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Snijders RJALM, Stoelinga AEC, Gevers TJG, Pape S, Biewenga M, Verdonk RC, de Jonge HJM, Vrolijk JM, Bakker SF, Vanwolleghem T, de Boer YS, Pronk MAMCB, Beuers UHW, van der Meer AJ, van Gerven NMF, Sijtsma MGM, Verwer BJ, Gisbertz IAM, Bartelink M, van den Brand FF, Sebib Korkmaz K, van den Berg AP, Guichelaar MMJ, Soufidi K, Levens AD, van Hoek B, Drenth JPH. Assessing the efficacy and safety of mycophenolate mofetil versus azathioprine in patients with autoimmune hepatitis (CAMARO trial): study protocol for a randomised controlled trial. Trials 2022; 23:1012. [PMID: 36514163 PMCID: PMC9745715 DOI: 10.1186/s13063-022-06890-w] [Citation(s) in RCA: 2] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 11/05/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Currently, the standard therapy for autoimmune hepatitis (AIH) consists of a combination of prednisolone and azathioprine. However, 15% of patients are intolerant to azathioprine which necessitates cessation of azathioprine or changes in therapy. In addition, not all patients achieve complete biochemical response (CR). Uncontrolled data indicate that mycophenolate mofetil (MMF) can induce CR in a majority of patients. Better understanding of first-line treatment and robust evidence from randomised clinical trials are needed. The aim of this study was to explore the potential benefits of MMF as compared to azathioprine, both combined with prednisolone, as induction therapy in a randomised controlled trial in patients with treatment-naive AIH. METHODS CAMARO is a randomised (1:1), open-label, parallel-group, multicentre superiority trial. All patients with AIH are screened for eligibility. Seventy adult patients with AIH from fourteen centres in the Netherlands and Belgium will be randomised to receive MMF or azathioprine. Both treatment arms will start with prednisolone as induction therapy. The primary outcome is biochemical remission, defined as serum levels of alanine aminotransferase and immunoglobulin G below the upper limit of normal. Secondary outcomes include safety and tolerability of MMF and azathioprine, time to remission, changes in Model For End-Stage Liver Disease (MELD)-score, adverse events, and aspects of quality of life. The study period will last for 24 weeks. DISCUSSION The CAMARO trial investigates whether treatment with MMF and prednisolone increases the proportion of patients in remission compared with azathioprine and prednisolone as the current standard treatment strategy. In addition, we reflect on the challenges of conducting a randomized trial in rare diseases. TRIAL REGISTRATION EudraCT 2016-001038-91 . Prospectively registered on 18 April 2016.
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Affiliation(s)
- Romée J. A. L. M. Snijders
- grid.10417.330000 0004 0444 9382Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands ,European Reference Network RARE-LIVER, Hamburg, Germany
| | - Anna E. C. Stoelinga
- grid.10419.3d0000000089452978Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tom J. G. Gevers
- grid.10417.330000 0004 0444 9382Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands ,European Reference Network RARE-LIVER, Hamburg, Germany ,grid.412966.e0000 0004 0480 1382Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands ,grid.5012.60000 0001 0481 6099Nutrim School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Simon Pape
- grid.10417.330000 0004 0444 9382Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands ,European Reference Network RARE-LIVER, Hamburg, Germany
| | - Maaike Biewenga
- grid.10419.3d0000000089452978Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert C. Verdonk
- grid.415960.f0000 0004 0622 1269Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Hendrik J. M. de Jonge
- grid.413508.b0000 0004 0501 9798Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, ‘s Hertogenbosch, The Netherlands
| | - Jan Maarten Vrolijk
- grid.415930.aDepartment of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Sjoerd F. Bakker
- grid.416373.40000 0004 0472 8381Department of Gastroenterology and Hepatology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Thomas Vanwolleghem
- grid.411414.50000 0004 0626 3418Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium
| | - Ynto S. de Boer
- European Reference Network RARE-LIVER, Hamburg, Germany ,grid.509540.d0000 0004 6880 3010Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location VU University Medical Center, Amsterdam, The Netherlands
| | - Martine A. M. C. Baven Pronk
- grid.413370.20000 0004 0405 8883Department of Gastroenterology and Hepatology, Groene Hart Hospital, Gouda, The Netherlands
| | - Ulrich H. W. Beuers
- European Reference Network RARE-LIVER, Hamburg, Germany ,grid.509540.d0000 0004 6880 3010Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Adriaan J. van der Meer
- grid.5645.2000000040459992XDepartment of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicole M. F. van Gerven
- Department of Gastroenterology and Hepatology, Rode Kruis Hospital, Beverwijk, The Netherlands
| | - Marijn G. M. Sijtsma
- Department of Gastroenterology and Hepatology, St. Jansdal Hospital, Harderwijk, The Netherlands
| | - Bart J. Verwer
- grid.416219.90000 0004 0568 6419Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Ingrid A. M. Gisbertz
- Department of Gastroenterology and Hepatology, Hospital Bernhoven, Uden, The Netherlands
| | - Maartje Bartelink
- grid.413649.d0000 0004 0396 5908Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands
| | - Floris F. van den Brand
- grid.440209.b0000 0004 0501 8269Department of Gastroenterology and Hepatology, OLVG Oost, Amsterdam, The Netherlands
| | - Kerem Sebib Korkmaz
- Department of Gastroenterology and Hepatology, IJselland Hospital, Capelle aan den Ijssel, The Netherlands
| | - Aad P. van den Berg
- grid.4494.d0000 0000 9558 4598Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Maureen M. J. Guichelaar
- grid.415214.70000 0004 0399 8347Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Khalida Soufidi
- grid.416905.fDepartment of Gastroenterology and Hepatology, Zuyderland, Heerlen, The Netherlands
| | - Amar D. Levens
- grid.10419.3d0000000089452978Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Bart van Hoek
- grid.10419.3d0000000089452978Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joost P. H. Drenth
- grid.10417.330000 0004 0444 9382Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands ,European Reference Network RARE-LIVER, Hamburg, Germany
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van den Brand FF, Snijders RJALM, de Boer YS, Verwer BJ, van Nieuwkerk CMJ, Bloemena E, Kuiken SD, Drenth JPH, Bouma G. Drug withdrawal in patients with autoimmune hepatitis in long-term histological remission: A prospective observational study. Eur J Intern Med 2021; 90:30-36. [PMID: 33865679 DOI: 10.1016/j.ejim.2021.03.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 02/24/2021] [Accepted: 03/15/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Recommendations for drug withdrawal in patients with autoimmune hepatitis (AIH) in longstanding remission are conflicting and rely on retrospective data. We prospectively investigated the predictive value of histological normalisation for successful treatment withdrawal in AIH patients. METHODS Non-cirrhotic patients with established AIH and complete biochemical remission (normalisation of serum alanine aminotransferase [ALT] or aspartate aminotransferase [AST] and immunoglobulin G [IgG]) of at least 2 years were biopsied. Immunosuppressive therapy was only withdrawn in patients with histological normalisation (histological activity index [HAI] ≤3) with a minimum follow-up of 12 months. RESULTS A total of 17 patients in biochemical remission for at least 2 years were included. Persistent histological inflammatory activity (HAI >3) precluded drug withdrawal in five patients. These had higher values of ALT (25 vs. 16 U/L; p = 0.01) and AST (26 vs. 22 U/L; p = 0.01) compared with patients in histological remission. Immunosuppressive medication was withdrawn in 12 patients; eight (67%, C.I. 40-93% p = 0.4) remained in remission during a median follow-up of 62 months (range: 13-75 months); and four (33%, C.I. 7-60% p = 0.4) required reinstitution of therapy after 1, 6, 11, and 40 months, all without clinical signs of disease progression or hepatic decompensation. No predictors of relapse were identified. CONCLUSION Two-thirds of the patients who prove to have histological normalisation after at least 2 years of biochemical remission achieve treatment-free remission. Although patient numbers were small and results should be interpreted with caution, these findings support a liver biopsy prior to drug withdrawal.
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Affiliation(s)
- Floris F van den Brand
- Amsterdam UMC, Vrije Universiteit Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, de Boelelaan 1117, Amsterdam, the Netherlands.
| | - Romée J A L M Snijders
- Amsterdam UMC, Vrije Universiteit Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, de Boelelaan 1117, Amsterdam, the Netherlands; Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, the Netherlands
| | - Ynto S de Boer
- Amsterdam UMC, Vrije Universiteit Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, de Boelelaan 1117, Amsterdam, the Netherlands
| | - Bart J Verwer
- Department of Gastroenterology and Hepatology, Spaarne Hospital, Haarlem, the Netherlands
| | - Carin M J van Nieuwkerk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, de Boelelaan 1117, Amsterdam, the Netherlands
| | - Elisabeth Bloemena
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pathology, Amsterdam, the Netherlands
| | - Sjoerd D Kuiken
- Department of Gastroenterology and Hepatology, OLVG, Amsterdam, the Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, the Netherlands
| | - Gerd Bouma
- Amsterdam UMC, Vrije Universiteit Amsterdam, Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, de Boelelaan 1117, Amsterdam, the Netherlands
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Verwer BJ, Scheffer PG, Vermue RP, Pouwels PJ, Diamant M, Tushuizen ME. NAFLD is related to Post-prandial Triglyceride-enrichment of HDL Particles in Association with Endothelial and HDL Dysfunction. Liver Int 2020; 40:2439-2444. [PMID: 32652824 PMCID: PMC7540355 DOI: 10.1111/liv.14597] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 12/21/2019] [Revised: 06/09/2020] [Accepted: 07/01/2020] [Indexed: 12/11/2022]
Abstract
NAFLD is closely related with the metabolic syndrome (MetS) and increased risk of cardiovascular disease. Liver fat associates with post-prandial hypertriglyceridemia, potentially contributing to triglyceride-enrichment of high-density lipoproteins (HDL-TG), and subsequent HDL dysfunction. We assessed liver fat by MR spectroscopy, and its association with HDL physiochemical properties, and endothelial function, measured as flow-mediated dilation (FMD), before and following three consecutive meals, in 36 men with type 2 diabetes mellitus (T2DM), with the MetS, and controls. Plasma triglycerides increased significantly following the meals (P < .001). Fasting HDL-TG was highest in T2DM, relative to MetS and controls (P = .002), and increased post-prandially in all groups (P < .001). HDL function was negatively associated with HDL-TG following three meals (r = -.32, P<.05). Liver fat associated with HDL-TG after three meals (r = .65, P < .001). HDL-TG was independently associated with FMD following three consecutive meals (r = -.477, P = .003). We conclude liver fat is associated with post-prandial HDL-TG enrichment which was closely related with endothelial and HDL dysfunction.
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Affiliation(s)
- Bart J. Verwer
- Department of Gastroenterology and HepatologyLeiden University Medical CenterLeidenThe Netherlands
| | - Peter G. Scheffer
- Department of Clinical ChemistryAmsterdam University Medical CentreAmsterdamThe Netherlands
| | - Rick P. Vermue
- Department of Clinical ChemistryAmsterdam University Medical CentreAmsterdamThe Netherlands
| | - Petra J. Pouwels
- Department of Physics & Medical TechnologyAmsterdam University Medical CentreAmsterdamThe Netherlands
| | - Michaela Diamant
- Department of Internal MedicineAmsterdam University Medical CentreAmsterdamThe Netherlands
| | - Maarten E. Tushuizen
- Department of Gastroenterology and HepatologyLeiden University Medical CenterLeidenThe Netherlands
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Ding L, Houben T, Oligschlaeger Y, Bitorina AV, Verwer BJ, Tushuizen ME, Shiri-Sverdlov R. Plasma Cathepsin D Activity Rather Than Levels Correlates With Metabolic Parameters of Type 2 Diabetes in Male Individuals. Front Endocrinol (Lausanne) 2020; 11:575070. [PMID: 33101209 PMCID: PMC7554511 DOI: 10.3389/fendo.2020.575070] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/11/2020] [Indexed: 02/01/2023] Open
Abstract
Objective Type 2 diabetes mellitus is a metabolic disorder characterized by insulin resistance. Previous studies in patients demonstrated that plasma levels of cathepsin D (CTSD), which is optimally active in the acidic environment of lysosomes, correlate with insulin resistance. As plasma pH is slightly reduced in type 2 diabetic patients and we have previously shown that plasma CTSD activity is causally linked to insulin levels in vivo, it is likely that the activity of CTSD in plasma will be increased in type 2 diabetes compared to healthy individuals. However, so far the interaction between CTSD activity and levels to postprandial metabolic derangements in type 2 diabetes is not known. Methods Eighteen type 2 diabetes and 16 age-matched healthy males were given 2 consecutive standardized mixed meals, after which blood samples were collected. Plasma metabolic parameters as well as CTSD levels and activity were measured, and changes in plasma pH was assessed. Results In line with the elevation of plasma free fatty acids (FFA) levels in male type 2 diabetics patients, plasma pH in type 2 diabetic individuals was decreased compared to male healthy individuals. While plasma CTSD levels were similar, plasma CTSD activity was increased in male type 2 diabetic compared to male healthy individuals. Besides, plasma CTSD activity rather than levels significantly correlated with indicators of type 2 diabetes (HbA1c, HOMA-IR and glucose). Furthermore, FFA was also independently associated with plasma CTSD activity (standardized β = 0.493, p = 0.007). Conclusions Despite similar plasma CTSD levels, type 2 diabetic male individuals showed increased plasma CTSD activity compared to healthy males, which was independently linked to plasma FFA levels. Our data therefore point toward plasma CTSD as a metabolic regulator in male type 2 diabetes.
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Affiliation(s)
- Lingling Ding
- Department of Molecular Genetics, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht Universtiy, Maastricht, Netherlands
| | - Tom Houben
- Department of Molecular Genetics, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht Universtiy, Maastricht, Netherlands
| | - Yvonne Oligschlaeger
- Department of Molecular Genetics, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht Universtiy, Maastricht, Netherlands
| | - Albert V. Bitorina
- Department of Molecular Genetics, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht Universtiy, Maastricht, Netherlands
| | - Bart J. Verwer
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Maarten E. Tushuizen
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Ronit Shiri-Sverdlov
- Department of Molecular Genetics, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht Universtiy, Maastricht, Netherlands
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van den Brand FF, van Nieuwkerk CMJ, Verwer BJ, de Boer YS, de Boer NKH, Mulder CJJ, Bloemena E, Bakker CM, Vrolijk JM, Drenth JPH, Tan ACITL, ter Borg F, ter Borg MJ, van den Hazel SJ, Inderson A, Tushuizen ME, Bouma G. Biochemical efficacy of tioguanine in autoimmune hepatitis: a retrospective review of practice in the Netherlands. Aliment Pharmacol Ther 2018; 48:761-767. [PMID: 30109891 PMCID: PMC6175236 DOI: 10.1111/apt.14939] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/16/2018] [Accepted: 07/18/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Azathioprine (AZA) and mercaptopurine (MP) are the cornerstone of steroid-sparing strategies in autoimmune hepatitis (AIH). Up to 20% of patients do not tolerate or respond to these regimens. AIM To evaluate retrospectively the tolerability and efficacy of tioguanine (thioguanine) (TG) therapy in selected patients with AIH and AIH variant syndromes. METHODS Records of 52 patients who received TG therapy were retrieved from nine hospitals in the Netherlands. Indications for TG treatment were intolerable side effects on AZA or MP (n = 38), insufficient response (n = 11) or first-line treatment (n = 3). Treatment efficacy was defined as normalisation of serum aminotransferases and serum immunoglobulin G. RESULTS No serious adverse events occurred in patients treated with TG during a median follow-up of 18 months (range 1-194). Treatment was well tolerated in 41 patients (79%), whereas four had tolerable (8%) and seven (13%) intolerable side effects. Thirty-eight patients were treated with TG after intolerable side effects on AZA or MP; 29 patients continued TG therapy of whom 24 (83%) achieved complete biochemical remission, four (14%) had incomplete and one (3%) had no response; nine discontinued treatment. Seven of 11 patients with insufficient response to AZA or MP were responsive to TG, three with complete and four with incomplete biochemical remission; four discontinued due to intolerance (n = 2) and non-response (n = 2). TG was effective in all AIH patients as first-line maintenance treatment. CONCLUSION In our retrospective review of TG therapy in selected patients with AIH or AIH variants who previously failed on AZA or MP, TG appeared tolerable with biochemical efficacy.
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Affiliation(s)
- Floris F. van den Brand
- Department of Gastroenterology and HepatologyAmsterdam Gastroenterology and MetabolismAmsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Carin M. J. van Nieuwkerk
- Department of Gastroenterology and HepatologyAmsterdam Gastroenterology and MetabolismAmsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Bart J. Verwer
- Department of Gastroenterology and HepatologySpaarne GasthuisHaarlemThe Netherlands
| | - Ynto S. de Boer
- Department of Gastroenterology and HepatologyAmsterdam Gastroenterology and MetabolismAmsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Nanne K. H. de Boer
- Department of Gastroenterology and HepatologyAmsterdam Gastroenterology and MetabolismAmsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Chris J. J. Mulder
- Department of Gastroenterology and HepatologyAmsterdam Gastroenterology and MetabolismAmsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Elisabeth Bloemena
- Department of PathologyAmsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Christine M. Bakker
- Department of Gastroenterology and HepatologyZuyderland Medical CenterHeerlenThe Netherlands
| | - Jan M. Vrolijk
- Department of Gastroenterology and HepatologyRijnstate HospitalArnhemThe Netherlands
| | - Joost P. H. Drenth
- Department of Gastroenterology and HepatologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Adriaan C. I. T. L. Tan
- Department of Gastroenterology and HepatologyCanisius Wilhelmina HospitalNijmegenThe Netherlands
| | - Frank ter Borg
- Department of Gastroenterology and HepatologyDeventer HospitalDeventerThe Netherlands
| | - Martijn J. ter Borg
- Department of Gastroenterology and HepatologyMaxima Medical CenterEindhovenThe Netherlands
| | - Sven J. van den Hazel
- Department of Gastroenterology and HepatologySlingeland HospitalDoetinchemThe Netherlands
| | - Akin Inderson
- Department of Gastroenterology and HepatologyLeiden University Medical CenterLeidenThe Netherlands
| | - Maarten E. Tushuizen
- Department of Gastroenterology and HepatologyLeiden University Medical CenterLeidenThe Netherlands
| | - Gerd Bouma
- Department of Gastroenterology and HepatologyAmsterdam Gastroenterology and MetabolismAmsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
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Baven-Pronk MAMC, Biewenga M, van Silfhout JJ, van den Berg AP, van Buuren HR, Verwer BJ, van Nieuwkerk CMJ, Bouma G, van Hoek B. Role of age in presentation, response to therapy and outcome of autoimmune hepatitis. Clin Transl Gastroenterol 2018; 9:165. [PMID: 29961755 PMCID: PMC6026593 DOI: 10.1038/s41424-018-0028-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 04/05/2018] [Accepted: 04/24/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Few studies with diverging results and a small sample size have compared autoimmune hepatitis (AIH) in the elderly to younger patients. AIM To unbiasedly investigate the role of age in behaviour and treatment outcome of AIH. METHODS All patients with probable or definite AIH type 1 in four tertiary academic centres were included in this retrospective-and since 2006 prospective-cohort study. Influence of age on presentation, remission and outcome of AIH were investigated. RESULTS 359 patients were included. Presence of cirrhosis at AIH diagnosis around 30% was independent of age. ALAT was higher at age 30-60 years on AIH diagnosis, and above age 60 there were less acute onset, less jaundice and more concurrent autoimmune disease. Remission was reached in 80.2%, incomplete remission in 18.7%, only 1.1% (all aged 50-65) was treatment-refractory. Age was not an independent predictor of remission, while cirrhosis was. Above age 45 there was more diabetes, above age 60 more loss of remission. Rate of progression to cirrhosis was 10% in the 10 years after diagnosis and unrelated to age at AIH diagnosis. With onset below age 30, there was more development of decompensated cirrhosis over time. With higher age at AIH diagnosis there was a lower survival free of liver-related death or liver transplantation. CONCLUSIONS AIH presents at all ages. Age influences features at diagnosis, but not response to treatment, while survival without liver-related death or liver transplantation decreases with higher age at diagnosis.
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Affiliation(s)
- Martine A M C Baven-Pronk
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Gastroenterology and Hepatology, Green Heart Hospital, Gouda, The Netherlands
| | - Maaike Biewenga
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joanne J van Silfhout
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Aad P van den Berg
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bart J Verwer
- Department of Gastroenterology and Hepatology, Vrije University Medical Center, Amsterdam, The Netherlands
| | - Carin M J van Nieuwkerk
- Department of Gastroenterology and Hepatology, Vrije University Medical Center, Amsterdam, The Netherlands
| | - Gerd Bouma
- Department of Gastroenterology and Hepatology, Vrije University Medical Center, Amsterdam, The Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands.
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7
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van Gerven NMF, Verwer BJ, Witte BI, van Erpecum KJ, van Buuren HR, Maijers I, Visscher AP, Verschuren EC, van Hoek B, Coenraad MJ, Beuers UHW, de Man RA, Drenth JPH, den Ouden JW, Verdonk RC, Koek GH, Brouwer JT, Guichelaar MMJ, Vrolijk JM, Mulder CJJ, van Nieuwkerk CMJ, Bouma G. Epidemiology and clinical characteristics of autoimmune hepatitis in the Netherlands. Scand J Gastroenterol 2014; 49:1245-54. [PMID: 25123213 DOI: 10.3109/00365521.2014.946083] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [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] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Epidemiological data on autoimmune hepatitis (AIH) are scarce. In this study, we determined the clinical and epidemiological characteristics of AIH patients in the Netherlands (16.7 million inhabitants). METHODS Clinical characteristics were collected from 1313 AIH patients (78% females) from 31 centers, including all eight academic centers in the Netherlands. Additional data on ethnicity, family history and symptoms were obtained by the use of a questionnaire. RESULTS The prevalence of AIH was 18.3 (95% confidential interval [CI]: 17.3-19.4) per 100,000 with an annual incidence of 1.1 (95% CI: 0.5-2) in adults. An incidence peak was found in middle-aged women. At diagnosis, 56% of patients had fibrosis and 12% cirrhosis in liver biopsy. Overall, 1% of patients developed HCC and 3% of patients underwent liver transplantation. Overlap with primary biliary cirrhosis and primary sclerosing cholangitis was found in 9% and 6%, respectively. The clinical course did not differ between Caucasian and non-Caucasian patients. Other autoimmune diseases were found in 26% of patients. Half of the patients reported persistent AIH-related symptoms despite treatment with a median treatment period of 8 years (range 1-44 years). Familial occurrence was reported in three cases. CONCLUSION This is the largest epidemiological study of AIH in a geographically defined region and demonstrates that the prevalence of AIH in the Netherlands is uncommon. Although familial occurrence of AIH is extremely rare, our twin data may point towards a genetic predisposition. The high percentage of patients with cirrhosis or fibrosis at diagnosis urges the need of more awareness for AIH.
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Affiliation(s)
- Nicole M F van Gerven
- Department of Gastroenterology and Hepatology, VU University Medical Center , Amsterdam , The Netherlands
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de Boer YS, van Gerven NMF, Zwiers A, Verwer BJ, van Hoek B, van Erpecum KJ, Beuers U, van Buuren HR, Drenth JPH, den Ouden JW, Verdonk RC, Koek GH, Brouwer JT, Guichelaar MMJ, Vrolijk JM, Kraal G, Mulder CJJ, van Nieuwkerk CMJ, Fischer J, Berg T, Stickel F, Sarrazin C, Schramm C, Lohse AW, Weiler-Normann C, Lerch MM, Nauck M, Völzke H, Homuth G, Bloemena E, Verspaget HW, Kumar V, Zhernakova A, Wijmenga C, Franke L, Bouma G. Genome-wide association study identifies variants associated with autoimmune hepatitis type 1. Gastroenterology 2014; 147:443-52.e5. [PMID: 24768677 DOI: 10.1053/j.gastro.2014.04.022] [Citation(s) in RCA: 202] [Impact Index Per Article: 20.2] [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: 12/19/2013] [Revised: 03/17/2014] [Accepted: 04/09/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Autoimmune hepatitis (AIH) is an uncommon autoimmune liver disease of unknown etiology. We used a genome-wide approach to identify genetic variants that predispose individuals to AIH. METHODS We performed a genome-wide association study of 649 adults in The Netherlands with AIH type 1 and 13,436 controls. Initial associations were further analyzed in an independent replication panel comprising 451 patients with AIH type 1 in Germany and 4103 controls. We also performed an association analysis in the discovery cohort using imputed genotypes of the major histocompatibility complex region. RESULTS We associated AIH with a variant in the major histocompatibility complex region at rs2187668 (P = 1.5 × 10(-78)). Analysis of this variant in the discovery cohort identified HLA-DRB1*0301 (P = 5.3 × 10(-49)) as a primary susceptibility genotype and HLA-DRB1*0401 (P = 2.8 × 10(-18)) as a secondary susceptibility genotype. We also associated AIH with variants of SH2B3 (rs3184504, 12q24; P = 7.7 × 10(-8)) and CARD10 (rs6000782, 22q13.1; P = 3.0 × 10(-6)). In addition, strong inflation of association signal was found with single-nucleotide polymorphisms associated with other immune-mediated diseases, including primary sclerosing cholangitis and primary biliary cirrhosis, but not with single-nucleotide polymorphisms associated with other genetic traits. CONCLUSIONS In a genome-wide association study, we associated AIH type 1 with variants in the major histocompatibility complex region, and identified variants of SH2B3and CARD10 as likely risk factors. These findings support a complex genetic basis for AIH pathogenesis and indicate that part of the genetic susceptibility overlaps with that for other immune-mediated liver diseases.
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Affiliation(s)
- Ynto S de Boer
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Nicole M F van Gerven
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Antonie Zwiers
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands; Department of Molecular Cell Biology and Immunology, VU University Medical Center, Amsterdam, The Netherlands
| | - Bart J Verwer
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Karel J van Erpecum
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Jannie W den Ouden
- Department of Gastroenterology and Hepatology, Haga Hospital, The Hague, The Netherlands
| | - Robert C Verdonk
- University of Groningen, University Medical Center Groningen, Department of Gastroenterology and Hepatology, Groningen, The Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Ger H Koek
- Department of Gastroenterology and Hepatology, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Johannes T Brouwer
- Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Maureen M J Guichelaar
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Jan M Vrolijk
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Georg Kraal
- Department of Molecular Cell Biology and Immunology, VU University Medical Center, Amsterdam, The Netherlands
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Carin M J van Nieuwkerk
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Janett Fischer
- Department of Internal Medicine, Neurology and Dermatology, Medical Clinic of Gastroenterology and Rheumatology, Section of Hepatology, University Hospital Leipzig, Leipzig, Germany
| | - Thomas Berg
- Department of Internal Medicine, Neurology and Dermatology, Medical Clinic of Gastroenterology and Rheumatology, Section of Hepatology, University Hospital Leipzig, Leipzig, Germany
| | - Felix Stickel
- Department of Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | | | - Christoph Schramm
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Markus M Lerch
- Department of Internal Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Matthias Nauck
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Henry Völzke
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Georg Homuth
- Interfaculty Institute for Genetics and Functional Genomics, University Medicine and Ernst-Moritz-Arndt-University Greifswald, Greifswald, Germany
| | - Elisabeth Bloemena
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands
| | - Hein W Verspaget
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vinod Kumar
- University of Groningen, University Medical Center Groningen, Department of Genetics, Groningen, The Netherlands
| | - Alexandra Zhernakova
- University of Groningen, University Medical Center Groningen, Department of Genetics, Groningen, The Netherlands
| | - Cisca Wijmenga
- University of Groningen, University Medical Center Groningen, Department of Genetics, Groningen, The Netherlands
| | - Lude Franke
- University of Groningen, University Medical Center Groningen, Department of Genetics, Groningen, The Netherlands
| | - Gerd Bouma
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands; Department of Molecular Cell Biology and Immunology, VU University Medical Center, Amsterdam, The Netherlands.
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van Gerven NMF, Verwer BJ, Witte BI, van Hoek B, Coenraad MJ, van Erpecum KJ, Beuers U, van Buuren HR, de Man RA, Drenth JPH, den Ouden JW, Verdonk RC, Koek GH, Brouwer JT, Guichelaar MMJ, Mulder CJJ, van Nieuwkerk KMJ, Bouma G. Relapse is almost universal after withdrawal of immunosuppressive medication in patients with autoimmune hepatitis in remission. J Hepatol 2013; 58:141-7. [PMID: 22989569 DOI: 10.1016/j.jhep.2012.09.009] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [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: 04/03/2012] [Revised: 09/04/2012] [Accepted: 09/06/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Current treatment strategies in autoimmune hepatitis (AIH) include long-term treatment with corticosteroids and/or azathioprine. Here we determined the risk of relapse after drug withdrawal in patients in long-term remission and factors associated with such a relapse. METHODS A total of 131 patients (out of a cohort including 844 patients) from 7 academic and 14 regional centres in the Netherlands were identified in whom treatment was tapered after at least 2 years of clinical and biochemical remission. Relapse was defined as alanine-aminotransferase levels (ALT) three times above the upper limit of normal and loss of remission as a rising ALT necessitating the reinstitution of drug treatment. RESULTS During follow-up, 61 (47%) patients relapsed and 56 (42%) had a loss of remission. In these 117 patients, 60 patients had fully discontinued medication whereas 57 patients were still on a withdrawal scheme. One year after drug withdrawal, 59% of the patients required retreatment, increasing to 73% and 81% after 2 and 3 years, respectively. Previous combination therapy of corticosteroids and azathioprine, a concomitant autoimmune disease and younger age at time of drug withdrawal were associated with an increased risk of relapse. Subsequent attempts for discontinuation after initial failure in 32 patients inevitably resulted in a new relapse. CONCLUSIONS This retrospective analysis indicates that loss of remission or relapse occurs in virtually all patients with AIH in long-term remission when immunosuppressive therapy is discontinued. These findings indicate a reluctant attitude towards discontinuation of immunosuppressive treatment in AIH patients.
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Affiliation(s)
- Nicole M F van Gerven
- Department of Gastroenterology and Hepatology, Vu University Medical Centre, Amsterdam, The Netherlands
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Verwer BJ, Bouma G, Bloemena E, Schreuder TCMA, Mulder CJJ, van Nieuwkerk KMJ. [Diagnosis and treatment of autoimmune hepatitis]. Ned Tijdschr Geneeskd 2009; 153:A247. [PMID: 19900315] [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] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Autoimmune hepatitis (AIH) is a progressive, chronic form of hepatitis of unknown cause that occurs in people of all ages. The diagnosis is based on characteristic clinical and biochemical abnormalities, absence of other causes of hepatitis and histopathological characteristics. The variety of symptoms that AIH patients may have and the importance of considering the disease is illustrated in three case studies. The first was a 22-year-old woman with fulminant hepatitis and jaundice. Corticosteroid and azathioprine treatment resulted in prolonged remission. The second patient, a 48-year-old woman, had hepatocellular carcinoma in a cirrhotic liver, based on AIH. Radiofrequency ablation was planned, after which the patient would be put on the waiting list for transplantation. The third patient was an 81-year-old man with impaired liver function and cirrhosis. His treatment was the same as in the first patient and resulted in remission as well. No curative therapy for AIH is yet available, but appropriate management of the disease can prolong survival, improve the quality of life, and avoid the need for liver transplantation.
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Schreuder TCMA, Verwer BJ, Nieuwkerk CMJV, Mulder CJJ. Nonalcoholic fatty liver disease: An overview of current insights in pathogenesis, diagnosis and treatment. World J Gastroenterol 2008; 14:2474-86. [PMID: 18442193 PMCID: PMC2708357 DOI: 10.3748/wjg.14.2474] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Estimates of people suffering from overweight (one billion) and obesity (300 million) are increasing. The accumulation of triglycerides in the liver, in the absence of excess alcohol intake, has been described in the early sixties. It was not until 1980, however, that Ludwig et al named this condition nonalcoholic steatohepatitis (NASH). Subsequently, nonalcoholic fatty liver disease (NAFLD) has been used as a general name for conditions ranging from simple steatosis through steatohepatitis to end-stage liver disease (cirrhosis). Many studies have demonstrated the significant correlation with obesity and insulin resistance. Other studies have revealed a significant correlation between hepatic steatosis, cardiovascular disease and increased intima-media thickness. WHO estimated that at least two million patients will develop cirrhosis due to hepatic steatosis in the years to come. Longitudinal cohort studies have demonstrated that those patients with cirrhosis have a similar risk to develop hepatocellular carcinoma as those with other causes of cirrhosis. Taken all together, NAFLD has become the third most important indication for liver transplantation. Therefore, training programmes in internal medicine, gastroenterology and hepatology should stress the importance of diagnosing this entity and treat properly those at risk for developing complications of portal hypertension and concomittant cardiovascular disease. This review will focus on the clinical characteristics, pathophysiology, imaging techniques and the readily available therapeutic options.
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Dinant S, de Graaf W, Verwer BJ, Bennink RJ, van Lienden KP, Gouma DJ, van Vliet AK, van Gulik TM. Risk assessment of posthepatectomy liver failure using hepatobiliary scintigraphy and CT volumetry. J Nucl Med 2007. [PMID: 17475954 DOI: 10.2967/jnumed.106.038430.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED A major part of morbidity and mortality after liver resections is caused by inadequate remnant liver function leading to liver failure. It is therefore important to develop accurate diagnostic tools that can predict the risk of liver resection-related morbidity and mortality. In this study, preoperative hepatobiliary scintigraphy of the future remnant liver and CT volumetric measurement of the future remnant liver were performed on patients who were to undergo liver resection. The accuracy of risk assessment for postoperative morbidity, liver failure, and mortality was evaluated. METHODS Forty-six patients who were scheduled for liver resection because of hepatobiliary tumors, including 17 patients with parenchymal disease (37%) and 13 patients with hilar cholangiocarcinoma (28%), were assessed preoperatively. Hepatobiliary scintigraphy was performed by drawing regions of interest around the future remnant to calculate (99m)Tc-mebrofenin uptake in it. CT volumetry was used to measure the volume of the total liver, the tumors, and the future remnant. Receiver-operating-characteristic analysis was performed to assess cutoff values for risk assessment of morbidity, liver failure, and mortality. Furthermore, univariate and multivariate analyses were performed to determine factors related to morbidity and mortality. RESULTS Morbidity and mortality rates were 61% and 11%, respectively. Liver failure occurred in 6 patients (13%). Significantly decreased uptake in the future remnant was found in patients in whom liver failure and liver failure-related mortality developed (P=0.003 and 0.02, respectively). The volume of the future remnant was not significantly associated with any of the outcome parameters. In receiver-operating-characteristic analysis, uptake cutoff values for liver failure and liver failure-related mortality were 2.5%/min/body surface area and 2.2%/min/body surface area, respectively. In multivariate analysis, uptake was the only significant factor associated with liver failure. CONCLUSION Preoperative measurement of (99m)Tc-mebrofenin uptake in the future remnant liver on hepatobiliary scintigraphy proved more valuable than measurement of the volume of the future remnant on CT in assessing the risk of liver failure and liver failure-related mortality after partial liver resection.
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Affiliation(s)
- Sander Dinant
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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Dinant S, de Graaf W, Verwer BJ, Bennink RJ, van Lienden KP, Gouma DJ, van Vliet AK, van Gulik TM. Risk assessment of posthepatectomy liver failure using hepatobiliary scintigraphy and CT volumetry. J Nucl Med 2007; 48:685-92. [PMID: 17475954 DOI: 10.2967/jnumed.106.038430] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.5] [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: 12/22/2022] Open
Abstract
UNLABELLED A major part of morbidity and mortality after liver resections is caused by inadequate remnant liver function leading to liver failure. It is therefore important to develop accurate diagnostic tools that can predict the risk of liver resection-related morbidity and mortality. In this study, preoperative hepatobiliary scintigraphy of the future remnant liver and CT volumetric measurement of the future remnant liver were performed on patients who were to undergo liver resection. The accuracy of risk assessment for postoperative morbidity, liver failure, and mortality was evaluated. METHODS Forty-six patients who were scheduled for liver resection because of hepatobiliary tumors, including 17 patients with parenchymal disease (37%) and 13 patients with hilar cholangiocarcinoma (28%), were assessed preoperatively. Hepatobiliary scintigraphy was performed by drawing regions of interest around the future remnant to calculate (99m)Tc-mebrofenin uptake in it. CT volumetry was used to measure the volume of the total liver, the tumors, and the future remnant. Receiver-operating-characteristic analysis was performed to assess cutoff values for risk assessment of morbidity, liver failure, and mortality. Furthermore, univariate and multivariate analyses were performed to determine factors related to morbidity and mortality. RESULTS Morbidity and mortality rates were 61% and 11%, respectively. Liver failure occurred in 6 patients (13%). Significantly decreased uptake in the future remnant was found in patients in whom liver failure and liver failure-related mortality developed (P=0.003 and 0.02, respectively). The volume of the future remnant was not significantly associated with any of the outcome parameters. In receiver-operating-characteristic analysis, uptake cutoff values for liver failure and liver failure-related mortality were 2.5%/min/body surface area and 2.2%/min/body surface area, respectively. In multivariate analysis, uptake was the only significant factor associated with liver failure. CONCLUSION Preoperative measurement of (99m)Tc-mebrofenin uptake in the future remnant liver on hepatobiliary scintigraphy proved more valuable than measurement of the volume of the future remnant on CT in assessing the risk of liver failure and liver failure-related mortality after partial liver resection.
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Affiliation(s)
- Sander Dinant
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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Abstract
A method for automatic lineage assignment of acute leukemias was developed. Input are eight list mode data files acquired with a FACScan flow cytometer. For each cell, four parameters are measured: forward light scatter, orthogonal light scatter, fluorescein fluorescence, and phycoerythrin fluorescence. Eight data files are acquired in the following sequence: unstained, isotype controls, CD10/CD19, CD20/CD5, CD3/CD22, CD7/CD33, HLADR/CD13, and CD34/CD38. First, each of the data files 3 to 8 are clustered independently employing an algorithm based on nearest neighbors. Next, the clusters are associated across the data files to form cell populations, using the assumption of light scatter invariance across tubes for each population. The mean positions of each cell population are fed into a decision tree. The decision tree first identifies normal cell populations, i.e., monocytes, neutrophils, eosinophils, basophils, NK cells, T-lymphocytes, and B-lymphocytes. After elimination of the normal cell populations from the data space, the residual cell populations are classified as B-lineage ALL, T-lineage ALL, AML, AUL, B-CLL, or unknown. The effectiveness of this novel approach is shown with case studies of B-lymphoid, T-lymphoid, and Myeloid acute leukemias.
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MESH Headings
- Antigens, CD/analysis
- Antigens, CD20
- Antigens, CD34
- Antigens, Differentiation, B-Lymphocyte/analysis
- B-Lymphocytes/immunology
- B-Lymphocytes/pathology
- Burkitt Lymphoma/pathology
- CD3 Complex/analysis
- Cell Separation
- Eosinophils/pathology
- Flow Cytometry/methods
- HLA-DR Antigens/analysis
- Humans
- Image Processing, Computer-Assisted
- Immunohistochemistry/methods
- Killer Cells, Natural/pathology
- Leukemia, Myeloid, Acute/pathology
- Leukemia-Lymphoma, Adult T-Cell/pathology
- Monocytes/pathology
- Neprilysin/analysis
- Neutrophils/pathology
- T-Lymphocytes/immunology
- T-Lymphocytes/pathology
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Affiliation(s)
- B J Verwer
- Becton Dickinson Immunocytometry Systems, San Jose, California
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