Is the Y90-radioembolization treatment effective on the intermediate-advanced stage of hepatocellular carcinoma and what is the albumin-bilirubin score's prediction factor for survival?

Background and Aim

Radioembolization (RE) is a one of the palliative treatments that have been used to down stage and/or increase the survival time in intermediate-advanced stages of HCC. We aimed to evaluate the clinical impact of RE and the clinical use of the albumin-bilirubin (ALBI) score as a predictor for survival in HCC patients.

Materials and Methods

Fifty-nine unresectable hepatocellular carcinoma (HCC) patients were enrolled. RE was performed in 28 of them (group 1) and 31 patients were followed up in the natural course (NC) (group 2). Patients were classified according to the Child-Pugh score (only cirrhotic patients), Barcelona clinic liver cancer (BCLC) staging, and ALBI scores were also calculated.

Results

All patients in Group 1 were cirrhotic and their BCLC stages were as follows: 60.7% stage B and 39.3% stage C. In Group 2, 83.9% of patients were cirrhotic and their BCLC stages were as follows: 9.7% stage B, 51.6% stage C, and 38.7% stage D. Mortality rates were 82% and 100% in Groups 1 and 2, respectively. The median overall survival (OS) was 13.5 months (95% CI: 10.4-16.6 months) and 4.5 months (95% CI: 3.5-5.5 months) in Groups 1 and 2, respectively (p=0.000). When RE was applied to patients with ALBI Grade 1 and 2, the median OS was statistically higher than in the NC group, respectively (p<0.001, p<0.001).

Conclusion

RE is an effective treatment method at the advanced stages of HCC. The ALBI score is a more useful and practical than the other prognostic tools.

TASL Practice Guidance on the Clinical Assessment and Management of Patients with Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is a multisystem disease and is significantly associated with obesity, insulin resistance, type 2 diabetes mellitus, metabolic syndrome, and cardiovascular disease. NAFLD has become the most prevalent chronic liver disease in Western countries, and the proportion of NAFLD-related cirrhosis among patients on liver transplantation waiting lists has increased. In light of the accumulated data about NAFLD, and to provide a common approach with multi-disciplines dealing with the subject, it has become necessary to create new guidance for diagnosing and treating NAFLD. This guidance was prepared following an interdisciplinary study under the leadership of the Turkish Association for the Study of the Liver (TASL), Fatty Liver Special Interest Group. This new TASL Guidance is a practical application guide on NAFLD and was prepared to standardize the clinical approach to diagnosing and treating NAFLD patients. This guidance reflects many advances in the field of NAFLD. The proposals in this guidance are meant to aid decision-making in clinical practice. The guidance is primarily intended for gastroenterology, endocrinology, metabolism diseases, cardiology, internal medicine, pediatric specialists, and family medicine specialists.

Mucocutaneous Manifestations and Associated Factors in Patients with Crohn's Disease

BACKGROUND

One-third of all extraintestinal manifestations are mucocutaneous findings in patients with Crohn's disease and there is a relationship between some risk factors. Our aim is to evaluate factors associated with mucocutaneous manifestations in our cohort of patients with Crohn's disease with a follow-up duration of up to 25 years.

METHODS

In the study, 336 patients with Crohn's disease who were followed up between March 1986 and October 2011 were included. The demographic characteristics, Crohn's disease-related data, and accompanying mucocutaneous manifestations were recorded. The cumulative probability of mucocutaneous extraintestinal manifestations and possible risk factors were analyzed.

RESULTS

Oral and skin involvement were detected in 109 (32%) and 31 (9.2%) patients, respectively. The cumulative probability of developing oral and skin manifestations were 43.2% and 20.3%, respectively. Cox regression analysis showed that female gender (odds ratio: 3.28, 95% CI: 1.51-7.14, P = .003) and corticosteroid use (odds ratio: 7.88, 95% CI: 1.07-57.97, P = .043) are independently associated with the development of skin manifestations, while family history (odds ratio: 3.59, 95% CI: 2.18-5.93, P < .001) and inflammatory-type disease (odds ratio: 1.776, 95% CI: 1.21-2.61, P = .004) were independently associated with the development of oral ulcers.

CONCLUSION

Mucocutaneous extraintestinal manifestations are associated with female gender, corticosteroid use, family history, and disease type in a large cohort of patients with Crohn's disease. Defining the specific relationships of immune-mediated diseases will help to better understand the pathogenesis of Crohn's disease and associated mucocutaneous manifestations and to use more effective treatments.

Is there any predictor for relapse after treatment withdrawal in autoimmune hepatitis patients in the real life?

Backgrounds and Aims

In autoimmune hepatitis, there are uncertainties about whether to discontinue the treatment, when the treatment should be discontinued, and the risks of relapse in the cases where remission is achieved with immunosuppressive therapy. In this study, patients with AIH, whose immunosuppressive treatments were discontinued, were evaluated for the rates of remission and the risk of relapse.

Materials and Methods

A total of 119 patients, who were diagnosed with AIH based on the AIHG scoring systems between 1990 and 2015, were evaluated. Patients were receiving standard azathioprine and steroid therapy. The treatment was discontinued in patients, who had been receiving treatment for at least 2 years, who had no clinical complaints, and whose aminotransferases were normal and when an increase occurred in AST values more than two times the normal after the treatment was interrupted, the case was considered as a relapse.

Results

Among the patients, 83%(n = 99) were women. When the patients were diagnosed with AIH, their mean age was 36 ± 16(8–79) years; 70.6%(n = 84) were type 1, 3.4%(n = 4) type 2, and 26%(n = 31) were autoantibody-negative AIH. At the time of discontinuation, liver biopsy was performed in 8 of the patients and minimal-mild abnormalities were detected. Patients whose treatment was discontinued received treatment for an average of 101 ± 75(range: 24–280, median: 68.5) months; and, they were followed up for an average of 19 (1–110) months during the period without medication. Relapse occurred in 67%(n = 12) of the patients with drug withdrawal. Relapse occurred within the first 12 months in 67% of these patients (n = 8) and developed with an acute hepatitis attack in 42%. None of the clinical, laboratory, and histological data were found to be effective on relapse.

Conclusion

In patients with AIH, relapse occurs in two-thirds of patients within an average of 19 month after the discontinuation of the medication. Most relapses occur at the early period and they are accompanied by an acute hepatitis attack.

The effect of liver test abnormalities on the prognosis of COVID-19

INTRODUCTION

COVID-19 caused by the SARS-CoV-2 continues to spread rapidly across the world. In our study, we aim to investigate the relationship between the liver enzymes on admission (AST, ALT, ALP, GGT) and severity of COVID-19. We evaluated course of disease, hospital stay, liver damage and mortality.

MATERIALS AND METHODS

Our study included 614 patients who were hospitalized with the diagnosis of COVID-19 between 03.16.20 and 05.12.20. Patients with liver disease, hematological and solid organ malignancy with liver metastases were excluded, resulting in 554 patients who met our inclusion criteria. We retrospectively evaluated liver transaminase levels, AST/ALT ratio, cholestatic enzyme levels and R ratio during hospital admission and these were compared in terms of morbidity, mortality and clinical course.

RESULTS

Mean age of 554 subjects were 66.21±15.45 years, 328 (59.2%) were men. The mean values of liver enzymes on admission were AST (36.2±33.6U/L), ALT (34.01±49.34U/L), ALP (78.8±46.86U/L), GGT (46.25±60.05U/L). Mortality rate and need for intensive care unit were statistically significant in subjects that had high ALT-AST levels during their admission to the hospital (p=0.001). According to the ROC analysis AST/ALT ratio was a good marker of mortality risk (AUC=0.713: p=0.001) and expected probability of intensive care unit admission (AUC=0.636: p=0.001). R ratio, which was used to evaluate prognosis, showed a poor prognosis rate of 26.5% in the cholestatic injury group, 36.1% in the mixed pattern group and 30% in the hepato-cellular injury group (p 0.001).

CONCLUSIONS

ALT-AST elevation and AST/ALT ratio >1 was associated with more severe course and increased mortality in COVID-19.

Cryptogenic liver cirrhosis and hepatitis E virus (HEV): Are they related?

INTRODUCTION AND OBJECTIVES

Hepatitis E virus (HEV) is one of the most common causes of acute hepatitis. In recent years, its role in the development of chronic hepatitis and cirrhosis especially in immunosuppressed patients and its wide range of extrahepatic involvement have increased the amount of research on HEV. In this study we aimed to investigate the presence of HEV infection in individuals with cryptogenic cirrhosis.

MATERIALS AND METHODS

HEV antibodies were analysed using the Anti HEV enzyme-linked immunosorbent assay (ELISA) kit (anti-HEV ELISA; Diapro Prodiagnostic Bioprobes, Milan, Italy). HEV RNA was isolated with using QIAMP Viral RNA mini kit (QIAGEN, Hilden, Germany). The HEV RNA titre was detected with the Rotor Gene 3000 real time polymerase chain reaction (PCR) system using GenoSen's HEV (Rotor Gene) Quantitative Real Time PCR Kit (Genome Diagnostics Private Limited, the Netherlands).

RESULTS

Our study included 21 healthy volunteers (12 males) and 35 cryptogenic cirrhosis patients (19 males). The ages of the patients and the controls were similar (46±12.1 vs. 37.5±9.7years). The mean Child-Pugh score was 8±2.5. The anti HEV immunoglobulin G(IgG) positivity rate was 9.5% and 25.7% in the control and patient groups respectively (p>0.05). HEV RNA positivity was not detected in the control group, but 3 cases (8.6%) in the patient group were positive (p>0.05). The HEV RNA, aspartate aminotransferase (AST) and alanine aminotransferase(ALT) levels for these 3 cases were 326.461copies/mL, 91IU/L and 67IU/L; 480copies/mL, 68IU/L and 36IU/L and 72copies/mL, 42IU/L and 24IU/L respectively. There were positive correlations between HEV RNA levels and AST and ALT levels (p<0.05).

CONCLUSIONS

Anti HEVIgG and HEV RNA positivity rates are high in cryptogenic cirrhosis although it is not statistically significant and there is a positive correlation between HEV RNA and aminotransferases.

The development of extraintestinal manifestation and related risk factors in Crohn's patients

BACKGROUND

Crohn's disease (CD) primarily involves gastrointestinal tract; however, it can present with extraintestinal manifestations (EIMs), which leads to significant morbidity. Frequency of EIMs and associated risk factors vary due to genetic and environmental differences in studies.

AIM

To examine the frequency and risk factors associated with EIMs in CD.

METHOD

Patients with CD under follow-up from March 1986 to October 2011 were included in this study. Demographics, type of EIMs, autoimmune diseases, and clinical features of CD were recorded. Frequency of EIMs and associated risk factors were analyzed.

RESULTS

Three hundred thirty-six patients with CD were included in the study (mean follow-up duration 7.54 years). 55.4% (n: 186) were male and the mean age at diagnosis of CD was 30.6 years (range, 10.3-68.2 years). At least one EIM was detected in 47.3% and multiple EIMs in 22.9% of the cohort. Oral, joint, and skin involvements (32.4%, 24.7%, 9.2%, respectively) were the most common EIMs. Female gender (OR: 2.19, 95% CI: 1.34-3.58, p = 0.001), corticosteroid usage (OR: 2.32, 95% CI: 1.28-4.22, p = 0.007), and positive family history (OR: 5.61, 95% CI: 1.95-3.58, p = 0.001) were independent risk factors for EIM development. Colonic involvement (OR: 3.93, 95% CI: 1.59-9.68, p = 0.003), no surgical operation (OR: 2.31, 95% CI: 1.14-4.68, p = 0.020), and corticosteroid usage (OR: 2.85, 95% CI: 1.07-7.61, p = 0.037) were independent risk factors for multiple EIM development.

CONCLUSION

Although the immunological and clinical associations between EIMs and CD cannot be fully elucidated, identifying specific relationships of immune-mediated diseases will help to better understand CD pathogenesis.

A micro-elimination approach to addressing hepatitis C in Turkey

BACKGROUND

In 2016, WHO passed the Global Health Sector Strategy on Viral Hepatitis (GHSS), calling for its elimination by 2030. Two years later, Turkey approved a strategy to reach the WHO targets. This study reports new national prevalence data, breaks it down by subpopulation, and models scenarios to reach HCV elimination.

METHODS

Literature was reviewed for estimates of HCV disease burden in Turkey. They were discussed with stakeholders and used as inputs to develop a disease burden model. The infected population was estimated by sequelae for the years 2015-2030. Three scenarios were developed to evaluate the disease burden in Turkey: a Base 2017 scenario, representing the current standard of care in Turkey; an increased treatment scenario, representing the impact of improved access to DAAs; and a WHO targets scenario, which meet the WHO GHSS viral hepatitis targets of a 65% reduction in mortality and 90% diagnosis rate of the infected population by 2030.

RESULTS

At the beginning of 2017, 271,000 viremic infections were estimated. Of these, 58,400 were diagnosed and 10,200 treated. Modelling results showed that, with the current treatment paradigm in Turkey, by 2030 the total number of viremic HCV infections would decline by 35%, while liver-related deaths, hepatocellular carcinoma (HCC), and decompensated cirrhosis would decrease by 10-25%. In the increased treatment scenario, by 2030 viremic HCV infections would decrease by 50%; liver-related deaths, HCC and decompensated cirrhosis would decrease by 45-70%. In the WHO targets scenario, HCV infections would decrease by 80%; sequelae would decrease by 80-85%. Data on disease burden in micro-elimination target subpopulations are largely unavailable.

CONCLUSIONS

To meet the WHO Global Health Sector Strategy targets for the elimination of HCV, Turkey needs to increase treatment. Better data are needed as well as countrywide access to DAAs.

Mutations in Core Gene Region of Hepatitis B Virus in Patients with Chronic Hepatitis B

BACKGROUND

The HBV core protein plays a major role in host immune response. Mutations occurring in the HBV core gene may cause alterations in the major epitopes being effective in the host immune response. Until now, the persistent effects of core gene mutations on HBV infections have not been fully understood. The aim of this study is to analyze the core gene mutations for epitopes in the T lymphocytes [T helper (Th) and cytotoxic (CTL)] and B cell and C terminal region in patients with chronic hepatitis using ultra-deep pyrosequencing (UDPS) method.

METHODS

Eleven patients with chronic hepatitis B infection were included in the study. Amplification of the core gene was performed by a conventional PCR method. Mutations in the epitopes for T lymphocytes (Th and CTL) and B cell and in the C terminal region of HBV core gene were screened by UDPS. These mutations were analyzed in HBeAg positive and negative patients.

RESULTS

The minimum percentages of amino acid substitutions were found with 0.9% in HBeAg positive patients and 1.2% in negative patients. The number of missense mutation was higher in patients with HBeAg positive than negative patients (p < 0.005). The number of amino acid substitutions in the region of aa49 - 69 in the Th epitopes was found to be the highest in both HBeAg positive and negative patients. The mutation frequency was higher in the C-terminal region of the core protein compared to the Th, CTL, and B cell regions and these were more common in subjects with high-grade fibrosis. Some types of mutations (V27I, R47H, Y132I, R174STOP, S181P, Q182K) were only detected in subjects with liver cirrhosis.

CONCLUSIONS

Unlike literature, our results show that there is no significant increase in number of mutations in the core gene of the virus during the anti-HBe positive period. The role of low abundance variants and mutations in the immune system can be understood using methods such as UDPS in the near future.

Low recurrence rate of hepatocellular carcinoma following ledipasvir and sofosbuvir treatment in a real-world chronic hepatitis C patients cohort

The aims of the present study were to evaluate the efficacy and tolerability of ledipasvir/sofosbuvir (LDV/SOF) with or without ribavirin in the treatment of chronic hepatitis C (CHC) in patients with advanced liver disease and to analyse whether the use of LDV/SOF treatment is associated with a new occurrence of hepatocellular carcinoma (HCC) during and after LDV/SOF treatment. The Turkish Early Access Program provided LDV/SOF treatment to a total of 200 eligible CHC patients with advanced liver disease. The median follow-up period was 22 months. All patients were Caucasian, 84% were infected with genotype 1b, and 24% had a liver transplantation before treatment. The sustained virological response (SVR12) was 86.0% with ITT analysis. SVR12 was similar among patients with Child-Pugh classes A, B and C disease and transplant recipients. From baseline to SVR12, serum ALT level and MELD score were significantly improved (P < 0.001). LDV/SOF treatment was generally well tolerated. Only one patient developed a new diagnosed HCC. Seventeen of the 35 patients, who had a history of previous HCC, developed HCC recurrence during the LDV/SOF treatment or by a median follow-up of 6 months after treatment. HCC recurrence was less commonly observed in patients who received curative treatment for HCC compared with those patients who received noncurative treatment (P = 0.007). In conclusion, LDV/SOF with or without ribavirin is an effective and tolerable treatment in CHC patients with advanced liver disease. Eradication is associated with improvements in liver function and a reduced risk of developing a new occurrence of HCC.

Gastroesophageal Reflux in Asymptomatic Patients with Diabetes: An Impedance Study Diabetes, Obesity and Gastroesophageal Reflux

Introduction Gastroesophageal reflux disease (GERD) is more frequent in patients with diabetes mellitus (DM).The aim of the present study was to evaluate gastroesophageal reflux (GER) in asymptomatic patients with DM using 24-h pH impedance.

Materials and Methods 19 healthy controls and 35 patients with DM without typical GERD symptoms were enrolled in the study. A 24-h pH-impedance study, esophageal manometry and gastroscopy were performed on all patients with DM. In the control group, an impedance study was performed on all subjects, and gastroscopy and esophageal manometry were performed on those who consented to the procedures. Patients with diabetes were categorized as obese [body mass index (BMI)>30 kg/m2] or non-obese (BMI<30 kg/m2) and both groups were compared with healthy controls.

Results The mean BMI was similar in the control group (27.3±2.6 kg/m2) and the diabetic group (28.7±5 kg/m2) (p>0.05).Erosive esophagitis was found in 7.5% of the DM group. Esophageal dysmotility was higher in diabetics compared to the control group (45.5 vs. 11%, p=0.04). Neuropathy was found to be an independent risk factor for dysmotility. The mean DeMeester score (DMS) (25.6±32.5 vs. 11.2±17, p=0.01) and bolus exposure time (2.1±1.3 vs.1.3±1.3 min, p=0.009) were higher in the DM group compared with the control group.The difference was mainly observed between obese diabetics and the control group (p<0.05). The mean DMS, pathologic acid reflux, and esophageal dysmotility rate were higher in patients without complications of DM (p<0.05). BMI was higher in these patients than in patients with complications.

Conclusion Acid reflux is common in patients with diabetes.GER is associated with the existence of obesity rather than hyperglycemia.

Should we worry about incidental gastrointestinal tract involvement in positron emission tomography/computed tomography as gastroenterologist?

BACKGROUND AND AIM

Positron emission tomography/computed tomography(PET/CT) scans detects benign clinical conditions in addition to malignancy, and this leads to additional investigation and expenditure. The purpose of our study was to assess the endoscopic and histopathologic results of incidental 18F-FDG uptake in the GI tract.

PATIENTS AND METHOD

We enrolled 110 patients who underwent gastroscopy/colonoscopy for incidental GI tract involvement in PET/CT. Histopathologic and endoscopic results were compared with FDG uptake level, pattern of uptake(diffuse/focal), and site of involvement.

RESULTS

In our study, 52.7% of the patients were male and the mean age was 57±11 years. Among the participants, 47.3% and 52.7% of patients had upper GI tract and colorectal involvement in PET/CT, respectively. Gastritis and colonic polyps were the most common endoscopic diagnoses that caused FDG uptake in the upper and lower GI tract, respectively. Endoscopic evaluation was normal in 23.6% of patients with pathologic FDG involvement. The rates of adenomatous polyps, malignancy, and hyperplastic polyps were 18.5%, 13.6%, and 6.8%, respectively. The mean SUVmax were higher in malignant lesions than in non-malignant lesions (14.3±8.9 vs. 9.3±5.3)(p=0.02). Diffuse or focal FDG involvement patterns on PET/CT did not help to discriminate malignancy in the GI tract.

CONCLUSION

Malignancy was detected in only 13.6% of patients with FDG involvement in the GI tract, and the involvement pattern(diffuse/focal) and SUVmax did not differentiate malignancy.

Analysis of Hepatitis C Virus NS5A Region in Patients with Cirrhosis Using an Ultra-Deep Pyrosequencing Method

BACKGROUND

HCV (Hepatitis C Virus) is genetically more diverse than HBV and HIV (Human Immunodeficiency Virus) and exists as quasispecies within infected individuals. This is due to the lack of efficient proofreading of the viral RNA-dependent RNA polymerase. Consequently, quasispecies emerge depending on the mutation rate of the viral polymerase, which may display a high level of genetic variability in a population. In infected individuals, HCV replicates and circulates as quasispecies composed of a complex mixture of different but closely related genomes that undergoes continuous change due to competitive selection and cooperation between arising mutants. The aim of this study is to investigate mutations in the NS5A region as a whole, including ISDR, PKRBD, IRRDR, and V3 of HCV genotype 1b cirrhosis patients being naive and nonresponders, treated with IFN (interferon) + ribavirin (RBN) by using an ultra-deep pyrosequencing method (UDPS).

METHODS

During the study, five patients (four females, and one male, mean age 59.8 ± 11 years) with HCV related cirrhosis were analyzed. Three patients received IFN + RBN for six months, but two patients did not receive any therapy. HCV-RNA concentrations in patients' sera were determined using a COBAS AMPLICOR HCV MONITOR Test, Version 2.0. Genotyping was performed by using a commercial reverse hybridization method, Line Probe Assay. The quasispecies for the NS5A region were investigated using UDPS.

RESULTS

All five patients were HCV genotype 1b (Mean Child-Pugh score 7.2 ± 1.9, 2 pts Child A, 2 pts Child B, and one pt Child C) but only one patient had hepatocellular carcinoma (HCC). A total of 19 different mutations were detected in each of the five patients (ranging from 3 to 6 mutations per patient). In all five patients, several mutations in the ISDR and PKR-BD regions were detected. On the other hand, mutations in the V3 and IRRDR regions were only detected in one patient.

CONCLUSIONS

UDPS is a new sequencing technology and a very sensitive method in detection of quasispecies with low frequency NS5A region mutations. These mutations may affect the antiviral response and development of HCC. However, further studies in larger number of patients should be conducted to clarify this hypothesis.

Genes of major histocompatibility complex class II influence chronic C hepatitis treatment with interferon in hemodialysis patients

The prevalence of anti-HCV among patients on hemodialysis is consistently higher than in the general population, indicating that patients on hemodialysis programs are at risk of acquiring HCV infection. The response to interferon alpha 2b (IFN -α 2b) therapy in chronic C hepatitis depends on viral and host factors. We treated 22 chronic C hepatitis uremic patients with IFN- α 2b (3 MU three times a week) and compared interferon responsive and unresponsive patients with regard to HLA II genes. HLA II genes were investigated by PCR-SSP low resolution, anti-HCV with ELISA II and HCV-RNA with reverse transcriptase “nested” PCR. Findings: HLA DRB1*13 is 50% positive in the non-responder group (four women, four men, mean age; 28.8±11.9 years) and 7% in the responder group (five women, nine men, mean age; 32.2±7.8 years) (p<0.05). There was no difference with respect to HLA genes between controls (six women, eight men, mean age; 29.5 ± 12.8 years) and patients (nine women, 13 men, mean age; 31.0 ± 9.3 years) (HLA DRB1*13 is 28% and 22% positive, respectively). We conclude that major histocompatibility complex class II genes influence the outcome of chronic C hepatitis treatment with IFN -α 2b.

Current state and clinical outcome in Turkish patients with hepatocellular carcinoma

AIM

To investigate clinical, etiological, and prognostic features in patients with hepatocellular carcinoma.

METHODS

Patients with hepatocellular carcinoma who were followed-up from 2001 to 2011 were included in the study. The diagnosis was established by histopathological and/or radiological criteria. We retrospectively reviewed clinical and laboratory data, etiology of primary liver disease, imaging characteristics and treatments. Child-Pugh and Barcelona Clinic Liver Cancer stage was determined at initial diagnosis. Kaplan-Meier survival analysis was done to find out treatment effect on survival. Risk factors for vascular invasion and overall survival were investigated by multivariate Cox regression analyses.

RESULTS

Five hundred and forty-five patients with hepatocellular carcinoma were included in the study. Viral hepatitis was prevalent and 68 patients either had normal liver or were non-cirrhotic. Overall median survival was 16 (13-19) mo. Presence of extrahepatic metastasis was associated with larger tumor size (OR = 3.19, 95%CI: 1.14-10.6). Independent predictor variables of vascular invasion were AFP (OR = 2.95, 95%CI: 1.38-6.31), total tumor diameter (OR = 3.14, 95%CI: 1.01-9.77), and hepatitis B infection (OR = 5.37, 95%CI: 1.23-23.39). Liver functional reserve, tumor size/extension, AFP level and primary treatment modality were independent predictors of overall survival. Transarterial chemoembolization (HR = 0.38, 95%CI: 0.28-0.51) and radioembolization (HR = 0.36, 95%CI: 0.18-0.74) provided a comparable survival benefit in the real life setting. Surgical treatments as resection and transplantation were found to be associated with the best survival compared with loco-regional treatments (log-rank, P < 0.001).

CONCLUSION

Baseline liver function, oncologic features including AFP level and primary treatment modality determines overall survival in patients with hepatocellular carcinoma.

Belching in Irritable Bowel Syndrome: An Impedance Study

Background/Aims

There are limited data about the relation between belching and irritable bowel syndrome (IBS). We aim to evaluate belching in patients with IBS.

Methods

Twenty-five patients with IBS and 12 healthy volunteers were enrolled in the study. IBS was diagnosed in accordance with the Rome III criteria. All patients were questioned about the presence of symptoms for belching, gastroesophageal reflux disease, and dyspepsia. Esophageal manometry and 24-hour pH-impedance were performed in all patients and healthy volunteers. Each of the patients with IBS underwent gastroscopy and colonoscopy.

Results

Demographic features were similar in both groups (P > 0.05). The belching rate was 32% in patients with IBS. The mean DeMeester score was significantly higher in IBS patients (13.80 ± 14.40 vs 6.04 ± 5.60, P = 0.027) and 24% of patients had pathologic acid reflux (DeMeester score > 14). Gastroscopy was normal in all patients. Symptom association probability positivity was detected in 24% of patients in the impedance study. The rate of weak acid reflux was also significantly higher in patients with IBS (97.00 ± 56.20 vs 58.20 ± 29.30, P = 0.025). The number of supine gas reflux (7.50 ± 6.40 vs 2.42 ± 2.80, P = 0.001) and supragastric belches was significantly higher in patients with IBS (51.20 ± 41.20 vs 25.08 ± 15.20, P = 0.035). Although the number of gastric belching was higher in controls, the difference did not reach statistical significance (12.10 ± 17.60 vs 4.90 ± 3.80, P = 0.575). We did not find any correlation between belching and any symptoms of IBS.

Conclusions

Belching is frequent in patients with IBS. Non-erosive reflux disease is frequent in IBS, which may be related to supragastric belching.

Global prevalence and genotype distribution of hepatitis C virus infection in 2015: a modelling study

BACKGROUND

The 69th World Health Assembly approved the Global Health Sector Strategy to eliminate hepatitis C virus (HCV) infection by 2030, which can become a reality with the recent launch of direct acting antiviral therapies. Reliable disease burden estimates are required for national strategies. This analysis estimates the global prevalence of viraemic HCV at the end of 2015, an update of-and expansion on-the 2014 analysis, which reported 80 million (95% CI 64-103) viraemic infections in 2013.

METHODS

We developed country-level disease burden models following a systematic review of HCV prevalence (number of studies, n=6754) and genotype (n=11 342) studies published after 2013. A Delphi process was used to gain country expert consensus and validate inputs. Published estimates alone were used for countries where expert panel meetings could not be scheduled. Global prevalence was estimated using regional averages for countries without data.

FINDINGS

Models were built for 100 countries, 59 of which were approved by country experts, with the remaining 41 estimated using published data alone. The remaining countries had insufficient data to create a model. The global prevalence of viraemic HCV is estimated to be 1·0% (95% uncertainty interval 0·8-1·1) in 2015, corresponding to 71·1 million (62·5-79·4) viraemic infections. Genotypes 1 and 3 were the most common cause of infections (44% and 25%, respectively).

INTERPRETATION

The global estimate of viraemic infections is lower than previous estimates, largely due to more recent (lower) prevalence estimates in Africa. Additionally, increased mortality due to liver-related causes and an ageing population may have contributed to a reduction in infections.

FUNDING

John C Martin Foundation.

Role of several cytokines and adhesion molecules in the diagnosis and prediction of survival of hepatocellular carcinoma

BACKGROUND AND STUDY AIMS

There is still need for accurate markers for early diagnosis of hepatocellular carcinoma (HCC) and assessment of prognosis. The aim of this study is to investigate interleukin (IL)-32, IL-1 beta, IL-18, vascular cell adhesion molecule (VCAM)-1, and epithelial cell adhesion molecule (EpCAM) in the diagnosis and assessment of prognosis of HCC.

PATIENTS AND METHODS

Fifty patients with HCC and 15 healthy volunteers were enroled into this prospective study. Serum samples were obtained at the first admission before any treatment was given. Serum IL-32, IL-1 beta, IL-18, VCAM-1, and EpCAM levels were determined using ELISA kits.

RESULTS

The mean age of the patient group and controls was 60±9years and 56±8years, respectively. The mean serum level of IL-32 was higher in patients with HCC than in the control subjects (65.1 vs. 14.1pg/mL; p<0.001). IL-18 levels were significantly higher in the HCC group (546.5 vs. 157.8pg/mL; p<0.001). EpCAM (20.3 vs. 1.5pg/mL; p<0.001) and VCAM (6.5 vs. 1.8μg/mL; p<0.001) levels were also higher in patients with HCC. The mean level of IL-1 beta in the HCC group was similar to that in the control subjects (1.9 vs. 1.9pg/mL; p=0.97). Fifty-eight per cent of the patients with HCC died at 7.3months (median). Cytokine levels except EpCAM did not correlate with survival (p>0.05). Alpha-foetoprotein, IL-32, IL-18, EpCAM, and VCAM had valuable cutoff levels to differentiate between patients with HCC and control group (p<0.001).

CONCLUSIONS

Although cytokines can be a diagnostic marker for HCC, they did not have any significant prognostic value in patients with HCC. Only EpCAM may be used to determine the prognosis of HCC, thereby assisting with treatment management.

Role of biochemistry and cytological analysis of cyst fluid for the differential diagnosis of pancreatic cysts: A retrospective cohort study

BACKGROUND

Management of pancreatic cysts is based on neoplastic-nonneoplastic discrimination. Endoscopic ultrasound (EUS) enables to differentiate neoplastic-nonneoplastic lesions and also allows fine-needle aspiration (FNA). In this study, we aim to assess feasibility and clinical relevance of cytological and biochemical analysis in differential diagnosis of cystic pancreatic lesions in patients who had undergone endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) due to pancreatic cysts.

METHODS

Participants were 96 patients who had undergone EUS-FNA for differential diagnosis of pancreatic cysts. Pancreatic cysts were classified as benign-mucinous, nonmucinous, and malignant according to patient history, physical examination, EUS appearance, and cystic fluid assessment. Tumor markers (CEA, CA(cancer antigens) 72.4, CA 19-9) , amylase, lipase and cytological assesment were compared between 3 different groups. Receiver-operating characteristics (ROC) curves were constructed to identify appropriate cut-off values.

RESULTS

Fluid CEA and CA 72.4 levels for benign-mucinous and malignant cysts were significantly higher than for nonmucinous cysts (P ≤ 0.04). A cut-off CEA level of 207 ng/mL differentiated mucinous etiology with a sensitivity of 72.7%, specificity of 97.7%, and accuracy of 89.5%. The sensitivity, specificity, and accuracy of the CA 72.4 cut-off level of 3.32 ng/mL were 80%, 69.5%, and 73.6%, respectively.

CONCLUSION

Cyst fluid CEA and CA 72.4 levels have a high accuracy in discriminating mucinous from nonmucinous cysts. When combined with cytology their accuracy rate increases.

Predictors of treatment requirement in HBeAg-negative chronic hepatitis B patients with persistently normal alanine aminotransferase and high serum HBV DNA levels

OBJECTIVES

Serum alanine aminotransferase (ALT) is a controversial marker for disease monitoring in hepatitis B e antigen (HBeAg)-negative chronic hepatitis B (CHB) patients. The aim of this study was to determine the fibrosis stage and histological activity index (HAI) in HBeAg-negative CHB patients with persistently normal ALT (PNALT) and high serum HBV DNA (≥2000 IU/ml) and to investigate clinical risk factors for the requirement of treatment through the examination of liver biopsy specimens.

METHODS

HBeAg-negative CHB patients with PNALT (≤40 IU/l) and high serum HBV DNA (≥2000 IU/ml) were included. HBV fibrosis stage and HAI were scored according to the Ishak system. Multivariate logistic regression analysis was used to estimate the independent risk factors for fibrosis stage ≥2 and/or HAI ≥6. Receiver operating characteristic curve analysis was used to determine an optimal age cut-off for liver biopsy.

RESULTS

A total 120 patients were enrolled. These patients had a mean HBV DNA level of 123680±494500 IU/ml; the HBV DNA load was 2000-20000 IU/ml in 68 patients (56.6%) and ≥20000 IU/ml in 52 (43.4%). Eighteen patients (15%) had moderate-to-severe histological activity (HAI ≥6). Forty-three patients (35.9%) had a fibrosis stage ≥2. Forty-eight patients (40%) had a fibrosis stage ≥2 and/or HAI ≥6. On multivariate logistic regression analysis, independent variables associated with fibrosis stage ≥2 and/or HAI ≥6 included age and HBV DNA viral load. Patients with HBV DNA 2000-20000 IU/ml were more likely to require treatment compared to those with a viral load ≥20000 IU/ml. The optimal age cut-off to predict fibrosis stage ≥2 and/or HAI ≥6 was 46 years.

CONCLUSIONS

Significant liver damage was detected in 40% of CHB patients with PNALT and high HBV DNA upon biopsy. Age and HBV DNA viral load were independent predictors of significant liver damage. A biopsy to determine the degree of liver damage is advisable for CHB patients older than 46 years.

Retention during capsule endoscopy: Is it a real problem in routine practice?

OBJECTIVE

This study evaluated the risks and outcomes of capsule retention during capsule endoscopy (CE) for investigating small bowel disease. Capsule retention is the most serious complication of CE.

METHODS

Before CE, the gastrointestinal tract was evaluated for blockages with computerized tomography. Analysis of CE was made retrospectively.

RESULTS

Capsule endoscopy was used to investigate obscure bleeding (90.2%; n = 324) or other symptoms (9.8%; n = 35). The capsule retention rate was 11/359 (3.1%); it was retained in a malignant lesion area (adenocarcinoma or melanoma) in two patients (18.2%), in the small bowel in an ulcerated area in five patients (45.5%), and in the oesophagus/stomach in four patients (36.4%) due to dysmotility. None of the patients had symptoms of obstruction.

CONCLUSIONS

Scanning patients before CE did not predict capsule retention. Retention is a complication of CE, but occurs as a result of the underlying disease. The risk of retention is increased in patients with motility disorders, suspected small bowel ulcers or malignancies.

Can Helicobacter pylori be eradicated with high-dose proton pump inhibitor in extensive metabolizers with the CYP2C19 genotypic polymorphism?

Proton pump inhibitors (PPI) metabolism and pharmacokinetics are regulated by cytochrome P450 enzymes in the liver. Cytochrome P450 2C19 (CYP2C19) polymorphism plays an import role in the metabolism of PPIs. The three possible genotypes for CYP2C19 each has a distinct effect on the pharmacodynamics of PPIs. Homozygote extensive metabolizers (HomEM) are the most frequent genotype and have two wild-types (non-mutant) (*1/*1) alleles. HomEM is associated with increased enzyme activity, which increases the rate of PPI metabolism. Intragastric pH, which is required for eradication, is lowest in HomEM. In HomEMs, an insufficient increase in intragastric pH results in decreased anti-Helicobacter pylori (HP) efficacy of the antibiotics and, therefore, lower eradication rates. We determined whether the HP eradication rate would increase after high-dose PPI treatment of extensive PPI metabolizers who had been treated unsuccessfully with a standard PPI dose. In our report, increasing the PPI dosage in patients with genotype polymorphisms may be effective on eradication rates. Eradication rates are directly affected by CYP2C19 polymorphisms, and eradication treatments should be planned considering such genotypic polymorphisms. Hence, CYP2C19 genotyping prior to treatment may facilitate determination of the optimum PPI dose to improve the therapeutic outcome. However, further researches are required to confirm this hypothesis.

Does gastroesophageal reflux increase chronic obstructive pulmonary disease exacerbations?

BACKGROUND

The relationship between chronic obstructive pulmonary disease (COPD) exacerbations and gastroesophageal reflux (GER) has been investigated less than asthma-GER. We aimed to evaluate the presence of GER in patients with COPD and its impact on exacerbations.

METHODS

We included 24 patients with stable mild-moderate stage COPD and 19 volunteers as the control group. We conducted a gastroesophageal reflux disease (GERD) symptom questionnaire, gastroscopy, manometry, and an ambulatory 24-h pH-impedance study.

RESULTS

According to the GERD questionnaire, only 5 (20.8%) patients with COPD had typical GER symptoms. According to the 24-h pH-impedance study, the mean DeMeester score (DMS) was 38.1 ± 34.6 in the COPD group and 13.3 ± 16.8 in the control group (p = 0.01). The acid reflux (DMS > 14.7) rate was higher in patients with COPD than in controls (73.9% vs 26.3%, p = 0.01). The symptom association probability positivity rate was 17.4% (n = 4) in the COPD group, which was similar to the controls (p = 0.11). The mean proximal extension rate of reflux (Z 17 cm) was 26.4 ± 12.9% in the COPD group. The proximal extent of reflux was positively correlated with the number of COPD exacerbations per year (p = 0.03, r = 0.448). In the motility results, only 2 (20%) patients in the control group had a minor motility disorder. Seventeen (70.8%) patients in the COPD group had a minor motility disorder, and 4 (16.7%) had major motility disorders (p < 0.001).

CONCLUSION

In our study, gastroesophageal reflux was frequent in patients with COPD, but only a quarter had typical reflux symptoms. The proximal extent of reflux may trigger frequent exacerbations of COPD.

What is the impact of capsule endoscopy in the long term period?

AIM: To assess the clinical impact of capsule endoscopy (CE) in the long-term follow-up period in patients with obscure gastrointestinal bleeding (OGIB).

METHODS: One hundred and forty-one patients who applied CE for OGIB between 2009 and 2012 were retrospectively analyzed, and this cohort was then questioned prospectively. Demographic data of the patients were determined via the presence of comorbid diseases, use of non-steroidal anti-inflammatory drugs anticoagulant-antiaggregant agents, previous diagnostic tests for bleeding episodes, CE findings, laboratory tests and outcomes.

RESULTS: CE was performed on 141 patients because of OGIB. The capsule was retained in the upper gastrointestinal (GI) system in two of the patients, thus video monitoring was not achieved. There were 139 patients [62% male, median age: 72 years (range: 13-93 years) and a median follow-up duration: 32 mo (range: 6-82 mo)]. The overall diagnostic yield of CE was 84.9%. Rebleeding was determined in 40.3% (56/139) of the patients. The rebleeding rates of patients with positive and negative capsule results at the end of the follow-up were 46.6% (55/118) and 4.8% (1/21), respectively. In the multivariate analysis, usage of NSAIDs, anticoagulant-antiaggregant therapies (OR = 5.8; 95%CI: 1.86-18.27) and vascular ectasia (OR = 6.02; 95%CI: 2.568-14.146) in CE were detected as independent predictors of rebleeding. In the univariate analysis, advanced age, comorbidity, and overt bleeding were detected as predictors of rebleeding.

CONCLUSION: CE is a reliable method in the diagnosis of obscure GI bleeding. Negative CE correlated with a significantly lower rebleeding risk in the long-term follow-up period.

Steroid-refractory inflammatory bowel disease is a risk factor for CMV infection

OBJECTIVE

Patients with inflammatory bowel disease (IBD) show increased the prevalence of cytomegalovirus (CMV) infection due to the severity of the disease and the immunosuppressive treatments they receive. The aim of this study was to determine the prevalence of CMV infection in IBD patients and identify the risk factors for CMV infection with different demographic characteristics in IBD patients.

PATIENTS AND METHODS

We enrolled 85 patients diagnosed with IBD (43 with ulcerative colitis (UC) and 42 with Crohn's disease (CD)) in this prospective study. The clinical disease activities of UC and CD were assessed using Truelove-Witts and Crohn's disease activity index (CDAI). CMV infection was assessed by detection of DNA using real-time polymerase chain reaction (PCR) in blood samples and quantitative PCR in colonic biopsy specimens and by detection of inclusion bodies using hematoxylin-eosin staining.

RESULTS

Thirteen patients with IBD exhibited concomitant CMV infection. CMV infection was not detected in any of the patients in remission. Viral loads measured in the colonic mucosa of infected patients ranged from 800-7000 genome copies/mL total extracted DNA. The mean serum CMV DNA level was 1694 ± 910 copies/mL (range: 800-3800). The rate of steroid resistance in CMV-positive cases was significantly higher than that in CMV-negative cases (p = 0.001). CD with acute exacerbation was a risk factor for CMV disease (p = 0.04). All of the CMV-positive patients received immunosuppressive treatments.

CONCLUSIONS

CMV infection should be suspected in steroid-resistant UC and CD. Antiviral treatment improved the clinical outcome in steroid-resistant IBD cases with serum CMV DNA levels above 1000 copies/mL.

Effect of cytochrome P450 2C19 polymorphisms on the Helicobacter pylori eradication rate following two-week triple therapy with pantoprazole or rabeprazole

OBJECTIVE

Cytochrome P450 2C19 (CYP2C19) polymorphisms play an important role in the metabolism of proton pump inhibitors. Rabeprazole is primarily metabolized via non-enzymatic pathways. In this study, we determined whether rabeprazole- and pantoprazole-based eradication treatments were influenced by CYP2C19 polymorphisms.

PATIENTS AND METHODS

A total of 200 patients infected with Helicobacter pylori were treated with either 40 mg of pantoprazole or 20 mg of rabeprazole plus 500 mg of clarithromycin, 1000 mg of amoxicillin twice daily for 2 weeks. CYP2C19 genotype status was determined by Polymerase Chain Reaction (PCR)-restriction-fragment-length polymorphism. The genotypes of cytochrome P450 2C19 were classified as homozigote extensive metabolizer (HomEM), heterozigote metabolizer (HetEM) and poor metabolizer (PM). The CYP2C19 genotype of all patients, the effectiveness of the treatment, the effect of the genotypic polymorphism on the treatment were assessed.

RESULTS

The frequencies of HotEM, HetEM, PM were 78%, 19.5% and 2.5%, respectively. 48% (n = 96) of the patients received treatment with rabeprazole and 52% (n = 104) with pantoprazole. The eradication rate was 64.7% for HomEM, 79.4% for HetEM, 100% for PM (p = 0.06). In HetEM, PM, are considered as a single group, the eradication rates were higher in patients with the HetEM and PM (HetEM+PM) genotypes than in those with the wild-type genotype (81.8 vs. 64.7% p = 0.031). Among the patients treated with rabeprazole, the eradication rates were significantly lower in those with the HomEM genotype than in those with the HetEM+PM genotypes (60% vs. 85.7% p = 0.023).

CONCLUSIONS

The genotypic polymorphism is effective on the rate of eradication. Eradication treatment rate with rabeprazole is influenced by CYP2C19 genotype.

Tenofovir disoproxil fumarate has a substantial efficacy against multidrug-resistant strains of hepatitis B virus

BACKGROUND & AIMS

To evaluate the efficacy of tenofovir in chronic hepatitis B (CHB) patients with adefovir resistance (ADF-R) and suboptimal response to adefovir (ADF-S).

METHODS

Nucleos(t)ide analogue (NA)-naïve patients and patients with previous adefovir failure receiving tenofovir therapy for at least 6 months were included in the study. Biochemical and virological tests were obtained at baseline and 3-month intervals in the first year and every 6 months thereafter. The primary outcome measure was complete virological response (CVR) (HBVDNA < 20 IU/ml). CVR rates were calculated by Kaplan-Meier analysis, and a multivariate Cox proportional hazard model was generated to find out factors independently associated with CVR.

RESULTS

A total of 165 patients (118 men, mean age 42 ± 12, 64 HBeAg(+) ) were included in the study. There were 105 patients in NA-naïve, 32 patients in ADF-S and 28 patients in ADF-R groups. All patients in the ADF-R group had multidrug resistance patterns. Mean duration of tenofovir treatment was 29 ± 14 months. CVR rates in NA-naïve, ADF-S and ADF-R groups were 65% vs. 75% vs. 58% at 12th month, 77% vs. 87% vs. 79% at 24th month and 83% vs. 94% vs. 79% at 36th month respectively. According to multivariate Cox regression model, HBeAg positivity (HR = 0.56, 95%CI 0.36-0.86, P = 0.008), high baseline HBVDNA level (HR = 0.64, 95%CI 0.55-0.74, P < 0.001) and ADF-R (HR = 0.47, 95%CI 0.28-0.81, P = 0.006) were independent predictors for CVR. Seven patients encountered mild renal dysfunction and were managed by dose adjustments.

CONCLUSION

CVR rates during the follow-up show that tenofovir has a decreased, yet still potent in vivo efficacy against multidrug-resistant strains of HBV.

Seroprevalence of hepatitis B and C virus infections and risk factors in Turkey: a fieldwork TURHEP study

The present study was designed to determine the seroprevalence of hepatitis B and C virus (HBV, HCV) infections and risk factors in the Turkish general population. Participants were enrolled from urban and rural areas of the predetermined 23 EUROSTAT NUTS 2 region. A two-stage stratified sampling method was used to select participants from these regions (n = 5460; 50.9% females; mean (SD) age: 40.8 (14.7) years). Sociodemographics, clinical characteristics and risk factors were recorded at home visits. The seropositivity rates for hepatitis B surface antigen (HBsAg), anti-HCV, anti-HBs and anti-HBc total were 4.0%, 1.0%, 31.9% and 30.6%, respectively. Among HBsAg-positive cases, 94.5% were anti-HBe-positive, 70.2% were HBV-DNA-positive and 2.8% were anti-HDV total positive; 99.1% of HBV infections were of genotype D. Close contact with a hepatitis patient (OR 3.24; 95% CI 2.25-4.66; p < 0.001), living in the southeastern region (OR 2.74; 95% CI 1.7-4.45; p < 0.001), male gender (OR 1.77; 95% CI 1.28-2.46; p < 0.001), being married (OR 1.62; 95% CI 1.02-2.57; p 0.038), educational level less than high school (OR 1.53; 95% CI 1.04-2.26; p 0.03), orodental interventions (OR 1.54; 95% CI 1.01-2.35; p 0.047) and a history of non-disposable syringe use (OR 1.4; 95% CI 1.01-1.96; p 0.045) were significant determinants of HBsAg positivity. Age ≥50 years (OR 2; 95% CI 1.09-4.3; p 0.026) was the only significant predictor of anti-HCV positivity. In conclusion, our findings revealed an HBsAg positivity in 4% and anti-HCV positivity in 1% of the adult population and at least one-third of the population has been exposed to HBV infection in Turkey.

Small bowel mucosal damage in familial Mediterranean fever: results of capsule endoscopy screening

OBJECTIVE

Familial Mediterranean fever (FMF) is the most common form of autoinflammatory diseases. We aimed to evaluate the small bowel mucosa by capsule endoscopy (CE) in FMF patients for investigation of other possible causes of abdominal pain.

MATERIAL AND METHODS

The study group consisted of 41 patients with FMF. A standard questionnaire was used to record the gastrointestinal symptoms, other clinical findings, Mediterranean fever gene (MEFV) mutations, and history of medications including non-steroidal anti-inflammatory drugs (NSAIDs). Gastroscopy, colonoscopy and small bowel CE were performed in all patients, and biopsies were taken from terminal ileum and duodenum.

RESULTS

The mean age of the patients was 34 ± 11 years, 63% of them were female, and 76.5% of them were carrying MEFV exon 10 mutations. Only one patient used NSAIDs in addition to colchicine. In endoscopic investigations, gastric erosion was detected in only one patient, and no significant findings were detected in colonoscopy. CE showed small bowel mucosal defects in 44% (erosions in 26.8%, ulcer in 17.1%) and edema in 29.3% of the patients. Most (64%) of the ulcer and erosions were localized to jejunum, and only 24% were in ileum. Mitotic changes as an indirect finding of colchicine toxicity were not different from the changes observed in samples of independent group of patients with irritable bowel syndrome.

CONCLUSION

Mucosal defect was observed in half of the FMF patients, which may be associated with underlying inflammation or chronic colchicine exposure. Detection of nonspecific chronic inflammation without mitotic changes supports that mucosal defects may be associated with the autoinflammatory process.

Effects of polymorphisms in interferon λ 3 (interleukin 28B) on sustained virologic response to therapy in patients with chronic hepatitis D virus infection

BACKGROUND & AIMS

We investigated the association between interferon λ 3 (IFNL3) genotype (also known as interleukin 28B) and response to IFNα therapy in patients with chronic hepatitis D virus (HDV) infection.

METHODS

We studied IFNL3 genotypes of 32 patients (19 men; median age, 42.5 y) with chronic HDV infection. Nineteen patients (59%) were treated with pegylated IFNα and 13 patients (41%) were treated with standard IFNα, for at least 12 months. Levels of HDV RNA were measured before the initiation of treatment and every 6 months thereafter; patients were followed up for a median time of 16 months (range, 6-164 mo) after treatment ended. We used real-time polymerase chain reaction to classify the IFNL3 polymorphism rs12979860 as CC, CT, or TT, and rs8099917 as TT, GT, or GG. A virologic response was defined as undetectable HDV RNA in serum, and a sustained virologic response (SVR) was defined as undetectable HDV RNA after cessation of treatment until the end of the follow-up period. We evaluated the association between IFNL3 polymorphism and treatment response using univariate and multivariate analyses.

RESULTS

After treatment, a response was achieved in 16 patients (50%) and an SVR was achieved in 9 (28%). The percentages of patients with CC, CT, and TT at rs12979860 were 47%, 47%, and 6%, respectively; the percentages of patients with TT, GT, and GG at rs8099917 were 69%, 28%, and 3%, respectively. Rates of SVR were 27%, 27%, and 50% in patients with CC, CT, TT at rs12979860 (P = .78 for CC vs CT vs TT) and 36%, 11%, and 0% in patients with TT, GT, and GG at rs8099917 (P = .30 for TT vs GT vs GG).

CONCLUSIONS

The IFNL3 polymorphisms rs12979860 and rs8099917 do not significantly affect responses of patients with chronic HDV infection to treatment with IFNα.

Infliximab in inflammatory bowel disease: attention to adverse events

OBJECTIVE

To assess the efficacy and adverse effects of infliximab in patients with Crohn's disease and ulcerative colitis who are resistant to conventional therapy or having fistulising type Crohn's disease.

PATIENTS AND METHODS

The patients with a diagnosis of inflammatory bowel disease received infliximab between 2007 and 2009 were followed-up prospectively. Infliximab 5 mg/kg was given at week 0, 2, 6, and every 8 weeks thereafter. Early and late adverse events occurring during the treatment were recorded for each patient.

RESULTS

There were 36 patients [mean age 35±12, 17 male] included in the study. Thirty-two (88%) patients were receiving concomitant long-term immunosuppressive therapy. Complete or partial response was obtained in 75% of all patients. At least one adverse event was observed in 10 (28%) patients. Anaphylaxis was seen in 2 (6%) patients, mild acute infusion reaction in 2 (6%) patients, hypotension in 2 (6%) patients, respiratory distress in 2 (6%) patients, skin rash and eruptions in 2 (6%) patients, one hypertension (3%) and one (3%) tightness in the chest. Treatment was continued in all except patients with anaphylaxis. No infection, tumour or cases of death were observed.

CONCLUSIONS

Several adverse events might be observed in patients who receive infliximab. Care should be given to patients whom treatment was restarted after a break in regard to anaphylaxis. No serious adverse event was observed during infliximab treatment except allergic events.

Acute hepatitis B due to immune-escape mutations in a naturally immune patient

Incidence of hepatitis B virus infection (HBV) has been greatly reduced globally after the introduction of universal vaccination programs. However, another potential threat was noticed almost 2 decades ago, which is the selection of antibody escape HBV strains. Antibody or immune escape strains of HBV carry mutations in the S gene which encodes "a" determinant region located at amino acid positions 124 to 149. Certain mutations in this region, which promotes antibody response, might lead to an alteration in the antigenicity of hepatitis B surface antigen (HBsAg). Anti-HBs might fail to neutralize the mutant virus and transmission or reappearance of infection in previously immunized individuals can be possible. Herein, we report a patient with known HBV seropositivity (HBsAg negative, anti-HBs positive, anti-HBc IgG positive) for more than 10 years who developed a symptomatic acute hepatitis due to occurrence of immune escape mutants in the absence of any immunosuppression or cytotoxic chemotherapy. To the best of our knowledge, this is the first reported case of acute hepatitis B due to escape mutations in a naturally immune patient.

Historical epidemiology of hepatitis C virus (HCV) in selected countries

Chronic infection with hepatitis C virus (HCV) is a leading indicator for liver disease. New treatment options are becoming available, and there is a need to characterize the epidemiology and disease burden of HCV. Data for prevalence, viremia, genotype, diagnosis and treatment were obtained through literature searches and expert consensus for 16 countries. For some countries, data from centralized registries were used to estimate diagnosis and treatment rates. Data for the number of liver transplants and the proportion attributable to HCV were obtained from centralized databases. Viremic prevalence estimates varied widely between countries, ranging from 0.3% in Austria, England and Germany to 8.5% in Egypt. The largest viremic populations were in Egypt, with 6,358,000 cases in 2008 and Brazil with 2,106,000 cases in 2007. The age distribution of cases differed between countries. In most countries, prevalence rates were higher among males, reflecting higher rates of injection drug use. Diagnosis, treatment and transplant levels also differed considerably between countries. Reliable estimates characterizing HCV-infected populations are critical for addressing HCV-related morbidity and mortality. There is a need to quantify the burden of chronic HCV infection at the national level.

The present and future disease burden of hepatitis C virus (HCV) infection with today's treatment paradigm

The disease burden of hepatitis C virus (HCV) is expected to increase as the infected population ages. A modelling approach was used to estimate the total number of viremic infections, diagnosed, treated and new infections in 2013. In addition, the model was used to estimate the change in the total number of HCV infections, the disease progression and mortality in 2013-2030. Finally, expert panel consensus was used to capture current treatment practices in each country. Using today's treatment paradigm, the total number of HCV infections is projected to decline or remain flat in all countries studied. However, in the same time period, the number of individuals with late-stage liver disease is projected to increase. This study concluded that the current treatment rate and efficacy are not sufficient to manage the disease burden of HCV. Thus, alternative strategies are required to keep the number of HCV individuals with advanced liver disease and liver-related deaths from increasing.

Strategies to manage hepatitis C virus (HCV) disease burden

The number of hepatitis C virus (HCV) infections is projected to decline while those with advanced liver disease will increase. A modeling approach was used to forecast two treatment scenarios: (i) the impact of increased treatment efficacy while keeping the number of treated patients constant and (ii) increasing efficacy and treatment rate. This analysis suggests that successful diagnosis and treatment of a small proportion of patients can contribute significantly to the reduction of disease burden in the countries studied. The largest reduction in HCV-related morbidity and mortality occurs when increased treatment is combined with higher efficacy therapies, generally in combination with increased diagnosis. With a treatment rate of approximately 10%, this analysis suggests it is possible to achieve elimination of HCV (defined as a >90% decline in total infections by 2030). However, for most countries presented, this will require a 3-5 fold increase in diagnosis and/or treatment. Thus, building the public health and clinical provider capacity for improved diagnosis and treatment will be critical.

Efficacy of tenofovir in adefovir-experienced patients compared with treatment-naive patients with chronic hepatitis B

BACKGROUND

Tenofovir (TDF) has similar antiviral efficacy in both treatment-naive and lamivudine-resistant chronic hepatitis B (CHB) patients. Data on TDF use in patients with adefovir (ADV) resistance is inconsistent. The aim of our study was to assess antiviral efficacy of TDF against nucleoside analogue-naive (NN) and ADV-resistant (ADV-R) CHB and suboptimal responders to ADV (ADV-S).

METHODS

A database of 135 CHB patients treated with TDF was analysed. A total of 37 patients with incomplete data were excluded and analysis was performed in 98 (44 NN, 30 ADV-R and 24 ADV-S). Patients with primary ADV-R mutations had either A181T/V or N236T mutations or both. HBV DNA was measured at 3-month intervals until month 24. Primary outcome measures were comparison of the decline of HBV DNA between the three treatment groups.

RESULTS

NN patients had higher baseline HBV DNA compared with ADV-R and ADV-S patients (6.08 log10 IU/ml versus 5.53 and 4.88, respectively; P=0.002). By exponential regression analysis, HBV DNA decline kinetics differed between the three groups. HBV DNA decline was faster in NN patients compared to ADV-R and ADV-S CHB patients (P=0.002 and P=0.004, respectively). Undetectable HBV DNA was achieved in 77.2%, 60% and 75% of NN, ADV-R and ADV-S CHB patients, respectively, at month 12 (P= not significant).

CONCLUSIONS

HBV DNA decline is slower in ADV-experienced patients compared with treatment-naive patients. The clinical significance of this slow response may be important in patients with critical liver reserve and high viral load. Optimal combination treatment (TDF+ entecavir) could be considered in these patients.

Treatment failure may lead to accelerated fibrosis progression in patients with chronic hepatitis C

Chronic hepatitis C (CHC) patients with treatment failure (TF) remain at risk of continuing fibrosis progression. However, it has not been investigated whether there is an increased risk of accelerated fibrosis progression after failed interferon-based therapy. We aimed to investigate long-term influence of TF on fibrosis progression compared with untreated patients with CHC. We studied 125 patients with CHC who underwent paired liver biopsies from 1994 to 2012. Patients with advanced fibrosis were excluded from the analysis. Sixty-three patients had TF, and 62 patients were treatment-naïve (TN). Annual fibrosis progression rate (FPR) was calculated, and significant fibrosis progression (SFP) was defined as ≥ 2 stage increase in fibrosis during follow-up. Multiple regression analyses were performed to find out independent predictors of FPR and SFP. Demographic characteristics and duration between paired liver biopsies were similar in TF and TN groups. Baseline alanine aminotransferase and gamma-glutamyl transferase (GGT) levels (71 ± 31 vs 47 ± 22, P < 0.001 and 49 ± 39 vs 36 ± 28, P = 0.027, respectively), baseline mean fibrosis stage (2.2 ± 0.7 vs 1.9 ± 0.7, P = 0.018) and histologic activity index (6.3 ± 1.9 vs 4.3 ± 1.6, P < 0.001) were higher in the TF group compared with the TN group. In regression analyses, the strongest independent predictor of fibrosis progression was the GGT level (OR: 1.03, 95%CI 1.01-1.5, P < 0.001). Treatment experience (OR: 5.97, 95%CI 1.81-19.7, P = 0.003) also appeared as an independent predictor of both FPR and SFP. Failed interferon-based CHC treatment may lead to accelerated FPR in the long-term compared with the natural course.

Analysis of potential antiviral resistance mutation profiles within the HBV reverse transcriptase in untreated chronic hepatitis B patients using an ultra-deep pyrosequencing method

The potential antiviral resistance mutations within hepatitis B virus (HBV) reverse transcriptase (RT) region for nucleos(t)ide analogues (NA) are not well known. Especially, the effect of pre-existing antiviral drug resistance mutations in untreated patients in comparison to the resistance developed after treatment is not still clear. Sixteen naive chronic hepatitis B patients were studied. None of the patients had received NA treatment prior to the serum samples being collected. Forty-two potential NA resistance (NAr) mutation sites were screened by ultra-deep pyrosequencing (UDPS). After therapy, mutations conferring treatment resistance were detected by LiPA. Serum samples taken before treatment showed no classic primary or compensatory/secondary drug resistance mutations. However, NAr mutations found in 6 isolates (37.5%) involved 7 positions including rtL91I, rtT128I, rtQ215P, rtF221Y, rtN238D, rtC256S, and rtI266G. Substitutions at 3 NAr mutation sites (rtT128I, rtN238D, and rtC256S) were detected in 3 unresponsive patients developing drug resistance after NA treatment. One patient with rtI266G mutation also developed drug resistance after lamivudine (LAM) therapy. However, the relationship between rtI266G mutation and NA drug resistance was not previously reported. These results suggest that association of potential mutations besides the primary and secondary/compensatory resistance mutations should be investigated. Investigation of NAr mutations before treatment may be important for the success of the treatment.

Co-infection with hepatitis B does not alter treatment response in chronic hepatitis C

BACKGROUND/AIM

To investigate the clinical features and treatment response in patients with hepatitis B (HBV) and hepatitis C virus (HCV) co-infection receiving anti-HCV therapy.

PATIENTS AND METHOD

Patients with HBV/HCV co-infection, who were eligible for anti-HCV therapy, were included in the study. Patients had detectable HBsAg for at least 6 months and detectable HCV-RNA before the initiation of therapy. Primary end-point was the proportion of patients achieving sustained virological response (SVR). HBV serology and HBV-DNA results obtained during the follow-up were assessed to determine HBV clearance or reactivation after anti-HCV therapy.

RESULTS

There were 612 patients in the HCV cohort and 52 (8.5%) of them were HBV/HCV co-infected. Twenty-eight patients (20 male, mean age: 47 ± 12) received anti-HCV treatment and followed-up for a mean duration of 53 months (12-156). Fifteen patients received peginterferon/ribavirin combination while the remaining patients received standard interferon/ribavirin combination (n=6) or standard interferon monotherapy (n=7). Patients receiving interferon monotherapy were under chronic hemodialysis therapy. SVR was achieved in 14 (50%) patients at the end of follow-up. The proportion of patients with SVR in three treatment arms were not significantly different (P=0.78). Eight of 11 patients with detectable HBV-DNA cleared HBV-DNA during treatment. Seven (25%) patients experienced a rebound in HBV-DNA, and one patient experienced an acute hepatitis flare which was controlled by tenofovir therapy. Two (7%) patients cleared HBsAg and one of them was seroconverted to anti-HBs.

CONCLUSION

Co-infection with HBV does not have a negative impact on the efficacy of anti-HCV treatment, but HBV-DNA should be monitored to overcome the risk of HBV exacerbation.

Role of the line probe assay INNO-LiPA HBV DR and ultradeep pyrosequencing in detecting resistance mutations to nucleoside/nucleotide analogues in viral samples isolated from chronic hepatitis B patients

Despite the effectiveness of nucleoside/nucleotide analogues in the treatment of chronic hepatitis B (CHB), their long-term administration is associated with the emergence of resistant hepatitis B virus (HBV) mutants. In this study, mutations resulting in antiviral resistance in HBV DNA samples isolated from 23 CHB patients (nine treatment naïve and 14 treated previously) were studied using a line probe assay (INNO-LiPA HBV DR; Innogenetics) and ultradeep pyrosequencing (UDPS) methods. Whilst the INNO-LiPA HBV DR showed no resistance mutations in HBV DNA samples from treatment-naive patients, mutations mediating lamivudine resistance were detected in three samples by UDPS. Among patients who were treated previously, 19 mutations were detected in eight samples using the INNO-LiPA HBV DR and 29 mutations were detected in 12 samples using UDPS. All mutations detected by the INNO-LiPA HBV DR were also detected by UDPS. There were no mutations that could be detected by INNO-LiPA HBV DR but not by UDPS. A total of ten mutations were detected by UDPS but not by INNO-LiPA HBV DR, and the mean frequency of these mutations was 14.7 %. It was concluded that, although INNO-LiPA HBV DR is a sensitive and practical method commonly used for the detection of resistance mutations in HBV infection, UDPS may significantly increase the detection rate of genotypic resistance in HBV at an early stage.

Durability of sustained virologic response in chronic hepatitis C

BACKGROUND/AIMS

The aim of this study is to investigate the rate of sustained virologic response (SVR) in chronic hepatitis C patients receiving antiviral treatment.

METHODS

The files of patients with chronic hepatitis C treated with interferon±ribavirin between 1995 and 2009 were reviewed retrospectively. Six months after the end of treatment, patients with negative hepatitis C virus (HCV)-RNA (<50 IU/mL, as determined by the polymerase chain reaction method) were enrolled in the study.

RESULTS

The mean age of 196 patients (89 males) was 46.13±11.10 years (range, 17 to 73 years). In biopsies, the mean stage was 1.50±0.94; histological activity index was 7.18±2.43. In total, 139 patients received pegylated interferon (IFN)+ribavirin, 21 patients received classical IFN+ribavirin, and 36 patients received IFN alone. The HCV genotypes of 138 patients were checked: 77.5% were genotype 1b, and 22.5% were other genotypes. After achievement of SVR, the median follow-up period was 33.5 months (range, 6 to 112 months), and in this period relapse was only detected in two patients (1.02%) at 18 and 48 months after treatment.

CONCLUSIONS

In total, 98.9% of patients with SVR in chronic hepatitis C demonstrated truly durable responses over the long-term follow-up period of 3 years; relapsed patients had intermittent or low-grade viremia.