Section of Transplant and Immunology, Yale School of Medicine, New Haven, CT, USA.
| | - Anna Czlonkowska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Massimo Zuin
- UO Medicina Generale Epatologia e Gastroenterologia Medica ASST Santi Paolo e Carlo, Milano, Italy
| | - David Cassiman
- Department of Gastroenterology-Hepatology and Department of Chronic Diseases and Metabolism, University Hospitals, Leuven, Belgium
| | | | - Aurelia Poujois
- Département de Neurologie, Centre de Référence de la Maladie de Wilson, Hôpital Fondation Adolphe de Rothschild, Paris, France
| | | | - Gerald Denk
- Medizinische Klinik und Poliklinik II/Transplantation Center, LMU Klinikum, München, Germany
| | - Rubens G Cury
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Peter Ott
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Aftab Ala
- Department of Gastroenterology and Hepatology, Royal Surrey NHS Foundation Trust, Surrey, UK; Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK; Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Renata D'Inca
- UOC Gastroenterologia Azienda Ospedaliera di Padova, Padova, Italy
| | - Eduardo Couchonnal-Bedoya
- Hospices Civils de Lyon - Hôpital Femme Mère Enfant - Hépatologie, Gastroentérologie et Nutrition Pédiatrique, Centre de Référence de la Maladie de Wilson, Bron, France
| | | | | | | | - Karl Heinz Weiss
- Department of Internal Medicine, Salem Medical Center, Heidelberg, Germany
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9
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Affiliation(s)
- Gerald Denk
- Medizinische Klinik und Poliklinik II/ Transplantationszentrum, Klinikum der Universität München-Großhadern, Marchioninistraße 15, 81377, München, Deutschland.
| | - Christian Lange
- Medizinische Klinik und Poliklinik II / Transplantationszentrum, Klinikum der Universität München-Großhadern, München, Deutschland
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10
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Reiter FP, Ben Khaled N, Ye L, Zhang C, Seidensticker M, op den Winkel M, Denk G, Geier A, De Toni EN. Advances in Pharmacotherapy of Hepatocellular Carcinoma: A State-of-the-Art Review. Dig Dis 2022; 40:565-580. [PMID: 34644705 PMCID: PMC9501734 DOI: 10.1159/000520095] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/02/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Due to the number of emerging new treatment options, the systemic treatment of hepatocellular carcinoma (HCC) is rapidly changing. We provide here an overview of the current landscape of systemic treatment of HCC and discuss its potential future development. SUMMARY HCC is a leading cause of tumor-related death worldwide. Despite the efforts aimed at reducing the prevalence of HCC through vaccination and antiviral treatment, and the implementation of screening programs for early tumor detection, most patients are diagnosed with or progress to advanced HCC. For approximately 10 years, sorafenib has been the only effective systemic treatment available for these patients. Recently, however, a number of new systemic compounds, comprising several multi-kinase inhibitors and immune-checkpoint inhibitors, have been approved for treatment of HCC. These new agents are opening a plethora of therapeutic options for the future therapy of HCC. KEY MESSAGES The rapid progress in the treatment of HCC raises the question of the optimal combination and sequence of these agents in the treatment of patients with advanced disease. The substantial improvements in terms of objective response and survival indicate that the use of immune-checkpoint inhibitors-based treatment combinations may be extended to patients with intermediate-stage HCC.
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Affiliation(s)
- Florian P. Reiter
- Division of Hepatology, Department of Medicine II, University Hospital Würzburg, Würzburg, Germany,*Florian P. Reiter,
| | - Najib Ben Khaled
- Department of Medicine II, University Hospital Munich, Munich, Germany,German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Liangtao Ye
- Department of Medicine II, University Hospital Munich, Munich, Germany,Center for Digestive Diseases, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Changhua Zhang
- Center for Digestive Diseases, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Max Seidensticker
- Department of Radiology, University Hospital Munich, Munich, Germany
| | | | - Gerald Denk
- Department of Medicine II, University Hospital Munich, Munich, Germany
| | - Andreas Geier
- Division of Hepatology, Department of Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Enrico N. De Toni
- Department of Medicine II, University Hospital Munich, Munich, Germany
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11
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Weber S, Allgeier J, Denk G, Gerbes AL. Marked Increase of Gamma-Glutamyltransferase as an Indicator of Drug-Induced Liver Injury in Patients without Conventional Diagnostic Criteria of Acute Liver Injury. Visc Med 2021; 38:223-228. [DOI: 10.1159/000519752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 09/17/2021] [Indexed: 11/19/2022] Open
Abstract
<b><i>Introduction:</i></b> Clinically significant drug-induced liver injury (DILI) is defined by elevations of alanine aminotransferase (ALT) ≥5 times the upper limit of normal (ULN), alkaline phosphatase (ALP) ≥2 × ULN, or ALT ≥3 × ULN and total bilirubin TBIL >2 × ULN. However, DILI might also occur in patients who do not reach those thresholds and still may benefit from discontinuation of medication. <b><i>Methods:</i></b> Fifteen patients recruited for our prospective study on potentially hepatotoxic drugs were included. DILI diagnosis was based on RUCAM (Roussel Uclaf Causality Assessment Method) score and expert opinion and was supported by an in vitro test using monocyte-derived hepatocyte-like (MH) cells. <b><i>Results:</i></b> Median RUCAM score was 6 (range 4–8), indicating that DILI was possible or probable in all cases. The predominant types of liver injury were mixed (60%) and cholestatic (40%). While no elevation above 2 × ULN of ALP and TBIL was observed, gamma-glutamyltransferase (GGT) above 2 × ULN was identified in 8 of the patients. Six of the 15 patients did not achieve full remission and showed persistent elevation of GGT, which was significantly associated with peak GGT elevation above 2 × ULN (<i>p</i> = 0.005). <b><i>Conclusion:</i></b> Here we present a case series of patients with liver enzyme elevation below the conventional thresholds who developed DILI with a predominant GGT elevation leading to drug withdrawal and/or chronic elevation of liver parameters, in particular of GGT. Thus, we propose that DILI should be considered in particular in cases with marked increase of GGT even if conventional DILI threshold levels are not reached, resulting in discontinuation of the causative drug and/or close monitoring of the patients.
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12
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Reiter FP, Ye L, Ofner A, Schiergens TS, Ziesch A, Brandl L, Ben Khaled N, Hohenester S, Wimmer R, Artmann R, He Y, Lee SM, Mayr D, Zhang C, Gerbes AL, Mayerle J, Denk G, De Toni EN. p70 Ribosomal Protein S6 Kinase Is a Checkpoint of Human Hepatic Stellate Cell Activation and Liver Fibrosis in Mice. Cell Mol Gastroenterol Hepatol 2021; 13:95-112. [PMID: 34537439 PMCID: PMC8593664 DOI: 10.1016/j.jcmgh.2021.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/08/2021] [Accepted: 09/08/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Progression of chronic liver disease (CLD) to liver cirrhosis and liver cancer is a major global cause of morbidity and mortality. Treatment options capable of inhibiting progression of liver fibrosis when etiological treatment of CLD is not available or fails have yet to be established. We investigated the role of serine/threonine kinase p70 ribosomal protein S6 kinase (p70S6K) as checkpoint of fibrogenesis in hepatic stellate cells (HSCs) and as target for the treatment of liver fibrosis. APPROACH & RESULTS Immunohistochemistry was used to assess p70S6K expression in liver resection specimen. Primary human or murine HSCs from wild-type or p70S6K-/- mice as well as LX-2 cells were used for in vitro experiments. Specific small interfering RNA or CEP-1347 were used to silence or inhibit p70S6K and assess its functional relevance in viability, contraction and migration assays, fluorescence-activated cell sorting, and Western blot. These results were validated in vivo by a chemical model of fibrogenesis using wild-type and p70S6K-/- mice. Expression of p70S6K was significantly increased in human cirrhotic vs noncirrhotic liver-tissue and progressively increased in vitro through activation of primary human HSCs. Conversely, p70S6K induced fibrogenic activation of HSCs in different models, including the small interfering RNA-based silencing of p70S6K in HSC lines, experiments with p70S6K-/- cells, and the pharmacological inhibition of p70S6K by CEP-1347. These findings were validated in vivo as p70S6K-/- mice developed significantly less fibrosis upon exposure to CCl4. CONCLUSIONS We establish p70S6K as a checkpoint of fibrogenesis in vitro and in vivo and CEP-1347 as potential treatment option that can safely be used for long-term treatment.
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Affiliation(s)
- Florian P. Reiter
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany,Division of Hepatology, Department of Medicine II, University Hospital Würzburg, Würzburg, Germany,Liver Center, University Hospital, LMU Munich, Munich, Germany,Correspondence Address correspondence to: Florian P. Reiter, MD, Department of Medicine II, Liver Center Munich, University of Munich, Marchioninistraße 15, D-81377 Munich, Germany. fax: +49-931-201-640023.
| | - Liangtao Ye
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany,Liver Center, University Hospital, LMU Munich, Munich, Germany,Center for Digestive Diseases, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Andrea Ofner
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany,Liver Center, University Hospital, LMU Munich, Munich, Germany
| | - Tobias S. Schiergens
- Department of General, Visceral and Transplantation Surgery, University Hospital, LMU Munich, Munich, Germany,Biobank of the Department of General, Visceral and Transplantation Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Andreas Ziesch
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany,Liver Center, University Hospital, LMU Munich, Munich, Germany
| | - Lydia Brandl
- Institute of Pathology, LMU Munich, Munich, Germany
| | - Najib Ben Khaled
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany,Liver Center, University Hospital, LMU Munich, Munich, Germany
| | - Simon Hohenester
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany,Liver Center, University Hospital, LMU Munich, Munich, Germany
| | - Ralf Wimmer
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany,Liver Center, University Hospital, LMU Munich, Munich, Germany
| | - Renate Artmann
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany,Liver Center, University Hospital, LMU Munich, Munich, Germany
| | - Yulong He
- Center for Digestive Diseases, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Serene M.L. Lee
- Department of General, Visceral and Transplantation Surgery, University Hospital, LMU Munich, Munich, Germany,Biobank of the Department of General, Visceral and Transplantation Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Doris Mayr
- Institute of Pathology, LMU Munich, Munich, Germany
| | - Changhua Zhang
- Center for Digestive Diseases, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Alexander L. Gerbes
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany,Liver Center, University Hospital, LMU Munich, Munich, Germany
| | - Julia Mayerle
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany,Liver Center, University Hospital, LMU Munich, Munich, Germany
| | - Gerald Denk
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany,Liver Center, University Hospital, LMU Munich, Munich, Germany,Transplantation Center Munich, University Hospital, LMU Munich, Munich, Germany
| | - Enrico N. De Toni
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany,Liver Center, University Hospital, LMU Munich, Munich, Germany
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13
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Weber S, Rek S, Eser-Valeri D, Padberg F, Reiter FP, De Toni E, Hohenester S, Zimny S, Rehm M, Guba MO, Gerbes AL, Denk G. The Psychosocial Burden on Liver Transplant Recipients during the COVID-19 Pandemic. Visc Med 2021; 382:1-8. [PMID: 34373832 PMCID: PMC8339032 DOI: 10.1159/000517158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/10/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction Due to the coronavirus disease 19 (COVID-19) pandemic, multiple measures have been implemented including social distancing and curfews. Both the disease and measures might cause stress, particularly in persons at risk, such as liver transplant (LT) recipients. Here, we evaluated the impact on psychosocial well-being of LT recipients. Methods Seventy-nine LT recipients and 83 nontransplanted controls participated in this study. Questionnaires comprising the WHO-five well-being index (WHO-5), the University of California at Los Angeles (UCLA) Loneliness Scale, and the preliminary COVID-19 Pandemic Mental Health Questionnaire (CoPaQ) were distributed among them. For the WHO-5 and UCLA Loneliness Scale, means of sum scores were compared between both groups, while a comparison on item level was conducted for the CoPaQ. Results The general well-being was similar in LT recipients and controls (WHO-5: 64.0 ± 20.5% vs. 66.4 ± 17.3%), while the UCLA Loneliness Scale indicated a higher level of perceived social isolation (1.90 ± 0.51 vs. 1.65 ± 0.53, p = 0.001). The CoPaQ indicated higher risk perception regarding health issues, in particular concerning the fear of having severe consequences in case of a COVID-19 infection (3.1 ± 1.1 vs. 2.2 ± 1.3, p < 0.001), higher risk-avoiding behavior and stronger adherence to pandemic measures in LT recipients. Conclusion During the COVID-19 pandemic, LT recipients displayed a higher risk perception, a more pronounced risk-avoiding behavior and a higher perception of loneliness, while the overall well-being was comparable to nontransplanted controls.
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Affiliation(s)
- Sabine Weber
- Department of Medicine II, LMU Klinikum, Munich, Germany
| | - Stephanie Rek
- Department of Psychiatry and Psychotherapy, LMU Klinikum, Munich, Germany.,International Max Planck Research School for Translational Psychiatry (IMPRS-TP), Munich, Germany
| | | | - Frank Padberg
- Department of Psychiatry and Psychotherapy, LMU Klinikum, Munich, Germany
| | - Florian P Reiter
- Department of Medicine II, LMU Klinikum, Munich, Germany.,Division of Hepatology, Department of Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Enrico De Toni
- Department of Medicine II, LMU Klinikum, Munich, Germany
| | | | | | - Markus Rehm
- Department of Anesthesiology, LMU Klinikum, Munich, Germany
| | - Markus Otto Guba
- Department of General, Visceral, Transplantation, Vascular, and Thoracic Surgery, LMU Klinikum, Munich, Germany
| | | | - Gerald Denk
- Department of Medicine II, LMU Klinikum, Munich, Germany.,Transplant Center, LMU Klinikum, Munich, Germany
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14
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Reiter FP, Hadjamu NJ, Nagdyman N, Zachoval R, Mayerle J, De Toni EN, Kaemmerer H, Denk G. Congenital heart disease-associated liver disease: a narrative review. Cardiovasc Diagn Ther 2021; 11:577-590. [PMID: 33968635 DOI: 10.21037/cdt-20-595] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Congenital heart diseases (CHD) can be associated with liver dysfunction. The cause for liver impairment can result out of a wide spectrum of different causes, including liver congestion, hypoxemia or low cardiac output. Fortunately, most CHD show a good long-term outcome from a cardiac perspective, but great attention should be paid on non-cardiac health problems that develop frequently in patients suffering from CHD. The treatment of liver dysfunction in CHD requires a close multidisciplinary management in a vulnerable patient collective. Unfortunately, structured recommendations on the management of liver dysfunction in patients with CHD are scarce. The objective of this review is to provide insights on the pathophysiology and etiologies of liver dysfunction as one of the most relevant non-cardiac problems related to CHD. Furthermore, we advise here on the management of liver disease in CHD with special attention on assessment of liver dysfunction, management of portal hypertension as well as on surveillance and management of hepatocellular carcinoma (HCC). A multidisciplinary perspective may help to optimize morbidity and mortality in the long-term course in these patients. However, as evidence is low in many aspects, we encourage the scientific community to perform prospective studies to gain more insights in the treatment of liver dysfunction in patients with CHD.
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Affiliation(s)
- Florian P Reiter
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Nino J Hadjamu
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Nicole Nagdyman
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Reinhart Zachoval
- Transplantation Center Munich, University Hospital, LMU Munich, Munich, Germany
| | - Julia Mayerle
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Enrico N De Toni
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Harald Kaemmerer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Gerald Denk
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany.,Transplantation Center Munich, University Hospital, LMU Munich, Munich, Germany
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15
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Niess H, Börner N, Muenchhoff M, Khatamzas E, Stangl M, Graf A, Girl P, Georgi E, Koliogiannis D, Denk G, Irlbeck M, Werner J, Guba M. Liver transplantation in a patient after COVID-19 - Rapid loss of antibodies and prolonged viral RNA shedding. Am J Transplant 2021; 21:1629-1632. [PMID: 33047475 PMCID: PMC7675727 DOI: 10.1111/ajt.16349] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/17/2020] [Accepted: 09/26/2020] [Indexed: 01/25/2023]
Abstract
To date, little is known about the duration and effectiveness of immunity as well as possible adverse late effects after an infection with SARS-CoV-2. Thus it is unclear, when and if liver transplantation can be safely offered to patients who suffered from COVID-19. Here, we report on a successful liver transplantation shortly after convalescence from COVID-19 with subsequent partial seroreversion as well as recurrence and prolonged shedding of viral RNA.
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Affiliation(s)
- Hanno Niess
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University, Munich, Germany,Correspondence Hanno Niess
| | - Nikolaus Börner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Maximilian Muenchhoff
- Virology, Max von Pettenkofer Institute, Ludwig-Maximilian-University, Munich, Germany,German Center for Infection Research (DZIF, Partner Site Munich, Munich, Germany
| | - Elham Khatamzas
- Department of Internal Medicine III, Ludwig-Maximilians-University, Munich, Germany
| | - Manfred Stangl
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Alex Graf
- Laboratory for Functional Genome Analysis, Gene-Center, Ludwig-Maximilians-University, Munich, Germany
| | - Philipp Girl
- Bundeswehr Institute of Microbiology, Munich, Germany
| | - Enrico Georgi
- Bundeswehr Institute of Microbiology, Munich, Germany
| | - Dionysios Koliogiannis
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Gerald Denk
- Department of Internal Medicine II, Ludwig-Maximilians-University, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, Ludwig-Maximilians-University, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Markus Guba
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University, Munich, Germany
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16
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Mountford S, Effenberger M, Noll-Puchta H, Griessmair L, Ringleb A, Haas S, Denk G, Reiter FP, Mayr D, Dinarello CA, Tilg H, Bufler P. Modulation of Liver Inflammation and Fibrosis by Interleukin-37. Front Immunol 2021; 12:603649. [PMID: 33746950 PMCID: PMC7970756 DOI: 10.3389/fimmu.2021.603649] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 02/08/2021] [Indexed: 12/20/2022] Open
Abstract
Background and Aims: Chronic inflammation induces liver fibrosis, cirrhosis and potentially liver cancer. Kupffer cells modulate hepatic stellate cells by secreting immunologically active proteins as TGF-β. TGF-β promotes liver fibrosis via the activation of Sma- and Mad-related protein 3. IL-37 broadly suppresses innate and adaptive immune responses. Intracellular IL-37 interacts with Smad3. We hypothesize that IL-37 downregulates the activation of hepatic Kupffer and stellate cells and interferes with the TGF-β signaling cascade to modulate liver fibrogenesis. Methods: The role of IL-37 on liver inflammation and fibrogenesis was assessed in three mouse models as well as isolated Kupffer- and stellate cells. Serum IL-37 was tested by ELISA in a clinical cohort and correlated with liver disease severity. Results: Transgene expression of IL-37 in mice extends survival, reduces hepatic damage, expression of early markers of fibrosis and histologically assessed liver fibrosis after bile duct ligation. IL-37tg mice were protected against CCl4-induced liver inflammation. Colitis-associated liver inflammation and fibrosis was less severe in IL-10 knockout IL-37tg mice. Spontaneous and LPS/TGF-β-induced cytokine release and profibrogenic gene expression was lower in HSC and KC isolated from IL-37tg mice and IL-37 overexpressing, IL-1β stimulated human LX-2 stellate cells. However, administration of recombinant human IL-37 did not modulate fibrosis pathways after BDL in mice, LX2 cells or murine HSCs. In a large clinical cohort, we observed a positive correlation of serum IL-37 levels with disease severity in liver cirrhosis. Conclusions: Predominantly intracellular IL-37 downregulates liver inflammation and fibrosis. The correlation of serum IL-37 with disease severity in cirrhosis suggests its potential as a novel target modulating the course of liver fibrosis.
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Affiliation(s)
- Steffeni Mountford
- Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Maria Effenberger
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology & Metabolism, Medical University of Innsbruck, Innsbruck, Austria
| | - Heidi Noll-Puchta
- Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Lucas Griessmair
- Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Andrea Ringleb
- Department of Pediatrics, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Sonja Haas
- RNA Biology, Ethris GmbH, Planegg, Germany
| | - Gerald Denk
- Department of Medicine II, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Florian P. Reiter
- Department of Medicine II, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Doris Mayr
- Department of Pathology, Institute of Pathology, Ludwig-Maximilians-University, Munich, Germany
| | - Charles A. Dinarello
- Department of Medicine and Immunology, University of Colorado Denver, Aurora, CO, United States
| | - Herbert Tilg
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology & Metabolism, Medical University of Innsbruck, Innsbruck, Austria
| | - Philip Bufler
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité Universitätsmedizin Berlin, Berlin, Germany
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17
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Schoenberg MB, Ehmer U, Umgelter A, Bucher JN, Koch DT, Börner N, Nieß H, Denk G, De Toni EN, Seidensticker M, Andrassy J, Angele MK, Werner J, Guba MO. Liver transplantation versus watchful waiting in hepatocellular carcinoma patients with complete response to bridging therapy - a retrospective observational study. Transpl Int 2021; 34:465-473. [PMID: 33368655 DOI: 10.1111/tri.13808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/04/2020] [Accepted: 12/22/2020] [Indexed: 12/13/2022]
Abstract
Bridging therapy to prevent progression on the waiting list can result in a sustained complete response (sCR). In some patients, the liver transplantation (LT) risk might exceed those of tumor recurrence. We thus evaluated whether a watchful waiting (CR-WW) strategy could be a feasible alternative to transplantation (CR-LT). We performed a retrospective analysis of overall survival (OS) and recurrence-free survival (RFS) of patients with a sCR (CR > 6 months). Permitted bridging included thermoablation, resection, and combinations of either with transarterial chemoembolization. Patients were divided into the intended treatment strategies CR-WW and CR-LT. 39 (18.40%) sCR patients from 212 were investigated. 22 patients were treated with a CR-LT and 17 patients a CR-WW strategy. Five-year RFS was lower in the CR-WW than in the CR-LT group [53.3% (22.1%; 77.0%) and 84.0% (57.6%; 94.7%)]. 29.4% (5/17) CR-WW patients received salvage transplantation because of recurrence. OS (5-year) was 83.9% [56.8%; 94.7%] after LT and 75.4% [39.8%; 91.7%] after WW. Our analysis shows that the intuitive decision made by our patients in agreement with their treating physicians for a watchful waiting strategy in sCR can be justified. Applied on a larger scale, this strategy could help to reduce the pressure on the donor pool.
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Affiliation(s)
- Markus Bo Schoenberg
- Department of General-, Visceral-, and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Ursula Ehmer
- Medical Department II, Technical University of Munich, Munich, Germany
| | - Andreas Umgelter
- Medical Department II, Technical University of Munich, Munich, Germany.,Interdisciplinary Emergency Room, Vivantes Humboldt Hospital, Berlin, Germany
| | - Julian Nikolaus Bucher
- Department of General-, Visceral-, and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Dominik Thomas Koch
- Department of General-, Visceral-, and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Nikolaus Börner
- Department of General-, Visceral-, and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Hanno Nieß
- Department of General-, Visceral-, and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Gerald Denk
- Department of Medicine II, LMU Munich, University Hospital, Munich, Germany.,Transplantation Center Munich, Ludwig-Maximilians-University, Munich, Germany
| | | | - Max Seidensticker
- Department of Radiology, Ludwig-Maximilians-University, Munich, Germany
| | - Joachim Andrassy
- Department of General-, Visceral-, and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Martin Kurt Angele
- Department of General-, Visceral-, and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Jens Werner
- Department of General-, Visceral-, and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Markus Otto Guba
- Department of General-, Visceral-, and Transplantation Surgery, Ludwig-Maximilians-University, Munich, Germany.,Transplantation Center Munich, Ludwig-Maximilians-University, Munich, Germany
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18
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Schoenberg MB, Anger HJW, Bucher JN, Denk G, De Toni EN, Seidensticker M, Andrassy J, Angele MK, Werner J, Guba MO. Liver Transplantation for Extended Criteria Hepatocellular Carcinoma Using Stable Response to Locoregional Therapy and Alpha-Fetoprotein as Selection Criteria. Visc Med 2020; 36:506-515. [PMID: 33447607 PMCID: PMC7768105 DOI: 10.1159/000506752] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 02/17/2020] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Current practice to only prioritize hepatocellular carcinoma (HCC) that fulfill the Milan criteria (INMC) is changing, since it causes the exclusion of patients who could benefit from liver transplantation. To select patients outside MC (OUTMC) for transplantation, we implemented extended selection criteria without up-front morphometric restrictions containing surrogate parameters of tumor biology. METHODS OUTMC patients were considered without restrictions of morphometrics and received locoregional treatment after interdisciplinary consultation. Our dynamic selection criteria for OUTMC patients required (INMUC): (1) treatment response over (2) at least 6 months and (3) alpha-fetoprotein ≤400 ng/mL over the entire evaluation period. Patients with INMC tumors served as control and internal validation cohort. RESULTS 31 of 170 liver transplant candidates were OUTMC. Of these, 8 dropped out. The remaining 23 patients met the selection criteria and underwent transplantation. Recurrence-free survival was higher in patients transplanted INMC compared to those OUTMC INMUC (92.2% vs. 70.8%; p = 0.026) after 5 years of follow-up. Overall survival showed no significant difference (p = 0.552). With dynamic selection of transplant candidates, recurrence could also be predicted for the INMC patients as internal validation cohort (c-index: 0.896; CI 0.588-0.981, p = 0.005). CONCLUSION Dynamic selection criteria for the stratification of patients with OUTMC HCCs is feasible and allows for excellent long-term results and acceptable tumor recurrence rates comparable to INMC patients.
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Affiliation(s)
- Markus Bo Schoenberg
- Department of General, Visceral, and Transplantation Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | | | - Julian Nikolaus Bucher
- Department of General, Visceral, and Transplantation Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Gerald Denk
- Medical Department II, Ludwig-Maximilians-University Munich, Munich, Germany
- Transplantation Center Munich, Ludwig-Maximilians-University Munich, Campus Grosshadern, Munich, Germany
- Liver Center Munich, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Enrico Narciso De Toni
- Medical Department II, Ludwig-Maximilians-University Munich, Munich, Germany
- Liver Center Munich, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Max Seidensticker
- Department of Radiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Joachim Andrassy
- Department of General, Visceral, and Transplantation Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Martin Kurt Angele
- Department of General, Visceral, and Transplantation Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Markus Otto Guba
- Department of General, Visceral, and Transplantation Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
- Transplantation Center Munich, Ludwig-Maximilians-University Munich, Campus Grosshadern, Munich, Germany
- Liver Center Munich, Ludwig-Maximilians-University Munich, Munich, Germany
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19
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Hohenester S, Kanitz V, Schiergens T, Einer C, Nagel J, Wimmer R, Reiter FP, Gerbes AL, De Toni EN, Bauer C, Holdt L, Mayr D, Rust C, Schnurr M, Zischka H, Geier A, Denk G. IL-18 but Not IL-1 Signaling Is Pivotal for the Initiation of Liver Injury in Murine Non-Alcoholic Fatty Liver Disease. Int J Mol Sci 2020; 21:ijms21228602. [PMID: 33202693 PMCID: PMC7696705 DOI: 10.3390/ijms21228602] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/06/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is rising in prevalence, and a better pathophysiologic understanding of the transition to its inflammatory phenotype (NASH) is key to the development of effective therapies. To evaluate the contribution of the NLRP3 inflammasome and its downstream effectors IL-1 and IL-18 in this process, we applied the true-to-life “American lifestyle-induced obesity syndrome” (ALiOS) diet mouse model. Development of obesity, fatty liver and liver damage was investigated in mice fed for 24 weeks according to the ALiOS protocol. Lipidomic changes in mouse livers were compared to human NAFLD samples. Receptor knockout mice for IL-1 and IL-18 were used to dissect the impact of downstream signals of inflammasome activity on the development of NAFLD. The ALiOS diet induced obesity and liver steatosis. The lipidomic changes closely mimicked changes in human NAFLD. A pro-inflammatory gene expression pattern in liver tissue and increased serum liver transaminases indicated early liver damage in the absence of histological evidence of NASH. Mechanistically, Il-18r−/−- but not Il-1r−/− mice were protected from early liver damage, possibly due to silencing of the pro-inflammatory gene expression pattern. Our study identified NLRP3 activation and IL-18R-dependent signaling as potential modulators of early liver damage in NAFLD, preceding development of histologic NASH.
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Affiliation(s)
- Simon Hohenester
- Department of Medicine II, University Hospital, LMU Munich, 81377 Munich, Germany; (J.N.); (R.W.); (F.P.R.); (A.L.G.); (E.N.D.T.); (G.D.)
- Correspondence:
| | - Veronika Kanitz
- Institute of Pathology, Faculty of Medicine, LMU Munich, 80337 Munich, Germany; (V.K.); (D.M.)
| | - Tobias Schiergens
- Department of General, Visceral and Transplantation Surgery, University Hospital, LMU Munich, 81377 Munich, Germany;
| | - Claudia Einer
- Institute of Molecular Toxicology and Pharmacology, Helmholtz Center Munich, German Research Center for Environmental Health, 85764 Neuherberg, Germany; (C.E.); (H.Z.)
| | - Jutta Nagel
- Department of Medicine II, University Hospital, LMU Munich, 81377 Munich, Germany; (J.N.); (R.W.); (F.P.R.); (A.L.G.); (E.N.D.T.); (G.D.)
| | - Ralf Wimmer
- Department of Medicine II, University Hospital, LMU Munich, 81377 Munich, Germany; (J.N.); (R.W.); (F.P.R.); (A.L.G.); (E.N.D.T.); (G.D.)
| | - Florian P. Reiter
- Department of Medicine II, University Hospital, LMU Munich, 81377 Munich, Germany; (J.N.); (R.W.); (F.P.R.); (A.L.G.); (E.N.D.T.); (G.D.)
| | - Alexander L. Gerbes
- Department of Medicine II, University Hospital, LMU Munich, 81377 Munich, Germany; (J.N.); (R.W.); (F.P.R.); (A.L.G.); (E.N.D.T.); (G.D.)
| | - Enrico N. De Toni
- Department of Medicine II, University Hospital, LMU Munich, 81377 Munich, Germany; (J.N.); (R.W.); (F.P.R.); (A.L.G.); (E.N.D.T.); (G.D.)
| | - Christian Bauer
- Division of Gastroenterology, Endocrinology, Infectiology and Metabolism, University Hospital Giessen and Marburg, Campus Marburg, Philipps University Marburg, 35043 Marburg, Germany;
| | - Lesca Holdt
- Institute of Laboratory Medicine, University Hospital, LMU Munich, 81377 Munich, Germany;
| | - Doris Mayr
- Institute of Pathology, Faculty of Medicine, LMU Munich, 80337 Munich, Germany; (V.K.); (D.M.)
| | - Christian Rust
- Department of Medicine I, Hospital Barmherzige Brüder, 80639 Munich, Germany;
| | - Max Schnurr
- Division of Clinical Pharmacology, University Hospital, LMU Munich, 80336 Munich, Germany;
| | - Hans Zischka
- Institute of Molecular Toxicology and Pharmacology, Helmholtz Center Munich, German Research Center for Environmental Health, 85764 Neuherberg, Germany; (C.E.); (H.Z.)
- Institute of Toxicology and Environmental Hygiene, Technical University Munich, School of Medicine, 80802 Munich, Germany
| | - Andreas Geier
- Division of Hepatology, University Hospital Würzburg, 97080 Würzburg, Germany;
| | - Gerald Denk
- Department of Medicine II, University Hospital, LMU Munich, 81377 Munich, Germany; (J.N.); (R.W.); (F.P.R.); (A.L.G.); (E.N.D.T.); (G.D.)
- Transplantation Center Munich, University Hospital, LMU Munich, 81377 Munich, Germany
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20
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Bourhis H, Gerbes AL, Op den Winkel M, Denk G. [Elevated liver enzymes]. MMW Fortschr Med 2020; 162:59-67. [PMID: 33164192 DOI: 10.1007/s15006-020-4404-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Hélène Bourhis
- Ludwig-Maximilians-Universität, Medizinische Klinik und Poliklinik II, München, Germany.
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21
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Bösch F, Börner N, Kemmner S, Lampert C, Jacob S, Koliogiannis D, Stangl M, Michel S, Kneidinger N, Schneider C, Fischereder M, Irlbeck M, Denk G, Werner J, Angele MK, Guba MO. Attenuated early inflammatory response in solid organ recipients with COVID-19. Clin Transplant 2020; 34:e14027. [PMID: 32589760 PMCID: PMC7361260 DOI: 10.1111/ctr.14027] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/23/2020] [Indexed: 12/12/2022]
Abstract
Immunosuppression leaves transplanted patients at particular risk for severe acute respiratory syndrome 2 (SARS‐CoV‐2) infection. The specific features of coronavirus disease 2019 (COVID‐19) in immunosuppressed patients are largely unknown and therapeutic experience is lacking. Seven transplanted patients (two liver, three kidneys, one double lung, one heart) admitted to the Ludwig‐Maximilians‐University Munich because of COVID‐19 and tested positive for SARS‐CoV‐2 were included. The clinical course and the clinical findings were extracted from the medical record. The two liver transplant patients and the heart transplant patient had an uncomplicated course and were discharged after 14, 18, and 12 days, respectively. Two kidney transplant recipients were intubated within 48 hours. One kidney and the lung transplant recipients were required to intubate after 10 and 15 days, respectively. Immunosuppression was adapted in five patients, but continued in all patients. Compared to non‐transplanted patients at the ICU (n = 19) the inflammatory response was attenuated in transplanted patients, which was proven by decreased IL‐6 blood values. This analysis might provide evidence that continuous immunosuppression is safe and probably beneficial since there was no hyperinflammation evident. Although transplanted patients might be more susceptible to an infection with SARS‐CoV‐2, their clinical course seems to be similar to immunocompetent patients.
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Affiliation(s)
- Florian Bösch
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany.,Transplantation Center Munich, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Nikolaus Börner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany.,Transplantation Center Munich, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Stephan Kemmner
- Transplantation Center Munich, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Christopher Lampert
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Sven Jacob
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Dionysios Koliogiannis
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany.,Transplantation Center Munich, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Manfred Stangl
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany.,Transplantation Center Munich, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Sebastian Michel
- Transplantation Center Munich, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany.,Clinic of Cardiac Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | - Nikolaus Kneidinger
- Transplantation Center Munich, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany.,Department of Internal Medicine V, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), University of Munich, LMU, Munich, Germany
| | - Christian Schneider
- Transplantation Center Munich, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany.,Center for Thoracic Surgery Munich, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Michael Fischereder
- Transplantation Center Munich, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany.,Renal Division, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Gerald Denk
- Transplantation Center Munich, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany.,Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany.,Transplantation Center Munich, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Martin K Angele
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany.,Transplantation Center Munich, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Markus O Guba
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University Munich, Munich, Germany.,Transplantation Center Munich, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
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22
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Reiter FP, Obermeier W, Jung J, Denk G, Mahajan UM, De Toni EN, Schirra J, Mayerle J, Schulz C. Prevalence, Resistance Rates, and Risk Factors of Pathogens in Routine Bile Cultures Obtained during Endoscopic Retrograde Cholangiography. Dig Dis 2020; 39:42-51. [PMID: 32521535 DOI: 10.1159/000509289] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 06/09/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION AND OBJECTIVE Acute cholangitis is a life-threatening condition. The early initiation of antibiotic therapy significantly impacts the course of disease. Only few data are available on distribution and resistance profiles of bile pathogens. Here, we report on an analysis of routinely acquired bile specimens and provide an overview of the prevalence, resistance rates, and risk factors for the presence of pathogens in bile. METHODS Bile cultures obtained from 388 endoscopic retrograde cholangiographies (ERCs) with corresponding clinical data were analysed in 208 patients. RESULTS The majority (84.8%) of cultures yielded positive for at least 1 organism. Abundance was highest for Enterococcus faecalis, Enterococcus faecium, and Escherichia coli. Multiresistant organisms were present in 14.9%. The initial antibiotic regimen was changed in 44.1%, which increased the length of hospital stay significantly (***p < 0.001). Pre-existing papillotomy (EPT) or biliary drainage was associated with higher frequency of bile pathogens (**p < 0.01) in a univariate analysis. Multivariate analysis confirmed these results for EPT and revealed significantly more positive results for pathogens, gram-negative bacteria, and fungi in patients with biliary drainage. Significant differences in the prevalence of pathogens were observed between relevant subgroups of ERC indications. The highest susceptibility rates were observed for linezolid and tigecycline in gram-positive bacteria and for meropenem and gentamicin in gram-negative bacteria. CONCLUSIONS Our study provides a comprehensive analysis of the distribution, resistance profiles, and risk factors for the detection of bile pathogens. The frequent change in initial antibiotic treatment highlights the importance of routine bile culture and indicates that current schemas of empirical treatment might not cover the contemporary spectrum of pathogens in bile.
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Affiliation(s)
- Florian P Reiter
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany, .,Liver Center, University Hospital, LMU Munich, Munich, Germany,
| | - Wolfgang Obermeier
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany.,Liver Center, University Hospital, LMU Munich, Munich, Germany
| | - Jette Jung
- Max von Pettenkofer-Institut für Hygiene und Medizinische Mikobiologie, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Gerald Denk
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany.,Liver Center, University Hospital, LMU Munich, Munich, Germany
| | - Ujjwal M Mahajan
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany.,Liver Center, University Hospital, LMU Munich, Munich, Germany
| | - Enrico N De Toni
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany.,Liver Center, University Hospital, LMU Munich, Munich, Germany
| | - Jörg Schirra
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany.,Liver Center, University Hospital, LMU Munich, Munich, Germany
| | - Julia Mayerle
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany.,Liver Center, University Hospital, LMU Munich, Munich, Germany
| | - Christian Schulz
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany.,Liver Center, University Hospital, LMU Munich, Munich, Germany
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23
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Liwinski T, Casar C, Ruehlemann MC, Bang C, Sebode M, Hohenester S, Denk G, Lieb W, Lohse AW, Franke A, Schramm C. A disease-specific decline of the relative abundance of Bifidobacterium in patients with autoimmune hepatitis. Aliment Pharmacol Ther 2020; 51:1417-1428. [PMID: 32383181 DOI: 10.1111/apt.15754] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 01/26/2020] [Accepted: 04/06/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND The pathogenesis of autoimmune hepatitis (AIH) is poorly understood and little is known about enteric microbiota in AIH. AIM To investigate disease-specific microbiome alterations in AIH. METHODS The V1-V2 variable regions of the 16S rRNA gene were sequenced in faecal samples from 347 patients with AIH and controls (AIH n = 72, healthy controls (HC) n = 95, primary biliary cholangitis (PBC) n = 99 and ulcerative colitis (UC) n = 81). RESULTS Biodiversity (Shannon entropy) was decreased in AIH patients compared to HC (P = 0.016), which was partially reversed by azathioprine (P = 0.011). Regarding between-sample diversity, AIH patients separated from HC, PBC and UC individuals (all P = 0.001). Compared to HC, decreased relative abundance of anaerobic genera such as Faecalibacterium and an increase of Veillonella and the facultative anaerobic genera Streptococcus and Lactobacillus were detected. Importantly, a disease-specific decline of relative abundance of Bifidobacterium was observed in AIH patients. Lack of Bifidobacterium was associated with failure to achieve remission of AIH (P < 0.001). Of potential therapeutic implication, Bifidobacterium abundance correlated with average protein intake (P < 0.001). Random forests classification between AIH and PBC on the microbiome signature yielded an area under receiver operating characteristic curve (AUC) of 0.787 in the training cohort, and an AUC of 0.849 in an external validation cohort. CONCLUSION Disease-specific faecal microbial alterations were identified in patients with AIH. Intestinal dysbiosis in AIH was characterised by a decline of Bifidobacterium, which was associated with increased disease activity. These results point to the contribution of intestinal microbiota to AIH pathogenesis and to novel therapeutic targets.
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Affiliation(s)
- Timur Liwinski
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network for Hepatological Diseases (ERN-RARE-LIVER), Hamburg, Germany
| | - Christian Casar
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network for Hepatological Diseases (ERN-RARE-LIVER), Hamburg, Germany
| | - Malte C Ruehlemann
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Corinna Bang
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Marcial Sebode
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network for Hepatological Diseases (ERN-RARE-LIVER), Hamburg, Germany
| | - Simon Hohenester
- Department of Medicine II, Liver Center Munich, LMU Munich, University Hospital, Munich, Germany
| | - Gerald Denk
- Department of Medicine II, Liver Center Munich, LMU Munich, University Hospital, Munich, Germany
| | - Wolfgang Lieb
- Institute of Epidemiology, Christian-Albrechts-University of Kiel, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Ansgar W Lohse
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network for Hepatological Diseases (ERN-RARE-LIVER), Hamburg, Germany
| | - Andre Franke
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Christoph Schramm
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network for Hepatological Diseases (ERN-RARE-LIVER), Hamburg, Germany.,Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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24
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Hohenester S, Kanitz V, Kremer AE, Paulusma CC, Wimmer R, Kuehn H, Denk G, Horst D, Oude Elferink R, Beuers U. Glycochenodeoxycholate Promotes Liver Fibrosis in Mice with Hepatocellular Cholestasis. Cells 2020; 9:cells9020281. [PMID: 31979271 PMCID: PMC7072501 DOI: 10.3390/cells9020281] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/15/2020] [Accepted: 01/19/2020] [Indexed: 02/06/2023] Open
Abstract
Hydrophobic bile salts are considered to promote liver fibrosis in cholestasis. However, evidence for this widely accepted hypothesis remains scarce. In established animal models of cholestasis, e.g., by Mdr2 knockout, cholestasis and fibrosis are both secondary to biliary damage. Therefore, to test the specific contribution of accumulating bile salts to liver fibrosis in cholestatic disease, we applied the unique model of inducible hepatocellular cholestasis in cholate-fed Atp8b1G308V/G308V mice. Glycochenodeoxycholate (GCDCA) was supplemented to humanize the murine bile salt pool, as confirmed by HPLC. Biomarkers of cholestasis and liver fibrosis were quantified. Hepatic stellate cells (HSC) isolated from wild-type mice were stimulated with bile salts. Proliferation, cell accumulation, and collagen deposition of HSC were determined. In cholestatic Atp8b1G308V/G308V mice, increased hepatic expression of αSMA and collagen1a mRNA and excess hepatic collagen deposition indicated development of liver fibrosis only upon GCDCA supplementation. In vitro, numbers of myofibroblasts and deposition of collagen were increased after incubation with hydrophobic but not hydrophilic bile salts, and associated with EGFR and MEK1/2 activation. We concluded that chronic hepatocellular cholestasis alone, independently of biliary damage, induces liver fibrosis in mice in presence of the human bile salt GCDCA. Bile salts may have direct pro-fibrotic effects on HSC, putatively involving EGFR and MEK1/2 signaling.
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Affiliation(s)
- Simon Hohenester
- Department of Medicine II, University Hospital, LMU Munich, 81377 Munich, Germany; (R.W.); (G.D.)
- Correspondence:
| | - Veronika Kanitz
- Institute of Pathology, Faculty of Medicine, LMU Munich, 80337 Munich, Germany;
| | - Andreas E. Kremer
- Department of Medicine I, Friedrich-Alexander-University Erlangen-Nürnberg, 91054 Erlangen, Germany; (A.E.K.); (H.K.)
| | - Coen C. Paulusma
- Tytgat Institute for Liver and Intestinal Research, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, 1018 TV Amsterdam, The Netherlands; (C.C.P.); (R.O.E.); (U.B.)
| | - Ralf Wimmer
- Department of Medicine II, University Hospital, LMU Munich, 81377 Munich, Germany; (R.W.); (G.D.)
| | - Helen Kuehn
- Department of Medicine I, Friedrich-Alexander-University Erlangen-Nürnberg, 91054 Erlangen, Germany; (A.E.K.); (H.K.)
| | - Gerald Denk
- Department of Medicine II, University Hospital, LMU Munich, 81377 Munich, Germany; (R.W.); (G.D.)
| | - David Horst
- Department of Pathology, Charité—Universitätsmedizin, 10117 Berlin, Germany;
| | - Ronald Oude Elferink
- Tytgat Institute for Liver and Intestinal Research, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, 1018 TV Amsterdam, The Netherlands; (C.C.P.); (R.O.E.); (U.B.)
| | - Ulrich Beuers
- Tytgat Institute for Liver and Intestinal Research, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, 1018 TV Amsterdam, The Netherlands; (C.C.P.); (R.O.E.); (U.B.)
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25
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Rühlemann M, Liwinski T, Heinsen F, Bang C, Zenouzi R, Kummen M, Thingholm L, Tempel M, Lieb W, Karlsen T, Lohse A, Hov J, Denk G, Lammert F, Krawczyk M, Schramm C, Franke A. Consistent alterations in faecal microbiomes of patients with primary sclerosing cholangitis independent of associated colitis. Aliment Pharmacol Ther 2019; 50:580-589. [PMID: 31250469 PMCID: PMC6899739 DOI: 10.1111/apt.15375] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 02/26/2019] [Accepted: 05/24/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Single-centre studies reported alterations of faecal microbiota in patients with primary sclerosing cholangitis (PSC). As regional factors may affect microbial communities, it is unclear if a microbial signature of PSC exists across different geographical regions. AIM To identify a robust microbial signature of PSC independent of geography and environmental influences. METHODS We included 388 individuals (median age, 47 years; range, 15-78) from Germany and Norway in the study, 137 patients with PSC (n = 75 with colitis), 118 with ulcerative colitis (UC) and 133 healthy controls. Faecal microbiomes were analysed by 16S rRNA gene sequencing (V1-V2). Differences in relative abundances of single taxa were subjected to a meta-analysis. RESULTS In both cohorts, microbiota composition (beta-diversity) differed between PSC patients and controls (P < 0.001). Random forests classification discriminated PSC patients from controls in both geographical cohorts with an average area under the curve of 0.88. Compared to healthy controls, many new cohort-spanning alterations were identified in PSC, such as an increase of Proteobacteria and the bile-tolerant genus Parabacteroides, which were detected independent from geographical region. Associated colitis only had minor effects on microbiota composition, suggesting that PSC itself drives the faecal microbiota changes observed. CONCLUSION Compared to healthy controls, numerous microbiota alterations are reproducible in PSC patients across geographical regions, clearly pointing towards a microbiota composition that is shaped by the disease itself and not by environmental factors. These reproducibly altered microbial populations might provide future insights into the pathophysiology of PSC.
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26
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Einer C, Leitzinger C, Lichtmannegger J, Eberhagen C, Rieder T, Borchard S, Wimmer R, Denk G, Popper B, Neff F, Polishchuk EV, Polishchuk RS, Hauck SM, von Toerne C, Müller JC, Karst U, Baral BS, DiSpirito AA, Kremer AE, Semrau J, Weiss KH, Hohenester S, Zischka H. A High-Calorie Diet Aggravates Mitochondrial Dysfunction and Triggers Severe Liver Damage in Wilson Disease Rats. Cell Mol Gastroenterol Hepatol 2018; 7:571-596. [PMID: 30586623 PMCID: PMC6407159 DOI: 10.1016/j.jcmgh.2018.12.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 12/13/2018] [Accepted: 12/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In Wilson disease, ATP7B mutations impair copper excretion into bile. Hepatic copper accumulation may induce mild to moderate chronic liver damage or even acute liver failure. Etiologic factors for this heterogeneous phenotype remain enigmatic. Liver steatosis is a frequent finding in Wilson disease patients, suggesting that impaired copper homeostasis is linked with liver steatosis. Hepatic mitochondrial function is affected negatively both by copper overload and steatosis. Therefore, we addressed the question of whether a steatosis-promoting high-calorie diet aggravates liver damage in Wilson disease via amplified mitochondrial damage. METHODS Control Atp7b+/- and Wilson disease Atp7b-/- rats were fed either a high-calorie diet (HCD) or a normal diet. Copper chelation using the high-affinity peptide methanobactin was used in HCD-fed Atp7b-/- rats to test for therapeutic reversal of mitochondrial copper damage. RESULTS In comparison with a normal diet, HCD feeding of Atp7b-/- rats resulted in a markedly earlier onset of clinically apparent hepatic injury. Strongly increased mitochondrial copper accumulation was observed in HCD-fed Atp7b-/- rats, correlating with severe liver injury. Mitochondria presented with massive structural damage, increased H2O2 emergence, and dysfunctional adenosine triphosphate production. Hepatocellular injury presumably was augmented as a result of oxidative stress. Reduction of mitochondrial copper by methanobactin significantly reduced mitochondrial impairment and ameliorated liver damage. CONCLUSIONS A high-calorie diet severely aggravates hepatic mitochondrial and hepatocellular damage in Wilson disease rats, causing an earlier onset of the disease and enhanced disease progression.
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Affiliation(s)
- Claudia Einer
- Institute of Molecular Toxicology and Pharmacology, Helmholtz Center Munich, German Research Center for Environmental Health, Neuherberg, Germany; Department of Medicine II, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Christin Leitzinger
- Institute of Molecular Toxicology and Pharmacology, Helmholtz Center Munich, German Research Center for Environmental Health, Neuherberg, Germany
| | - Josef Lichtmannegger
- Institute of Molecular Toxicology and Pharmacology, Helmholtz Center Munich, German Research Center for Environmental Health, Neuherberg, Germany
| | - Carola Eberhagen
- Institute of Molecular Toxicology and Pharmacology, Helmholtz Center Munich, German Research Center for Environmental Health, Neuherberg, Germany
| | - Tamara Rieder
- Institute of Toxicology and Environmental Hygiene, Technical University Munich, Munich, Germany
| | - Sabine Borchard
- Institute of Molecular Toxicology and Pharmacology, Helmholtz Center Munich, German Research Center for Environmental Health, Neuherberg, Germany
| | - Ralf Wimmer
- Department of Medicine II, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Gerald Denk
- Department of Medicine II, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Bastian Popper
- Department of Anatomy and Cell Biology, Biomedical Center, Ludwig-Maximilians-University, Planegg-Martinsried, Germany; Core Facility Animal Models, Biomedical Center, Ludwig-Maximilians-University, Planegg-Martinsried, Germany
| | - Frauke Neff
- Institute of Pathology, Helmholtz Center Munich, German Research Center for Environmental Health, Neuherberg, Germany
| | | | | | - Stefanie M Hauck
- Research Unit Protein Science, Helmholtz Center Munich, German Research Center for Environmental Health, Neuherberg, Germany
| | - Christine von Toerne
- Research Unit Protein Science, Helmholtz Center Munich, German Research Center for Environmental Health, Neuherberg, Germany
| | | | - Uwe Karst
- Institute of Inorganic and Analytical Chemistry, University of Münster, Münster, Germany
| | - Bipin S Baral
- Roy J. Carver Department of Biochemistry, Biophysics and Molecular Biology, Iowa State University, Ames, Iowa
| | - Alan A DiSpirito
- Roy J. Carver Department of Biochemistry, Biophysics and Molecular Biology, Iowa State University, Ames, Iowa
| | - Andreas E Kremer
- Department of Medicine I, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Jeremy Semrau
- Department of Civil and Environmental Engineering, University of Michigan, Ann Arbor, Michigan
| | - Karl Heinz Weiss
- Department of Gastroenterology, Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Simon Hohenester
- Department of Medicine II, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Hans Zischka
- Institute of Molecular Toxicology and Pharmacology, Helmholtz Center Munich, German Research Center for Environmental Health, Neuherberg, Germany; Institute of Toxicology and Environmental Hygiene, Technical University Munich, Munich, Germany.
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Hohenester S, Christiansen S, Nagel J, Wimmer R, Artmann R, Denk G, Bischoff M, Bischoff G, Rust C. Lifestyle intervention for morbid obesity: effects on liver steatosis, inflammation, and fibrosis. Am J Physiol Gastrointest Liver Physiol 2018; 315:G329-G338. [PMID: 29878845 DOI: 10.1152/ajpgi.00044.2018] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The prevalence of obesity-related nonalcoholic fatty liver disease (NAFLD) is rising. NAFLD may result in nonalcoholic steatohepatitis (NASH), progressing to liver cirrhosis. Weight loss is recommended to treat obesity-related NASH. Lifestyle intervention may improve NASH; however, pertinent trials have so far focused on overweight patients, whereas patients with obesity are at highest risk of developing NAFLD. Furthermore, reports of effects on liver fibrosis are scarce. We evaluated the effect of lifestyle intervention on NAFLD in a real-life cohort of morbidly obese patients. In our observational study, 152 patients underwent lifestyle intervention, with a follow-up of 52 weeks. Noninvasive measures of obesity, metabolic syndrome, liver steatosis, liver damage, and liver fibrosis were analyzed. Treatment response in terms of weight loss was achieved in 85.1% of patients. Dysglycemia and dyslipidemia improved. The proportion of patients with fatty liver dropped from 98.1 to 54.3% ( P < 0.001). Weight loss >10% was associated with better treatment response ( P = 0.0009). Prevalence of abnormal serum transaminases fell from 81.0 to 50.5% ( P < 0.001). The proportion fibrotic patients, as determined by the NAFLD fibrosis score, dropped from 11.8 to 0% ( P < 0.05). Low serum levels of adiponectin correlated with degree of liver damage, i.e., serum liver transaminases ( r = -0,32, P < 0.05). Serum levels of adiponectin improved with intervention. In conclusion, lifestyle intervention effectively targeted obesity and the metabolic syndrome. Liver steatosis, damage and fibrosis were ameliorated in this real-life cohort of morbidly obese patients, mediated in part by changes in the adipokine profile. Patients with weight loss of >10% seemed to benefit most. NEW & NOTEWORTHY We demonstrate new evidence that lifestyle intervention is effective in treating NAFLD in the important group of patients with (morbid) obesity. Although current guidelines on the therapy of NASH recommend weight loss of 5-7%, weight reduction >10% may be favorable in morbid obesity. Serum levels of adipokines correlate with liver damage, which is indicative of their pathogenetic importance in human NASH. Our study adds to the limited body of evidence that NAFLD-associated liver fibrosis may resolve with lifestyle intervention.
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Affiliation(s)
- Simon Hohenester
- Department of Medicine II, University Hospital, LMU Munich, Munich , Germany
| | - Simon Christiansen
- Center for Clinical Nutrition and Preventive Medicine, Hospital Barmherzige Brüder , Munich , Germany
| | - Jutta Nagel
- Department of Medicine II, University Hospital, LMU Munich, Munich , Germany
| | - Ralf Wimmer
- Department of Medicine II, University Hospital, LMU Munich, Munich , Germany
| | - Renate Artmann
- Department of Medicine II, University Hospital, LMU Munich, Munich , Germany
| | - Gerald Denk
- Department of Medicine II, University Hospital, LMU Munich, Munich , Germany
| | - Monika Bischoff
- Center for Clinical Nutrition and Preventive Medicine, Hospital Barmherzige Brüder , Munich , Germany
| | - Gert Bischoff
- Center for Clinical Nutrition and Preventive Medicine, Hospital Barmherzige Brüder , Munich , Germany.,Department of Medicine I, Hospital Barmherzige Brüder , Munich , Germany
| | - Christian Rust
- Center for Clinical Nutrition and Preventive Medicine, Hospital Barmherzige Brüder , Munich , Germany.,Department of Medicine I, Hospital Barmherzige Brüder , Munich , Germany
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28
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Mak'Anyengo R, Duewell P, Reichl C, Hörth C, Lehr HA, Fischer S, Clavel T, Denk G, Hohenester S, Kobold S, Endres S, Schnurr M, Bauer C. Nlrp3-dependent IL-1β inhibits CD103+ dendritic cell differentiation in the gut. JCI Insight 2018. [PMID: 29515025 DOI: 10.1172/jci.insight.96322] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Inflammatory bowel disease (IBD) is associated with enhanced levels of the IL-1 family cytokines IL-1β and IL-18, which are activated by the Nlrp3 inflammasome. Here, we investigated the role of inflammasome-driven cytokine release on T cell polarization and DC differentiation in steady state and T cell transfer colitis. In vitro and in vivo data showed that IL-1β induces Th17 polarization and increases GM‑CSF production by T cells. Reduced IL-1β levels in Nlrp3-/- mice correlated with enhanced FLT3L levels and increased frequency of tolerogenic CD103+ DC. In the T cell transfer colitis model, Nlrp3 deficiency resulted in lower IL‑1β levels, reduced Th17 immunity, and less severe colitis. Unaltered IL-18 levels in both mouse strains pointed toward Nlrp3-independent processing. Importantly, cohousing revealed that the gut microbiome had no impact on the observed Nlrp3-/- phenotype. This study demonstrates that NLRP3 acts as a molecular switch of intestinal homeostasis by shifting local immune cells toward an inflammatory phenotype via IL-1β.
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Affiliation(s)
- Rachel Mak'Anyengo
- Center of Integrated Protein Science Munich (CIPS-M) and Division of Clinical Pharmacology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Peter Duewell
- Center of Integrated Protein Science Munich (CIPS-M) and Division of Clinical Pharmacology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Cornelia Reichl
- Center of Integrated Protein Science Munich (CIPS-M) and Division of Clinical Pharmacology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Christine Hörth
- Center of Integrated Protein Science Munich (CIPS-M) and Division of Clinical Pharmacology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Hans-Anton Lehr
- Institute of Pathology, Medizin Campus Bodensee, Friedrichshafen, Germany
| | - Sandra Fischer
- Core Facility Microbiome, ZIEL-Institute for Food and Health, Technische Universität München, Freising-Weihenstephan, Germany
| | - Thomas Clavel
- Core Facility Microbiome, ZIEL-Institute for Food and Health, Technische Universität München, Freising-Weihenstephan, Germany.,Institute of Medical Microbiology, RWTH University Hospital, Aachen, Germany
| | - Gerald Denk
- Medizinische Klinik und Poliklinik II, Klinikum der Universität München, Munich, Germany
| | - Simon Hohenester
- Medizinische Klinik und Poliklinik II, Klinikum der Universität München, Munich, Germany
| | - Sebastian Kobold
- Center of Integrated Protein Science Munich (CIPS-M) and Division of Clinical Pharmacology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Stefan Endres
- Center of Integrated Protein Science Munich (CIPS-M) and Division of Clinical Pharmacology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Max Schnurr
- Center of Integrated Protein Science Munich (CIPS-M) and Division of Clinical Pharmacology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Christian Bauer
- Division of Gastroenterology, Endocrinology, Infectiology and Metabolism, University Hospital Giessen and Marburg, Campus Marburg, Philipps University Marburg, Marburg, Germany
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Einer C, Hohenester S, Wimmer R, Wottke L, Artmann R, Schulz S, Gosmann C, Simmons A, Leitzinger C, Eberhagen C, Borchard S, Schmitt S, Hauck SM, von Toerne C, Jastroch M, Walheim E, Rust C, Gerbes AL, Popper B, Mayr D, Schnurr M, Vollmar AM, Denk G, Zischka H. Data on chow, liver tissue and mitochondrial fatty acid compositions as well as mitochondrial proteome changes after feeding mice a western diet for 6-24 weeks. Data Brief 2017; 15:163-169. [PMID: 29034285 PMCID: PMC5633826 DOI: 10.1016/j.dib.2017.09.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 09/12/2017] [Indexed: 10/26/2022] Open
Abstract
The data presented in this article describe the fatty acid composition of chow, liver tissue and isolated liver mitochondria from mice fed for 6-24 weeks with a high caloric western diet (WD) in comparison to control diet (normal diet, ND). The fatty acid composition was measured via gas chromatography flame ionization detection (GC-FID). Moreover, WD-induced mitochondrial protein changes are presented in this work and were analyzed by mass spectrometry (LC-MS/MS). For further interpretation and discussion of the presented data please refer to the research article entitled "Mitochondrial adaptation in steatotic mice" (Einer et al., 2017) [1].
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Affiliation(s)
- Claudia Einer
- Institute of Molecular Toxicology and Pharmacology, Helmholtz Center Munich, German Research Center for Environmental Health, 85764 Neuherberg, Germany
| | - Simon Hohenester
- Department of Medicine II - Grosshadern, Liver Center Munich, LMU Munich, 81377 Munich, Germany
| | - Ralf Wimmer
- Department of Medicine II - Grosshadern, Liver Center Munich, LMU Munich, 81377 Munich, Germany
| | - Lena Wottke
- Department of Medicine II - Grosshadern, Liver Center Munich, LMU Munich, 81377 Munich, Germany
| | - Renate Artmann
- Department of Medicine II - Grosshadern, Liver Center Munich, LMU Munich, 81377 Munich, Germany
| | - Sabine Schulz
- Institute of Molecular Toxicology and Pharmacology, Helmholtz Center Munich, German Research Center for Environmental Health, 85764 Neuherberg, Germany
| | - Christian Gosmann
- Institute of Molecular Toxicology and Pharmacology, Helmholtz Center Munich, German Research Center for Environmental Health, 85764 Neuherberg, Germany
| | - Alisha Simmons
- Institute of Molecular Toxicology and Pharmacology, Helmholtz Center Munich, German Research Center for Environmental Health, 85764 Neuherberg, Germany
| | - Christin Leitzinger
- Institute of Molecular Toxicology and Pharmacology, Helmholtz Center Munich, German Research Center for Environmental Health, 85764 Neuherberg, Germany
| | - Carola Eberhagen
- Institute of Molecular Toxicology and Pharmacology, Helmholtz Center Munich, German Research Center for Environmental Health, 85764 Neuherberg, Germany
| | - Sabine Borchard
- Institute of Molecular Toxicology and Pharmacology, Helmholtz Center Munich, German Research Center for Environmental Health, 85764 Neuherberg, Germany
| | - Sabine Schmitt
- Institute of Toxicology and Environmental Hygiene, Technical University of Munich, 80802 Munich, Germany
| | - Stefanie M Hauck
- Research Unit Protein Science, Helmholtz Center Munich, German Research Center for Environmental Health, 85764 Neuherberg, Germany
| | - Christine von Toerne
- Research Unit Protein Science, Helmholtz Center Munich, German Research Center for Environmental Health, 85764 Neuherberg, Germany
| | - Martin Jastroch
- Institute of Diabetes and Obesity, Helmholtz Center Munich, German Research Center for Environmental Health, 85764 Neuherberg, Germany
| | - Ellen Walheim
- Institute of Diabetes and Obesity, Helmholtz Center Munich, German Research Center for Environmental Health, 85764 Neuherberg, Germany
| | - Christian Rust
- Department of Medicine I, Krankenhaus Barmherzige Brüder, 80639 Munich, Germany
| | - Alexander L Gerbes
- Department of Medicine II - Grosshadern, Liver Center Munich, LMU Munich, 81377 Munich, Germany
| | - Bastian Popper
- Biomedical Center, Department of Anatomy and Cell biology, LMU Munich, 82152 Planegg, Martinsried,, Germany
| | - Doris Mayr
- Department of Pathology, LMU Munich, 80337 Munich, Germany
| | - Max Schnurr
- Division of Clinical Pharmacology & Center for Integrated Protein Science Munich (CIPSM), Klinikum der Universität München, 80337 Munich, Germany
| | - Angelika M Vollmar
- Department of Pharmacy - Center for Drug Research, Pharmaceutical Biology, LMU Munich, 81377 Munich, Germany
| | - Gerald Denk
- Department of Medicine II - Grosshadern, Liver Center Munich, LMU Munich, 81377 Munich, Germany
| | - Hans Zischka
- Institute of Molecular Toxicology and Pharmacology, Helmholtz Center Munich, German Research Center for Environmental Health, 85764 Neuherberg, Germany.,Institute of Toxicology and Environmental Hygiene, Technical University of Munich, 80802 Munich, Germany
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Fickert P, Hirschfield GM, Denk G, Marschall HU, Altorjay I, Färkkilä M, Schramm C, Spengler U, Chapman R, Bergquist A, Schrumpf E, Nevens F, Trivedi P, Reiter FP, Tornai I, Halilbasic E, Greinwald R, Pröls M, Manns MP, Trauner M. norUrsodeoxycholic acid improves cholestasis in primary sclerosing cholangitis. J Hepatol 2017; 67:549-558. [PMID: 28529147 DOI: 10.1016/j.jhep.2017.05.009] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 04/12/2017] [Accepted: 05/06/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIM Primary sclerosing cholangitis (PSC) represents a devastating bile duct disease, currently lacking effective medical therapy. 24-norursodeoxycholic acid (norUDCA) is a side chain-shortened C23 homologue of UDCA and has shown potent anti-cholestatic, anti-inflammatory and anti-fibrotic properties in a preclinical PSC mouse model. A randomized controlled trial, including 38 centers from 12 European countries, evaluated the safety and efficacy of three doses of oral norUDCA (500mg/d, 1,000mg/d or 1,500mg/d) compared with placebo in patients with PSC. METHODS One hundred sixty-one PSC patients without concomitant UDCA therapy and with elevated serum alkaline phosphatase (ALP) levels were randomized for a 12-week treatment followed by a 4-week follow-up. The primary efficacy endpoint was the mean relative change in ALP levels between baseline and end of treatment visit. RESULTS norUDCA reduced ALP levels by -12.3%, -17.3%, and -26.0% in the 500, 1,000, and 1,500mg/d groups (p=0.029, p=0.003, and p<0.0001 when compared to placebo), respectively, while a +1.2% increase was observed in the placebo group. Similar dose-dependent results were found for secondary endpoints, such as ALT, AST, γ-GT, or the rate of patients achieving ALP levels <1.5× ULN. Serious adverse events occurred in seven patients in the 500mg/d, five patients in the 1,000mg/d, two patients in the 1500mg/d group, and three in the placebo group. There was no difference in reported pruritus between treatment and placebo groups. CONCLUSIONS norUDCA significantly reduced ALP values dose-dependently in all treatment arms. The safety profile of norUDCA was excellent and comparable to placebo. Consequently, these results justify a phase III trial of norUDCA in PSC patients. Lay summary: Effective medical therapy for primary sclerosing cholangitis (PSC) is urgently needed. In this phase II clinical study in PSC patients, a side chain-shortened derivative of ursodeoxycholic acid, norursodeoxycholic acid (norUDCA), significantly reduced serum alkaline phosphatase levels in a dose-dependent manner during a 12-week treatment. Importantly, norUDCA showed a favorable safety profile, which was similar to placebo. The use of norUDCA in PSC patients is promising and will be further evaluated in a phase III clinical study. ClinicalTrials.gov number: NCT01755507.
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Affiliation(s)
- Peter Fickert
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Gideon M Hirschfield
- Centre for Liver Research and NIHR Biomedical Research Unit, University of Birmingham, United Kingdom
| | - Gerald Denk
- Department of Medicine II, Liver Center Munich, Ludwig Maximilians University (LMU), Munich, Germany
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Istvan Altorjay
- Department of Gastroenterology, School of Medicine, Debrecen University, Debrecen, Hungary
| | - Martti Färkkilä
- University of Helsinki and Clinic of Gastroenterology, Helsinki University Hospital, Helsinki, Finland
| | - Christoph Schramm
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ulrich Spengler
- Department of Internal Medicine 1, Rheinische Friedrich-Wilhelm's University Bonn, Bonn, Germany
| | - Roger Chapman
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, United Kingdom
| | - Annika Bergquist
- Department of Gastroenterology and Hepatology, Karolinska University Hospital, Karolinska Institute, Huddinge, Stockholm, Sweden
| | - Erik Schrumpf
- Section of Gastroenterology, Department of Transplantation Medicine, Division of Cancer Medicine, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Frederik Nevens
- Hepatology, University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Palak Trivedi
- Centre for Liver Research and NIHR Biomedical Research Unit, University of Birmingham, United Kingdom
| | - Florian P Reiter
- Department of Medicine II, Liver Center Munich, Ludwig Maximilians University (LMU), Munich, Germany
| | - Istvan Tornai
- Department of Gastroenterology, School of Medicine, Debrecen University, Debrecen, Hungary
| | - Emina Halilbasic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | | | | | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
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Deppe C, Zachoval R, Denk G, Delius M, Blume C, Hilgendorff A, Flemmer A, Mahner S, Hasbargen U. Schwangerschaften mit Child-B-Leberzirrhose aufgrund einer Gallengangsatresie, Fallbericht. Geburtshilfe Frauenheilkd 2016. [DOI: 10.1055/s-0036-1592837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Lichtmannegger J, Leitzinger C, Wimmer R, Schmitt S, Schulz S, Kabiri Y, Eberhagen C, Rieder T, Janik D, Neff F, Straub BK, Schirmacher P, DiSpirito AA, Bandow N, Baral BS, Flatley A, Kremmer E, Denk G, Reiter FP, Hohenester S, Eckardt-Schupp F, Dencher NA, Adamski J, Sauer V, Niemietz C, Schmidt HHJ, Merle U, Gotthardt DN, Kroemer G, Weiss KH, Zischka H. Methanobactin reverses acute liver failure in a rat model of Wilson disease. J Clin Invest 2016; 126:2721-35. [PMID: 27322060 DOI: 10.1172/jci85226] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 04/12/2016] [Indexed: 12/15/2022] Open
Abstract
In Wilson disease (WD), functional loss of ATPase copper-transporting β (ATP7B) impairs biliary copper excretion, leading to excessive copper accumulation in the liver and fulminant hepatitis. Current US Food and Drug Administration- and European Medicines Agency-approved pharmacological treatments usually fail to restore copper homeostasis in patients with WD who have progressed to acute liver failure, leaving liver transplantation as the only viable treatment option. Here, we investigated the therapeutic utility of methanobactin (MB), a peptide produced by Methylosinus trichosporium OB3b, which has an exceptionally high affinity for copper. We demonstrated that ATP7B-deficient rats recapitulate WD-associated phenotypes, including hepatic copper accumulation, liver damage, and mitochondrial impairment. Short-term treatment of these rats with MB efficiently reversed mitochondrial impairment and liver damage in the acute stages of liver copper accumulation compared with that seen in untreated ATP7B-deficient rats. This beneficial effect was associated with depletion of copper from hepatocyte mitochondria. Moreover, MB treatment prevented hepatocyte death, subsequent liver failure, and death in the rodent model. These results suggest that MB has potential as a therapeutic agent for the treatment of acute WD.
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Stemberger M, Seybold U, Eberle J, Denk G, Kolligs F, Kaspar M, Guba M, Pichler M, Spannagl M. Haemophilia-related outcome after liver transplantation and treatment with sofosbuvir/ribavirin in a HCV-HIV coinfected man with liver failure and hepatocellular carcinoma. Haemophilia 2015; 21:e131-e133. [PMID: 25622556 DOI: 10.1111/hae.12599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2014] [Indexed: 11/26/2022]
Affiliation(s)
- M Stemberger
- Haemostaseologie, Medizinische Klinik und Poliklinik IV, Klinikum der LMU, Munich, Germany
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Denk G, Omary AJ, Reiter FP, Hohenester S, Wimmer R, Holdenrieder S, Rust C. Soluble intracellular adhesion molecule, M30 and M65 as serum markers of disease activity and prognosis in cholestatic liver diseases. Hepatol Res 2014; 44:1286-98. [PMID: 24451045 DOI: 10.1111/hepr.12304] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 01/12/2014] [Accepted: 01/16/2014] [Indexed: 12/12/2022]
Abstract
AIM Hepatic apoptosis is involved in the pathogenesis of immune-mediated liver diseases such as autoimmune hepatitis (AIH), primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC). The aim of our study was to quantify distinct markers of apoptosis in sera of patients with AIH, PBC and PSC, and to evaluate correlation with markers of disease activity and prognosis. METHODS Sera of patients with AIH, PBC and PSC, and of healthy controls were collected and distinct cell death markers were quantified using a bead-based multiplex enzyme linked immunosorbent assay (soluble intracellular adhesion molecule [sICAM], macrophage migration inhibitory factor [MIF], soluble Fas [sFas], plasminogen activator inhibitor 1 [PAI-1]) or single enzyme-linked immunosorbent assays (DNAse, M30, M65). RESULTS In comparison with healthy controls, the apoptotic markers sFas, sICAM (only in PSC patients), M30 and the cell death marker M65 were substantially elevated in sera of patients with immune-mediated liver diseases, whereas DNAse activity was reduced. Interestingly, patients with advanced PSC presented with higher levels of sICAM, M30 and M65 than patients with mild PSC. Regression analysis revealed correlations between serum levels of sICAM, M30 and M65 with the Mayo Risk Score for PSC, and of M65 with the Mayo Risk Score for PBC. CONCLUSION Concentrations of the serum markers of apoptosis sFas and M30 and of the marker of total cell death M65 are elevated in patients with immune-mediated liver diseases, whereas activity of DNAse is reduced. In patients with PSC, sICAM, M30 and M65 may serve as indicators for disease activity and prognosis.
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Affiliation(s)
- Gerald Denk
- Department of Medicine II - Grosshadern, University of Munich, Munich, Germany
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Kurktschiev PD, Raziorrouh B, Schraut W, Backmund M, Wächtler M, Wendtner CM, Bengsch B, Thimme R, Denk G, Zachoval R, Dick A, Spannagl M, Haas J, Diepolder HM, Jung MC, Gruener NH. Dysfunctional CD8+ T cells in hepatitis B and C are characterized by a lack of antigen-specific T-bet induction. ACTA ACUST UNITED AC 2014; 211:2047-59. [PMID: 25225458 PMCID: PMC4172217 DOI: 10.1084/jem.20131333] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
In humans infected with hepatitis B or C, high expression of a protein called T-bet in virus-fighting immune cells is associated with spontaneous clearance of the virus. Absence of T-bet was more often seen in patients whose infections became chronic. The transcription factor T-bet regulates the production of interferon-γ and cytotoxic molecules in effector CD8 T cells, and its expression correlates with improved control of chronic viral infections. However, the role of T-bet in infections with differential outcome remains poorly defined. Here, we report that high expression of T-bet in virus-specific CD8 T cells during acute hepatitis B virus (HBV) and hepatitis C virus (HCV) infection was associated with spontaneous resolution, whereas T-bet deficiency was more characteristic of chronic evolving infection. T-bet strongly correlated with interferon-γ production and proliferation of virus-specific CD8 T cells, and its induction by antigen and IL-2 stimulation partially restored functionality in previously dysfunctional T-bet–deficient CD8 T cells. However, restoration of a strong interferon-γ response required additional stimulation with IL-12, which selectively induced the phosphorylation of STAT4 in T-bet+ CD8 T cells. The observation that T-bet expression rendered CD8 T cells responsive to IL-12 suggests a stepwise mechanism of T cell activation in which T-bet facilitates the recruitment of additional transcription factors in the presence of key cytokines. These findings support a critical role of T-bet for viral clearance and suggest T-bet deficiency as an important mechanism behind chronic infection.
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Affiliation(s)
- Peter D Kurktschiev
- Institute for Immunology, Ludwig-Maximilians-University, 80539 Munich, Germany Department of Medicine II, University Hospital Munich, 80539 Munich, Germany
| | - Bijan Raziorrouh
- Institute for Immunology, Ludwig-Maximilians-University, 80539 Munich, Germany Department of Medicine II, University Hospital Munich, 80539 Munich, Germany
| | - Winfried Schraut
- Institute for Immunology, Ludwig-Maximilians-University, 80539 Munich, Germany Department of Medicine II, University Hospital Munich, 80539 Munich, Germany
| | - Markus Backmund
- Department of Medicine II, University Hospital Munich, 80539 Munich, Germany PiT - Praxis im Tal, 80331 Munich, Germany
| | - Martin Wächtler
- Department of Medicine, Klinikum Schwabing, 81925 Munich, Germany
| | | | - Bertram Bengsch
- Department of Medicine II, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Gerald Denk
- Department of Medicine II, University Hospital Munich, 80539 Munich, Germany
| | - Reinhart Zachoval
- Department of Medicine II, University Hospital Munich, 80539 Munich, Germany
| | - Andrea Dick
- Laboratory of Immunogenetics and Molecular Diagnostics, 80539 Munich, Germany
| | - Michael Spannagl
- Laboratory of Immunogenetics and Molecular Diagnostics, 80539 Munich, Germany
| | - Jürgen Haas
- Division of Infection and Pathway Medicine, University of Edinburgh, Edinburgh EH16 4SB, Scotland, UK
| | - Helmut M Diepolder
- Department of Medicine II, University Hospital Munich, 80539 Munich, Germany
| | | | - Norbert H Gruener
- Institute for Immunology, Ludwig-Maximilians-University, 80539 Munich, Germany Department of Medicine II, University Hospital Munich, 80539 Munich, Germany
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Raziorrouh B, Heeg M, Kurktschiev P, Schraut W, Zachoval R, Wendtner C, Wächtler M, Spannagl M, Denk G, Ulsenheimer A, Bengsch B, Pircher H, Diepolder HM, Grüner NH, Jung MC. Inhibitory phenotype of HBV-specific CD4+ T-cells is characterized by high PD-1 expression but absent coregulation of multiple inhibitory molecules. PLoS One 2014; 9:e105703. [PMID: 25144233 PMCID: PMC4140833 DOI: 10.1371/journal.pone.0105703] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 07/22/2014] [Indexed: 01/01/2023] Open
Abstract
Background T-cell exhaustion seems to play a critical role in CD8+ T-cell dysfunction during chronic viral infections. However, up to now little is known about the mechanisms underlying CD4+ T-cell dysfunction during chronic hepatitis B virus (CHB) infection and the role of inhibitory molecules such as programmed death 1 (PD-1) for CD4+ T-cell failure. Methods The expression of multiple inhibitory molecules such as PD-1, CTLA-4, TIM-3, CD244, KLRG1 and markers defining the grade of T-cell differentiation as CCR7, CD45RA, CD57 and CD127 were analyzed on virus-specific CD4+ T-cells from peripheral blood using a newly established DRB1*01-restricted MHC class II Tetramer. Effects of in vitro PD-L1/2 blockade were defined by investigating changes in CD4+ T-cell proliferation and cytokine production. Results CD4+ T-cell responses during chronic HBV infection was characterized by reduced Tetramer+CD4+ T-cell frequencies, effector memory phenotype, sustained PD-1 but low levels of CTLA-4, TIM-3, KLRG1 and CD244 expression. PD-1 blockade revealed individualized patterns of in vitro responsiveness with partly increased IFN-γ, IL-2 and TNF-α secretion as well as enhanced CD4+ T-cell expansion almost in treated patients with viral control. Conclusion HBV-specific CD4+ T-cells are reliably detectable during different courses of HBV infection by MHC class II Tetramer technology. CD4+ T-cell dysfunction during chronic HBV is basically linked to strong PD-1 upregulation but absent coregulation of multiple inhibitory receptors. PD-L1/2 neutralization partly leads to enhanced CD4+ T-cell functionality with heterogeneous patterns of CD4+ T-cell rejunivation.
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Affiliation(s)
- Bijan Raziorrouh
- Medical Department II and Institute for Immunology, University of LMU Munich, Munich, Germany
- * E-mail:
| | - Malte Heeg
- Medical Department II and Institute for Immunology, University of LMU Munich, Munich, Germany
- Department of Nephrology/Rheumatology, University of Göttingen, Göttingen, Germany
| | - Peter Kurktschiev
- Medical Department II and Institute for Immunology, University of LMU Munich, Munich, Germany
| | - Winfried Schraut
- Medical Department II and Institute for Immunology, University of LMU Munich, Munich, Germany
| | - Reinhart Zachoval
- Medical Department II and Institute for Immunology, University of LMU Munich, Munich, Germany
| | | | - Martin Wächtler
- Medical Department, Klinikum München-Schwabing, Munich, Germany
| | - Michael Spannagl
- Laboratory of Immunogenetics/Molecular Diagnostics, University of LMU Munich, Munich, Germany
| | - Gerald Denk
- Medical Department II and Institute for Immunology, University of LMU Munich, Munich, Germany
| | - Axel Ulsenheimer
- Medical Department II and Institute for Immunology, University of LMU Munich, Munich, Germany
| | - Bertram Bengsch
- Medical Department II, University of Freiburg, Freiburg, Germany
| | | | - Helmut M. Diepolder
- Medical Department II and Institute for Immunology, University of LMU Munich, Munich, Germany
| | - Norbert H. Grüner
- Medical Department II and Institute for Immunology, University of LMU Munich, Munich, Germany
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Pratschke S, Trumm CG, Clevert DA, Denk G, Angele MK. [Successful prophylactic embolization of an intrahepatic pseudoaneurysm after split liver transplantation]. ROFO-FORTSCHR RONTG 2012; 184:835-6. [PMID: 22618485 DOI: 10.1055/s-0032-1312767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Denk G. [3 decades of child bronchoscopy: indications, technic and results]. Prax Klin Pneumol 1984; 38:291-4. [PMID: 6483771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Abstract
A detoxification regimen has been found to be safe for use by individuals exposed to recreational (abused) and medical drugs, patent medicines, occupational and environmental chemicals. Patients with high blood pressure had a mean reduction of 30.8 mm systolic, 23.3 mm diastolic. Cholesterol level mean reduction was 19.5 mg/100ml, while triglycerides did not change. Medical complications associated with the program were rare, occurring in less than three percent of the subjects. The program resulted in improvements in psychological test scores. The mean increase in Wechsler Adult Intelligence Scale IQ was 6.7 points. High Minnesota Multiphasic Personality Inventory profiles decreased on the third scale (10.7), the fourth scale (8.0), the fifth scale (4.5) and the sixth scale (8.0). The decrease in the fourth scale suggests hope for sociopaths, a group with fourth scale scores not improved by National Institute for Mental Health or Narcotic Addict Rehabilitation Act inpatient programs.
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HJančik F, Czysz W, Sterzel RH, Rodek E, Denk G. 2.1 Anorganische industrielle produkte. Anal Bioanal Chem 1980. [DOI: 10.1007/bf00474311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Denk G, Klein K, Khodadadeh F, Stamm R, Tari E. �ber die Reaktion von Kaolin mit Alkalilaugen bei Gegenwart von Alkali- oder Erdalkaliverbindungen. Z Anorg Allg Chem 1979. [DOI: 10.1002/zaac.19794590112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Denk G, Czysz W, Sterzel RH, Pribyl M, Henning K, Heinerth E, Knorr F. 2. Spezielle Produkte und Anwendungsgebiete. Anal Bioanal Chem 1978. [DOI: 10.1007/bf00440223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Eliassaf J, Czysz W, Katyal M, Johannsen L, Čiha M, Rodek E, Jančik F, Bohnstedt U, Denk G, Ciuhandu G, Reif H. 2. Spezielle Produkte und Anwendungsgebiete. Anal Bioanal Chem 1978. [DOI: 10.1007/bf00440220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Sterzel RH, Seifert B, Laird CK, Rodek E, Denk G, Katyal M, Jančik F, Johannsen L, Czysz W. 1.2 Anorganische Analyse. Anal Bioanal Chem 1978. [DOI: 10.1007/bf00491822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Henning K, Bühler AE, Lukac S, Čiha M, Jančik F, Denk G, Sterzel RH, Přibyl M, Sebastiani E, Schmidt W, Légrádi L. II. Anorganische substanzen. Anal Bioanal Chem 1975. [DOI: 10.1007/bf00527996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Senkýř J, Sterzel RH, Czysz W, Henning K, Denk G, Bartušek M, Anders U, Přibyl M, Seifert B. II. Anorganische Substanzen. Anal Bioanal Chem 1975. [DOI: 10.1007/bf00454466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Jančik F, Cuihandu G, Keil R, Sterzel RH, Roscovanu A, Czysz W, Denk G, Čiha M, Henning K, Eliassaf J, Přibyl M, Svátek E, Berge H, Sommer L, Untze W, Rasch J, Jeney K. II. Anorganische substanzen. Anal Bioanal Chem 1974. [DOI: 10.1007/bf00445964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Meyer zur Heyde M, Hoffmann H, Denk G, Eliassaf J, Heinerth E, Henning K, Šenkýř J, Czysz W, Schärtl F, Sebastiani E, Lüschow HM, Jančik F, Ciuhandu G, Malý J, Martin C, Klimisch HJ. IV. Spezielle Anwendungsgebiete. Anal Bioanal Chem 1974. [DOI: 10.1007/bf00450865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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