Strategies and endpoints of antifibrotic drug trials: Summary and recommendations from the AASLD Emerging Trends Conference, Chicago, June 2014

There is an urgent need to develop antifibrotic therapies for chronic liver disease, and clarify which endpoints in antifibrotic trials will be acceptable to regulatory agencies. The American Association for the Study of Liver Diseases sponsored an endpoints conference to help accelerate the efficient testing of antifibrotic agents and develop recommendations on clinical trial design for liver fibrosis. In this review, we summarize the salient and novel elements of this conference and provide directions for future clinical trial design. The article follows the structure of the conference and is organized into five areas: (1) antifibrotic trial design; (2) preclinical proof-of-concept studies; (3) pharmacological targets, including rationale and lessons to learn; (4) rational drug design and development; and (5) consensus and recommendations on design of clinical trials in liver fibrosis. Expert overviews and collaborative discussions helped to summarize the key unmet needs and directions for the future, including: (1) greater clarification of at-risk populations and study groups; (2) standardization of all elements of drug discovery and testing; (3) standardization of clinical trial approaches; (4) accelerated development of improved noninvasive markers; and (5) need for exploration of potential off-target toxicities of future antifibrotic drugs.

Cavitary lung lesions in systemic lupus: an unusual presentation

Lupus is a multisystem disease with varied clinical manifestations. Cavitary lung lesions in lupus could be secondary to infections, embolism, or underlying vasculitis. We report a man who presented with lung cavitations and was diagnosed as lupus, secondary antiphospholipid syndrome, and plasma cell dyscrasia. The lesions resolved after the initiation of immunosuppressive therapy. All the previous case reports have been reviewed and the possible mechanisms underlying this association are discussed.

Nonalcoholic steatohepatitis and the metabolic syndrome

Nonalcoholic fatty liver disease (NAFLD) is a major form of chronic liver disease in adults and children. It is one of the consequences of the current obesity epidemic, and can progress to nonalcoholic steatohepatitis (NASH), characterized by steatosis, inflammation, and progressive fibrosis, ultimately leading to cirrhosis and end-stage liver disease. The factors implicated in this progression are poorly understood. NASH is closely associated with obesity and the metabolic syndrome. Recent studies emphasize the role of insulin resistance, oxidative stress, lipid peroxidation, and cytokine release in the development of NASH. This review summarizes the current knowledge on the etiology and pathomechanism of NASH and the role of the metabolic syndrome in NASH development.

Adiponectin decreases C-reactive protein synthesis and secretion from endothelial cells: evidence for an adipose tissue-vascular loop

BACKGROUND AND OBJECTIVE

Inflammation is pivotal in atherosclerosis. C-reactive protein (CRP), in addition to being a cardiovascular risk marker, may also be proatherogenic. We have previously shown that in addition to the liver, human aortic endothelial cells (HAECs) synthesize and secrete CRP. Whereas CRP levels are increased in obesity, metabolic syndrome, and diabetes, levels of adiponectin are reduced in these conditions. We tested the hypothesis that adiponectin reduces CRP synthesis and secretion in HAECs under normoglycemic (5.5 mmol/L glucose) and hyperglycemic conditions (15 mmol/L glucose).

METHODS AND RESULTS

Adiponectin dose-dependently reduced CRP mRNA and protein from HAECs. Adiponectin treatment of HAECs significantly decreased IkappaB phosphorylation and NFkappaB binding activity. There was no effect of adiponectin on STAT or C/EBP transcriptional activity. Adiponectin also activated AMP kinase resulting in decreased NFkappaB activity and decreased CRP mRNA and protein. These effects of adiponectin were mimicked by AICAR, an activator of AMPK, and reversed by inhibition of AMPK. Thus, adiponectin reduces CRP synthesis and secretion from HAECs under hyperglycemia via upregulation of AMP kinase and downregulation of NFkappaB. Similar findings were observed in rat primary hepatocytes.

CONCLUSIONS

Thus, in obesity and diabetes, the hypoadiponectinemia could exacerbate the proinflammatory state by inducing CRP production.

De novo nonalcoholic fatty liver disease after liver transplantation

Hepatic steatosis is a recognized problem in patients after orthotopic liver transplant (OLT). However, de novo development of nonalcoholic fatty liver disease (NAFLD) has not been well described. The aim of this study was to determine the prevalence and predictors of de novo NAFLD after OLT. A retrospective analysis was performed on 68 OLT patients with donor liver biopsies and posttransplantation liver biopsies. Individual medical charts were reviewed for demographics, indication for OLT, serial histology reports, genotypes for hepatitis C, comorbid conditions, and medications. Liver biopsies were reviewed blindly and graded according to the Brunt Scoring System. Multivariate logistic regression analysis was used to study the risk factors for developing NAFLD. The interval time from OLT to subsequent follow-up liver biopsy was 28 +/- 18 months. A total of 12 patients (18%) developed de novo NAFLD, and 6 (9%) developed de novo NASH. The regression model indicated that the use of angiotensin-converting enzyme inhibitors (ACE-I) was associated with a reduced risk of developing NAFLD after OLT (odds ratio, 0.09; 95% confidence interval, 0.010-0.92; P = 0.042). Increase in body mass index (BMI) of greater than 10% after OLT was associated with a higher risk of developing NAFLD (odds ratio, 19.38; 95% confidence interval, 3.50-107.40; P = 0.001). In conclusion, de novo NAFLD is common in the post-OLT setting, with a significant association with weight gain after transplant. The use of an ACE-I may reduce the risk of developing post-OLT NAFLD.

Apoptotic body engulfment by a human stellate cell line is profibrogenic

Hepatocyte apoptosis and stellate cell activation are both features of chronic liver diseases, but a relationship between these events has not been explored. In macrophages, engulfment of apoptotic bodies induces expression of transforming growth factor-beta (TGF-beta), a profibrogenic cytokine. We examined whether a similar response occurs in stellate cells. Fluorescently labeled hepatocyte apoptotic bodies were added to cultures of primary and immortalized human stellate cells. Stellate cells, but not hepatocytes, readily engulfed apoptotic bodies in a time-dependent manner as assessed by confocal microscopy. The activation of primary and immortalized human stellate cells after incubation with apoptotic bodies, as well as their fibrogenic activity, was indicated by an increase in alpha-smooth muscle actin (primary cells), TGF-beta1, and collagen alpha1(I) mRNA (primary and immortalized cells). The profibrogenic response was dependent upon apoptotic body engulfment, because nocodazole, a microtubule-inhibiting agent, blocked both the engulfment and the increase of TGF-beta1 and collagen alpha1(I) mRNA. As described in primary rodent stellate cells, up-regulation of collagen alpha1(I) mRNA was inhibited by a PI-3K inhibitor (LY294002) and a p38 mitogen-activated protein kinase inhibitor (SB203580) in LX-1 cells. In conclusion, these data support a model in which engulfment of hepatocyte apoptotic bodies by stellate cells leads to a fibrogenic response by eliciting a kinase-signaling pathway.

Cholangiocarcinoma

Chronic inflammatory disease of the biliary tract predispose to the development of cholangiocarcinoma. For example, the prevalence of cholangiocarcinoma is between 7% to 14% in patients with primary sclerosing cholangitis. The diagnosis of cholangiocarcinoma is challenging because it is difficult to distinguish benign from malignant strictures. Recently, several advances have helped in the diagnosis of cholangiocarcinoma. The serum Ca 19-9 value is a useful adjunct for the diagnosis of malignant stictures in the absence of bacterial cholangitis. The recent development of digital image analysis for assessing biopsy specimens and brush cytology is also useful for the diagnosis of malignant strictures. Positron emission tomography is a new imaging technique that uses 18F fluoro-2-deoxy-D-glucose to noninvasively assess metabolism in human tissues. Early studies suggest that this technique is sensitive in identifying small bile duct cancers. Thus, the combination of a Ca 19-9 value, digital image analysis, and positron emission tomography scanning have greatly helped in the differential diagnosis of benign from malignant strictures. Management of cholangiocarcinoma is also challenging with limited survival after surgical resection. Recently, we have shown that preoperative chemoirradiation followed by liver transplantation results in prolonged disease-free survival in highly selected patients with early bile duct cancers. Successful treatment outcome of these patients highlights the need for an early diagnosis of cholangiocarcinoma using the approaches described above.

The economic impact of clinical pharmacists' unsolicited recommendations

Clinical pharmacists in a 580-bed teaching hospital reported all targeted recommendations that occurred during a 5-month evaluation period. Five types of clinical recommendations were identified: (1) to start drug therapy, (2) to stop drug therapy, (3) to increase drug dose, (4) to decrease drug dose, and (5) to suggest alternative drug therapy. Two thousand sixty-four unsolicited, accepted recommendations were submitted to the investigator by approximately eight holders of full-time equivalent positions dedicated to clinical pharmacy services during the evaluation period. Three hundred forty-four recommendations were selected (every sixth submitted recommendation) and evaluated for their economic impact. The costs of drugs, monitoring, and treatment for the drug regimens were compared before and after each recommendation. Three classes of drugs (antineoplastics, anti-infectives, and gastrointestinal agents) contributed more than 90% of the economic impact. The net economic impact of the evaluated recommendations was a cost saving of $4636.06; this extrapolated to a net cost saving of $34.10 per pharmacist-day.

Vestibular and auditory function in Usher's syndrome

Usher's syndrome is a recessive hereditary disorder in which a congenital hearing loss is combined with nyctalopia, retinal degeneration, and restriction of visual fields. The results of a comprehensive ophthalmic and neurotologic study on 70 patients are reported. Two distinct clinical and presumed genetic types were discernible on the basis of hearing impairment and vestibular sensitivity and, to a lesser extent, deterioration of retinal photoreceptor function. Such a classification has proved valuable in diagnosis, prognosis, and genetic counselling.

Usher's syndrome. Ophthalmic and neuro-otologic findings suggesting genetic heterogeneity

The conditions of 70 patients with Usher's syndrome were studied by ophthalmic and neuro-otologic examinations. Two distinct clinical and presumed genetic types were discernible on the basis of differences in hearing impairment, vestibular sensitivity, and, to a lesser extent, deterioration in retinal photoreceptor function. Distinguishing these two types has relevance for both diagnosis and genetic counseling of patients with Usher's syndrome.

Anatomic specificity of central vestibular signs in posterior fossa lesions

The reliability of central vestibular signs such as decruitment in signifying retrolabyrinthine lesions has been well established. This study was initiated to determine if this and other central vestibular signs, individually or collectively, indicate involvement of specific anatomic structures in the posterior fossa. Forty-six patients with morphologic lesions defined by computerized tomography (CT), pneumo-CT autopsy were studied. Oculomotor signs showed a statistically significant correlation with lesions of the archicerebellum. The other central vestibular signs did not show any correlation.

Central vestibular signs, posterior fossa pathology and computerized tomography-regional blood brain circulation

Central vestibular signs are sensitive indicators of lesions in the posterior fossa. With the availability of computerized tomography and computerized tomography-regional blood brain circulation, the identification of suspected retrolabyrinthine lesions has improved considerably. This is a report about the reliability of central vestibular signs in predicting posterior fossa lesions.

Pitfalls in detecting vestibular decruitment with air calorics

Vestibular decruitment is a pathological finding which indicates retrolabyrinthine disease. In the overwhelming majority of cases, it is consistent with posterior fossa pathology. Weak and strong caloric stimulations must be applied with precision for detecting decruitment. Air-caloric stimulation has inherent limitation in regards to reproducing the strength of the stimulus. Thus, it is inadequate for decruitment detection. It is, therefore, advisable to use water-caloric testing to assess vestibular decruitment or recruitment as one of the most revealing diagnostic clues in our neurotologic armamentarium.

Old and new in Ménière disease

The clinical experience is increasing, but still there is no uniform understanding in the substrate of Ménière's disease. The criteria of the diagnosis is loose and great controversy exists in the therapeutic efforts. A bewildering number of concepts and methods have been suggested and praised as the best answers in solving the problem until the next claim of success shatters the popularity of earlier allegations. The array of articles in the world literature for the past 25 years treats the entity of Ménière's disease in general and from the viewpoint of etiology, pathology, histology, clinical diagnosis and treatment. This review is concerned primarily with the treatment aspect of the literature. All the published ideas, regimens and techniques have one significant feature in common. They all claim success but not in 100% of the cases. Recovery varies from about 60% to 80%. Those cases considered "improved" are 20% to 30% and the rate of failure is between 10% and 25%. The diagnostic tools and capabilities have improved considerably. For treatment, except for reasonable medical or surgical palliation, nothing more can be offered than was offered a half century ago.

Vestibular decruitment in central nervous system disease

The differential caloric test consisting of a weak and of a strong stimulation may provide evidence of certain vestibulo-oculomotor abnormality. The phenomenon of vestibular decruitment serves as an indication of central nervous system or intracranial pathology. A classification of the degree of decruitment was attempted in 139 patients exhibiting this phenomenon. Ample evidence is provided that vestibular decruitment is indicative of a variety of intracranial lesions predominantly in the posterior fossa. Decruitment was encountered with hypo- and hyperactive vestibular responses alike and also in patients in whom there was no deficit in end organ sensitivity. The armamentarium of neurotologic testing is enriched by the differential caloric stimulations providing an indication of the "site of lesion."

Vestibular decruitment

Vestibular decruitment is a qualitative phenomenon of the caloric nystagmus. It is a pathognomonic finding which indicates or strongly suggests central nervous system pathology.

Diffential diagnosis of the caloric nystagmus

Diagnostic considerations based upon the nystagmogram are limited. Quantitative assessment of horizontal canal sensitivity is available through the use of culmination frequency or culmination slow phase velocity. Qualitative characteristics of nystagmometry have been sought but with no satisfactory results. Three distinctive features of the caloric nystagmus were evaluated and were found to be suggestive or outrightly pathognomonic for retrolabyrinthine or central nervous system abnormalities. These are: (1) Vestibular decruitment. The disproportionate caloric responsiveness when a weak stimulus elicits a more intense nystagmic reaction than a strong stimulus is capable of creating. (2) Hyperactive vestibular responsiveness (3) Ocular fixation reversal phenomenon. Contrary to the normal behaviour, the elimination of fixation decreases the nystagmus intensity instead of facilitating the evoked nystagmus. The assessment of these qualitative features of the caloric nystagmus in addition to the quantitative measurements widens the scope of our diagnostic capabilities.