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Sanyal AJ, Ratziu V, Loomba R, Anstee QM, Kowdley KV, Rinella ME, Sheikh MY, Trotter JF, Knapple W, Lawitz EJ, Abdelmalek MF, Newsome PN, Boursier J, Mathurin P, Dufour JF, Berrey MM, Shiff SJ, Sawhney S, Capozza T, Leyva R, Harrison SA, Younossi ZM. Results from a new efficacy and safety analysis of the REGENERATE trial of obeticholic acid for treatment of pre-cirrhotic fibrosis due to non-alcoholic steatohepatitis. J Hepatol 2023; 79:1110-1120. [PMID: 37517454 DOI: 10.1016/j.jhep.2023.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/30/2023] [Accepted: 07/06/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND & AIMS Obeticholic acid (OCA) is a first-in-class farnesoid X receptor agonist and antifibrotic agent in development for the treatment of pre-cirrhotic liver fibrosis due to non-alcoholic steatohepatitis (NASH). We aimed to validate the original 18-month liver biopsy analysis from the phase III REGENERATE trial of OCA for the treatment of NASH with a consensus panel analysis, provide additional histology data in a larger population, and evaluate safety from >8,000 total patient-years' exposure with nearly 1,000 participants receiving study drug for >4 years. METHODS Digitized whole-slide images were evaluated independently by panels of three pathologists using the NASH Clinical Research Network scoring system. Primary endpoints were (1) ≥1 stage improvement in fibrosis with no worsening of NASH or (2) NASH resolution with no worsening of fibrosis. Safety was assessed by laboratory values and adverse events. RESULTS Prespecified efficacy analyses included 931 participants. The proportion of participants achieving a ≥1 stage improvement in fibrosis with no worsening of NASH was 22.4% for OCA 25 mg vs. 9.6% for placebo (p <0.0001). More participants receiving OCA 25 mg vs. placebo achieved NASH resolution with no worsening of fibrosis (6.5% vs. 3.5%, respectively; p = 0.093). Histology data in a larger population of 1,607 participants supported these results. Safety data included 2,477 participants. The incidence of treatment-emergent adverse events (TEAEs), serious TEAEs, and deaths was not substantively different across treatment groups. Pruritus was the most common TEAE. Rates of adjudicated hepatic, renal, and cardiovascular events were low and similar across treatment groups. CONCLUSIONS These results confirm the antifibrotic effect of OCA 25 mg. OCA was generally well tolerated over long-term dosing. These data support a positive benefit:risk profile in patients with pre-cirrhotic liver fibrosis due to NASH. IMPACT AND IMPLICATIONS Patients with non-alcoholic steatohepatitis (NASH) often have liver scarring (fibrosis), which causes an increased risk of liver-related illness and death. Preventing progression of fibrosis to cirrhosis or reversing fibrosis are the main goals of drug development for NASH. In this clinical trial of obeticholic acid (OCA) in patients with NASH (REGENERATE), we reaffirmed our previous results demonstrating that OCA was superior to placebo in improving fibrosis using a more rigorous consensus panel analysis of liver biopsies taken at month 18. We also showed that OCA treatment resulted in dose-dependent reductions of serum liver biochemistries and liver stiffness measurements compared with placebo, even in participants in whom histologic fibrosis did not change at 18 months, providing evidence that the benefit of OCA extends beyond what is captured by the ordinal NASH CRN scoring system. OCA was well tolerated with a favorable safety profile supporting a positive benefit: risk profile in patients with pre-cirrhotic liver fibrosis due to NASH.
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Affiliation(s)
- Arun J Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, VA, USA.
| | - Vlad Ratziu
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Institute for Cardiometabolism and Nutrition, Paris, France
| | - Rohit Loomba
- University of California, San Diego, La Jolla, CA, USA
| | - Quentin M Anstee
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle Upon Tyne, UK; Newcastle NIHR Biomedical Research Center, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | - Mary E Rinella
- University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | | | | | | | - Eric J Lawitz
- Texas Liver Institute, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Manal F Abdelmalek
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Philip N Newsome
- National Institute for Health Research Birmingham Biomedical Research Centre, Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Jérôme Boursier
- Angers University Hospital, Angers University, Angers, France
| | | | | | | | | | | | | | - Rina Leyva
- Intercept Pharmaceuticals, Morristown, NJ, USA
| | | | - Zobair M Younossi
- Beatty Liver and Obesity Research Program, Center for Liver Diseases, Inova Medicine, Falls Church, VA, USA
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Harrison SA, Abdelmalek MF, Neff G, Gunn N, Guy CD, Alkhouri N, Bashir MR, Freilich B, Kohli A, Khazanchi A, Sheikh MY, Leibowitz M, Rinella ME, Siddiqui MS, Kipnes M, Moussa SE, Younes ZH, Bansal M, Baum SJ, Borg B, Ruane PJ, Thuluvath PJ, Gottwald M, Khan M, Chen C, Melchor-Khan L, Chang W, DePaoli AM, Ling L, Lieu HD. Aldafermin in patients with non-alcoholic steatohepatitis (ALPINE 2/3): a randomised, double-blind, placebo-controlled, phase 2b trial. Lancet Gastroenterol Hepatol 2022; 7:603-616. [PMID: 35325622 DOI: 10.1016/s2468-1253(22)00017-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 05/06/2023]
Abstract
BACKGROUND Non-alcoholic steatohepatitis (NASH) is characterised by hepatic steatosis, inflammation, and injury, and is associated with an increased risk of liver transplantation and death. NASH affects more than 16 million people in the USA, and there is no approved therapy. The aim of this study was to evaluate the safety and efficacy of aldafermin, an engineered analogue of the gut hormone fibroblast growth factor 19 (FGF19). METHODS In this randomised, double-blind, placebo-controlled, phase 2b study (ALPINE 2/3) in patients with biopsy-confirmed NASH and stage 2 or 3 fibrosis, we randomly assigned patients stratified by fibrosis stage in a 1:1:1:1 ratio to receive placebo, aldafermin 0·3 mg, 1·0 mg, or 3·0 mg once daily for 24 weeks at 30 study sites in the USA. Patients, investigators, the funder, and all other staff, were masked to treatment assignment throughout the study. The primary endpoint was an improvement in liver fibrosis of at least one stage with no worsening of NASH at week 24. Analyses were done by intention-to-treat. This trial is registered with ClinicalTrials.gov, number NCT03912532, and has been completed. FINDINGS Between May 16, 2019, and Sept 4, 2020, 786 patients were screened, of whom 171 were randomly assigned to a treatment group and included in the intention-to-treat population: 43 in the 0·3 mg aldafermin group, 42 in the 1·0 mg group, 43 in the 3·0 mg group, and 43 in the placebo group. In total, 145 (85%) of patients completed treatment. At week 24, among patients with biopsies at both baseline and week 24, was seven (19%) of 36 patients in the placebo group, 11 (31%) of 36 in the 0·3 mg aldafermin group (difference 90% CI 12% [-9 to 33]; p=0·11), five (15%) of 34 patients in the 1·0 mg group (difference -5% [-24 to 13]; p=0·80), and 11 (30%) of 37 patients in the 3·0 mg group (difference 10% [-9 to 30]; p=0·12) had an improvement in liver fibrosis of at least one stage with no worsening of NASH, without meeting the prespecified significance for dose response (p=0·55). Adverse events were mostly mild or moderate in severity. Diarrhoea occurred in six (14%) of 43 patients in the placebo group, three (7%) of 43 patients in the 0·3 mg aldafermin group, five (12%) of 41 patients in the 1·0 mg group, and ten (23%) of 43 patients in the 3·0 mg group. Incidences of serious adverse events and discontinuations owing to adverse events were similar between groups. INTERPRETATION Aldafermin was generally well tolerated but did not produce a significant dose response on fibrosis improvement of at least one stage with no worsening of NASH, despite positive effects on a number of secondary endpoints. The findings of this trial may have implications for the design of future NASH trials. FUNDING NGM Biopharmaceuticals.
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Affiliation(s)
- Stephen A Harrison
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Pinnacle Clinical Research, San Antonio, TX, USA
| | - Manal F Abdelmalek
- Division of Gastroenterology and Hepatology, Duke University, Durham, NC, USA
| | - Guy Neff
- Covenant Research, Sarasota, FL, USA
| | - Nadege Gunn
- Pinnacle Clinical Research, San Antonio, TX, USA
| | - Cynthia D Guy
- Department of Pathology, Duke University, Durham, NC, USA
| | | | - Mustafa R Bashir
- Department of Radiology and Medicine, Duke University, Durham, NC, USA
| | | | | | | | | | | | - Mary E Rinella
- Department of Medicine (Gastroenterology and Hepatology), Northwestern University, Chicago, IL, USA
| | | | - Mark Kipnes
- Diabetes & Glandular Disease Clinic, San Antonio, TX, USA
| | | | | | - Meena Bansal
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Seth J Baum
- Excel Medical Clinical Trials, Boca Raton, FL, USA
| | - Brian Borg
- Southern Therapy and Advanced Research, Jackson, MS, USA
| | | | | | | | - Mujib Khan
- NGM Biopharmaceuticals, South San Francisco, CA, USA
| | - Charles Chen
- NGM Biopharmaceuticals, South San Francisco, CA, USA
| | | | - William Chang
- NGM Biopharmaceuticals, South San Francisco, CA, USA
| | | | - Lei Ling
- NGM Biopharmaceuticals, South San Francisco, CA, USA.
| | - Hsiao D Lieu
- NGM Biopharmaceuticals, South San Francisco, CA, USA
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Fouad Y, Palmer M, Chen M, Regev A, Banerjee R, Myers R, Riccio R, Torstenson R, Younes R, Arora PS, Landgren H, Karsdal MA, Blake M, Shapiro DA, Gruss HJ, Sheikh MY, Attia D, Bollipo S, Smith AD, Freilich B, Gish RG, Schuppan D. Redefinition of Fatty Liver Disease from NAFLD to MAFLD through the Lens of Drug Development and Regulatory Science. J Clin Transl Hepatol 2022; 10:374-382. [PMID: 35528969 PMCID: PMC9039717 DOI: 10.14218/jcth.2021.00408] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 09/25/2021] [Accepted: 09/30/2021] [Indexed: 12/04/2022] Open
Abstract
Metabolic (dysfunction)-associated fatty liver disease (MAFLD) affects a third of the population and is a leading cause of liver-related death. Since no effective treatments exist, novel approaches to drug development are required. Unfortunately, outdated terminology and definitions of the disease are hampering efforts to develop new drugs and treatments. An international consensus panel has put forth an influential proposal for the disease to be renamed from nonalcoholic fatty liver disease (NAFLD) to MAFLD, including a proposal for how the disease should be diagnosed. As allies with the many stakeholders in MAFLD care-including patients, patients' advocates, clinicians, researchers, nurse and allied health groups, regional societies, and others-we are aware of the negative consequences of the NAFLD term and definition. We share the sense of urgency for change and will act in new ways to achieve our goals. Although there is much work to be done to overcome clinical inertia and reverse worrisome recent trends, the MAFLD initiative provides a firm foundation to build on. It provides a roadmap for moving forward toward more efficient care and affordable, sustainable drug and device innovation in MAFLD care. We hope it will bring promising new opportunities for a brighter future for MAFLD care and improve care and outcomes for patients of one of the globe's largest and costliest public health burdens. From this viewpoint, we have revisited this initiative through the perspectives of drug development and regulatory science.
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Affiliation(s)
- Yasser Fouad
- Department of Gastroenterology, Hepatology, and Endemic Medicine, Faculty of Medicine, Minia University, Minia, Egypt
- Correspondence to: Yasser Fouad, Endemic Medicine Department, Minia University, Main Road, Minia 11432, Egypt. Tel: +20-1091318555, Fax: +20-1-114721500, E-mail: ; Detlef Schuppan, Institute of Translational Immunology and Research Center for Immune Therapy, University Medical Center, Mainz, Germany; Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA. Tel: +49-6131-17-7356, Fax: +49-6131-177357, E-mail:
| | - Melissa Palmer
- Gannex/Ascletis Pharma Co Ltd, Beijing, China
- Liver Consulting LLC, New York, NY, USA
| | - Minjun Chen
- Division of Bioinformatics and Biostatistics, National Center for Toxicological Research, US Food and Drug Administration, Jefferson, AR, USA
| | - Arie Regev
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Rob Myers
- Gilead Sciences Inc, Foster City, CA, USA
| | | | | | - Ramy Younes
- Boehringer Ingelheim International, GmbH, Ingelheim, Germany
| | | | | | | | | | | | | | | | - Dina Attia
- Gastroenterology and Hepatology Department, Beni-Suef University, Beni Suef, Egypt
| | - Steven Bollipo
- Department of Gastroenterology and Endoscopy, John Hunter Hospital, Newcastle, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | | | | | - Robert G. Gish
- Division of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, CA, USA
| | - Detlef Schuppan
- Institute of Translational Immunology and Research Center for Immune Therapy, University Medical Center, Mainz, Germany
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Correspondence to: Yasser Fouad, Endemic Medicine Department, Minia University, Main Road, Minia 11432, Egypt. Tel: +20-1091318555, Fax: +20-1-114721500, E-mail: ; Detlef Schuppan, Institute of Translational Immunology and Research Center for Immune Therapy, University Medical Center, Mainz, Germany; Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA. Tel: +49-6131-17-7356, Fax: +49-6131-177357, E-mail:
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4
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Younossi ZM, Ratziu V, Loomba R, Rinella M, Anstee QM, Goodman Z, Bedossa P, Geier A, Beckebaum S, Newsome PN, Sheridan D, Sheikh MY, Trotter J, Knapple W, Lawitz E, Abdelmalek MF, Kowdley KV, Montano-Loza AJ, Boursier J, Mathurin P, Bugianesi E, Mazzella G, Olveira A, Cortez-Pinto H, Graupera I, Orr D, Gluud LL, Dufour JF, Shapiro D, Campagna J, Zaru L, MacConell L, Shringarpure R, Harrison S, Sanyal AJ. Obeticholic acid for the treatment of non-alcoholic steatohepatitis: interim analysis from a multicentre, randomised, placebo-controlled phase 3 trial. Lancet 2019. [PMID: 31813633 DOI: 10.3410/f.725273573.793504763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Non-alcoholic steatohepatitis (NASH) is a common type of chronic liver disease that can lead to cirrhosis. Obeticholic acid, a farnesoid X receptor agonist, has been shown to improve the histological features of NASH. Here we report results from a planned interim analysis of an ongoing, phase 3 study of obeticholic acid for NASH. METHODS In this multicentre, randomised, double-blind, placebo-controlled study, adult patients with definite NASH, non-alcoholic fatty liver disease (NAFLD) activity score of at least 4, and fibrosis stages F2-F3, or F1 with at least one accompanying comorbidity, were randomly assigned using an interactive web response system in a 1:1:1 ratio to receive oral placebo, obeticholic acid 10 mg, or obeticholic acid 25 mg daily. Patients were excluded if cirrhosis, other chronic liver disease, elevated alcohol consumption, or confounding conditions were present. The primary endpoints for the month-18 interim analysis were fibrosis improvement (≥1 stage) with no worsening of NASH, or NASH resolution with no worsening of fibrosis, with the study considered successful if either primary endpoint was met. Primary analyses were done by intention to treat, in patients with fibrosis stage F2-F3 who received at least one dose of treatment and reached, or would have reached, the month 18 visit by the prespecified interim analysis cutoff date. The study also evaluated other histological and biochemical markers of NASH and fibrosis, and safety. This study is ongoing, and registered with ClinicalTrials.gov, NCT02548351, and EudraCT, 20150-025601-6. FINDINGS Between Dec 9, 2015, and Oct 26, 2018, 1968 patients with stage F1-F3 fibrosis were enrolled and received at least one dose of study treatment; 931 patients with stage F2-F3 fibrosis were included in the primary analysis (311 in the placebo group, 312 in the obeticholic acid 10 mg group, and 308 in the obeticholic acid 25 mg group). The fibrosis improvement endpoint was achieved by 37 (12%) patients in the placebo group, 55 (18%) in the obeticholic acid 10 mg group (p=0·045), and 71 (23%) in the obeticholic acid 25 mg group (p=0·0002). The NASH resolution endpoint was not met (25 [8%] patients in the placebo group, 35 [11%] in the obeticholic acid 10 mg group [p=0·18], and 36 [12%] in the obeticholic acid 25 mg group [p=0·13]). In the safety population (1968 patients with fibrosis stages F1-F3), the most common adverse event was pruritus (123 [19%] in the placebo group, 183 [28%] in the obeticholic acid 10 mg group, and 336 [51%] in the obeticholic acid 25 mg group); incidence was generally mild to moderate in severity. The overall safety profile was similar to that in previous studies, and incidence of serious adverse events was similar across treatment groups (75 [11%] patients in the placebo group, 72 [11%] in the obeticholic acid 10 mg group, and 93 [14%] in the obeticholic acid 25 mg group). INTERPRETATION Obeticholic acid 25 mg significantly improved fibrosis and key components of NASH disease activity among patients with NASH. The results from this planned interim analysis show clinically significant histological improvement that is reasonably likely to predict clinical benefit. This study is ongoing to assess clinical outcomes. FUNDING Intercept Pharmaceuticals.
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Affiliation(s)
- Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Vlad Ratziu
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Institute for Cardiometabolism and Nutrition, Paris, France
| | - Rohit Loomba
- NAFLD Rsearch Center, University of California San Diego, San Diego, CA, USA
| | - Mary Rinella
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Quentin M Anstee
- The Newcastle Liver Research Group, Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Zachary Goodman
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Pierre Bedossa
- Service d'Anatomie Pathologique, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Andreas Geier
- Department of Hepatology, University of Wuerzburg, Wuerzburg, Germany
| | | | - Philip N Newsome
- National Institute for Health Research Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK; Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - David Sheridan
- Institute of Translational & Stratified Medicine, University of Plymouth and University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - James Trotter
- Baylor Health, Liver Consultants of Texas, Dallas, TX, USA
| | | | - Eric Lawitz
- Texas Liver Institute, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Manal F Abdelmalek
- Division of Gastroenterology and Hepatology, Duke University Medical Center, Durham, NC, USA
| | | | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Canada
| | - Jerome Boursier
- HIFIH Laboratory, UPRES EA3859, SFR 4208, Angers University, Angers, France; Hepato-Gastroenterology Department, Angers University Hospital, Angers, France
| | | | | | - Giuseppe Mazzella
- Dipartimento di Scienze Mediche e Chirurgiche, University of Bologna, Bologna, Italy
| | - Antonio Olveira
- Department of Gastroenterology, Hospital Universitario La Paz, Madrid, Spain
| | - Helena Cortez-Pinto
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Isabel Graupera
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Spain; Institut D'investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - David Orr
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - Lise Lotte Gluud
- The Gastrounit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Jean-Francois Dufour
- University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | | | | | - Luna Zaru
- Intercept Pharmaceuticals, San Diego, CA, USA
| | | | | | | | - Arun J Sanyal
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, VA, USA.
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5
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Younossi ZM, Ratziu V, Loomba R, Rinella M, Anstee QM, Goodman Z, Bedossa P, Geier A, Beckebaum S, Newsome PN, Sheridan D, Sheikh MY, Trotter J, Knapple W, Lawitz E, Abdelmalek MF, Kowdley KV, Montano-Loza AJ, Boursier J, Mathurin P, Bugianesi E, Mazzella G, Olveira A, Cortez-Pinto H, Graupera I, Orr D, Gluud LL, Dufour JF, Shapiro D, Campagna J, Zaru L, MacConell L, Shringarpure R, Harrison S, Sanyal AJ. Obeticholic acid for the treatment of non-alcoholic steatohepatitis: interim analysis from a multicentre, randomised, placebo-controlled phase 3 trial. Lancet 2019; 394:2184-2196. [PMID: 31813633 DOI: 10.1016/s0140-6736(19)33041-7] [Citation(s) in RCA: 724] [Impact Index Per Article: 144.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 10/24/2019] [Accepted: 10/30/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Non-alcoholic steatohepatitis (NASH) is a common type of chronic liver disease that can lead to cirrhosis. Obeticholic acid, a farnesoid X receptor agonist, has been shown to improve the histological features of NASH. Here we report results from a planned interim analysis of an ongoing, phase 3 study of obeticholic acid for NASH. METHODS In this multicentre, randomised, double-blind, placebo-controlled study, adult patients with definite NASH, non-alcoholic fatty liver disease (NAFLD) activity score of at least 4, and fibrosis stages F2-F3, or F1 with at least one accompanying comorbidity, were randomly assigned using an interactive web response system in a 1:1:1 ratio to receive oral placebo, obeticholic acid 10 mg, or obeticholic acid 25 mg daily. Patients were excluded if cirrhosis, other chronic liver disease, elevated alcohol consumption, or confounding conditions were present. The primary endpoints for the month-18 interim analysis were fibrosis improvement (≥1 stage) with no worsening of NASH, or NASH resolution with no worsening of fibrosis, with the study considered successful if either primary endpoint was met. Primary analyses were done by intention to treat, in patients with fibrosis stage F2-F3 who received at least one dose of treatment and reached, or would have reached, the month 18 visit by the prespecified interim analysis cutoff date. The study also evaluated other histological and biochemical markers of NASH and fibrosis, and safety. This study is ongoing, and registered with ClinicalTrials.gov, NCT02548351, and EudraCT, 20150-025601-6. FINDINGS Between Dec 9, 2015, and Oct 26, 2018, 1968 patients with stage F1-F3 fibrosis were enrolled and received at least one dose of study treatment; 931 patients with stage F2-F3 fibrosis were included in the primary analysis (311 in the placebo group, 312 in the obeticholic acid 10 mg group, and 308 in the obeticholic acid 25 mg group). The fibrosis improvement endpoint was achieved by 37 (12%) patients in the placebo group, 55 (18%) in the obeticholic acid 10 mg group (p=0·045), and 71 (23%) in the obeticholic acid 25 mg group (p=0·0002). The NASH resolution endpoint was not met (25 [8%] patients in the placebo group, 35 [11%] in the obeticholic acid 10 mg group [p=0·18], and 36 [12%] in the obeticholic acid 25 mg group [p=0·13]). In the safety population (1968 patients with fibrosis stages F1-F3), the most common adverse event was pruritus (123 [19%] in the placebo group, 183 [28%] in the obeticholic acid 10 mg group, and 336 [51%] in the obeticholic acid 25 mg group); incidence was generally mild to moderate in severity. The overall safety profile was similar to that in previous studies, and incidence of serious adverse events was similar across treatment groups (75 [11%] patients in the placebo group, 72 [11%] in the obeticholic acid 10 mg group, and 93 [14%] in the obeticholic acid 25 mg group). INTERPRETATION Obeticholic acid 25 mg significantly improved fibrosis and key components of NASH disease activity among patients with NASH. The results from this planned interim analysis show clinically significant histological improvement that is reasonably likely to predict clinical benefit. This study is ongoing to assess clinical outcomes. FUNDING Intercept Pharmaceuticals.
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Affiliation(s)
- Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Vlad Ratziu
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Institute for Cardiometabolism and Nutrition, Paris, France
| | - Rohit Loomba
- NAFLD Rsearch Center, University of California San Diego, San Diego, CA, USA
| | - Mary Rinella
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Quentin M Anstee
- The Newcastle Liver Research Group, Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Zachary Goodman
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Pierre Bedossa
- Service d'Anatomie Pathologique, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Andreas Geier
- Department of Hepatology, University of Wuerzburg, Wuerzburg, Germany
| | | | - Philip N Newsome
- National Institute for Health Research Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK; Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - David Sheridan
- Institute of Translational & Stratified Medicine, University of Plymouth and University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - James Trotter
- Baylor Health, Liver Consultants of Texas, Dallas, TX, USA
| | | | - Eric Lawitz
- Texas Liver Institute, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Manal F Abdelmalek
- Division of Gastroenterology and Hepatology, Duke University Medical Center, Durham, NC, USA
| | | | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Canada
| | - Jerome Boursier
- HIFIH Laboratory, UPRES EA3859, SFR 4208, Angers University, Angers, France; Hepato-Gastroenterology Department, Angers University Hospital, Angers, France
| | | | | | - Giuseppe Mazzella
- Dipartimento di Scienze Mediche e Chirurgiche, University of Bologna, Bologna, Italy
| | - Antonio Olveira
- Department of Gastroenterology, Hospital Universitario La Paz, Madrid, Spain
| | - Helena Cortez-Pinto
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Isabel Graupera
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Spain; Institut D'investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - David Orr
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - Lise Lotte Gluud
- The Gastrounit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Jean-Francois Dufour
- University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | | | | | - Luna Zaru
- Intercept Pharmaceuticals, San Diego, CA, USA
| | | | | | | | - Arun J Sanyal
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, VA, USA.
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Atla PR, Sheikh MY, Gill F, Kundu R, Choudhury J. Predictors of hospital re-admissions among Hispanics with hepatitis C-related cirrhosis. Ann Gastroenterol 2016; 29:515-520. [PMID: 27708520 PMCID: PMC5049561 DOI: 10.20524/aog.2016.0072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 06/23/2016] [Indexed: 12/23/2022] Open
Abstract
Background Hospital re-admissions in decompensated cirrhosis are associated with worse patient outcomes. Hispanics have a disproportionately high prevalence of hepatitis C virus (HCV)-related morbidity and mortality. The goal of this study was to evaluate the factors affecting re-admission rates among Hispanics with HCV-related cirrhosis. Methods A total of 292 consecutive HCV-related cirrhosis admissions (Hispanics 189, non-Hispanics 103) from January 2009 to December 2012 were retrospectively reviewed; 132 were cirrhosis-related re-admissions. The statistical analysis was performed using STATA version 11.1. Chi-square/Fisher’s exact and Student’s t-tests were used to compare categorical and continuous variables, respectively. Multivariate logistic regression analysis was performed to identify predictors for hospital readmissions. Results Among the 132 cirrhosis-related readmissions, 71% were Hispanics while 29% were non-Hispanics (P=0.035). Hepatic encephalopathy (HE) and esophageal variceal hemorrhage were the most frequent causes of the first and subsequent readmissions. Hispanics with readmissions had a higher Child-Turcotte-Pugh (CTP) class (B and C) and higher model for end-stage liver disease (MELD) scores (≥15), as well as a higher incidence of alcohol use, HE, spontaneous bacterial peritonitis, hepatocellular carcinoma, and varices (P<0.05). The majority of the study patients (81%) had MELD scores <15. Multivariate regression analysis identified alcohol use (OR 2.63; 95%CI 1.1-6.4), HE (OR 5.5; 95%CI 2-15.3), varices (OR 3.2; 95%CI 1.3-8.2), and CTP class (OR 3.3; 95%CI 1.4–8.1) as predictors for readmissions among Hispanics. Conclusion CTP classes B and C, among other factors, were the major predictors for hospital readmissions in Hispanics with HCV-related cirrhosis. The majority of these readmissions were due to HE and variceal hemorrhage.
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Affiliation(s)
- Pradeep R Atla
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Francisco, Fresno MEP (Pradeep R. Atla, Muhammad Y. Sheikh, Rabindra Kundu, Jayanta Choudhury), Fresno, California, USA
| | - Muhammad Y Sheikh
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Francisco, Fresno MEP (Pradeep R. Atla, Muhammad Y. Sheikh, Rabindra Kundu, Jayanta Choudhury), Fresno, California, USA
| | - Firdose Gill
- Department of Medicine, Kaiser Permanente Fresno Medical Center (Firdose Gill), Fresno, California, USA
| | - Rabindra Kundu
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Francisco, Fresno MEP (Pradeep R. Atla, Muhammad Y. Sheikh, Rabindra Kundu, Jayanta Choudhury), Fresno, California, USA
| | - Jayanta Choudhury
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Francisco, Fresno MEP (Pradeep R. Atla, Muhammad Y. Sheikh, Rabindra Kundu, Jayanta Choudhury), Fresno, California, USA
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Dever JB, Sheikh MY. Editorial: spontaneous bacterial peritonitis--bacteriology, diagnosis, treatment, risk factors and prevention. Authors' reply. Aliment Pharmacol Ther 2015; 41:1298. [PMID: 25968149 DOI: 10.1111/apt.13226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- J B Dever
- Department of Gastroenterology, San Diego VA Healthcare System, San Diego, CA, USA.
| | - M Y Sheikh
- Division of Gastroenterology & Hepatology, University of California San Francisco, Fresno, CA, USA
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8
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Dever JB, Sheikh MY. Review article: spontaneous bacterial peritonitis--bacteriology, diagnosis, treatment, risk factors and prevention. Aliment Pharmacol Ther 2015; 41:1116-31. [PMID: 25819304 DOI: 10.1111/apt.13172] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Revised: 02/02/2015] [Accepted: 03/03/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a severe and often fatal infection in patients with cirrhosis and ascites. AIM To review the known and changing bacteriology, risk factors, ascitic fluid interpretation, steps in performing paracentesis, treatment, prophylaxis and evolving perspectives related to SBP. METHODS Information was obtained from reviewing medical literature accessible on PubMed Central. The search term 'spontaneous bacterial peritonitis' was cross-referenced with 'bacteria', 'risk factors', 'ascites', 'paracentesis', 'ascitic fluid analysis', 'diagnosis', 'treatment', 'antibiotics', 'prophylaxis', 'liver transplantation' and 'nutrition'. RESULTS Gram-positive cocci (GPC) such as Staphylococcus, Enterococcus as well as multi-resistant bacteria have become common pathogens and have changed the conventional approach to treatment of SBP. Health care-associated and nosocomial SBP infections should prompt greater vigilance and consideration for alternative antibiotic coverage. Acid suppressive and beta-adrenergic antagonist therapies are strongly associated with SBP in at-risk individuals. CONCLUSIONS Third-generation, broad-spectrum cephalosporins remain a good initial choice for SBP treatment. Levofloxacin is an acceptable alternative for patients not receiving long-term flouroquinolone prophylaxis or for those with a penicillin allergy. For uncomplicated SBP, early oral switch therapy is reasonable. Alternative antibiotics such as pipercillin-tazobactam should be considered for patients with nosocomial SBP or for patients who fail to improve on traditional antibiotic regimens. Selective albumin supplementation remains an important adjunct in SBP treatment. Withholding acid suppressive medication deserves strong consideration, and discontinuing beta-adrenergic antagonist therapy in patients with end-stage liver disease and resistant ascites is standard care. Liver transplant evaluation should be undertaken for patients who develop SBP barring contraindications.
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Affiliation(s)
- J B Dever
- Department of Gastroenterology, VA San Diego Healthcare System, San Diego, CA, USA
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Mullen KD, Sanyal AJ, Bass NM, Poordad FF, Sheikh MY, Frederick RT, Bortey E, Forbes WP. Rifaximin is safe and well tolerated for long-term maintenance of remission from overt hepatic encephalopathy. Clin Gastroenterol Hepatol 2014; 12:1390-7.e2. [PMID: 24365449 DOI: 10.1016/j.cgh.2013.12.021] [Citation(s) in RCA: 142] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 12/05/2013] [Accepted: 12/06/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Rifaximin is a gut-selective, oral antimicrobial agent shown to reduce the recurrence of overt hepatic encephalopathy (HE) and HE-related hospitalizations in a 6-month, randomized, controlled trial (RCT). We performed a phase 3, open-label maintenance study to assess the safety and rate of hospitalization with long-term rifaximin use. METHODS We conducted a 24-month, open-label maintenance study of rifaximin (550 mg, twice daily) in patients with HE who participated in the previous RCT of rifaximin or new patients enrolled from March 2007 to December 2010. Safety was assessed (adverse events, clinical laboratory parameters) for the integrated population of all patients, who were given rifaximin 550 mg twice daily (all-rifaximin population, N = 392). Safety and hospitalization data were compared between the group given placebo in the original RCT (n = 159) and those given rifaximin (n = 140). RESULTS In the all-rifaximin population, the median exposure to rifaximin was 427.0 days (range, 2-1427 d), with 510.5 person-years of exposure. The profile and rate of adverse events with long-term rifaximin treatment were similar to those of the original RCT. There was no increase in the rate of infections, including with Clostridium difficile, or development of bacterial antibiotic resistance. Rates of hospitalizations with long-term rifaximin administration remained low: the HE-related hospitalization rate, normalized for exposure (0.21; all-rifaximin population), was similar to that of the rifaximin group in the original RCT (0.30), and lower than that for the placebo group (0.72). CONCLUSIONS Long-term treatment (≥24 mo) with rifaximin (550 mg, twice daily) appears to provide a continued reduction in the rate of HE-related and all-cause hospitalization, without an increased rate of adverse events. ClinicalTrials.gov number: NCT00686920.
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Affiliation(s)
- Kevin D Mullen
- Case Western Reserve University School of Medicine, Cleveland, Ohio.
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, Richmond, Virginia
| | - Nathan M Bass
- Divison of Gastroenterology, University of California San Francisco, San Francisco, California
| | - Fred F Poordad
- The Texas Liver Institute/University of Texas Health Science Center, San Antonio, Texas
| | - Muhammad Y Sheikh
- University of California San Francisco Fresno Medical Education Program, Fresno, California
| | - R Todd Frederick
- Division of Hepatology, California Pacific Medical Center, San Francisco, California
| | - Enoch Bortey
- Salix Pharmaceuticals, Inc, Raleigh, North Carolina
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Mathur J, Guthrie JD, Javed U, Sheikh MY. Evaluation of the Association between Compensated Hepatitis C Infectivity and Endothelial Dysfunction, Using Flow-Mediated Vasodilatation of the Brachial Artery. Journal of Diagnostic Medical Sonography 2014. [DOI: 10.1177/8756479314531854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background and Aim: We prospectively investigated, using sonographic methods, whether hepatitis C infection in compensated patients is related to endothelial dysfunction of the brachial artery, a potential indicator of subclinical atherosclerosis. Methods: Brachial artery flow-mediated dilatation (FMD) was used as a noninvasive test to measure the endothelial function of the brachial artery among the cases and the controls. The peak systolic velocity (PSV) and the resistive index (RI) were also measured. Multivariate statistics were used to compare the FMD, PSV, and RI in 28 cases (diagnosed with hepatitis C) and 14 healthy controls, all of whom were without cardiovascular risk factors or a history of cardiovascular disease. Results: Flow-mediated dilatation (baseline to 1 minute post-cuff inflation) was positively correlated with the patient’s body mass index (BMI) (Pearson’s r = .309, P = .025). When the BMI was accounted for using analysis of covariance (ANCOVA), there was no evidence for a significant difference between the mean FMD of the cases versus the controls ( F = 0.11, P = .598). The mean FMD was 6.6% (95% confidence interval [CI], 3.1%-10.2%) among the cases and 7.3% (95% CI, 1.1%-13.6%) among the controls. Peak systolic velocity and RI (baseline to 3 minutes post-cuff inflation) were not positively correlated with BMI. The mean PSV was 0.57 m/s (95% CI, 0.51-0.66) for the cases and 0.64 m/s (95% CI, 0.56-0.72) for the controls; repeated measures analysis of variance (ANOVA) indicated no significant difference ( F = 1.65, P = .208). Similarly, the mean RI was 0.87 (95% CI, 0.85-0.89) among the cases and 0.64 (95% CI, 0.82-0.88) among the controls, with no significant difference ( P = .772). Conclusion: Our results show that hepatitis C positivity in compensated patients, in the absence of cardiovascular risk factors, does not appear to be independently associated with endothelial dysfunction when objectively analyzed by brachial artery flow-mediated vasodilatation.
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Affiliation(s)
- Jagrati Mathur
- Division of Internal Medicine, University of California, San Francisco, Fresno, CA, USA
| | - Joy D. Guthrie
- Medical Imaging, Community Regional Medical Center, Fresno, CA, USA
| | - Usman Javed
- Medical Imaging, Community Regional Medical Center, Fresno, CA, USA
- Division of Cardiology, University of California, San Francisco, Fresno, CA, USA
| | - Muhammad Y. Sheikh
- Division of Gastroenterology, University of California, San Francisco, Fresno, CA, USA
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Sheikh MY, Atla PR, Ameer A, Sadiq H, Sadler PC. Seroprevalence of Hepatitis B and C Infections among Healthy Volunteer Blood Donors in the Central California Valley. Gut Liver 2012; 7:66-73. [PMID: 23423771 PMCID: PMC3572322 DOI: 10.5009/gnl.2013.7.1.66] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 05/17/2012] [Accepted: 06/10/2012] [Indexed: 12/29/2022] Open
Abstract
Background/Aims The Central California Valley has a diverse population with significant proportions of Hispanics and Asians. This cross-sectional study was conducted to evaluate the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) in healthy blood donors in the Valley. Methods A total of 217,738 voluntary blood donors were identified between 2006 and 2010 (36,795 first-time donors; 180,943 repeat donors). Results Among the first-time donors, the HBV and HCV prevalence was 0.28% and 0.52%, respectively. Higher HBV prevalence seen in Asians (3%) followed by Caucasians (0.05%), African Americans (0.15%), and Hispanics (0.05%). Hmong had a HBV prevalence of 7.63% with a peak prevalence of 8.76% among the 16- to 35-year-old age group. Highest HCV prevalence in Native Americans (2.8) followed by Caucasians (0.59%), Hispanics (0.45%), African Americans (0.38%), and Asians (0.2%). Conclusions Ethnic disparities persist with regard to the prevalence of HBV and HCV in the Central California Valley. The reported prevalence may be an underestimate because our study enrolled healthy volunteer blood donors only. The development of aggressive public health measures to evaluate the true prevalence of HBV and HCV and to identify those in need of HBV and HCV prevention measures and therapy is critically important.
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Affiliation(s)
- Muhammad Y Sheikh
- Division of Gastroenterology & Hepatology, University of California San Francisco Fresno Medical Education Program, Fresno, CA, USA. ; Department of Medicine, Community Regional Medical Center, University of California San Francisco Fresno Medical Education Program, Fresno, CA, USA
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12
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Guthrie JD, Sheikh MY, Morrell S, Neal D. A Case-Control Study to Compare the Likelihood of Detecting Liver Disorders Using Coincident Measures of Doppler-Derived Portal Vein Pressure Gradients, Hepatic Venous Waveforms, and the Echogenicity of Liver Parenchyma. Journal of Diagnostic Medical Sonography 2012. [DOI: 10.1177/8756479312450617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A case-control study based on the records of 465 adult patients receiving abdominal sonograms predicted the likelihood of liver damage, as detected by serum biomarkers, biopsy, and/or endoscopy, to increase systematically with respect to (a) an increase in echogenicity from grade 1 (odds ratio [OR] = 2.94) through 2 (OR = 10.50) to 3 (OR = 14.91) coincident with (b) a dampening of the hepatic venous waveform (HVW) from biphasic (OR = 1.66) to monophasic (OR = 3.68) and (c) a simultaneous elevation in the portal vein pressure gradient, adjusted for portal vein diameter (PVPG) from level 1 (OR = 1.85) through 2 (OR = 3.23) to 3 (OR = 3.35). Echogenicity consistently exhibited higher sensitivities but lower specificities than the HVW and PVPG. The lowest specificities were found among patients with a body mass index >25, proposed to be associated with intrahepatic fat infiltration causing false positives in the absence of hepatopathology.
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Affiliation(s)
- Joy D. Guthrie
- FSDMS Community Regional Medical Center, Fresno, CA, USA
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13
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Ratziu V, Sheikh MY, Sanyal AJ, Lim JK, Conjeevaram H, Chalasani N, Abdelmalek M, Bakken A, Renou C, Palmer M, Levine RA, Bhandari BR, Cornpropst M, Liang W, King B, Mondou E, Rousseau FS, McHutchison J, Chojkier M. A phase 2, randomized, double-blind, placebo-controlled study of GS-9450 in subjects with nonalcoholic steatohepatitis. Hepatology 2012; 55:419-28. [PMID: 22006541 PMCID: PMC3779694 DOI: 10.1002/hep.24747] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 09/14/2011] [Indexed: 12/13/2022]
Abstract
UNLABELLED In nonalcoholic steatohepatitis (NASH), the extent of hepatocyte apoptosis correlates with disease severity. Reducing hepatocyte apoptosis with the selective caspase inhibitor GS-9450 has a potential for altering the course of the liver disease. In this phase 2, double-blind study, 124 subjects with biopsy-proven NASH were randomized to once-daily placebo or 1, 5, 10, or 40 mg GS-9450 for 4 weeks. Absolute and percent changes from baseline in ALT levels, AST levels, and caspase-3-cleaved cytokeratin (CK)-18 fragments at week 4 were assessed by an analysis of covariance model with adjustment for baseline values. In the 40-mg group, mean (SD) ALT decreased by 47 (43) U/L from baseline to week 4 (P < 0.0001 versus placebo), and the proportion of subjects with normal ALT increased from 0% to 35% at week 4. In the 40-mg group, mean AST decreased by 13 U/L from baseline (not significant), and the proportion with normal AST increased from 20% at baseline to 48% at week 4. By week 4, mean CK-18 fragment levels had decreased to 393 (723) U/L in the GS-9450 10-mg group and 125 (212) U/L in the 40-mg group, but these reductions were not statistically significant. No serious adverse events were reported during treatment, and the percentage of subjects with at least one treatment-emergent grade 3 or 4 laboratory abnormality ranged from 11.5% to 17% across the GS-9450 treatment groups versus 35% in the placebo group. CONCLUSION GS-9450 treatment induced significant reductions in ALT levels in NASH patients. Reductions in CK-18 fragment levels also occurred, although they were not statistically significant. At appropriate therapeutic indices, selective caspase inhibitors may be a promising treatment option in patients with NASH.
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Affiliation(s)
- Vlad Ratziu
- Université Pierre et Marie Curie, Hôpital Pitié-Salpêtrière, Paris, France.
| | | | - Arun J. Sanyal
- Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Joseph K. Lim
- Yale Liver Center, Yale University School of Medicine, New Haven, CT
| | | | | | - Manal Abdelmalek
- Department of Medicine, Duke University Medical Center, Durham, NC
| | | | | | | | - Robert A. Levine
- Division of Gastroenterology, State University of New York Upstate Medical University, Syracuse, NY
| | | | | | - Wei Liang
- Gilead Sciences, Inc., Foster City, CA
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Atla PR, Sheikh MY, Mascarenhas R, Choudhury J, Mills P. Survival of patients with hepatocellular carcinoma in the San Joaquin Valley: a comparison with California Cancer Registry data. Ann Gastroenterol 2012; 25:138-146. [PMID: 24714222 PMCID: PMC3959402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Accepted: 02/21/2012] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Variation in the survival of patients with hepatocellular carcinoma (HCC) is related to racial differences, socioeconomic disparities and treatment options among different populations. METHODS A retrospective review of the data from medical records of patients diagnosed with HCC were analyzed at an urban tertiary referral teaching hospital and compared to patients in the California Cancer Registry (CCR) - a participant in the Survival Epidemiology and End Results (SEER)program of the National Cancer Institute (NCI). The main outcome measure was overall survival rates. RESULTS 160 patients with the diagnosis of HCC (M/F=127/33), mean age 59.7±10 years, 32% white, 49% Hispanic, 12% Asian and 6% African American. Multivariate analysis identified tumor size, model for end-stage liver disease (MELD) score, portal vein invasion and treatment offered as the independent predictors of survival (p <0.05). Survival rates across racial groups were not statistically significant. 5.6% received curative treatments (orthotopic liver transplantation, resection, rediofrequency ablation) (median survival 69 months), 34.4% received nonsurgical treatments (trans-arterial chemoembolization, systemic chemotherapy) (median survival 9 months), while 60% received palliative or no treatment (median survival 3 months) (p <0.001). CONCLUSION There was decreased survival in our patient population with HCC beyond 2 years. 60% of our study population received only palliative or no treatment suggesting a possible lack of awareness of chronic liver disease as well as access to appropriate surveillance modalities. Ethnic disparities such as Hispanic predominance in this study in contrast to the CCR/SEER database may have been a contributing factor for poorer outcome.
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Affiliation(s)
- Pradeep R. Atla
- Department of Medicine, Community Regional Medical Center (Pradeep R. Atla)
| | - Muhammad Y. Sheikh
- Department of Internal Medicine (Muhammad Y. Sheikh, Ranjan Mascarenhas, Jayanta Choudhury, Paul Mills),Division of Gastroenterology and Hepatology (Muhammad Y. Sheikh, Ranjan Mascarenhas, Jayanta Choudhury), UCSF Fresno MEP, California, USA,
Correspondence to: Muhammad Y. Sheikh, MD, FACP, FACG, Ass. Prof. of Clinical Medicine & Surgery, University of California San Francisco (UCSF), Chief, Division of Gastroenterology & Hepatology, UCSF-Fresno, Community Regional Medical Center, 2826 Fresno Street, Endoscopy Suite, 1st Floor, Fresno, California 93701, USA, Tel: +1 559 459 3882, Fax: +1 559 459 3887, e-mail:
| | - Ranjan Mascarenhas
- Department of Internal Medicine (Muhammad Y. Sheikh, Ranjan Mascarenhas, Jayanta Choudhury, Paul Mills),Division of Gastroenterology and Hepatology (Muhammad Y. Sheikh, Ranjan Mascarenhas, Jayanta Choudhury), UCSF Fresno MEP, California, USA
| | - Jayanta Choudhury
- Department of Internal Medicine (Muhammad Y. Sheikh, Ranjan Mascarenhas, Jayanta Choudhury, Paul Mills),Division of Gastroenterology and Hepatology (Muhammad Y. Sheikh, Ranjan Mascarenhas, Jayanta Choudhury), UCSF Fresno MEP, California, USA
| | - Paul Mills
- Department of Internal Medicine (Muhammad Y. Sheikh, Ranjan Mascarenhas, Jayanta Choudhury, Paul Mills)
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Abstract
BACKGROUND/AIM Thrombocytopenia is a common finding in patients with cirrhosis and may lead to unnecessary referral for bone marrow (BM) biopsy. To date, the prevalence of cirrhosis in patients with thrombocytopenia who receive BM biopsy is largely unknown. MATERIALS AND METHODS Between fiscal years 2006-2010, 744 patients (≥18 years) who underwent BM biopsies for thrombocytopenia at our hospital were identified retrospectively. 541 patients were excluded who had hematologic malignancies and received chemotherapy. Remaining 203 patients with predominant isolated thrombocytopenia were included in the study. RESULTS Of 203 patients, 136 (67%) had a normal and 67 (33%) had an abnormal BM examination. Prevalence of cirrhosis in the study population was 35% (95% CI: 28.4-41.9). 51% patients with normal BM were found to have cirrhosis compared to 3% of patients with abnormal BM exam (P < 0.0001). Common causes of cirrhosis were nonalcoholic steatohepatitis (NASH) (47%), followed by alcohol and Hepatitis C virus infection. Idiopathic thrombocytopenia and myelodysplastic syndrome were most frequent causes of thrombocytopenia in patients without cirrhosis. Patients with NASH had higher body mass index (BMI) (33.4 vs. 25.8, P < 0.001) and lower MELD scores (11.1 vs. 16, P = 0.028) when compared to non-NASH patients with cirrhosis. CONCLUSION Approximately, one third (35%) of patients with cirrhosis induced thrombocytopenia may undergo unwarranted BM biopsies. Clinical diagnosis of cirrhosis is still a challenge for many physicians, particularly with underlying NASH. We propose cirrhosis to be the prime cause of isolated thrombocytopenia.
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Affiliation(s)
- Muhammad Y. Sheikh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco (UCSF) Fresno Medical Education Program (MEP), Fresno, California, USA,Correspondence to: Dr. Muhammad Y. Sheikh, Division of Gastroenterology and Hepatology, University of California San Francisco (UCSF) Fresno Medical Education Program (MEP), Community Regional Medical Center, 2826 Fresno Street, Endoscopy Suite, 1st Floor, Fresno, 93701, California, USA. E-mail:
| | - Rahim Raoufi
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco (UCSF) Fresno Medical Education Program (MEP), Fresno, California, USA
| | - Pradeep R. Atla
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco (UCSF) Fresno Medical Education Program (MEP), Fresno, California, USA
| | - Muhammad Riaz
- Department of Family Medicine and Internal Medicine, UCSF Fresno MEP, Fresno, California, USA
| | - Chad Oberer
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Francisco (UCSF) Fresno Medical Education Program (MEP), Fresno, California, USA
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Sheikh MY, Mouanoutoua M, Walvick MD, Khang L, Singh J, Stoltz S, Mills PK. Prevalence of hepatitis B virus (HBV) infection among Hmong immigrants in the San Joaquin Valley. J Community Health 2011; 36:42-6. [PMID: 20532597 PMCID: PMC3020291 DOI: 10.1007/s10900-010-9283-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Chronic hepatitis B infection (HBV) is the major cause of primary liver cancer worldwide and Asians are disproportionately affected. The prevalence of HBV among most Asian American groups has been well documented, except in Hmong immigrants in the United States. The aim of this study was to determine the prevalence of HBV among Hmong immigrants in the San Joaquin Valley of California. A convenient sample of 534 Hmong age ≥18 years was recruited at various locations throughout Fresno County. Blood samples from study participants were collected and tested for hepatitis B surface antigen (HBsAg) by enzyme-immunoassay. Two hundred and eighty-nine females and 245 males of Hmong descent (mean age, 43.93) were screened. Eighty-nine (41 males and 48 females) were positive for HBsAg, which accounts for a prevalence of 16.7% (95% C.I. 13.5–19.9). The majorities of HBsAg positive patients were ≥40 years (64.2%), married (66.7%), born in Laos (87.3%), and had lived in the United States ≥20 years (62.5%). Only 37.5% of the participants reported having a primary care physician. Our study revealed that approximately one out of every six Hmong immigrants screened was infected with HBV. Based on our findings, more than one-third of these infected patients have no primary care physician to provide further treatment, surveillance for liver cancer, or vaccination of their families. This supports the Institute of Medicine’s recent recommendations to the Center for Disease Control to engage in a national Hepatitis B surveillance system.
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Affiliation(s)
- Muhammad Y Sheikh
- Division of Gastroenterology and Hepatology, Community Regional Medical Center, University of California San Francisco Fresno Medical Education Program, 2826 Fresno Street, Endoscopy Suite, 1st Floor, Fresno, CA 93701, USA.
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Bass NM, Mullen KD, Sanyal A, Poordad F, Neff G, Leevy CB, Sigal S, Sheikh MY, Beavers K, Frederick T, Teperman L, Hillebrand D, Huang S, Merchant K, Shaw A, Bortey E, Forbes WP. Rifaximin treatment in hepatic encephalopathy. N Engl J Med 2010; 362:1071-81. [PMID: 20335583 DOI: 10.1056/nejmoa0907893] [Citation(s) in RCA: 784] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatic encephalopathy is a chronically debilitating complication of hepatic cirrhosis. The efficacy of rifaximin, a minimally absorbed antibiotic, is well documented in the treatment of acute hepatic encephalopathy, but its efficacy for prevention of the disease has not been established. METHODS In this randomized, double-blind, placebo-controlled trial, we randomly assigned 299 patients who were in remission from recurrent hepatic encephalopathy resulting from chronic liver disease to receive either rifaximin, at a dose of 550 mg twice daily (140 patients), or placebo (159 patients) for 6 months. The primary efficacy end point was the time to the first breakthrough episode of hepatic encephalopathy. The key secondary end point was the time to the first hospitalization involving hepatic encephalopathy. RESULTS Rifaximin significantly reduced the risk of an episode of hepatic encephalopathy, as compared with placebo, over a 6-month period (hazard ratio with rifaximin, 0.42; 95% confidence interval [CI], 0.28 to 0.64; P<0.001). A breakthrough episode of hepatic encephalopathy occurred in 22.1% of patients in the rifaximin group, as compared with 45.9% of patients in the placebo group. A total of 13.6% of the patients in the rifaximin group had a hospitalization involving hepatic encephalopathy, as compared with 22.6% of patients in the placebo group, for a hazard ratio of 0.50 (95% CI, 0.29 to 0.87; P=0.01). More than 90% of patients received concomitant lactulose therapy. The incidence of adverse events reported during the study was similar in the two groups, as was the incidence of serious adverse events. CONCLUSIONS Over a 6-month period, treatment with rifaximin maintained remission from hepatic encephalopathy more effectively than did placebo. Rifaximin treatment also significantly reduced the risk of hospitalization involving hepatic encephalopathy. (ClinicalTrials.gov number, NCT00298038.)
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Affiliation(s)
- Nathan M Bass
- University of California, San Francisco, San Francisco, California, USA
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Rodriguez-Torres M, Jeffers LJ, Sheikh MY, Rossaro L, Ankoma-Sey V, Hamzeh FM, Martin P. Peginterferon alfa-2a and ribavirin in Latino and non-Latino whites with hepatitis C. N Engl J Med 2009; 360:257-67. [PMID: 19144941 DOI: 10.1056/nejmoa0805062] [Citation(s) in RCA: 141] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Race has been shown to be a factor in the response to therapy for hepatitis C virus (HCV) infection, and limited data suggest that ethnic group may be as well; however, Latinos and other ethnic subpopulations have been underrepresented in clinical trials. We evaluated the effect of Latino ethnic background on the response to treatment with peginterferon alfa-2a and ribavirin in patients infected with HCV genotype 1 who had not been treated previously. METHODS In a multicenter, open-label, nonrandomized, prospective study, 269 Latino and 300 non-Latino whites with HCV infection received peginterferon alfa-2a, at a dose of 180 microg per week, and ribavirin, at a dose of 1000 or 1200 mg per day, for 48 weeks, and were followed through 72 weeks. The primary end point was a sustained virologic response. We enrolled Latinos whose parents and grandparents spoke Spanish as their primary language; nonwhite Latinos were excluded. RESULTS Baseline characteristics were similar in the Latino and non-Latino groups, although higher proportions of Latino patients were 40 years of age or younger, had a body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) of more than 27 or more than 30, and had cirrhosis. The rate of sustained virologic response was higher among non-Latino whites than among Latinos (49% vs. 34%, P<0.001). The absence of HCV RNA in serum was more frequent in non-Latino whites at week 4 (P=0.045) and throughout the treatment period (P<0.001 for all other comparisons). Latino or non-Latino background was an independent predictor of the rate of sustained virologic response in an analysis adjusted for baseline differences in BMI, cirrhosis, and other characteristics. Adherence to treatment did not differ significantly between the two groups. The numbers of patients with adverse events and dose modifications were similar in the two groups, but fewer Latino patients discontinued therapy because of adverse events. CONCLUSIONS Treatment with peginterferon alfa-2a and ribavirin for 48 weeks resulted in rates of sustained virologic response among patients infected with HCV genotype 1 that were lower among Latino whites than among non-Latino whites. Strategies to improve the sustained virologic response in Latinos are needed. (ClinicalTrials.gov number, NCT00107653.)
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Sheikh MY, Javed U, Singh J, Choudhury J, Deen O, Dhah K, Peterson MW. Bedside sublingual video imaging of microcirculation in assessing bacterial infection in cirrhosis. Dig Dis Sci 2009; 54:2706-11. [PMID: 19117129 PMCID: PMC2778688 DOI: 10.1007/s10620-008-0664-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2008] [Accepted: 12/08/2008] [Indexed: 12/29/2022]
Abstract
Bacterial infections are common in cirrhosis and can lead to life-threatening complications. Sidestream dark-field (SDF) imaging has recently emerged as a noninvasive tool for capturing real-time video images of sublingual microcirculation in critically ill patients with sepsis. The objective of this study was to assess the utility of SDF in determining underlying infection in patients with cirrhosis. Sublingual microcirculation was compared among patients with compensated cirrhosis (Group A, n=13), cirrhosis without sepsis (Group B, n=18), cirrhosis with sepsis (Group C, n=14), and sepsis only (Group D, n=10). The blood flow was semi-quantitatively evaluated in four equal quadrants in small (10-25 mm); medium (26-50 mm); and large (51-100 mm) sublingual capillaries. The blood flow was described as no flow (0), intermittent flow (1), sluggish flow (2), and continuous flow (3). The overall flow score or microvascular flow index (MFI) was measured for quantitative assessment of microcirculation and predicting power for concurrent infection in cirrhosis. Marked impairment was observed at all levels of microvasculature in Groups B and C when compared with Group A. This effect was restricted to small vessels only when Group B was compared with Group C. MFI<1.5 was found to have highest sensitivity (100%) and specificity (100%) for infection in decompensated cirrhosis. SDF imaging of sublingual microcirculation can be a useful bedside diagnostic tool to assess bacterial infection in cirrhosis.
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Affiliation(s)
- Muhammad Y. Sheikh
- Division of Gastroenterology and Hepatology, University of California San Francisco-Fresno Medical Education Program, Community Regional Medical Center, 2823 Fresno Street, 1st Floor, Endoscopy Suite, Fresno, CA 93721 USA
| | - Usman Javed
- Division of Cardiology, University of California San Francisco-Fresno Medical Education Program, Fresno, CA USA
| | - Jasjit Singh
- Department of Internal Medicine, University of California San Francisco-Fresno Medical Education Program, Fresno, CA USA
| | - Jayanta Choudhury
- Division of Gastroenterology and Hepatology, University of California San Francisco-Fresno Medical Education Program, Community Regional Medical Center, 2823 Fresno Street, 1st Floor, Endoscopy Suite, Fresno, CA 93721 USA
| | - Omer Deen
- Division of Gastroenterology and Hepatology, University of California San Francisco-Fresno Medical Education Program, Community Regional Medical Center, 2823 Fresno Street, 1st Floor, Endoscopy Suite, Fresno, CA 93721 USA
| | - Kulraj Dhah
- Division of Gastroenterology and Hepatology, University of California San Francisco-Fresno Medical Education Program, Community Regional Medical Center, 2823 Fresno Street, 1st Floor, Endoscopy Suite, Fresno, CA 93721 USA
| | - Michael W. Peterson
- Department of Internal Medicine, University of California San Francisco-Fresno Medical Education Program, Fresno, CA USA
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Abstract
Chronic infection with hepatitis C virus (HCV) can induce insulin resistance (IR) in a genotype-dependent fashion, thus contributing to steatosis, progression of fibrosis and resistance to interferon therapy. The molecular mechanisms in genotype 1 patients that lead to metabolic syndrome are still ambiguous. Based on our current understanding, HCV proteins associate with mitochondria and endoplasmic reticulum and promote oxidative stress. The latter mediates signals involving the p38 mitogen-activated protein kinase and activates nuclear factor kappa B. This transcription factor plays a key role in the expression of cytokines, tumor necrosis factor alpha (TNF-alpha), interleukin 6, interleukin 8, tumor growth factor beta, and Fas ligand. TNF-alpha inhibits the function of insulin receptor substrates and decreases the expression of the glucose transporter and lipoprotein lipase in peripheral tissues, which is responsible for the promotion of insulin resistance. Furthermore, reduced adiponectin levels, loss of adiponectin receptors, and decreased anti-inflammatory peroxisome proliferator-activated receptor alpha in the liver of HCV patients may contribute to reduced fatty acid oxidation, inflammation, and eventually lipotoxicity. This chain of events may be initiated by HCV-associated IR and provides a direction for future research in the areas of therapeutic intervention.
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Affiliation(s)
- Muhammad Y Sheikh
- Division of Gastroenterology and Hepatology, University of California San Francisco Fresno Education Program, Community Regional Medical Center, Fresno, CA 93721, USA.
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Seronello S, Sheikh MY, Choi J. Redox regulation of hepatitis C in nonalcoholic and alcoholic liver. Free Radic Biol Med 2007; 43:869-82. [PMID: 17697932 DOI: 10.1016/j.freeradbiomed.2007.05.036] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2007] [Revised: 05/26/2007] [Accepted: 05/30/2007] [Indexed: 12/19/2022]
Abstract
Hepatitis C virus (HCV) is an RNA virus of the Flaviviridae family that is estimated to have infected 170 million people worldwide. HCV can cause serious liver disease in humans, such as cirrhosis, steatosis, and hepatocellular carcinoma. HCV induces a state of oxidative/nitrosative stress in patients through multiple mechanisms, and this redox perturbation has been recognized as a key player in HCV-induced pathogenesis. Studies have shown that alcohol synergizes with HCV in the pathogenesis of liver disease, and part of these effects may be mediated by reactive species that are generated during hepatic metabolism of alcohol. Furthermore, reactive species and alcohol may influence HCV replication and the outcome of interferon therapy. Alcohol consumption has also been associated with increased sequence heterogeneity of the HCV RNA sequences, suggesting multiple modes of interaction between alcohol and HCV. This review summarizes the current understanding of oxidative and nitrosative stress during HCV infection and possible combined effects of HCV, alcohol, and reactive species in the pathogenesis of liver disease.
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Affiliation(s)
- Scott Seronello
- School of Natural Sciences, University of California at Merced, Merced, CA 95344, USA
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22
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Sanyal AJ, Fontana RJ, Di Bisceglie AM, Everhart JE, Doherty MC, Everson GT, Donovan JA, Malet PF, Mehta S, Sheikh MY, Reid AE, Ghany MG, Gretch DR. The prevalence and risk factors associated with esophageal varices in subjects with hepatitis C and advanced fibrosis. Gastrointest Endosc 2006; 64:855-64. [PMID: 17140886 DOI: 10.1016/j.gie.2006.03.007] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2005] [Accepted: 03/13/2006] [Indexed: 01/04/2023]
Abstract
BACKGROUND The factors predictive of the presence or the absence of esophageal varices in hepatitis C virus (HCV) and advanced fibrosis have not been defined. OBJECTIVES To define the prevalence of esophageal varices and the factors that are positively and negatively with such varices in hepatitis C and advanced fibrosis. DESIGN A prospective study of esophageal varices and associated risk factors in subjects with hepatitis C and advanced fibrosis. SETTING Prerandomization data from the HALT-C (hepatitis C long-term antiviral treatment against cirrhosis) clinical trial. PATIENTS AND INTERVENTION Subjects with bridging fibrosis or cirrhosis, who were virologic nonresponders to treatment with pegylated interferon alpha 2a and ribavirin, underwent endoscopy. RESULTS Sixteen percent of subjects with bridging fibrosis (95/598) and 39% of subjects with cirrhosis (164/418) had varices (P < .0001); 2% of subjects with bridging fibrosis (13/598) and 11% of those with cirrhosis (48/418) had medium or large varices. Subjects with bridging fibrosis and varices had a significantly lower platelet count and higher bilirubin and international normalized ratio (INR) compared with those without varices, suggesting that the biopsy may have underestimated the severity of fibrosis. A platelet count >150,000/mm(3) was associated with a negative predictive value of 99% for esophageal varices. By logistic regression modeling, African American race and female sex were protective, whereas a lower platelet count and higher bilirubin and INR predicted varices (c statistic, 0.758). CONCLUSIONS The risk of having varices increases with decreasing platelet counts, increasing bilirubin, and INR. The probability of having medium or large varices at platelet counts >150,000/mm(3) is negligible in this population.
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Affiliation(s)
- Arun J Sanyal
- Division of Gastroenterology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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23
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Fontana RJ, Sanyal AJ, Mehta S, Doherty MC, Neuschwander-Tetri BA, Everson GT, Kahn JA, Malet PF, Sheikh MY, Chung RT, Ghany MG, Gretch DR. Portal hypertensive gastropathy in chronic hepatitis C patients with bridging fibrosis and compensated cirrhosis: results from the HALT-C trial. Am J Gastroenterol 2006; 101:983-92. [PMID: 16573786 DOI: 10.1111/j.1572-0241.2006.00461.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The clinical significance of portal hypertensive gastropathy (PHG) in patients with compensated liver disease is not well established. The aim of this study was to determine the prevalence and correlates of PHG in a large cohort of patients with chronic hepatitis C virus (HCV) infection and bridging fibrosis/compensated cirrhosis entering the randomized phase of the Hepatitis C Antiviral Long-term Treatment against Cirrhosis trial (HALT-C). METHODS The presence and severity of PHG in 1,016 HCV patients with no prior history of gastrointestinal bleeding was determined at surveillance endoscopy using the New Italian Endoscopy Club criteria. RESULTS Overall, 37% of HALT-C patients had PHG with 34% having mild and 3% with severe changes. The mucosal mosaic pattern was identified in 33%, red marks in 15%, and gastric antral vascular ectasia (GAVE) features in only 3%. Independent correlates of PHG included biochemical markers of liver disease severity (lower serum albumin, higher bilirubin), portal hypertension (lower platelet count), insulin resistance (higher glucose), and non-African American race. Independent correlates of GAVE included a history of smoking, nonsteroidal anti-inflammatory drugs (NSAIDs) use within the past year, and higher serum bilirubin and glucose levels. There was a strong positive association between the presence of PHG and esophageal varices (p < 0.0001). CONCLUSIONS PHG is associated with the histological and biochemical severity of liver disease in patients with HCV and advanced fibrosis but is mild in most patients. The clinical relevance of these findings will be further explored during the randomized phase of the HALT-C study.
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Affiliation(s)
- Robert J Fontana
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
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Abstract
The quantitative liver-spleen scan (QLSS) can estimate the functional hepatic mass and the organ volumes by precise measurement of sulfur colloid (SC) distribution. The normal range determined in prior studies was estimated from patients with absence of chronic liver disease in which intense fasting appeared to produce slightly abnormal values. This study was to determine the effect of fasting or fed status and colloid particle size on quantitative measurements from the QLSS in a small cohort of normal individuals. Twelve persons without any medical problems had QLSS taken twice, 2 weeks apart, one fasting and one postprandial. Patients were scanned after injection of 5-6 mCi of SC; six patients were given solution A (5- to 12-microm particle size) and six patients solution B (2- to 12-microm particle size). SPECT and planar analysis were performed. SC distribution of total counts between the liver and the spleen {[L/(L + S)]t ratio}, liver-spleen index (LSI), and liver-bone marrow index (LBI) were calculated. The perfused hepatic mass (PHM) is the average of the LSI and LBI. Spleen and liver volumes are expressed as milliliters per pound ideal body weight (IBW). Results showed that the liver and spleen volumes (solution B postprandial, 9.27 +/- 2.48 and 1.47 +/- 0.57 ml/lb IBW, respectively) and LBI were not affected by the type of SC solution or by ingestion status. L/(L + S) total and pixel count ratios were significantly higher for solution B and postprandial studies. [L/(L + S)]t, LSI, and PHM increased significantly (P < 0.05) from fasting to postprandial for solution A (0.71 +/- 0.13 vs 0.79 +/- 0.08, 80 +/- 14 vs 91 +/- 8, and 102 +/- 10 vs 106 +/- 8, respectively) and for solution B (0.81 +/- 0.05 vs 0.90 +/- 0.02, 86 +/- 4 vs 95 +/- 3, and 101 +/- 5 vs 110 +/- 3). Neither fasting nor postprandial LSI and PHM were significantly different between solution A and solution B. We conclude the following. (1) The QLSS functional indices in "true" normal patients fall within the previously reported normal range. (2) Calculated liver and spleen volumes are not altered by fasting or sulfur colloid particle size. (3) Fasting significantly decreased the [L/(L + S)]t, LSI, and PHM. (4) A postprandial scan may be preferable since the normal values for [L/(L + S)]t, LSI, and PHM are greater, with a narrower range, than fasting values.
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Affiliation(s)
- John C Hoefs
- Division of Gastroenterology/Liver Disease Program, Department of Medicine, University of California, Irvine/ UCI Medical Center, Orange, California 92868, USA.
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25
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Banerjee SS, Eyden B, Trenholm PW, Sheikh MY, Wakamatsu K, Ancans J, Rosai J. Monotypic angiomyolipoma of the nasal cavity: a heretofore undescribed occurrence. Int J Surg Pathol 2001; 9:309-15. [PMID: 12574849 DOI: 10.1177/106689690100900410] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A monotypic angiomyolipoma of the nasal cavity in a 34-year-old woman is described. Tumor cells were spindled or epithelioid and contained glycogen and diastase-resistant PAS-positive granules. There were few mitoses, and necrosis was absent, indicating a benign tumor. The stroma was markedly vascular, and a few adipocytes were seen in one area. Cells were positive for melanocyte and muscle markers. Electron microscopy revealed abundant dense granules. Although melanin was absent histochemically, it was present using a chemical assay, and the granules may, therefore, be atypical melanosomes. Fine actin filaments, attachment plaques and lamina were present. Initial assessment of the lesion indicated malignant melanoma, but the immunostaining and histologic features indicated monotypic angiomyolipoma. To the best of our knowledge, this is the first such case in the nasal cavity.
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Affiliation(s)
- S S Banerjee
- Department of Histopathology, Christie Hospital NHS Trust, Manchester, UK
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26
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Haq TU, Sanaullah M, Mohsin H, Sheikh MY, Ahmed B. Percutaneous transhepatic biliary stenting. J PAK MED ASSOC 2001; 51:308-12. [PMID: 11715902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
OBJECTIVE Bilary stenting with endoprosthesis is a palliative procedure to relieve malignant biliary obstruction. Percutaneous transhepatic technique has been employed whenever endoscopic technique was not possible or had failed. SETTING Angiography/intervention suite, department of radiology, Aga Khan University hospital, Karachi. METHODS We present retrospective analysis of 17 patients with malignant jaundice who were treated with percutaneous techniques after the endoscopic route had failed. RESULTS The success rate was 94% with placement of single plastic stent in 14 patients, double stents in 3 patients and self-expandable stent in one patient. The overall complication rate was 41% including sepsis, liver abscess, biloma formation, biliary leakage and stent occlusion. There was one procedure related death due to severe sepsis. CONCLUSION Percutaneous transhepatic biliary stenting is an alternative procedure to relieve malignant biliary obstruction with high complication rate and should be reserved for selected patients in whom endoscopic route has failed.
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Affiliation(s)
- T U Haq
- Department of Radiology, Aga Khan University Hospital, Karachi
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27
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Guarner C, Runyon BA, Heck M, Young S, Sheikh MY. Effect of long-term trimethoprim-sulfamethoxazole prophylaxis on ascites formation, bacterial translocation, spontaneous bacterial peritonitis, and survival in cirrhotic rats. Dig Dis Sci 1999; 44:1957-62. [PMID: 10548343 DOI: 10.1023/a:1026649730012] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Selective intestinal decontamination with norfloxacin is useful in preventing spontaneous bacterial peritonitis in cirrhotic patients and also in cirrhotic rats. The emergence of norfloxacin-resistant infections in these patients warrants a search for alternative therapies. The aim of this study was to evaluate the effect of long-term trimethoprim-sulfamethoxazole administration on carbon tetrachloride (CCl4) -induced cirrhosis in rats with specific attention to intestinal flora, bacterial translocation, spontaneous bacterial peritonitis (SBP), and survival. Male Sprague-Dawley rats received CCl4 administered weekly by gavage. After eight weeks of CCl4 administration rats were randomly allocated into two groups. Group I received daily overnight trimethoprim-sulfamethoxazole diluted in phenobarbital water during follow-up and group II did not. The rats were killed when gravely ill, and a laparotomy was performed to culture samples of cecal stool, mesenteric lymph nodes, and portal and inferior vena caval blood. There was a trend toward a reduction in the incidence of bacterial translocation (8/17 vs 11/14, respectively) and SBP (5/17 vs 7/14, respectively) in treated rats that were killed just before death compared to untreated rats. A decrease in the incidence of bacterial translocation caused by gram-negative bacilli was observed in group I (17.6% vs 78.6%, P < 0.01). The development of ascites was delayed in group I (P < 0.05) and survival was prolonged in group I (P < 0.05), despite a higher CCl4 dose in this group (P < 0.05). In conclusion, long-term prophylactic trimethoprim-sulfamethoxazole administration in CCl4-induced cirrhosis in rats delayed the development of ascites, prolonged survival, and reduced the incidence of gram-negative bacterial translocation but not of SBP, without increasing gram-positive episodes. These data suggest that trimethoprim-sulfamethoxazole might be a good alternative to norfloxacin for preventing gram-negative bacterial translocation.
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Affiliation(s)
- C Guarner
- Department of Medicine, University of Louisville, Kentucky, USA
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28
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Sheikh MY, Wright RA, Burruss JB. Dramatic resolution of skin lesions associated with porphyria cutanea tarda after interferon-alpha therapy in a case of chronic hepatitis C. Dig Dis Sci 1998; 43:529-33. [PMID: 9539647 DOI: 10.1023/a:1018854906444] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- M Y Sheikh
- Department of Medicine, University of Louisville, Kentucky 40292, USA
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29
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Husen YA, Khalid TR, Khan ZA, Sheikh MY. Non-visualization of lung markings below hemidiaphragm in subtle subpulmonic effusion: an old sign resuscitated. J PAK MED ASSOC 1997; 47:284-6. [PMID: 9510633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
To assess the lack of visibility of vascular markings under the hemidiaphragm on a frontal chest radiograph as a sign of pleural effusion, fifteen patients were collected showing this sign. Pleural effusion was diagnosed by ultrasound, comparison with previous or subsequent chest x-ray or computed tomography. Patients in the study group exhibited this sign in the absence of the classical signs of pleural effusion. In the control group, lack of visibility of blood vessels was observed in only 4.2% cases. Non-visualization of vascular markings below the hemidiaphragm should alert the interpreter to the possible presence of pleural effusion and a lateral or decubitus view or ultrasound examination may be carried out to rule out effusion.
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Affiliation(s)
- Y A Husen
- Department of Radiology, Aga Khan University Hospital, Karachi
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30
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Abstract
BACKGROUND/AIMS Translocation of indigenous bacteria from the gut lumen of cirrhotic animals to mesenteric lymph nodes appears to be an important step in the pathogenesis of spontaneous bacterial peritonitis. However, the sequence of events leading to translocation remains unclear. One of the most predictable risk factors for translocation is overgrowth of gut bacterial flora. The present study was designed to compare the intestinal aerobic bacterial flora of cecal stools at the time of sacrifice between cirrhotic and normal rats and to evaluate the role of intestinal aerobic bacterial overgrowth in bacterial translocation in cirrhotic rats. METHODS Thirty-five male Sprague-Dawley rats with carbon tetrachloride-induced cirrhosis and ascites and 10 normal rats were included in this study. Cirrhotic rats were sacrificed when ill and samples of ascitic fluid, mesenteric lymph nodes and cecal stool were taken for detecting quantitatively aerobic bacteria. RESULTS Total intestinal aerobic bacterial count in cecal stool at the time of sacrifice was significantly increased in cirrhotic rats with bacterial translocation with or without spontaneous bacterial peritonitis compared to cirrhotic rats without bacterial translocation (p<0.001 and p<0.001, respectively) and to normal rats (p<0.001 and p<0.001, respectively). Of the 42 species of bacteria translocating to the mesenteric lymph nodes, 41 (97.6%) were found in supranormal numbers in the stool at the time of sacrifice. CONCLUSIONS Carbon tetrachloride-induced cirrhotic rats with bacterial translocation have increased total intestinal aerobic bacteria count, and intestinal bacterial overgrowth appears to play an important role in bacterial translocation in this experimental model of cirrhosis in rats.
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Affiliation(s)
- C Guarner
- Department of Medicine, University of Louisville, KY 40292, USA
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31
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ul Haq T, Sheikh MY, Jadun CK, Ahmad MN, Husen YH. Percutaneous removal of biliary stone from anomalous right hepatic duct. J PAK MED ASSOC 1997; 47:94-6. [PMID: 9131863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- T ul Haq
- Department of Radiology, Aga Khan University Hospital, Karachi
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32
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Jones WF, Sheikh MY, McClave SA. AIDS-related non-Hodgkin's lymphoma of the pancreas. Am J Gastroenterol 1997; 92:335-8. [PMID: 9040219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Non-Hodgkin's lymphoma is a common complication in patients with human immunodeficiency virus infection that most frequently affects the gastrointestinal tract. We describe the first case report of non-Hodgkin's lymphoma primarily involving the pancreas in a 27-yr-old white man who presented with epigastric pain, weight loss, and jaundice (and was later found to be HIV seropositive). Endoscopic ultrasound and CT scan of the abdomen showed a large mass arising from the body and head of the pancreas obstructing the common bile duct. An attempted ERCP was unsuccessful due to extrinsic compression and distortion of the second part of the duodenum. A percutaneous CT-directed true-cut needle biopsy of the pancreas revealed a small noncleaved B-cell lymphoma. The patient was started on combination chemotherapy. His pancreatic mass, epigastric symptoms, and jaundice resolved completely. This case report illustrates an otherwise rare presentation of isolated pancreatic involvement of non-Hodgkin's lymphoma in a patient with acquired immunodeficiency syndrome. An approach to its diagnosis and management is summarized.
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Affiliation(s)
- W F Jones
- Division of Gastroenterology/Hepatology, University of Louisville School of Medicine, Kentucky, USA
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Sheikh MY, Husen YA, Pervez S, Khalid TR, Jaffer N, Afzal M. Computed tomography appearance of malignant schwannoma of the liver. Can Assoc Radiol J 1996; 47:183-5. [PMID: 8640414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Malignant schwannoma of the liver without associated neurofibromatosis is rare. The authors present one such case in a 35-year-old woman. Computed tomography demonstrated large liver masses with contiguous involvement of adjacent stomach tissue, consistent with local invasion.
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Affiliation(s)
- M Y Sheikh
- Department of Radiology, Aga Kahn University Hospital, Karachi, Pakistan
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Sheikh MY, Yousuf AH, Khalid TR, Islam MU, Ahmed MN. Coexistent tuberculosis and carcinoma of the colon. J PAK MED ASSOC 1995; 45:305-6. [PMID: 8920615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- M Y Sheikh
- Department of Diagnostic Radiology, Aga Khan University Hospital, Karachi
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Sheikh MY, Rana TA, Islam MU. Tuberculous mastitis mimicking malignancy--a case report with review of literature. J PAK MED ASSOC 1993; 43:122-3. [PMID: 8411616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- M Y Sheikh
- Department of Radiology, Aga Khan University Hospital, Karachi
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Sheikh MY, Rizvi IH, Ahmed I. Oesophageal carcinoma caused by betel nut. J PAK MED ASSOC 1992; 42:145-6. [PMID: 1381759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- M Y Sheikh
- Department of Radiology, Aga Khan University Medical Centre, Karachi
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Sheikh MY, Rizvi IH, Naeem SA, Ahmad I. Enterolithiasis secondary to intestinal tuberculosis. J PAK MED ASSOC 1991; 41:286-7. [PMID: 1766075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- M Y Sheikh
- Department of Radiology, Aga Khan University Medical Centre, Karachi
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Rana TA, Sheikh MY. Early diagnosis of ileocecal tuberculosis on small bowel enema. J PAK MED ASSOC 1990; 40:171-2. [PMID: 2125663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Aszalos AA, Bachur NR, Hamilton BK, Langlykke AF, Roller PP, Sheikh MY, Sutphin MS, Thomas MC, Wareheim DA, Wright LH. Microbial reduction of the side-chain carbonyl of daunorubicin and N-acetyldaunorubicin. J Antibiot (Tokyo) 1977; 30:50-8. [PMID: 838632 DOI: 10.7164/antibiotics.30.50] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Microorganisms reduced the side-chain carbonyl of daunorubicin to yield 13-dihydrodaunorubicin (daunorubicinol; daunomycinol). This microbial transformation occurred under aerobic conditions in agitated baffled shake flasks incubated at 37 degrees C. The microorganisms were first grown in a medium which supported dense growth. Daunorubicin-HCl was then added. Following a period of incubation, broths were adjusted to pH 10.0 and extracted with chloroform. Daunorubicinol was recovered and purified from the chloroform extracts by preparative TLC. Identity of the daunorubicinol was established by TLC and spectroscopy (UV-vis, IR, NMR, MS, CD and ORD). N-Acetyldaunorubicin was likewise reduced microbially to N-acetyldaunorubicinol. N-Acetyldaunorubicinol appears to be a new compound which is yet to be tested for antitumor activity.
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