One-year follow-up of the CAPSID randomized trial for high-dose convalescent plasma in severe COVID-19 patients

BACKGROUNDResults of many randomized trials on COVID-19 convalescent plasma (CCP) have been reported, but information on long-term outcome after CCP treatment is limited. The objectives of this extended observation of the randomized CAPSID trial are to assess long-term outcome and disease burden in patients initially treated with or without CCP.METHODSOf 105 randomized patients, 50 participated in the extended observation. Quality of life (QoL) was assessed by questionnaires and a structured interview. CCP donors (n = 113) with asymptomatic to moderate COVID-19 were included as a reference group.RESULTSThe median follow-up of patients was 396 days, and the estimated 1-year survival was 78.7% in the CCP group and 60.2% in the control (P = 0.08). The subgroup treated with a higher cumulative amount of neutralizing antibodies showed a better 1-year survival compared with the control group (91.5% versus 60.2%, P = 0.01). Medical events and QoL assessments showed a consistent trend for better results in the CCP group without reaching statistical significance. There was no difference in the increase in neutralizing antibodies after vaccination between the CCP and control groups.CONCLUSIONThe trial demonstrated a trend toward better outcome in the CCP group without reaching statistical significance. A predefined subgroup analysis showed a significantly better outcome (long-term survival, time to discharge from ICU, and time to hospital discharge) among those who received a higher amount of neutralizing antibodies compared with the control group. A substantial long-term disease burden remains after severe COVID-19.Trial registrationEudraCT 2020-001310-38 and ClinicalTrials.gov NCT04433910.FundingBundesministerium für Gesundheit (German Federal Ministry of Health).

Cytokine levels associated with favorable clinical outcome in the CAPSID randomized trial of convalescent plasma in patients with severe COVID-19

Objectives

To determine the profile of cytokines in patients with severe COVID-19 who were enrolled in a trial of COVID-19 convalescent plasma (CCP).

Methods

Patients were randomized to receive standard treatment and 3 CCP units or standard treatment alone (CAPSID trial, ClinicalTrials.gov NCT04433910). The primary outcome was a dichotomous composite outcome (survival and no longer severe COVID-19 on day 21). Time to clinical improvement was a key secondary endpoint. The concentrations of 27 cytokines were measured (baseline, day 7). We analyzed the change and the correlation between serum cytokine levels over time in different subgroups and the prediction of outcome in receiver operating characteristics (ROC) analyses and in multivariate models.

Results

The majority of cytokines showed significant changes from baseline to day 7. Some were strongly correlated amongst each other (at baseline the cluster IL-1ß, IL-2, IL-6, IL-8, G-CSF, MIP-1α, the cluster PDGF-BB, RANTES or the cluster IL-4, IL-17, Eotaxin, bFGF, TNF-α). The correlation matrix substantially changed from baseline to day 7. The heatmaps of the absolute values of the correlation matrix indicated an association of CCP treatment and clinical outcome with the cytokine pattern. Low levels of IP-10, IFN-γ, MCP-1 and IL-1ß on day 0 were predictive of treatment success in a ROC analysis. In multivariate models, low levels of IL-1ß, IFN-γ and MCP-1 on day 0 were significantly associated with both treatment success and shorter time to clinical improvement. Low levels of IP-10, IL-1RA, IL-6, MCP-1 and IFN-γ on day 7 and high levels of IL-9, PDGF and RANTES on day 7 were predictive of treatment success in ROC analyses. Low levels of IP-10, MCP-1 and high levels of RANTES, on day 7 were associated with both treatment success and shorter time to clinical improvement in multivariate models.

Conclusion

This analysis demonstrates a considerable dynamic of cytokines over time, which is influenced by both treatment and clinical course of COVID-19. Levels of IL-1ß and MCP-1 at baseline and MCP-1, IP-10 and RANTES on day 7 were associated with a favorable outcome across several endpoints. These cytokines should be included in future trials for further evaluation as predictive factors.

Results of the CAPSID randomized trial for high-dose convalescent plasma in patients with severe COVID-19

BACKGROUNDCOVID-19 convalescent plasma (CCP) has been considered a treatment option for COVID-19. This trial assessed the efficacy of a neutralizing antibody containing high-dose CCP in hospitalized adults with COVID-19 requiring respiratory support or intensive care treatment.METHODSPatients (n = 105) were randomized 1:1 to either receive standard treatment and 3 units of CCP or standard treatment alone. Control group patients with progress on day 14 could cross over to the CCP group. The primary outcome was a dichotomous composite outcome of survival and no longer fulfilling criteria for severe COVID-19 on day 21.ResultsThe primary outcome occurred in 43.4% of patients in the CCP group and 32.7% in the control group (P = 0.32). The median time to clinical improvement was 26 days in the CCP group and 66 days in the control group (P = 0.27). The median time to discharge from the hospital was 31 days in the CCP group and 51 days in the control group (P = 0.24). In the subgroup that received a higher cumulative amount of neutralizing antibodies, the primary outcome occurred in 56.0% of the patients (vs. 32.1%), with significantly shorter intervals to clinical improvement (20 vs. 66 days, P < 0.05) and to hospital discharge (21 vs. 51 days, P = 0.03) and better survival (day-60 probability of survival 91.6% vs. 68.1%, P = 0.02) in comparison with the control group.ConclusionCCP added to standard treatment was not associated with a significant improvement in the primary and secondary outcomes. A predefined subgroup analysis showed a significant benefit of CCP among patients who received a larger amount of neutralizing antibodies.Trial registrationClinicalTrials.gov NCT04433910.FundingBundesministerium für Gesundheit (German Federal Ministry of Health): ZMVI1-2520COR802.

Results of the CAPSID randomized trial for high-dose convalescent plasma in patients with severe COVID-19

BACKGROUNDCOVID-19 convalescent plasma (CCP) has been considered a treatment option for COVID-19. This trial assessed the efficacy of a neutralizing antibody containing high-dose CCP in hospitalized adults with COVID-19 requiring respiratory support or intensive care treatment.METHODSPatients (n = 105) were randomized 1:1 to either receive standard treatment and 3 units of CCP or standard treatment alone. Control group patients with progress on day 14 could cross over to the CCP group. The primary outcome was a dichotomous composite outcome of survival and no longer fulfilling criteria for severe COVID-19 on day 21.ResultsThe primary outcome occurred in 43.4% of patients in the CCP group and 32.7% in the control group (P = 0.32). The median time to clinical improvement was 26 days in the CCP group and 66 days in the control group (P = 0.27). The median time to discharge from the hospital was 31 days in the CCP group and 51 days in the control group (P = 0.24). In the subgroup that received a higher cumulative amount of neutralizing antibodies, the primary outcome occurred in 56.0% of the patients (vs. 32.1%), with significantly shorter intervals to clinical improvement (20 vs. 66 days, P < 0.05) and to hospital discharge (21 vs. 51 days, P = 0.03) and better survival (day-60 probability of survival 91.6% vs. 68.1%, P = 0.02) in comparison with the control group.ConclusionCCP added to standard treatment was not associated with a significant improvement in the primary and secondary outcomes. A predefined subgroup analysis showed a significant benefit of CCP among patients who received a larger amount of neutralizing antibodies.Trial registrationClinicalTrials.gov NCT04433910.FundingBundesministerium für Gesundheit (German Federal Ministry of Health): ZMVI1-2520COR802.

Effect of ET-A blockade on portal pressure and hepatic arterial perfusion in patients with cirrhosis: A proof of concept study

BACKGROUND/AIM

Endothelin causes vasoconstriction via the endothelin-A receptor (ET-A) in the intrahepatic circulation in cirrhosis and its increase leads to portal hypertension. The aim of the study was to investigate the acute effect of a selective ET-A antagonist in patients with portal hypertension and cirrhosis.

METHODS

Proof-of-concept study with two different substudies: (a) local intrahepatic administration of the ET-A antagonist BQ 123 and (b) systemic oral administration of the ET-A antagonist Ambrisentan. Portal pressure was determined by hepatic venous pressure gradient (HVPG, both substudies) and hepatic arterial blood flow (HABF) by intra-arterial Doppler measurements (substudy 1) before and under the ET-A antagonist. Systemic haemodynamic parameters were measured in substudy 2.

RESULTS

Twelve patients (Child-Pugh [CP] B/C n = 7/5) were included in substudy 1 and 14 patients (CP A/B/C n = 4/6/4) in substudy 2. The relative decrease in HVPG was -12.5% (IQR: -40% to 0%; P = .05) in substudy 1 and -5.0% (IQR: -11.5% to 0%; P = .01) in substudy 2. Substudy 1 revealed higher decrease in HVPG in CP B patients. HABF increased significantly and patients without portal pressure decrease showed a higher increase of HABF. Substudy 2 showed a slight decrease in the mean arterial pressure without changes of other systemic haemodynamic parameters.

CONCLUSION

Administration of a selective ET-A antagonist decreases the portal pressure in cirrhotic patients. This decrease was higher in CP B patients and the non-responders showed a higher increase in hepatic arterial flow. Selective ET-A antagonists might be a future treatment option in patients with portal hypertension.

Early Detection of Colorectal Cancer: a Multi-Center Pre-Clinical Case Cohort Study for Validation of a Combined DNA Stool Test

BACKGROUND

Although colonoscopy-based screening has proven to be highly effective in detecting colorectal cancer (CRC), participation rates remain disappointing. Development of CRC is associated with a number of genetic or somatic mutations. New, non-invasive stool tests are currently being developed based on the detection of these alterations. We investigated if a non-invasive stool assay can offer sufficient sensitivity and specificity to supplement colonoscopy-based screening.

METHODS

We compared a combined stool assay, which incorporates fecal occult blood testing (FOBT), quantification of human DNA (hDNA) as well as detection of genetic mutations of KRAS and BRAF (Combined DNA stool assay), with commercially available FOBT and M2-PK tests in a multi-centric six-armed pre-clinical case cohort study. Seven hundred thirty-four patients were recruited prior to elective/screening colonoscopy or prior to surgery in case of a recent CRC diagnosis. According to clinical assessment and colonoscopy/histology results, the following groups were assigned: controls, irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), hyperplastic polyps, adenomas, and CRC. Finally, 566 out of 734 patients (77.1%) were screened for CRC and overall gut status via colonoscopy, FOBT, M2-PK, with combined FOBT/M2-PK and the Combined DNA stool assay as described here.

RESULTS

All sensitivities and specificities are measured against histologically confirmed results by colonoscopy. Confirmed sensitivities for detecting colorectal cancer were 68% with FOBT, 83% with M2-PK, 90% with combined FOBT and M2-PK, and 85% with the Combined DNA stool assay. Specificities were 96% with FOBT, 61% with M2-PK, 62% with combined FOBT and M2-PK, and 92% with the Combined DNA stool assay in the control group with no pathological findings during colonoscopy.

CONCLUSIONS

The Combined DNA stool assay detects CRC with a significantly higher Youden Index than the other reviewed non-invasive screening options. The results also suggest that the Combined DNA stool assay represents a reliable assay for detecting colorectal cancer, sufficient to be recommended as a supplement to colonoscopy screening.

Resminostat plus sorafenib as second-line therapy of advanced hepatocellular carcinoma - The SHELTER study

BACKGROUND & AIMS

No established therapies for patients with hepatocellular carcinoma (HCC) and progression on first-line sorafenib treatment currently exist. This phase I/II trial investigated safety, pharmacokinetics and potential biomarkers of the histone deacetylase inhibitor resminostat and a combination therapy with resminostat and sorafenib.

METHODS

Patients with HCC and radiologically confirmed progression on sorafenib were treated in an exploratory, multi-center, open-label, uncontrolled, non-randomized, parallel group phase I/II study. In the combination group (n=38) four dose levels ranged from daily 200 to 600mg resminostat plus 400 to 800mg sorafenib. The monotherapy group (n=19) received 600mg resminostat.

RESULTS

57 patients received treatment. Most common adverse events were gastrointestinal disorders, thrombocytopenia and fatigue. Median maximal histone deacetylase inhibition and highest increase in H4-acetylation matched Tmax of resminostat. Sorafenib or the Child-Pugh score did not affect typical pharmacokinetics characteristics of resminostat. Efficacy assessment as progression-free survival-rate after 6 treatment cycles (12weeks, primary endpoint) was 12.5% for resminostat and 62.5% for resminostat plus sorafenib. Median time to progression and overall survival were 1.8 and 4.1months for resminostat and 6.5 and 8.0months for the combination, respectively. Zinc finger protein 64 (ZFP64) baseline expression in blood cells was found to correlate with overall survival.

CONCLUSIONS

The combination of sorafenib and resminostat in HCC patients was safe and showed early signs of efficacy. Sorafenib did not alter the pharmacokinetic profile of resminostat or its histone deacetylase inhibitory activity in vivo. A prognostic and potentially predictive role of ZFP64 for treatment with resminostat should be further investigated in HCC and possibly other cancer indications.

LAY SUMMARY

No established therapy for patients with advanced hepatocellular carcinoma and progression under first-line systemic treatment with sorafenib currently exists. Epigenetic modulation by inhibition of histone deacetylases might be able to overcome therapy resistance. This exploratory phase I/II clinical study in patients with radiologically confirmed progression under first-line treatment with sorafenib investigated the histone deacetylases inhibitor resminostat as single agent or in combination with continued application of sorafenib.

CLINICAL TRIAL REGISTRATION

The clinical trial has been registered at www.clinicaltrials.gov as NCT00943449.

[Extrapulmonary sarcoidosis: gastrointestinal involvement -case report and review of literature]

Sarcoidosis is a rare systemic disease characterized by noncaseating granulomas in affected organs. With > 90 % of all cases lung involvement is the most frequent site of manifestation of sarcoidosis, nevertheless multiple other organs can be affected. Extrapulmonary manifestations are lymph nodes, skin, nervous system, heart, eyes, bone marrow, spleen or gastrointestinal tract including liver and pancreas. Involvement of the gastrointestinal tract is rare, it can affect the whole intestine and is most frequently found in the stomach. Despite its infrequent manifestation, gastrointestinal sarcoidosis can have a significant clinical impact depending on the organ involved, so that early diagnosis is warranted. Medical treatment mainly consists of immunosuppressive therapy, most frequently with corticosteroids being the first treatment of choice. Dosage and duration of therapy is not well established yet. In the literature very limited data are available on this topic with randomized trials missing completely. The aim of this paper is to give a summary of the available data to this date.

[Epidemiology and risk factors of hepatocellular carcinoma]

BACKGROUND

The incidence of hepatocellular carcinoma (HCC) has increased over the past decades as a result of alcoholic liver disease, the metabolic syndrome and the increasing incidence of viral hepatitis B and C.

OBJECTIVES

An evaluation of the epidemiology of HCC, presentation and discussion of the risk factors for the development of HCC.

MATERIAL AND METHODS

This study was based on a literature review, analysis of the statistics of the World Health Organization (WHO), discussion of current basic research and expert recommendations.

RESULTS

The results show that HCC already represents the fifth most common malignancy in men and the ninth most common malignancy in women, and the incidence is still rising. The pronounced regional differences in prevalence and underlying risk factors are mainly, but not exclusively, due to the prevalence of chronic viral hepatitis B.

CONCLUSION

Hepatocellular carcinoma is a major medical problem. Primary prevention measures and suitable screening algorithms are gaining more and more importance.

Gemcitabine plus sorafenib versus gemcitabine alone in advanced biliary tract cancer: a double-blind placebo-controlled multicentre phase II AIO study with biomarker and serum programme

BACKGROUND

Since sorafenib has shown activity in different tumour types and gemcitabine regimens improved the outcome for biliary tract cancer (BTC) patients, we evaluated first-line gemcitabine plus sorafenib in a double-blind phase II study.

PATIENTS AND METHODS

102 unresectable or metastatic BTC patients with histologically proven adenocarcinoma of gallbladder or intrahepatic bile ducts, Eastern Cooperative Oncology Group (ECOG) 0-2 were randomised to gemcitabine (1000 mg/m2 once weekly, first 7-weeks+1-week rest followed by once 3-weeks+1-week rest) plus sorafenib (400 mg twice daily) or placebo. Treatment continued until progression or unacceptable toxicity. Tumour samples were prospectively stained for sorafenib targets and potential biomarkers. Serum samples (first two cycles) were measured for vascular endothelial growth factors (VEGFs), vascular endothelial growth factor receptor 2 (VEGFR-2) and stromal cell-derived factor 1 (SDF1)α by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Gemcitabine plus sorafenib was generally well tolerated. Four and three patients achieved partial responses in the sorafenib and placebo groups, respectively. There was no difference in the primary end-point, median progression-free survival (PFS) for gemcitabine plus sorafenib versus gemcitabine plus placebo (3.0 versus 4.9 months, P=0.859), and no difference for median overall survival (OS) (8.4 versus 11.2 months, P=0.775). Patients with liver metastasis after resection of primary BTC survived longer with sorafenib (P=0.019) compared to placebo. Patients who developed hand-foot syndrome (HFS) showed longer PFS and OS than patients without HFS. Two sorafenib targets, VEGFR-2 and c-kit, were not expressed in BTC samples. VEGFR-3 and Hif1α were associated with lymph node metastases and T stage. Absence of PDGFRβ expression correlated with longer PFS.

CONCLUSION

The addition of sorafenib to gemcitabine did not demonstrate improved efficacy in advanced BTC patients. Biomarker subgroup analysis suggested that some patients might benefit from combined treatment.

Human bone marrow mesenchymal stem cell-derived hepatocytes improve the mouse liver after acute acetaminophen intoxication by preventing progress of injury

Mesenchymal stem cells from human bone marrow (hMSC) have the potential to differentiate into hepatocyte-like cells in vitro and continue to maintain important hepatocyte functions in vivo after transplantation into host mouse livers. Here, hMSC were differentiated into hepatocyte-like cells in vitro (hMSC-HC) and transplanted into livers of immunodeficient Pfp/Rag2⁻/⁻ mice treated with a sublethal dose of acetaminophen (APAP) to induce acute liver injury. APAP induced a time- and dose-dependent damage of perivenous areas of the liver lobule. Serum levels of aspartate aminotransferase (AST) increased to similar levels irrespective of hMSC-HC transplantation. Yet, hMSC-HC resided in the damaged perivenous areas of the liver lobules short-term preventing apoptosis and thus progress of organ destruction. Disturbance of metabolic protein expression was lower in the livers receiving hMSC-HC. Seven weeks after APAP treatment, hepatic injury had completely recovered in groups both with and without hMSC-HC. Clusters of transplanted cells appeared predominantly in the periportal portion of the liver lobule and secreted human albumin featuring a prominent quality of differentiated hepatocytes. Thus, hMSC-HC attenuated the inflammatory response and supported liver regeneration after acute injury induced by acetaminophen. They hence may serve as a novel source of hepatocyte-like cells suitable for cell therapy of acute liver diseases.

Health care for osteoporosis in inflammatory bowel disease: unmet needs in care of male patients?

BACKGROUND AND AIMS

Osteoporosis is a frequent complication of inflammatory bowel disease (IBD). It may be related to IBD itself or to its therapy. In this study, the quality of care regarding diagnosis and treatment of osteoporosis was examined.

METHODS

In this retrospective, monocentric study 293 consecutive patients with IBD (98 ulcerative colitis, 195 Crohn's disease) were included. Information on age, gender, weight, nicotine abuse, course, disease pattern and medication was assessed, results of dual X-ray absorptiometry (DEXA-scan) were evaluated.

RESULTS

DEXA-scan was performed in 174 patients (59 male, 115 female). Bone mineral density (BMD) was impaired in 38.5% of these patients. Male patients were diagnosed more often with osteopenia or osteoporosis than females (55.9% vs. 29.6%, p=0.03) and had a risk of bone disease comparable to postmenopausal women. Additionally, duration of corticosteroid treatment and IBD were identified as risk factors for osteoporosis. Follow up DEXA-scan demonstrated an overall deterioration of BMD in patients with normal baseline results.

CONCLUSIONS

While in general, women are considered at higher risk for osteoporosis, male patients had a higher risk of impaired BMD, especially when under treatment with corticosteroids. The high incidence of reduced BMD supports the recommendation to screen patients with IBD at an early stage of disease, although a possible bias has to be considered for patients at a tertial referral centre for IBD. Patients with normal baseline DEXA-scan were still at risk to develop bone disease and it seems advisable to monitor patients with IBD for reduced BMD continually.

[Colon Polypectomy - And Then?]

Colorectal cancer (CRC) is the most frequent gastrointestinal tumour. Most CRC appear to arise from adenomas of the colon in a period of 10 or 15 years. The ultimately progression of benign adenomas to malignant CRC is known as the adenoma-carcinoma sequence. In addition, the description of the "serrated pathway" has shifted the focus of interest also towards to sessile serrated adenomas and traditional serrated adenomas in the development of CRC. It has been proven that the screening colonoscopy might prevent CRC by early detection of adenomatous polyps as precursors for colorectal cancer and polypectomy. Thus, disease-associated mortality of CRC could be reduced. Colonoscopy, the gold standard in CRC diagnosis, is recommended to men and women from the age of 55. On the one hand, there are requirements to the endoscopists. On the other hand there are also essential requirements to pathologists' findings. After polypectomy a risk stratification for aftercare based on endoscopic and histological findings is necessary. Endoscopic follow-up of high-risk patients (≥ 3 tubular adenomas, ≥ 1 adenoma ≥ 1 cm, tubulovillous or villous adenoma, ≥ 1 adenoma with high-grade intraepithelial neoplasia, ≥ 10 adenoma no matter what size or histological findings) should be done sooner (< 3 years). In contrast, colonoscopy in low-risk patients (1 or 2 [tubular] adenomas, size < 1 cm) should be performed later rather than sooner (> 5 years). Colonoscopic surveys under 12 months should be done only in exceptional and very serious situations. Pharmaceutical chemoprevention of adenomas or CRC are still part of clinical trails. More data are necessary.

Resminostat in advanced hepatocellular carcinoma (HCC): Overall survival subgroup analysis of prognostic factors in the SHELTER trial

e15088

Background: Previously published results of the phase I/II SHELTER study demonstrated efficacy and safety of the novel pan-HDAC inhibitor resminostat in second-line treatment of HCC patients (pts) who had progressed under first-line sorafenib. As patient baseline characteristics might influence treatment outcome, an analysis of their potential influence on overall survival (OS) was performed. Methods: 45 pts with advanced-stage HCC and centrally confirmed radiologic progression under first-line sorafenib were included in a multi-center, two-arm trial. Resminostat was administered either alone or in combination with sorafenib. A Cox proportional-hazards model was used to evaluate the interaction between baseline characteristics and the effect of the two treatment groups on overall survival. Results: In the combination group, pts with Child-Pugh-A, ECOG 0 or absence of vascular invasion had a statistically significant lower risk of death compared to pts with Child-Pugh-B (HR 0.19, 95% CI 0.06-0.55), ECOG 1 (HR 0.15, 95% CI 0.05-0.44), or vascular invasion (HR 0.37, 95% CI 0.15-0.93), respectively. For pts with BCLC-B there was a strong trend, although not statistically significant, of a lower risk of death when compared to pts with BCLC-C (HR 0.43, 95% CI 0.13-1.49). Etiology, prior TACE therapy, extrahepatic spread and interval between first- and second-line treatment had no impact on overall survival in this study. Similar findings were observed in the monotherapy group. Comparing the impact of these baseline characteristics in the combination and monotherapy group, no statistically significant different influence on OS between both treatment groups was observed. Conclusions: Resminostat in combination with sorafenib provides a substantial OS benefit (median OS of 8.1 months) for advanced HCC patients who had developed progressive tumor disease under first-line sorafenib therapy. Subgroup analysis of patient baseline characteristics revealed a significant influence of Child-Pugh index, ECOG classification, and vascular invasion on overall survival, whereas e.g. the interval between first- and second-line treatment had no impact on overall survival. Clinical trial information: NCT00943449.

Prognostic indicators of survival in patients with compensated and decompensated cirrhosis

BACKGROUND/AIMS

Patients with cirrhosis are classified in a compensated and a decompensated stage. Portal hypertension is responsible for most of the complications of cirrhosis that mark the transition from compensated to decompensated cirrhosis. The objectives of this study were (a) to analyse survival of the different stages and substages of cirrhosis and (b) to examine the prognostic value of the hepatic venous pressure gradient (HVPG) at each of the stages.

METHODS

A total of 729 patients with suspected cirrhosis underwent routine measurement of portal pressure and systemic haemodynamics between 11/1995 and 12/2004. The primary end-point of the study was death, collected until November 30th, 2006. Multivariable analysis was performed using two models to determine predictors of death at each stage.

RESULTS

A total of 443 patients were included in the study. The 1-year mortality was 5.4% in compensated and 20.2% in decompensated patients. Compensated patients in stage 1 (no varices) had a longer survival than stage 2 patients (varices present) (P = 0.015). In decompensated patients, survival was not different between stage 3 (ascites, with or without varices) and stage 4 (variceal haemorrhage, with or without ascites). Age and HVPG (cut-off 10 mmHg) were independent predictors of death in compensated patients, whereas MELD was in decompensated patients.

CONCLUSION

Survival rates and predictors of death are different between patients with compensated and decompensated cirrhosis. Unlike the Italian cohort staging system, ascites is a better stratifying clinical event than variceal haemorrhage in patients with decompensated cirrhosis. The presence of clinically significant portal hypertension has prognostic value in compensated cirrhosis.

Efficacy, safety, tolerability, and PK of the HDAC inhibitor resminostat in sorafenib-refractory hepatocellular carcinoma (HCC): Phase II SHELTER study

4115

Background: Resminostat (R), an oral HDAC inhibitor, was studied in the SHELTER trial evaluating safety, PK and efficacy in HCC patients (pts) refractory to sorafenib (S). R was explored as monotherapy and within a novel resensitization approach to overcome tolerance to S by the combination of both drugs. Methods: Pts with advanced HCC (BCLC B/C) were included in a multi-center, two-arm trial. Radiologic progression under S firstline therapy had to be confirmed by central review (RECIST) prior to study entry. A dose escalation of R (range 200 to 600 mg) combined with S (400 or 800 mg) was performed. Arm A investigated the drug combination (R+S), Arm B the monotherapy of R (600 mg). Primary objective was the progression-free survival rate (PFSR) after 12 weeks (w). Secondary objectives included safety, tolerability, tumor response, PFS, TTP, OS and the analyses of PK and biomarkers (BM), incl. AFP, VEGF, HDAC enzyme inhibition, histone acetylation and gene expressions in peripheral blood. Results: 50 pts were enrolled, dose escalation determined 600 mg R and 400 mg S for Arm A. Clinical activity results of 15 evaluable pts from combination treatment revealing a PFSR of 66.6% after 12 w, not all patients in Arm B already reached the 12 w staging. Most frequent AE were CTC grade 1-2 GI complaints (nausea, vomiting) and skin disorders (rash, pruritus, HFSR). Grade 3-4 toxicity (SAE reports) consisted mainly of non-hematological events mostly related to tumor disease. Plasma concentrations of both drugs correlated with administered doses and were in the expected range without obvious influence of preexisting liver disease. BM investigations revealed effective target modulation by R in both arms. Conclusions: The primary study objective was achieved for both treatment arms. R demonstrated a favorable PK, safety and tolerability profile, even in combination with S and despite preexisting liver disease, includig cirrhosis. The observed clinical activity emphazises the resensitizing activity of R by an epigenetic mode-of-action to overcome tolerance to S and warrants further development, in particular for combination therapy in both, first and second line HCC treatment.

Investigation of the HDAC inhibitor resminostat in patients with sorafenib-resistant hepatocellular carcinoma (HCC): Clinical data from the phase I/II SHELTER study

262

Background: Resminostat (4SC-201), an oral pan-HDAC inhibitor, is in clinical development in a variety of cancer indications. The SHELTER study aims to evaluate safety, tolerability and efficacy in HCC patients (pts) exhibiting progressive disease under sorafenib first-line therapy.

Methods: Pts with advanced HCC, (BCLC B or C) are included in a multi-center, open-label, two-arm parallel group trial. Radiologic progression under sorafenib is determined acc. to RECIST by central review prior to study entry. For Arm A, dose escalation of resminostat and sorafenib is performed to determine the MTD. Resminostat is administered orally once-daily in a “5+9” schedule, consisting of 5 consecutive treatment days followed by a 9-day rest period resulting in 14 day cycles on dose levels of 200 (DL1), 400 (DL2) and 600 mg (DL3+4), either combined with continuously taken sorafenib at 400 (DL1-3) or 800 mg (DL4) (Arm A), or as resminostat monotherapy (600 mg, Arm B). Primary objective is to determine progression-free survival after 12 weeks (w) (6 cycles). Secondary objectives include safety, tolerability, tumor response, TTP, OS, PK, biomarkers.

Results: To date, 39 pts were treated with 600 mg resminostat alone or on DL1-4 in combination with sorafenib. Up to now, no DLT occurred in 5 pts treated on DL4. Most frequently AE observed include CTC grade 1-2 gastrointestinal complaints such as nausea and vomiting and skin disorders like rash, pruritus and HFSR. CTC Grade 3-4 toxicity documented in SAE reports consisted mainly of no-hematological events and was mostly related to the tumor disease. Interim results revealed that 15 out of 27 pts (56%) assessed after 6 w of treatment, and 11 out of 24 pts after 12 w displayed SD. In one patient treated on DL2, SD persisted for more than 1 year along with good long-term tolerability.

Conclusions: Preliminary clinical data show a favorable drug profile of resminostat either in mono or in combination treatment with sorafenib. No DLT was observed on the highest DL of the combination therapy up to now. Initial data on toxicity and therapeutic activity to overcome resistance to sorafenib are promising and will be updated for the meeting.

KRAS mutation in metastatic pancreatic ductal adenocarcinoma: results of a multicenter phase II study evaluating efficacy of cetuximab plus gemcitabine/oxaliplatin (GEMOXCET) in first-line therapy

BACKGROUND

Genetic alterations within the epidermal growth factor receptor (EGFR) pathway, including KRAS mutations, have been demonstrated to be associated with response to EGFR inhibitors like cetuximab in colorectal cancers. Mutations in the KRAS gene have been found in 70-90% of pancreatic cancers. Unfortunately, the addition of cetuximab to chemotherapy did not increase response or survival in patients with advanced pancreatic cancer in phase II and phase III studies. The aim of this study was to evaluate the relationship between KRAS mutations and response or survival in patients with metastatic pancreatic cancer treated with cetuximab plus chemotherapy.

METHODS

Within a multicenter phase II trial, 64 patients with metastatic pancreatic cancer were treated with cetuximab in combination with gemcitabine and oxaliplatin until disease progression. Analyses of the EGFR pathway, including KRAS mutations, could be performed in 25 patients. Analyses were carried out following microdissection of the tumor.

RESULTS

Fourteen (56%) of the 25 patients examined harbored a point mutation in codon 12 of the KRAS gene. No differences between the groups were noted in median progression-free survival (104 days in KRAS wild-type patients vs. 118 days in patients with KRAS mutations). Overall survival was longer in wild-type patients compared to patients with KRAS mutations (263 vs. 162 days), but the difference did not reach statistical significance. A further analysis of our clinical phase II trial showed that the presence of a rash was significantly correlated with overall survival.

CONCLUSIONS

KRAS mutation in codon 12 may be associated with reduced survival compared to KRAS wild type. The role of KRAS mutations for cetuximab therapy in pancreatic cancer warrants further investigation in larger trials to exclude an epiphenomenon. Furthermore, the development of a rash is indicative of clinical benefit.

[Pregnancy under immunosuppression]

The desire to have children and pregnancy itself are important topics in the treatment of patients under immunosuppression. In this review the risks of frequently prescribed immunosuppressants are discussed regarding the safety of mother and child during and after pregnancy. Knowledge of the specific risks of immunosuppressants in pregnancy is important to balance the therapy between the patients' desire to be treated most effectively and to deliver a healthy child after an uncomplicated pregnancy. Generally, an interdisciplinary approach is advisable in treating and counseling immunosuppressed patients with a desire to have children and during pregnancy.

CD13: Waving the flag for a novel cancer stem cell target

Cancer stem cells (CSCs) are generally dormant or slowly cycling tumor cells that have the ability to reconstitute tumors. They are thought to be involved in tumor resistance to chemo/radiation therapy and tumor relapse and progression. However, neither their existence nor their identity within many cancers has been well defined. Here, we have demonstrated that CD13 is a marker for semiquiescent CSCs in human liver cancer cell lines and clinical samples and that targeting these cells might provide a way to treat this disease. CD13+ cells predominated in the G0 phase of the cell cycle and typically formed cellular clusters in cancer foci. Following treatment, these cells survived and were enriched along the fibrous capsule where liver cancers usually relapse. Mechanistically, CD13 reduced ROS-induced DNA damage after genotoxic chemo/radiation stress and protected cells from apoptosis. In mouse xenograft models, combination of a CD13 inhibitor and the genotoxic chemotherapeutic fluorouracil (5-FU) drastically reduced tumor volume compared with either agent alone. 5-FU inhibited CD90+ proliferating CSCs, some of which produce CD13+ semiquiescent CSCs, while CD13 inhibition suppressed the self-renewing and tumor-initiating ability of dormant CSCs. Therefore, combining a CD13 inhibitor with a ROS-inducing chemo/radiation therapy may improve the treatment of liver cancer.

Comparison of balloon vs. straight catheter for the measurement of portal hypertension

BACKGROUND

The hepatic venous pressure gradient (HVPG) is used as an estimation of portal pressure (PP) in the management of patients with cirrhosis. Two methods are available using either a straight or a balloon catheter, but have never been compared head-to-head.

AIM

To compare the two methods of determining HVPG, straight and balloon catheter, regarding reproducibility and reliability.

METHODS

In 47 patients with liver cirrhosis, HVPG was assessed using both catheters in sequence. In another 29 patients, the wedged hepatic venous pressure (WHVP) determined either with straight or balloon catheter was correlated with a direct measurement of PP. Variation coefficient and intraclass correlation coefficient were calculated.

RESULTS

Variation coefficients for balloon catheter were 0.07 (HVPG), 0.02 (WHVP) and 0.06 [free hepatic venous pressure (FHVP)]. Variation coefficients for straight catheter were 0.17 (HVPG), 0.06 (WHVP) and 0.07 (FHVP), demonstrating a significantly wider variation of the HVPG and WHVP measurements (P < 0.001). Comparison of WHVP with PP revealed a correlation coefficient of 0.72 (P = 0.004) using balloon catheter and 0.58 (P = 0.011) using straight catheter.

CONCLUSIONS

Measurements with the balloon catheter currently represent the most reliable and reproducible method to assess HVPG. The results are of particular clinical relevance if repeated measurements are required for therapeutic adjustments.

Thymostimulin versus placebo for palliative treatment of locally advanced or metastasised hepatocellular carcinoma: a phase III clinical trial

Background

Thymostimulin is a thymic peptide fraction with immune-mediated cytotoxicity against hepatocellular carcinoma (HCC) in vitro and palliative efficacy in advanced HCC in two independent phase II trials. The aim of this study was to assess the efficacy of thymostimulin in a phase III trial.

Methods

The study was designed as a prospective randomised, placebo-controlled, double-blind, multicenter clinical phase III trial. Between 10/2002 and 03/2005, 135 patients with locally advanced or metastasised HCC (Karnofsky ≥60%/Child-Pugh ≤ 12) were randomised to receive thymostimulin 75 mg s.c. 5×/week or placebo stratified according to liver function. Primary endpoint was twelve-month survival, secondary endpoints overall survival (OS), time to progression (TTP), tumor response, safety and quality of life. A subgroup analysis according to liver function, KPS and tumor stage (Okuda, CLIP and BCLC) formed part of the protocol.

Results

Twelve-month survival was 28% [95%CI 17-41; treatment] and 32% [95%CI 19-44; control] with no significant differences in median OS (5.0 [95% CI 3.7-6.3] vs. 5.2 [95% CI 3.5-6.9] months; p = 0.87, HR = 1.04 [95% CI 0.7-1.6]) or TTP (5.3 [95%CI 2.0-8.6] vs. 2.9 [95%CI 2.6-3.1] months; p = 0.60, HR = 1.13 [95% CI 0.7-1.8]). Adjustment for liver function, Karnofsky status or tumor stage did not affect results. While quality of life was similar in both groups, fewer patients on thymostimulin suffered from accumulating ascites and renal failure.

Conclusions

In our phase III trial, we found no evidence of any benefit to thymostimulin in the treatment of advanced HCC and there is therefore no justification for its use as single-agent treatment. The effect of thymostimulin on hepato-renal function requires further confirmation.

Trial Registration

Current Controlled Trials ISRCTN64487365.

Incorporating indocyanin green clearance into the Model for End Stage Liver Disease (MELD-ICG) improves prognostic accuracy in intermediate to advanced cirrhosis

BACKGROUND

The Model for End Stage Liver Disease (MELD) predicts mortality in end stage liver disease. Incorporation of serum sodium into the MELD may improve diagnostic accuracy in decompensated patients with ascites. However, other complications of cirrhosis are not reflected. This study investigates whether quantitative liver function tests predict survival and increase prognostic accuracy of the MELD.

METHODS

604 patients with suspected cirrhosis were staged clinically and haemodynamically. Galactose-elimination-capacity, sorbitol clearance, lidocaine metabolism and indocyanin green (ICG) half life were determined. Survival was the primary end point of the study. Prognostic effects of individual parameters were calculated using Cox regression models and ROC curves.

RESULTS

321 patients on standard pharmacological and endoscopic treatment (PET) and 74 patients undergoing transjugular portosystemic shunting (TIPS) were studied. Of all quantitative liver function tests, ICG half life was the most accurate in predicting survival. Upon incorporation into the MELD, it modified the score in patients with PET up to 35 points. Clinically relevant changes to the score, however, occurred in patients with a MELD score between 10 and 30, allowing an objective prognostic discrimination of individual survival based on laboratory liver function and blood flow. The MELD-ICG was validated in the second cohort of patients undergoing TIPS implantation.

CONCLUSION

ICG had the highest predictive value of the examined tests. Its incorporation into the MELD adds an estimation of liver blood flow and renders the new score MELD-ICG more accurate in predicting survival in intermediate to advanced cirrhosis than the MELD and MELD-Na.

Propranolol impairs liver regeneration after partial hepatectomy in C57Bl/6-mice by transient attenuation of hepatic lipid accumulation and increased apoptosis

OBJECTIVE

Acute hepatic fat accumulation appears to be crucial for liver regeneration after partial hepatectomy. Since fatty acids in the liver are provided by catecholamine-induced lipolysis in the adipose tissue, we investigated whether beta-adrenergic blockade of lipolysis might affect liver regeneration.

MATERIAL AND METHODS

Mice were treated with propranolol prior to partial hepatectomy. Subsequently, liver regeneration was evaluated histologically, by determination of the relative liver weight and the mitotic index at different time points after surgery.

RESULTS

Liver mass restoration was delayed by propranolol, which was associated with a lower hepatic triglyceride content. Ki-67 labelling indicated that liver regeneration was attenuated by propranolol through inhibition of mitosis. Hepatocytes were arrested in the G1 phase of the cell cycle, as shown by the expression of G1-related proteins such as proliferating cell nuclear antigen, cyclin D1 and cyclin-dependent kinase-2, and underwent apoptosis as indicated by detection of poly(adenosine diphosphate-ribose) polymerase fragments. beta-adrenergic blockade of the host animal did not provide transplanted hepatocytes with a growth advantage over host cells.

CONCLUSION

Impairment of liver regeneration by propranolol is related to the inhibition of acute hepatic fat accumulation and to a predisposition of hepatocytes to apoptosis.

Rapid development of a hepatocellular carcinoma in isolated thrombosis of hepatic veins (classic Budd-Chiari syndrome): case report and review of literature

Budd-Chiari syndrome and membranous obstruction of the inferior vena cava frequently result in the development of mostly benign hepatic lesions. In cases of membranous obstruction of the inferior vena cava, which is prevalent mostly in the East, these lesions often progress to hepatocellular carcinoma. In contrast, malignant transformation has not yet been recognised in patients with isolated hepatic vein thrombosis. We report the case of a 37-year-old male Caucasian who presented with acute Budd-Chiari syndrome without involvement of the inferior vena cava. Despite porto-caval shunting, a hepatocellular carcinoma developed within several months. Three hepatic lesions were treated by radiofrequency thermal ablation until liver transplantation was performed. This report emphasises the possibility of malignant transformation of regenerative nodules in patients with disturbed hepatic perfusion in general. Physicians must be aware of this when assessing regenerative nodules, especially as no unambiguous predictors for the development of hepatocellular carcinoma have been identified so far.

Hepatocyte differentiation of mesenchymal stem cells from human adipose tissue in vitro promotes hepatic integration in vivo

OBJECTIVE

The hepatic integration of human adipose tissue derived mesenchymal stem cells (hAT-MSCs) in vivo with or without prior differentiation to hepatocyte-like cells in vitro was investigated.

METHODS AND RESULTS

Cells, isolated either from peritoneal or subcutaneous adipose tissue, expressed mesenchymal stem cell surface markers and featured multiple lineage differentiation. Under conditions favouring hepatocyte differentiation, hAT-MSCs gained hepatocytic functions in vitro including urea formation, glycogen synthesis, cytochrome P450 enzyme activity, and expression of hepatocyte-specific transcripts of carbamoylphosphate synthetase, albumin and cytochrome P450 type 3A4 (CYP3A4). Transgenic expression of green fluorescent protein emerged upon hepatocyte differentiation when driven by the hepatocyte-specific promoter of the cytosolic phosphoenolpyruvate carboxykinase gene but was constitutive from the ubiquitin gene promoter. Human AT-MSCs were transplanted into livers of immunodeficient Pfp/Rag2-/- mice with or without prior hepatocyte differentiation in vitro. Donor-derived human cells engrafted in the mouse host liver predominantly in the periportal region of the liver lobule. They expressed HepPar1 and albumin, typical features of differentiated human hepatocytes, in the otherwise negative mouse liver background. Engraftment was significantly more efficient using hAT-MSCs pre-differentiated to hepatocyte-like cells in vitro as compared with undifferentiated cells.

CONCLUSIONS

Pre-differentiation of human MSCs from adipose tissue into hepatocyte-like cells in vitro facilitates long term functional hepatic integration in vivo.

Cetuximab plus gemcitabine/oxaliplatin (GEMOXCET) in first-line metastatic pancreatic cancer: a multicentre phase II study

Targeting the epidermal growth factor receptor pathway in pancreatic cancer seems to be an attractive therapeutic approach. This study assessed the efficacy of cetuximab plus the combination of gemcitabine/oxaliplatin in metastatic pancreatic cancer. Eligible subjects had histological or cytological diagnosis of metastatic pancreatic adenocarcinoma. The primary end point was response according to RECIST. Patients received cetuximab 400 mg m⁻² at first infusion followed by weekly 250 mg m⁻² combined with gemcitabine 1000 mg m⁻² as a 100 min infusion on day 1 and oxaliplatin 100 mg m⁻² as a 2-h infusion on day 2 every 2 weeks. Between January 2005 and August 2006, a total of 64 patients (22 women (34%), 42 men (66%); median age 64 years (range 31–78)) were enrolled at seven study centres. On October 2007, a total of 17 patients were alive. Sixty-two patients were evaluable for baseline and 61 for assessment of response to treatment in an intention-to-treat analysis. Six patients had an incomplete drug combination within the first cycle of the treatment plan (n=4 hypersensitivity reactions to the first cetuximab infusion, n=2 refused to continue therapy). Reported grade 3/4 toxicities (% of patients) were leukopaenia 15%, anaemia 8%, thrombocytopaenia 10%, diarrhoea 7%, nausea 18%, infection 18% and allergy 7%. Cetuximab-attributable skin reactions occurred as follows: grade 0: 20%, grade 1: 41%, grade 2: 30% and grade 3: 10%. The intention-to-treat analysis of 61 evaluable patients showed an overall response rate of 33%, including 1 (2%) complete and 19 (31%) partial remissions. There were 31% patients with stable and 36% with progressive disease or discontinuation of the therapy before re-staging. The presence of a grade 2 or higher skin rash was associated with a higher likelihood of achieving objective response. Median time to progression was 118 days, with a median overall survival of 213 days. A clinical benefit response was noted in 24 of the evaluable 61 patients (39%). The addition of cetuximab to the combination of gemcitabine and oxaliplatin is well tolerated but does not increase response or survival in patients with metastatic pancreatic cancer.

Course of Crohn's disease prior to establishment of the diagnosis

BACKGROUND

The course of Crohn's disease prior to the establishment of the diagnosis is widely unknown. Therefore, we instigated a survey amongst newly diagnosed patients.

PATIENTS AND METHODS

Patients diagnosed with CD less than 12 months before enrollment were included. Data on demography, social status, time interval to diagnosis, symptoms, and health care service use were collected in a retrospective, web-based, census. Patients were contacted in cooperation with two organizations: a German patients' organization (Deutsche Morbus Crohn/Colitis ulcerosa Vereinigung e.V. [DCCV]) and a professional organization of German gastroenterologists (Berufsverband der Niedergelassenen Gastroenterologen Deutschlands e.V. [bng]). Study participation was anonymous by use of a transaction number.

RESULTS

The median interval period between onset of first symptoms and diagnosis was 13 months. During this time, participants reported having five doctor consultations on average, with 44% of them having a mean of 1.5 hospitalizations. 65% were unfit for work with a 14 day median (2 to 480 days) due to their symptoms. A mean (+/-SD) of 8.6 (+/-7.1) diagnostic tests were performed before the diagnosis was established. Overall health state was judged as temporarily bad or very bad by 84% of the participants. Age at diagnosis, characteristic symptoms, and localization of the disease for the participants did not differ from previously reported international data.

DISCUSSION

This web-based survey shows a substantial time interval of over one year until diagnosis of Crohn's disease amongst the study participants. This period is characterized by both psychological stress and impaired ability to work.

Thymostimulin in advanced hepatocellular carcinoma: a phase II trial

Background

Thymostimulin is a thymic peptide fraction with immune-mediated cytotoxicity against hepatocellular carcinoma in vitro. In a phase II trial, we investigated safety and efficacy including selection criteria for best response in advanced or metastasised hepatocellular carcinoma.

Methods

44 patients (84 % male, median age 69 years) not suitable or refractory to conventional therapy received thymostimulin 75 mg subcutaneously five times per week for a median of 8.2 months until progression or complete response. 3/44 patients were secondarily accessible to local ablation or chemoembolisation. Primary endpoint was overall survival, secondary endpoint tumor response or progression-free survival. A multivariate Cox's regression model was used to identify variables affecting survival.

Results

Median survival was 11.5 months (95% CI 7.9–15.0) with a 1-, 2- and 3-year survival of 50%, 23% and 9%. In the univariate analysis, a low Child-Pugh-score (p = 0.01), a low score in the Okuda- and CLIP-classification (p < 0.001) or a low AFP-level (p < 0.001) were associated with better survival, but not therapy modalities other than thymostimulin (p = 0.1) or signs of an invasive HCC phenotype such as vascular invasion (p = 0.3) and metastases (p = 0.1). The only variables independently related to survival in the Cox's regression model were Okuda stage and presence of liver cirrhosis (p < 0.01) as well as response to thymostimulin (p < 0.05). Of 39/44 patients evaluable for response, two obtained complete responses (one after concomitant radiofrequency ablation), five partial responses (objective response 18%), twenty-four stable disease (tumor control rate 79%) and eight progressed. Median progression-free survival was 6.4 months (95% CI 0.8–12). Grade 1 local reactions following injection were the only side effects.

Conclusion

Outcome in our study rather depended on liver function and intrahepatic tumor growth (presence of liver cirrhosis and Okuda stage) in addition to response to thymostimulin, while an invasive HCC phenotype had no influence in the multivariate analysis. Thymostimulin could therefore be considered a safe and promising candidate for palliative treatment in a selected target population with advanced hepatocellular carcinoma, in particular as component of a multimodal therapy concept.

Trial registration

Current Controlled Trials ISRCTN29319366.

Kurzfassung der aktualisierten S3-Leitlinie „Diagnostik und Therapie der Hepatitis B”

Therapeutic option for hepatitis B virus infection have significantly improved in recent years. Moreover, new insights in the natural history of hepatitis B required an update of current national guidelines. Therefore, the German network of competence on viral hepatitis (Hep-Net) has revised guidelines on diagnosis and treatment og HBV incetion in cooperation with the national societies for Gastroenterology, Pathology, Virology, and Pediatric Gastroenterology. Important alterations concern the indication for antiviral therapy considering an HBV viremia of 104 copies/ml (2000 IU/ml) as a critical level. Moreover, specific recommendations how to prevent and to treat antiviral drug resistance are given. Finally, the importance of HBV in the context of organ and bone marrow transplantation, treatment of coinfections and children and prophylaxis of HBV is covered.

Hepatocyte differentiation of mesenchymal stem cells from rat peritoneal adipose tissue in vitro and in vivo

Mesenchymal tissues harbour stromal cells capable of multilineage differentiation. Here, we demonstrate the isolation of mesenchymal stem cells (MSC) from rat peritoneal adipose tissue capable of osteogenic and adipogenic differentiation. Under in vitro conditions favouring hepatocyte differentiation, these MSC gained characteristic functions of hepatocytes such as the capacity to synthesize urea or store glycogen. Hepatocyte-specific transcripts of dipeptidylpeptidase type IV (CD26), albumin, cytochrome P450 type 1A1 (CYP1A1) and connexin CX32 (CX32) were detected only in differentiated but not undifferentiated cells. Transient transgenic expression of luciferase could be stimulated by cAMP when driven by the hepatocyte-specific promoter of the cytosolic phosphoenolpyruvate carboxykinase (PCK1) gene. Finally, stem cell-derived hepatocytes from wild type (CD26+/+) rats were transplanted into the livers of CD26-deficient animals after lentiviral transduction with the GFP gene under the control of the ubiquitin promoter. GFP-positive cells engrafted in the host liver predominantly in the periportal region of the liver lobule. They continued to express CD26, a prominent feature of differentiated hepatocytes, indicating their topologically and functionally proper integration into the host liver parenchyma. Thus, MSCs from rat peritoneal adipose tissue exhibit the potential to differentiate into hepatocyte-like cells in vitro and in vivo.

Functional integration of hepatocytes derived from human mesenchymal stem cells into mouse livers

AIMS

At present, clinical success of hepatocyte transplantation as an alternative to whole liver transplantation is hampered by the limited availability of suitable donor organs for the isolation of transplantable hepatocytes. Hence, novel cell sources are required to deliver hepatocytes of adequate quality for clinical use. Mesenchymal stem cells (MSCs) from human bone marrow may have the potential to differentiate into hepatocytes in vitro and in vivo.

METHODS

Isolated MSCs were selected by density gradient centrifugation and plastic adherence, differentiated in the presence of human hepatocyte growth medium and transplanted in immunodeficient Pfp/Rag2 mice.

RESULTS

Here, we demonstrate that human MSCs gain in vitro the characteristic morphology and function of hepatocytes in response to specified growth factors. Specifically, preconditioned MSCs store glycogen, synthesise urea and feature the active hepatocyte-specific gene promoter of phosphoenolpyruvate carboxykinase (PCK1). After transplantation into livers of immunodeficient mice, preconditioned MSCs engraft predominantly in the periportal portion of the liver lobule. In situ, the cells continue to store glycogen and express PCK1, connexin32, albumin and the human hepatocyte-specific antigen HepPar1, indicating that the transplanted cells retain prominent qualities of hepatocytes after their regional integration.

CONCLUSION

MSCs derived from human bone marrow may serve as a novel source for the propagation of hepatocyte-like cells suitable for cell therapy in liver diseases.

[Pulmonary complication of liver disease]

Hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH) are two distinct pulmonary complications of liver disease, which seem pathogenetically linked to the presence of portal hypertension. The most common presenting symptom of both syndromes is dyspnoea, but HPS is more prevalent in 5-30% of patients. The diagnosis of HPS requires the documentation of arterial hypoxemia and intrapulmonary vascular dilatation with anatomical shunting. In contrast, POPH has a prevalence of 2-16% and is only considered proven, if other causes of the pulmonary hypertension than the high portal pressure are excluded. Moderate to severe HPS or POPH carry a poor prognosis and liver transplantation remains the only curative treatment, although POPH in particular is associated with high perioperative mortality.

Fr�hdiagnostik von Lebererkrankungen

In Germany, liver diseases are the leading cause of death through illness among 30 to 45 year olds. Most are chronic diseases and timely preventative or therapeutic measures could avert their manifestation or at least the following complications. Currently, screening for liver diseases is focused on specific groups at risk such as patients with alcohol abuse, relatives of patients with a genetic disease or individuals at risk of an infection with a viral hepatitis. For some diseases, studies have been started to test the practicability of population screening, which has already been successfully implemented for Hepatitis B and C in blood donors. Screening is also recommended for advanced liver disease. It helps to detect the development of cirrhosis and its complications namely varices and hepatocellular carcinoma.

Cardiac function after orthotopic liver transplantation and the effects of immunosuppression: a prospective randomized trial comparing cyclosporin (Neoral) and tacrolimus

There are several case reports in the literature that describe cardiac complications in the first few weeks after orthotopic liver transplantation (OLT) in patients receiving tacrolimus as their primary immunosuppressive therapy. In this study, we investigated the cardiac function of patients on tacrolimus (T) compared with those on cyclosporin (C) (Neoral; Novartis, Basel, Switzerland) immunosuppression, after OLT, in a prospective randomized trial. We randomized 40 adult patients with cirrhosis to either T or C with azathioprine and prednisolone immunosuppression and followed up on them for 3 months after OLT. All had detailed clinical, biochemical, electrocardiographic and echocardiographic assessments at regular intervals. Abnormalities in cardiac function were common after OLT and significant deterioration in left ventricular diastolic function was demonstrable up to 3 months in both patient groups. Cardiac function was similar in the T and C arms and no significant electrocardiographic differences were observed, although reduced heart rate variability (HRV) and higher mean serum brain natriuretic peptide (BNP) levels were identified in the T group. The percentage increase in posterior wall thickness was higher in the T group. Cardiac dysfunction as shown by worsening echocardiographic measures of left ventricular diastolic function and by clinical cardiac events is common in the first 3 months after OLT in patients with cirrhosis. HRV and BNP values in the T group were worse than in the C group, but this was not translated to an increase in cardiac clinical events in this study.

Indocyanine green clearance reflects reperfusion injury following liver transplantation and is an early predictor of graft function

BACKGROUND/AIMS

Primary graft dysfunction is difficult to predict. We have previously shown that indocyanine green clearance measured at 24 h following orthotopic liver transplantation predicts graft survival and outcome. We prospectively evaluated the use of indocyanine green clearance (with a cut-off value of 200 ml/min) as a marker of graft function following orthotopic liver transplantation and investigated its relationship with the markers of reperfusion injury during orthotopic liver transplantation.

METHODS

In all patients indocyanine green clearance was measured at 24 h. Repeated blood samples were taken before, during the anhepatic and reperfusion phase and up to 12 h following orthotopic liver transplantation to measure the levels of neutrophil elastase and reactive oxygen intermediates. All patients studied had normal hepatic arterial pulse on Doppler-ultrasound post orthotopic liver transplantation.

RESULTS

All patients with indocyanine green clearance >200 ml/min recovered following orthotopic liver transplantation and remained well up to 3 months of follow up. Four patients had an indocyanine green clearance <200 ml/min; three were re-transplanted for graft failure within 3 days of the transplant, while one survived after prolonged intensive support and hospitalization. Indocyanine green clearance significantly correlated with reactive oxygen intermediates production and neutrophil elastase during orthotopic liver transplantation (r=-0.61, p<0.002 and r=-0.66, p<0.0009, respectively). Indocyanine green clearance was also significantly correlated with alanine aminotransferase and prothrombin time at 24 h post-transplantation (r=-0.35, p<0.02 and r=-0.4, p<0.0077, respectively).

CONCLUSION

Indocyanine green reflects the degree of reperfusion injury and is a good early marker of primary graft function. Indocyanine green clearance over 200 ml/min is associated with favorable outcome.

Intrahepatic proliferation of 'naive' and 'memory' T cells during liver allograft rejection: primary immune response within the allograft

Liver allograft rejection is mediated by a primary response of T lymphocytes, followed by infiltration of the graft with a mixed inflammatory reaction. Using single and double label immunocytochemistry, we examined the proliferation index and the phenotype of leukocytes on liver biopsies from 10 patients with acute rejection before and after treatment with i.v. steroids, 10 patients with chronic rejection, 10 patients without rejection posttransplant, and 15 nongrafted, nonimmunosuppressed patients. Proliferation of mononuclear leukocytes (assessed by expression of Ki-67, a nuclear antigen associated with the cell cycle) inside the allograft was a prominent feature of acute and chronic rejection and was down-regulated by steroid treatment. Leukocytes in cell cycle were located predominantly in the portal tracts at the site of the inflammatory infiltrate. The majority of 'naive' (CD45RA+) and 'memory' (CD45RO+) CD4+ T lymphocytes were also periportally distributed. In contrast, CD8+ T lymphocytes, CD57+ natural killer cells, and CD68+ macrophages were located intraparenchymally throughout the liver lobules, whereas CD20+ B lymphocytes were only present in some of the portal tracts. Predominantly CD4+ and occasionally CD8+ lymphocytes were proliferating (assessed by double staining). The proliferating CD4+ cells were of both naive (CD4+, CD45RA+) and memory (CD4+, CD45RO+) phenotypes. To our knowledge, this is the first description of proliferating naive T lymphocytes in situ in liver allografts. These findings suggest that there may be a primary immune response generated within the allograft as well as in draining lymphatic tissue. This implicates not only intrahepatic proliferation of T lymphocytes as a prominent feature of rejection, but also suggests that the liver has a special immunological status comparable to that of lymphatic tissue.

Bile duct cells in primary biliary cirrhosis are 'primed' for apoptosis

OBJECTIVE

Primary biliary cirrhosis (PBC) is characterized by progressive, immune-mediated destruction of bile ducts (<75 microm diameter) and secondary changes related to cholestasis which may involve apoptosis. In this study we sought to examine the protein expression of genes involved in apoptosis in biliary epithelium of PBC cases.

DESIGN

In order to investigate the susceptibility of biliary epithelial cells to apoptosis and their ability to proliferate, we examined the expression of a number of apoptosis related proteins in early and late stage PBC and histologically normal liver control tissue using immunohistochemistry.

METHODS

Liver biopsies from 15 early (stages I and II) and 14 late (stages III and IV) cases of PBC and 15 normal cases were examined immunohistochemically for expression of p53, CD95/Fas, bax, bcl-x, bcl-2 and the proliferation marker Ki-67.

RESULTS

CD95/Fas, bax and bcl-x were identified in biliary epithelium in 8/15, 11/15 and 8/15 normal biopsies. Weak expression of bcl-2 was found, but p53 was not identified. In cases of PBC surviving bile ducts showed strong bax and bcl-x expression. Inflammatory infiltrates were strongly bcl-2 positive. In cases showing a marked ductular reaction there was increased reactivity for bax and bcl-x in ductules. No change in CD95/Fas or p53 expression was seen. An increase in Ki-67 positive biliary epithelial cells was seen in PBC cases, indicating cell cycle activity.

CONCLUSIONS

Bile duct epithelium constitutively expresses several genes involved in the execution of apoptosis but these cells also retain the ability to proliferate.

Peripheral eosinophil count both before and after liver transplantation predicts acute cellular rejection

Acute cellular rejection is common after orthotopic liver transplantation and an important cause of graft dysfunction. Eosinophils, potent mediators of tissue damage, have been implicated in the pathogenesis of acute rejection. We studied 55 patients, all of whom had a protocol biopsy 7 days after transplantation and whose peripheral eosinophil count was monitored daily for 11 days after transplantation. Patients were divided clinicopathologically into two groups: group A, without rejection, group B, with rejection. Group B (36% of patients) developed rejection within the 11-day study period. The pretransplant eosinophil count was significantly higher in group B, compared with group A (0.31 +/- 0.08 v 0.10 +/- 0.01 (x10(9)/L), p < .001). After transplantation, the eosinophil count fell to low levels in both groups. By day 3 there was a statistically significant rise in the eosinophil count in group B compared with group A, with a maximum at day 7 [0.51 +/- 0.06 v 0.26 +/- 0.03 (x10(9)/L) p < .001]. After treatment with steroids, the eosinophil count dropped to values similar to those in group A and remained low thereafter in 16 of 20 patients. Four patients had a second episode of rejection; in each of these, eosinophils were raised again and decreased with resolution of the rejection. An eosinophil count threshold of 0.13 (x10(9)/L) before transplantation and 0.33 (x10(9)/L) on day 7 after transplantation predicted the development of rejection (sensitivity 72/70%, specificity 66/63%, negative predictive value 82/79%). We conclude that a raised eosinophil count is associated with acute rejection. The raised eosinophil count before transplantation in group B suggests that these patients are predisposed to acute rejection, and earlier intervention may be indicated.