Cannabis use as a factor of lower corpulence in hepatitis C-infected patients: results from the ANRS CO22 Hepather cohort

Background

Patients with chronic hepatitis C virus (HCV) infection are at greater risk of developing metabolic disorders. Obesity is a major risk factor for these disorders, and therefore, managing body weight is crucial. Cannabis use, which is common in these patients, has been associated with lower corpulence in various populations. However, this relationship has not yet been studied in persons with chronic HCV infection.

Methods

Using baseline data from the French ANRS CO22 Hepather cohort, we used binary logistic and multinomial logistic regression models to test for an inverse relationship between cannabis use (former/current) and (i) central obesity (i.e., large waist circumference) and (ii) overweight and obesity (i.e., elevated body mass index (BMI)) in patients from the cohort who had chronic HCV infection. We also tested for relationships between cannabis use and both waist circumference and BMI as continuous variables, using linear regression models.

Results

Among the 6348 participants in the study population, 55% had central obesity, 13.7% had obesity according to their BMI, and 12.4% were current cannabis users. After multivariable adjustment, current cannabis use was associated with lower risk of central obesity (adjusted odds ratio, aOR [95% confidence interval, CI]: 0.45 [0.37–0.55]), BMI-based obesity (adjusted relative risk ratio (aRRR) [95% CI]: 0.27 [0.19–0.39]), and overweight (aRRR [95% CI]: 0.47 [0.38–0.59]). This was also true for former use, but to a lesser extent. Former and current cannabis use were inversely associated with waist circumference and BMI.

Conclusions

We found that former and, to a greater extent, current cannabis use were consistently associated with smaller waist circumference, lower BMI, and lower risks of overweight, obesity, and central obesity in patients with chronic HCV infection. Longitudinal studies are needed to confirm these relationships and to assess the effect of cannabis use on corpulence and liver outcomes after HCV cure.

Trial registration

ClinicalTrials.gov identifier: NCT01953458.

Severe liver fibrosis in the HCV cure era: major effects of social vulnerability, diabetes, and unhealthy behaviors

Background & Aims

After HCV cure, not all patients achieve significant liver fibrosis regression. We explored the effects of clinical and socio-behavioral factors on liver fibrosis, before and after HCV cure with direct-acting antivirals.

Methods

We analyzed data from the ongoing ANRS CO22 HEPATHER cohort, which prospectively collects clinical and socio-behavioral data on HCV-infected patients. Mixed-effects logistic regression models helped identify predictors of longitudinal measures of severe liver fibrosis, defined as a fibrosis-4 index >3.25. We also estimated the adjusted population attributable fractions (PAFs) for modifiable risk factors.

Results

Among the 9,692 study patients (accounting for 24,687 visits over 4 years of follow-up, 48.5% of which were post-HCV cure), 26% had severe fibrosis at enrolment. After multivariable adjustment, HCV-cured patients had an 87% lower risk of severe fibrosis. An inverse dose-response relationship was found for coffee consumption, with the risk of severe fibrosis diminishing by 58% per additional cup/day (adjusted odds ratio (aOR 0.42; 95% CI 0.38-0.46). Unemployment, low educational level, and diabetes were associated with a higher severe fibrosis risk (aOR 1.69; 95% CI 1.32-2.16, aOR 1.50; 95% CI 1.20-1.86, and aOR 4.27; 95% CI 3.15-5.77, respectively). Severe fibrosis risk was 3.6/4.6-fold higher in individuals with previous/current unhealthy alcohol use than in abstinent patients. All these associations remained valid after HCV cure. The risk factors accounting for the greatest severe fibrosis burden were unemployment, low education level, and diabetes (PAFs: 29%, 21%, and 17%, respectively).

Conclusions

Monitoring liver fibrosis after HCV cure is crucial for patients with low socioeconomic status, previous/current unhealthy alcohol use, and diabetes. Innovative HCV care models for the most socially vulnerable individuals and interventions for healthier lifestyles are needed to reinforce the positive effects of HCV cure on liver health.

Lay summary

After hepatitis C virus (HCV) cure, not all patients achieve significant liver fibrosis regression. Herein, we studied the effects of clinical and socio-behavioral factors on the risk of severe liver fibrosis. Coffee consumption was strongly inversely associated with severe fibrosis, while diabetes, previous and current unhealthy alcohol use were associated with a 4.3-, 3.6- and 4.6-fold higher risk of severe fibrosis, respectively. Unemployment and low educational level were also associated with a higher risk of severe fibrosis. All these associations remained valid after HCV cure. These results demonstrate the need to continue liver fibrosis monitoring in at-risk groups, and to facilitate healthier lifestyles after HCV cure as a clinical and public health priority.

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Liver fibrosis assessment is a key prognostic tool in the hepatitis C cure era.

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Significant liver fibrosis regression does not always occur after hepatitis C cure.

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Coffee intake displays protective effects on severe fibrosis even after HCV cure.

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Social vulnerability, diabetes, and unhealthy alcohol use predict severe fibrosis.

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Socio-behavioral factors are associated with severe fibrosis even after HCV cure.

Covid-19 in liver transplant recipients: the French SOT COVID registry

BACKGROUND

Notwithstanding the ongoing coronavirus disease-2019 (Covid-19) pandemic, information on its clinical presentation and prognosis in organ transplant recipients remains limited. The aim of this registry-based observational study was to report the characteristics and clinical outcomes of liver transplant (LT) recipients included in the French nationwide Registry of Solid Organ Transplant Recipients with Covid-19.

METHODS

COVID-19 was diagnosed in patients who had a positive PCR assay for SARS-CoV-2 or in presence of typical lung lesions on imaging or specific SARS-CoV-2 antibodies. Clinical and laboratory characteristics, management of immunosuppression, treatment for Covid-19, and clinical outcomes (hospitalization, admission to intensive care unit, mechanical ventilation, or death) were recorded.

RESULTS

Of the 104 patients, 67 were admitted to hospital and 37 were managed at home (including all 13 children). Hospitalized patients had a median age of 65.2 years (IQR: 58.1 - 73.2 years) and two thirds were men. Most common comorbidities included overweight (67.3%), hypertension (61.2%), diabetes (50.7%), cardiovascular disease (20.9%) and respiratory disease (16.4%). SARS-CoV-2 infection was identified after a median of 92.8 months (IQR: 40.1 - 194.7 months) from LT. During hospitalization, antimetabolites, mTOR inhibitor, and CNIs were withdrawn in 41.9%, 30.0% and 12.5% of patients, respectively. The composite endpoint of severe Covid-19 within 30 days after diagnosis was reached by 33.0% of the adult patients. The 30-day mortality rate was 20.0%, and 28.1% for hospitalized patients. Multivariate analysis identified that age was independently associated with mortality.

CONCLUSION

In our large nationwide study, Covid-19 in LT recipients was associated with a high mortality rate.

Fatty acid composition of the erythrocyte membrane and risk of hepatocellular carcinoma in cirrhotic patients

BACKGROUND

Disturbances in fatty acid (FA) metabolism have been reported in cirrhosis, but the role of FAs in the development of hepatocellular carcinoma (HCC) is still unclear. Biomarkers are a promising means to explore the associations between exogenous intake or endogenous production of FAs and cancer risk.

AIM

To estimate the relationship between fatty acid content in erythrocyte membranes and HCC risk in cirrhotic patients METHODS: The "CiRCE" case-control study recruited cirrhotic patients from six French hospitals between 2008 and 2012. Cases were cirrhotic patients with HCC (n = 349); controls were cirrhotic patients without HCC at inclusion (n = 550). FA composition of phospholipids in erythrocyte membranes was determined by high performance gas chromatography. Odds ratios for HCC risk according to FA concentrations were estimated with multivariable logistic regression.

RESULTS

HCC patients were older and more often men (P < 0.001). In both groups, saturated FAs represented more than 39% of all FAs in erythrocyte membranes, mono-unsaturated FAs around 14%, and polyunsaturated FAs around 46%. High levels of C15:0 + C17:0, C20:1 n-9, C18:2 n-6 and C20:2 n-6 were associated with higher risk of HCC. The levels of C18:0 and C20:4 n-6 were lower in HCC cases than in controls.

CONCLUSIONS

The FA composition of erythrocyte membranes differed according to the presence of HCC with higher levels of saturated FAs, linoleic and eicosadienoic acids, and lower levels of stearic and arachidonic acids. These alterations may reflect particular dietary patterns and/or altered FA metabolism. Further investigations are warranted.

Liver transplantation for critically ill cirrhotic patients: Stratifying utility based on pretransplant factors

The aim of this study was to produce a prognostic model to help predict posttransplant survival in patients transplanted with grade-3 acute-on-chronic liver failure (ACLF-3). Patients with ACLF-3 who underwent liver transplantation (LT) between 2007 and 2017 in 5 transplant centers were included (n = 152). Predictors of 1-year mortality were retrospectively screened and tested on a single center training cohort and subsequently tested on an independent multicenter cohort composed of the 4 other centers. Four independent pretransplant risk factors were associated with 1-year mortality after transplantation in the training cohort: age ≥53 years (P = .044), pre-LT arterial lactate level ≥4 mml/L (P = .013), mechanical ventilation with PaO₂ /FiO₂  ≤ 200 mm Hg (P = .026), and pre-LT leukocyte count ≤10 G/L (P = .004). A simplified version of the model was derived by assigning 1 point to each risk factor: the transplantation for Aclf-3 model (TAM) score. A cut-off at 2 points distinguished a high-risk group (score >2) from a low-risk group (score ≤2) with 1-year survival of 8.3% vs 83.9% respectively (P < .001). This model was subsequently validated in the independent multicenter cohort. The TAM score can help stratify posttransplant survival and identify an optimal transplantation window for patients with ACLF-3.

Outcome of patients treated with molecular adsorbent recirculating system albumin dialysis: A national multicenter study

Background and Aim

The molecular adsorbent recirculating system (MARS) is the most widely used device to treat liver failure. Nevertheless, data from widespread real‐life use are lacking.

Methods

This was a retrospective multicenter study conducted in all French adult care centers that used MARS between 2004 and 2009. The primary objective was to evaluate patient survival according to the liver disease and listing status. Factors associated with mortality were the secondary objectives.

Results

A total of 383 patients underwent 393 MARS treatments. The main indications were acute liver failure (ALF, 32.6%), and severe cholestasis (total bilirubin >340 μmol/L) (37.2%), hepatic encephalopathy (23.7%), and/or acute kidney injury–hepatorenal syndrome (22.9%) most often among patients with chronic liver disease. At the time of treatment, 34.4% of the patients were listed. Overall, the hospital survival rate was 49% (95% CI: 44–54%) and ranged from 25% to 81% depending on the diagnosis of the liver disease. In listed patients versus those not listed, the 1‐year survival rate was markedly better in the setting of nonbiliary cirrhosis (59% vs 15%), early graft nonfunction (80% vs 0%), and late graft dysfunction (72% vs 0%) (all P < 0.001). Among nonbiliary cirrhotic patients, hospital mortality was associated with the severity of liver disease (HE and severe cholestasis) and not being listed for transplant. In ALF, paracetamol etiology and ≥3 MARS sessions were associated with better transplant‐free survival.

Conclusion

Our study suggests that MARS should be mainly used as a bridge to liver transplantation. Survival was correlated with being listed for most etiologies and with the intensity of treatment in ALF.

Efficacy and safety of selective internal radiotherapy with yttrium-90 resin microspheres compared with sorafenib in locally advanced and inoperable hepatocellular carcinoma (SARAH): an open-label randomised controlled phase 3 trial

BACKGROUND

Sorafenib is the recommended treatment for patients with advanced hepatocellular carcinoma. We aimed to compare the efficacy and safety of sorafenib to that of selective internal radiotherapy (SIRT) with yttrium-90 (⁹⁰Y) resin microspheres in patients with hepatocellular carcinoma.

METHODS

SARAH was a multicentre, open-label, randomised, controlled, investigator-initiated, phase 3 trial done at 25 centres specialising in liver diseases in France. Patients were eligible if they were aged at least 18 years with a life expectancy greater than 3 months, had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1, Child-Pugh liver function class A or B score of 7 or lower, and locally advanced hepatocellular carcinoma (Barcelona Clinic Liver Cancer [BCLC] stage C), or new hepatocellular carcinoma not eligible for surgical resection, liver transplantation, or thermal ablation after a previously cured hepatocellular carcinoma (cured by surgery or thermoablative therapy), or hepatocellular carcinoma with two unsuccessful rounds of transarterial chemoembolisation. Patients were randomly assigned (1:1) by a permutated block method with block sizes two and four to receive continuous oral sorafenib (400 mg twice daily) or SIRT with ⁹⁰Y-loaded resin microspheres 2-5 weeks after randomisation. Patients were stratified according to randomising centre, ECOG performance status, previous transarterial chemoembolisation, and presence of macroscopic vascular invasion. The primary endpoint was overall survival. Analyses were done on the intention-to-treat population; safety was assessed in all patients who received at least one dose of sorafenib or underwent at least one of the SIRT work-up exams. This study has been completed and the final results are reported here. The trial is registered with ClinicalTrials.gov, number NCT01482442.

FINDINGS

Between Dec 5, 2011, and March 12, 2015, 467 patients were randomly assigned; after eight patients withdrew consent, 237 were assigned to SIRT and 222 to sorafenib. In the SIRT group, 53 (22%) of 237 patients did not receive SIRT; 26 (49%) of these 53 patients were treated with sorafenib. Median follow-up was 27·9 months (IQR 21·9-33·6) in the SIRT group and 28·1 months (20·0-35·3) in the sorafenib group. Median overall survival was 8·0 months (95% CI 6·7-9·9) in the SIRT group versus 9·9 months (8·7-11·4) in the sorafenib group (hazard ratio 1·15 [95% CI 0·94-1·41] for SIRT vs sorafenib; p=0·18). In the safety population, at least one serious adverse event was reported in 174 (77%) of 226 patients in the SIRT group and in 176 (82%) of 216 in the sorafenib group. The most frequent grade 3 or worse treatment-related adverse events were fatigue (20 [9%] vs 41 [19%]), liver dysfunction (25 [11%] vs 27 [13%]), increased laboratory liver values (20 [9%] vs 16 [7%]), haematological abnormalities (23 [10%] vs 30 [14%]), diarrhoea (three [1%] vs 30 [14%]), abdominal pain (six [3%] vs 14 [6%]), increased creatinine (four [2%] vs 12 [6%]), and hand-foot skin reaction (one [<1%] vs 12 [6%]). 19 deaths in the SIRT group and 12 in the sorafenib group were deemed to be treatment related.

INTERPRETATION

In patients with locally advanced or intermediate-stage hepatocellular carcinoma after unsuccessful transarterial chemoembolisation, overall survival did not significantly differ between the two groups. Quality of life and tolerance might help when choosing between the two treatments.

FUNDING

Sirtex Medical Inc.

The prognostic value of inflammation-based scores in advanced hepatocellular carcinoma patients prior to treatment with sorafenib

Background and Aims

The multikinase inhibitor sorafenib is the only currently approved drug for the indication of advanced hepatocellular carcinoma (HCC). It provides a limited gain in survival time but is frequently associated with adverse events. We currently lack simple prognostic factors in sorafenib-treated HCC patients. Various inflammation-based scores (IBSs) have been evaluated as predictors of tumor recurrence and survival in various malignancies (including HCC). The objective of the present study was to determine the prognostic value of IBSs for overall survival (OS) in advanced HCC patients prior to the initiation of sorafenib therapy.

Methods

Patients with Barcelona Clinic Liver Cancer stage C HCC were enrolled retrospectively between October 2007 and September 2015. To identify prognostic factors for OS, bivariate and multivariate analysis were performed using a Cox proportional hazards regression model.

Results

161 patients (87.0% males; median age: 67; median OS: 9.1 months) were enrolled. A multivariate analysis identified a body mass index <25kg/m² (hazard ratio (HR)=1.55, p<0.017), macroscopic vascular invasion (HR=1.63, p< 0.001), an AST level >38 U/L (HR=2.65, p<0.001), Child Pugh B stage (HR=2.59, p<0.001) and a systemic immune-inflammation index (SII) ≥600 × 10⁹ (HR 1.72, p=0.002) as independent risk factors for OS in advanced HCC.

Conclusion

IBSs (such as the SII) are novel, simple, low-cost prognostic indices in patients with advanced HCC. They may be of value in determining whether these patients may benefit from sorafenib therapy.

BRIP1 coding variants are associated with a high risk of hepatocellular carcinoma occurrence in patients with HCV- or HBV-related liver disease

The molecular mechanisms of hepatocellular carcinoma (HCC) carcinogenesis are still not fully understood. DNA repair defects may influence HCC risk. The aim of the study was to look for potential genetic variants of DNA repair genes associated with HCC risk among patients with alcohol- or viral-induced liver disease. We performed four case-control studies on 2,006 European- (Derivation#1 and #2 studies) and African-ancestry (Validation#1 and #2 studies) patients originating from several cohorts in order to assess the association between genetic variants on DNA repair genes and HCC risk using a custom array encompassing 94 genes. In the Derivation#1 study, the BRIP1 locus reached array-wide significance (Chi-squared SV-Perm, P=5.00×10^-4) among the 253 haplotype blocks tested for their association with HCC risk, in patients with viral cirrhosis but not among those with alcoholic cirrhosis. The BRIP1 haplotype block included three exonic variants (rs4986763, rs4986764, rs4986765). The BRIP1 'AAA' haplotype was significantly associated with an increased HCC risk [odds ratio (OR), 2.01 (1.19-3.39); false discovery rate (FDR)-P=1.31×10^-2]. In the Derivation#2 study, results were confirmed for the BRIP1 'GGG' haplotype [OR, 0.53 (0.36-0.79); FDR-P=3.90×10^-3]. In both Validation#1 and #2 studies, BRIP1 'AAA' haplotype was significantly associated with an increased risk of HCC [OR, 1.71 (1.09-2.68); FDR-P=7.30×10^-2; and OR, 6.45 (4.17-9.99); FDR-P=2.33×10^-19, respectively]. Association between the BRIP1 locus and HCC risk suggests that impaired DNA mismatch repair might play a role in liver carcinogenesis, among patients with HCV- or HBV-related liver disease.

[Which place for point-of-care screening tests in the diagnosis of hepatitis C infection among drug users?]

Hepatitis C is a severe disease, which often evolves into chronicity and for which there is no vaccine available. Therefore its screening is essential, especially among drug users who are the main reservoir of the hepatitis C virus (HCV). Current guidelines for screening are based on the detection of total anti-HCV antibodies (Ab) by means of third generation EIA. This test is performed in a laboratory from a venous sample. Alternative methods have been recently developed, including point-of-care tests (POCT) that offer many advantages. Their excellent diagnostic performance, their quick results and their ease of use by a large number of professionals are arguments in favor of widespread use of these tests. The expected benefits of the use of POCT are individual (better knowledge of HCV status, better access to care and treatment) but also collective (reduction of morbidity and mortality related to HCV and its cost in terms of public health) Because of their clinical interest, POCT should be refunded as well as the currently recommended screening test. In order to optimize their ease of use, POCT use should be integrated into an organized screening and hepatology follow-up system.

Stereotactic body radiation therapy as an ablative treatment for inoperable hepatocellular carcinoma

PURPOSE

To describe efficacy and safety of stereotactic body radiation therapy (SBRT) for the treatment of inoperable hepatocellular carcinoma.

METHODS

The records of 77 consecutive patients treated with SBRT for 97 liver-confined HCC were reviewed. A total dose of 45Gy in 3 fractions was prescribed to the 80% isodose line. Local control (LC), overall survival (OS), progression-free survival (PFS) and toxicity were studied.

RESULTS

The median follow-up was 12months. The median tumor diameter was 2.4cm. The LC rate was 99% at 1 and 2years. The 1 and 2-year OS were 81.8% and 56.6% respectively. The median time to progression was 9months (0-38). The rate of hepatic toxicity was 7.7% [1.6-13.7], 14.9% [5.7-23.2] and 23.1% [9.9-34.3] at 6months, 1year and 2years respectively. In multivariate analysis, female gender (HR 7.87 [3.14-19.69]), a BCLC B-C stage (HR 3.71 [1.41-9.76]), a sum of all lesion diameters ⩾2cm (HR 7.48 [2.09-26.83]) and a previous treatment (HR 0.10 [0.01-0.79]) were independent prognostic factors of overall survival.

CONCLUSION

SBRT allows high local control for inoperable hepatocellular carcinomas. It should be considered when an ablative treatment is indicated in Child A patients.

Effect of albumin in cirrhotic patients with infection other than spontaneous bacterial peritonitis. A randomized trial

BACKGROUND & AIMS

Albumin infusion improves renal function and survival in cirrhotic patients with spontaneous bacterial peritonitis (SBP) but its efficacy in other types of infections remains unknown. We investigated this issue through a multicenter randomized controlled trial.

METHODS

A total of 193 cirrhotic patients with a Child-Pugh score greater than 8 and sepsis unrelated to SBP were randomly assigned to receive antibiotics plus albumin (1.5 g/kg on day 1 and 1g/kg on day 3; albumin group [ALB]: n=96) or antibiotics alone (control group [CG]: n=97). The primary endpoint was the 3-month renal failure rate (increase in creatinine ⩾50% to reach a final value ⩾133 μmol/L). The secondary endpoint was 3-month survival rate.

RESULTS

Forty-seven (24.6%) patients died (ALB: n=27 vs. CG: n=20; 3-month survival: 70.2% vs. 78.3%; p=0.16). Albumin infusion delayed the occurrence of renal failure (mean time to onset, ALB: 29.0 ± 21.8 vs. 11.7 ± 9.1 days, p=0.018) but the 3-month renal failure rate was similar (ALB: 14.3% vs. CG: 13.5%; p=0.88). By multivariate analysis, MELD score (p<0.0001), pneumonia (p=0.0041), hyponatremia (p=0.031) and occurrence of renal failure (p<0.0001) were predictors of death. Of note, pulmonary edema developed in 8/96 (8.3%) patients in the albumin group of whom two died, one on the day and the other on day 33 following albumin infusion.

CONCLUSIONS

In cirrhotic patients with infections other than SBP, albumin infusion delayed onset of renal failure but did not improve renal function or survival at 3 months. Infusion of large amounts of albumin should be cautiously administered in the sickest cirrhotic patients.

[Curative treatment of hepatocellular carcinoma]

Hepatocellular carcinoma is the leading cause of death in cirrhotic patients and the third most common cause of cancer-related death. The main prognosis factors are related to tumor status (defined by number and sze of nodules, cell differentiation grade, vascular invasion, and extrahepatic spread), liver function (defined by Child-Pugh class, bilirubin, albumin, portal hypertension) and genera health status. Only a minority of patients (20-30%) are deemed suitable for potentially curative treatments including orthotopic liver transplantation and surgical resection. Only radiofrequency thermal ablation can challenge surgery for small size tumors but as after resection, local intrahepatic recurrences are common. Orthotopic liver transplantation offers hope for cure of both complicating cancer and the underlying chronic liver disease, cirrhosis, and for achieve the best outcomes in well-selected candidates. Hepatic resection is the treatment of choice in non-cirrhotic patients, where major resections can be performed with low rates of life-threatening complications and acceptable outcome.

[Is it possible to stop nucleos(t)ide analogue based therapy in chronic hepatitis B?]

Nucleos(t)ide analogues are very efficient in the treatment of chronic hepatitis B. In the HBe antigen positive patients, the HBe seroconversion rates range from 12 to 22% after one year of treatment. When HBe seroconversion occure, it is possible to stop the treatment with analogue but only in non cirrhotic patients. If the treatment with analogue is continued for at least 6 months after confirmed HBeAg seroconversion, the HBe seroconversion is durable in 70-90% of patients. The follow up should be done during years. Stopping the treatment is more problematic in HBe antigen negative patients. A virological relapse occur in 44 to 80% of cases and a biochemical relapse occur in 30 to 70% of cases. Stopping the treatment with an analogue in this population should be considered only in a prospective study with careful monitoring and with a long term follow up.

Anomalies épigénétiques et carcinogenèse hépatique

The molecular mechanisms involved in liver carcinogenesis are poorly understood. Over the past decade, epigenetic changes (DNA methylation) have received increasing attention for their potential involvement in the development of hepatocarcinoma. The DNA methylation level is influenced by environmental factors (folate and methionine diet), as well as by genetic factors (methylenetetrahydrofolate reductase/MTHFR polymorphisms). These findings provide new insight into the understanding of liver carcinogenesis. Interventional studies are now required to determine the role of folate supplementation in the development of liver tumors in targeted patients.

[Hepatitis A acquired from an asymptomatic adopted child]

We report the case of acute hepatitis in a 36-year-old woman that was acquired from an adopted African child with asymptomatic active infection. At present, most experts do not screen for hepatitis A. However, adoptive parents should be vaccinated against hepatitis A because of the risk of unrecognized active infection in adopted children from countries in which infection is endemic.

Perméabilité intestinale et cirrhose

Patients with cirrhosis are at increased risk of developing infections due to bacterial translocation. This process depends on three principal factors: bacterial overgrowth, immunodepression, and altered intestinal permeability. Intestinal barrier functions may be disturbed in cirrhosis, related to the toxic effects of alcohol (on mucosa and biological membranes) and portal hypertensive enteropathy. Few studies on the assessment of intestinal permeability in cirrhotic patients are available, and contradictory results may be explained by methodological differences. However, four studies using a differential sugar absorption test (lactulose-mannitol test, a combination of an oligosaccharide and a monosaccharide) showed an increased intestinal permeability in cirrhotic patients. The recurrence of spontaneous bacterial peritonitis can be appreciated only by one similar case history, a low rate of protides in ascites (<10 g/L), bilirubinemia > 55 micromol/L, and thrombocytopenia<98.000/mm3. These results suggest that primary antibiotherapy prophylaxis should be recommended, but this recommendation is limited by the risk of bacterial resistant selection and by the fact that no patient survival benefits was shown. Intestinal permeability could be another predictive factor to justify preventive antibiotherapy; but more studies are needed and methods should be standardized (technique used to measure permeability, patient groups involved).

[Managing the complications of cirrhosis]

The main complications of cirrhosis are gastrointestinal bleeding related to portal hypertension, ascites, spontaneous peritonitis, hepato-renal syndrome, encephalopathy and hepatocellular carcinoma. The apparition of these complications constitutes a major event for the patient. In addition to the etiological treatment, take charge of complications can improve the prognosis of the patients.

[Epidemiology and natural history of hepatitis C]

The estimated prevalence of hepatitis C infection in France is of 0.86%. The use of intravenous drugs is currently the main cause of hepatitis C infection and it may be responsible for 4400 new infections per year in France. The acute HCV infection is commonly asymptomatic and the progression from acute to chronic hepatitis range from 55 to 85%. Age at infection, alcohol consumption and gender have a significant impact on the progression of fibrosis. The fibrosis seems to progress linearly with an acceleration after 50 years of age. HCV is the second cause of cirrhosis and hepatocellular carcinoma in France.

[Evaluation of a new sequence of magnetic resonance cholangio-pancreatography in thick cut and one shot acquisition]

OBJECTIVES

To assess the accuracy and reproducibility of a new magnetic resonance cholangiopancreatography sequence (MRCP), using long echo time and "single shot" acquisition (providing high-contrast thick slices: 20 mm or more), in the morphological analysis of the biliary tree and pancreatic ducts.

METHODS

Fifty four patients with biliary and/or pancreatic disease were investigated with MRCP "single shot" thick slices. Biliary ducts were explored with MRCP "single shot", coronal and oblique coronal 20 mm thick slices on a 256 x 256 matrix. Natives pictures were reviewed by three independent radiologists, from three different institutions. MRCP results were compared with reference examinations in 54 cases (direct biligraphy methods: 54, CT scan: 11, endoscopic ultrasonography: 6, surgery: 6).

RESULTS

For detection of bile duct dilatation, the agreement of MRCP "single shot" thick slices was more than 96% (Kappa > 0.92) and the inter-observer agreement was excellent (Kappa=0.92). For detection of biliary tree and/or pancreatic duct obstruction, MRCP "single shot" thick slice sensitivity was above 89% and specificity was 75%. The malignant nature of the lesions was determined with a sensitivity of 100% and a specificity of 92%. MRCP "single shot" thick slices could not differentiate pancreatic carcinomas from distal main bile duct cholangiocarcinomas. MRCP "single shot" thick slices did not detect small stones ( 3 mm) of the common bile duct.

CONCLUSION

The excellent sensitivity, specificity and inter-observer agreement of MRCP "single shot" thick slices can be used to limit invasive imaging methods in the diagnosis of extrahepatic cholestasis.