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Snijders RJALM, Stoelinga AEC, Gevers TJG, Pape S, Biewenga M, Tushuizen ME, Verdonk RC, de Jonge HJM, Vrolijk JM, Bakker SF, Vanwolleghem T, de Boer YS, Baven Pronk MAMC, Beuers U, van der Meer AJ, Gerven NMFV, Sijtsma MGM, van Eijck BC, van IJzendoorn MC, van Herwaarden M, van den Brand FF, Korkmaz KS, van den Berg AP, Guichelaar MMJ, Levens AD, van Hoek B, Drenth JPH. An open-label randomised-controlled trial of azathioprine vs. mycophenolate mofetil for the induction of remission in treatment-naive autoimmune hepatitis. J Hepatol 2024; 80:576-585. [PMID: 38101756 DOI: 10.1016/j.jhep.2023.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 11/15/2023] [Accepted: 11/21/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND & AIMS Patients with autoimmune hepatitis (AIH) almost invariably require lifelong immunosuppressive treatment. There is genuine concern about the efficacy and tolerability of the current standard combination therapy of prednisolone and azathioprine. Mycophenolate mofetil (MMF) has emerged as an alternative option. The aim of this study was to compare MMF to azathioprine as induction therapy for AIH. METHODS In this 24-week, prospective, randomised, open-label, multicentre superiority trial, 70 patients with treatment-naive AIH received either MMF or azathioprine, both in combination with prednisolone. The primary endpoint was biochemical remission defined as normalisation of serum levels of alanine aminotransferase and IgG after 24 weeks of treatment. Secondary endpoints included safety and tolerability. RESULTS Seventy patients (mean 57.9 years [SD 14.0]; 72.9% female) were randomly assigned to the MMF plus prednisolone (n = 39) or azathioprine plus prednisolone (n = 31) group. The primary endpoint was met in 56.4% and 29.0% of patients assigned to the MMF group and the azathioprine group, respectively (difference, 27.4 percentage points; 95% CI 4.0 to 46.7; p = 0.022). The MMF group exhibited higher complete biochemical response rates at 6 months (72.2% vs. 32.3%; p = 0.004). No serious adverse events occurred in patients who received MMF (0%) but serious adverse events were reported in four patients who received azathioprine (12.9%) (p = 0.034). Two patients in the MMF group (5.1%) and eight patients in the azathioprine group (25.8%) discontinued treatment owing to adverse events or serious adverse events (p = 0.018). CONCLUSIONS In patients with treatment-naive AIH, MMF with prednisolone led to a significantly higher rate of biochemical remission at 24 weeks compared to azathioprine combined with prednisolone. Azathioprine use was associated with more (serious) adverse events leading to cessation of treatment, suggesting superior tolerability of MMF. IMPACT AND IMPLICATIONS This randomised-controlled trial directly compares azathioprine and mycophenolate mofetil, both in combination with prednisolone, for the induction of biochemical remission in treatment-naive patients with autoimmune hepatitis. Achieving complete remission is desirable to prevent disease progression. Patients assigned to the mycophenolate mofetil group reached biochemical remission more often and experienced fewer adverse events. The findings in this trial may contribute to the re-evaluation of international guidelines for the standard of care in treatment-naive patients with autoimmune hepatitis. TRIAL REGISTRATION NUMBER #NCT02900443.
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Affiliation(s)
- Romée J A L M Snijders
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands; European Reference Network RARE-LIVER, Germany
| | - Anna E C Stoelinga
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Tom J G Gevers
- Nutrim School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; European Reference Network RARE-LIVER, Germany
| | - Simon Pape
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands; European Reference Network RARE-LIVER, Germany
| | - Maaike Biewenga
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Maarten E Tushuizen
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Hendrik J M de Jonge
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Jan Maarten Vrolijk
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Sjoerd F Bakker
- Department of Gastroenterology and Hepatology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Thomas Vanwolleghem
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium; European Reference Network RARE-LIVER, Germany
| | - Ynto S de Boer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, location VU Medical Centre, Amsterdam, The Netherlands; European Reference Network RARE-LIVER, Germany
| | | | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands; European Reference Network RARE-LIVER, Germany
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, 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
| | - Brechje C van Eijck
- Department of Gastroenterology and Hepatology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Manon C van IJzendoorn
- Department of Gastroenterology and Hepatology, Hospital Bernhoven, Uden, The Netherlands
| | - Margot van Herwaarden
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, The Netherlands
| | | | - Kerem Sebib Korkmaz
- Department of Gastroenterology and Hepatology, IJselland Hospital, Capelle aan den Ijssel, the Netherlands
| | - Aad P van den Berg
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands; European Reference Network RARE-LIVER, Germany
| | - Maureen M J Guichelaar
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Amar D Levens
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands; European Reference Network RARE-LIVER, Germany.
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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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Pape S, Snijders RJALM, Gevers TJG, Chazouilleres O, Dalekos GN, Hirschfield GM, Lenzi M, Trauner M, Manns MP, Vierling JM, Montano-Loza AJ, Lohse AW, Schramm C, Drenth JPH, Heneghan MA, Alvarez F, Andrade R, Arikan C, Assis D, Bardou-Jacquet E, Biewenga M, Cancado E, Cazzagon N, Chazouillères O, Colloredo G, Cuarterolo M, Dalekos G, Debray D, Robles-Díaz M, Drenth J, Dyson J, Efe C, Engel B, Ferri S, Fontana R, Gatselis N, Gerussi A, Halilbasic E, Halliday N, Heneghan M, Hirschfield G, van Hoek B, Hørby Jørgensen M, Indolfini G, Iorio R, Jeong S, Jones D, Kelly D, Kerkar N, Lacaille F, Lammert C, Leggett B, Lenzi M, Levy C, Liberal R, Lleo A, Lohse A, Ines Lopez S, de Martin E, McLin V, Mieli-Vergani G, Milkiewicz P, Mohan N, Muratori L, Nebbia G, van Nieuwkerk C, Oo Y, Ortega A, Páres A, Pop T, Pratt D, Purnak T, Ranucci G, Rushbrook S, Schramm C, Stättermayer A, Swain M, Tanaka A, Taubert R, Terrabuio D, Terziroli B, Trauner M, Valentino P, van den Brand F, Villamil A, Wahlin S, Ytting H, Zachou K, Zeniya M. Systematic review of response criteria and endpoints in autoimmune hepatitis by the International Autoimmune Hepatitis Group. J Hepatol 2022; 76:841-849. [PMID: 35066089 DOI: 10.1016/j.jhep.2021.12.041] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 11/18/2021] [Accepted: 12/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Autoimmune hepatitis (AIH) has been well characterised and codified through the development of diagnostic criteria. These criteria have been adapted and simplified and are widely used in clinical practice. However, there is a need to update and precisely define the criteria for both treatment response and treatment. METHODS A systematic review was performed and a modified Delphi consensus process was used to identify and redefine the response criteria in autoimmune hepatitis. RESULTS The consensus process initiated by the International Autoimmune Hepatitis Group proposes that the term 'complete biochemical response' defined as 'normalization of serum transaminases and IgG below the upper limit of normal' be adopted to include a time point at 6 months after initiation of treatment. An insufficient response by 6 months was a failure to meet the above definition. Non-response was defined as '<50% decrease of serum transaminases within 4 weeks after initiation of treatment'. Remission is defined as liver histology with a Hepatitis Activity Index <4/18. Intolerance to treatment was agreed to stand for 'any adverse event possibly related to treatment leading to potential drug discontinuation'. CONCLUSIONS These definitions provide a simple and reproducible framework to define treatment response and non-response, irrespective of the therapeutic intervention. A consensus on endpoints is urgently required to set a global standard for the reporting of study results and to enable inter-study comparisons. Future prospective database studies are needed to validate these endpoints. LAY SUMMARY Consensus among international experts on response criteria and endpoints in autoimmune hepatitis is lacking. A consensus on endpoints is urgently required to set a global standard for the reporting of study results and to enable the comparison of results between clinical trials. Therefore, the International Autoimmune Hepatitis Group (IAIHG) herein presents a statement on 5 agreed response criteria and endpoints: complete biochemical response, insufficient response, non-response, remission, and intolerance to treatment, which can be used to guide future reporting.
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Affiliation(s)
- Simon Pape
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Romée J A L M Snijders
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Tom J G Gevers
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht 6229HX, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Oliver Chazouilleres
- Hepatology Department, Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, Saint-Antoine Hospital Assistance Publique-Hôpitaux de Paris, Paris, France; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly Medical School, Larissa, Greece
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada
| | - Marco Lenzi
- Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - John M Vierling
- Departments of Medicine and Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Hepatology, University of Alberta Hospital, Edmonton, Canada
| | - Ansgar W Lohse
- 1(st) Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Christoph Schramm
- 1(st) Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom; European Reference Network on Hepatological Diseases (ERN RARE-LIVER).
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4
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Taubert R, Engel B, Diestelhorst J, Hupa-Breier KL, Behrendt P, Baerlecken NT, Sühs KW, Janik MK, Zachou K, Sebode M, Schramm C, Londoño MC, Habes S, Oo YH, Lalanne C, Pape S, Schubert M, Hust M, Dübel S, Thevis M, Jonigk D, Beimdiek J, Buettner FFR, Drenth JPH, Muratori L, Adams DH, Dyson JK, Renand A, Graupera I, Lohse AW, Dalekos GN, Milkiewicz P, Stangel M, Maasoumy B, Witte T, Wedemeyer H, Manns MP, Jaeckel E. Quantification of polyreactive immunoglobulin G facilitates the diagnosis of autoimmune hepatitis. Hepatology 2022; 75:13-27. [PMID: 34473365 DOI: 10.1002/hep.32134] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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: 11/04/2020] [Revised: 07/26/2021] [Accepted: 08/16/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Detection of autoantibodies is a mainstay of diagnosing autoimmune hepatitis (AIH). However, conventional autoantibodies for the workup of AIH lack either sensitivity or specificity, leading to substantial diagnostic uncertainty. We aimed to identify more accurate serological markers of AIH with a protein macroarray. APPROACH AND RESULTS During the search for more-precise autoantibodies to distinguish AIH from non-AIH liver diseases (non-AIH-LD), IgG antibodies with binding capacities to many human and foreign proteins were identified with a protein macroarray and confirmed with solid-phase ELISAs in AIH patients. Subsequently, polyreactive IgG (pIgG) was exemplarily quantified by reactivity against human huntingtin-interacting protein 1-related protein in bovine serum albumin blocked ELISA (HIP1R/BSA). The diagnostic fidelity of HIP1R/BSA binding pIgG to diagnose AIH was assessed in a retrospective training, a retrospective multicenter validation, and a prospective validation cohort in cryoconserved samples from 1,568 adults from 10 centers from eight countries. Reactivity against HIP1R/BSA had a 25% and 14% higher specificity to diagnose AIH than conventional antinuclear and antismooth muscle antibodies, a significantly higher sensitivity than liver kidney microsomal antibodies and antisoluble liver antigen/liver pancreas antigen, and a 12%-20% higher accuracy than conventional autoantibodies. Importantly, HIP1R/BSA reactivity was present in up to 88% of patients with seronegative AIH and in up to 71% of AIH patients with normal IgG levels. Under therapy, pIgG returns to background levels of non-AIH-LD. CONCLUSIONS pIgG could be used as a promising marker to improve the diagnostic workup of liver diseases with a higher specificity for AIH compared to conventional autoantibodies and a utility in autoantibody-negative AIH. Likewise, pIgG could be a major source of assay interference in untreated AIH.
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Affiliation(s)
- Richard Taubert
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Bastian Engel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Jana Diestelhorst
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Katharina L Hupa-Breier
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Patrick Behrendt
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.,TWINCORE, Centre for Experimental and Clinical Infection Research, a Joint Venture between the Medical School Hannover (MHH) and the Helmholtz Centre for Infection Research (HZI), Hannover, Germany.,German Center for Infectious Disease Research (DZIF), Partner Site Hannover-Braunschweig, Hannover, Germany
| | - Niklas T Baerlecken
- Department of Clinical Immunology, Hannover Medical School, Hannover, Germany
| | | | - Maciej K Janik
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.,Liver and Internal Medicine Unit, Medical University of Warsaw, Warsaw, Poland
| | - Kalliopi Zachou
- Institute of Internal Medicine and Hepatology, Larissa, Greece.,Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Marcial Sebode
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.,1st Department of Medicine, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Christoph Schramm
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.,1st Department of Medicine, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany.,Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - María-Carlota Londoño
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.,Liver Unit, Hospital Clínic Barcelona, IDIBAPS, CIBEREHD, Barcelona, Spain
| | - Sarah Habes
- Hépato-Gastro-entérologie et Assistance Nutritionnelle, CHU Nantes, Nantes, France
| | | | - Ye H Oo
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.,Centre for Liver and Gastro Research, Institute of Immunology and Immunotherapy, The Medical School, National Institute of Health Research Birmingham Biomedical Research Centre, Birmingham, UK.,Liver Transplant and Hepatobiliary Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Claudine Lalanne
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Simon Pape
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.,Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maren Schubert
- Institute for Biochemistry, Biotechnology and Bioinformatics, Department of Biotechnology, Technische Universität Braunschweig, Braunschweig, Germany
| | - Michael Hust
- Institute for Biochemistry, Biotechnology and Bioinformatics, Department of Biotechnology, Technische Universität Braunschweig, Braunschweig, Germany
| | - Stefan Dübel
- Institute for Biochemistry, Biotechnology and Bioinformatics, Department of Biotechnology, Technische Universität Braunschweig, Braunschweig, Germany
| | - Mario Thevis
- Center for Preventive Doping Research, German Sport University Cologne, Cologne, Germany
| | - Danny Jonigk
- Institute for Pathology, Hannover Medical School, Hannover, Germany
| | - Julia Beimdiek
- Institute of Clinical Biochemistry, Hannover Medical School, Hannover, Germany
| | - Falk F R Buettner
- Institute of Clinical Biochemistry, Hannover Medical School, Hannover, Germany
| | - Joost P H Drenth
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.,Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luigi Muratori
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - David H Adams
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.,Centre for Liver and Gastro Research, Institute of Immunology and Immunotherapy, The Medical School, National Institute of Health Research Birmingham Biomedical Research Centre, Birmingham, UK.,Liver Transplant and Hepatobiliary Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jessica K Dyson
- Liver Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,NIHR Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Amédée Renand
- Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM Université de Nantes, Nantes, France
| | - Isabel Graupera
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.,Liver Unit, Hospital Clínic Barcelona, IDIBAPS, CIBEREHD, Barcelona, Spain
| | - Ansgar W Lohse
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.,1st Department of Medicine, University Medical Centre Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - George N Dalekos
- Institute of Internal Medicine and Hepatology, Larissa, Greece.,Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Piotr Milkiewicz
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.,Liver and Internal Medicine Unit, Medical University of Warsaw, Warsaw, Poland.,Translational Medicine Group, Pomeranian Medical University, Szczecin, Poland
| | - Martin Stangel
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Torsten Witte
- Department of Clinical Immunology, Hannover Medical School, Hannover, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Elmar Jaeckel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.,Department for Liver Transplantation, University Health Network of the University of Toronto, Toronto, Ontario, Canada
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5
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Laschtowitz A, Zachou K, Lygoura V, Pape S, Derben F, Jaeckel E, Oller-Moreno S, Weidemann S, Krech T, Piecha F, Schön G, Liebhoff AM, Al Tarrah M, Heneghan M, Drenth JP, Dalekos G, Taubert R, Lohse AW, Schramm C. Histological activity despite normal ALT and IgG serum levels in patients with autoimmune hepatitis and cirrhosis. JHEP Rep 2021; 3:100321. [PMID: 34381983 PMCID: PMC8333110 DOI: 10.1016/j.jhepr.2021.100321] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 10/27/2020] [Revised: 05/14/2021] [Accepted: 05/31/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND & AIMS In autoimmune hepatitis (AIH), normal levels of transaminases and IgG define biochemical remission and are considered the best surrogate markers for histological remission. This study assessed whether this also applies to patients with AIH cirrhosis. METHODS In this European multicentric study, we included 125 biopsies from 113 patients with AIH and histologically proven cirrhosis; 105 biopsies from 104 patients with AIH without cirrhosis served as controls. Biochemical parameters were available within 4 weeks of biopsy. AIH activity was graded according to the modified Hepatitis Activity Index (mHAI), with mHAI ≥4/18 considered to indicate risk of disease progression. RESULTS In total, 47 out of 125 liver biopsies were obtained from patients with AIH cirrhosis and normal ALT levels at time of biopsy. Only 26% (12/47) of those livers showed histological remission (mHAI <4/18), whereas 36% (17/47) showed moderate to high histological activity (mHAI ≥6/18). In patients with noncirrhotic AIH, 88% (46/52 biopsies) of cases with normal ALT levels had histological remission and only 4% (2/52) had an mHAI ≥6/18 (p <0.001). The addition of IgG to define complete biochemical remission only slightly improved the association with histological remission in the limited number of patients with AIH cirrhosis available for analysis [29% (5/17) of biopsies with mHAI <4/18]. ALT correlated closely with mHAI in AIH without cirrhosis but poorly in AIH with cirrhosis. CONCLUSIONS In contrast to patients with noncirrhotic AIH, in patients with AIH cirrhosis, who are at risk of disease progression, normal ALT levels and potentially also complete biochemical remission are poor surrogate markers of histological remission. Thus, new biomarkers are needed to monitor disease activity and progression in patients with AIH cirrhosis. LAY SUMMARY Autoimmune hepatitis (AIH) is an inflammatory disease of the liver that usually responds to immunosuppressive therapy. Serum transaminases and IgG levels within the normal ranges define complete biochemical remission and are considered as surrogate markers for histological disease activity. Here, we show that those biochemical markers are not sufficient to indicate low disease activity in patients with AIH and already established cirrhosis. Consequently, until better biomarkers for disease activity are found, only liver biopsy can reliably indicate disease activity in the presence of cirrhosis. Additional investigations, such as measurements of liver stiffness, should be undertaken to monitor non-invasively for disease progression in patients with AIH and established cirrhosis.
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Key Words
- AIH, autoimmune hepatitis
- ALD, alcoholic liver disease
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- Autoimmune hepatitis
- Biochemical remission
- Cirrhosis
- EASL, European Association for the Study of the Liver
- Histological activity
- ICC, intraclass correlation coefficient
- INR, international normalised ratio
- LLN, lower limit of normal
- Liver biopsy
- MELD, model for end-stage liver disease
- NAFLD, non-alcoholic fatty liver disease
- TE, transient elastography
- TIPS, transjugular intrahepatic portosystemic shunt
- ULN, upper limit of normal
- gamma-GT, gamma glutamyl transferase
- mHAI
- mHAI, modified Hepatitis Activity Index
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Affiliation(s)
- Alena Laschtowitz
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
| | - Kalliopi Zachou
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Centre of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Vasiliki Lygoura
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Centre of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Simon Pape
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Finn Derben
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Elmar Jaeckel
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Sergio Oller-Moreno
- Institute of Medical Systems Biology, Centre for Molecular Neurobiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Sören Weidemann
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
- Department of Pathology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Till Krech
- Department of Pathology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Felix Piecha
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Anna-Maria Liebhoff
- Institute of Medical Systems Biology, Centre for Molecular Neurobiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Munira Al Tarrah
- Institute of Liver Studies and Transplantation, King´s College Hospital, London, UK
| | - Michael Heneghan
- Institute of Liver Studies and Transplantation, King´s College Hospital, London, UK
| | - Joost P.H. Drenth
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - George Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Centre of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Richard Taubert
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Ansgar Wilhelm Lohse
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
- German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
- Hamburg Centre for Translational Immunology (HCTI), University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Schramm
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
- Hamburg Centre for Translational Immunology (HCTI), University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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6
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Affiliation(s)
| | - Simon Pape
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
| | - Tom J G Gevers
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboudumc, Nijmegen, The Netherlands
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7
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Pape S, Gevers TJG, Vrolijk JM, van Hoek B, Bouma G, van Nieuwkerk CMJ, Taubert R, Jaeckel E, Manns MP, Papp M, Sipeki N, Stickel F, Efe C, Ozaslan E, Purnak T, Nevens F, Kessener DJN, Kahraman A, Wedemeyer H, Hartl J, Schramm C, Lohse AW, Heneghan MA, Drenth JPH. High discontinuation rate of azathioprine in autoimmune hepatitis, independent of time of treatment initiation. Liver Int 2020; 40:2164-2171. [PMID: 32410363 PMCID: PMC7496382 DOI: 10.1111/liv.14513] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/20/2020] [Accepted: 05/07/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Guidelines regarding treatment for autoimmune hepatitis (AIH) favour two strategies for azathioprine (AZA) introduction: concurrent with steroids at induction or delayed by 2-4 weeks. The safety and efficacy of both strategies have been unexplored. METHODS We established a cohort of 900 AIH patients from 12 centres in 7 European countries. There were 631 patients who used AZA as part of the therapeutic regimen. We distinguished two groups: patients with early AZA (<2 weeks) or delayed AZA initiation (≥2 weeks). Primary outcome was discontinuation of AZA in the first year of treatment. Cox regression and propensity score matching was performed to determine difference in outcomes between groups. RESULTS Patients with early AZA initiation had significantly lower transaminases and bilirubin at baseline. Discontinuation rates of AZA did not differ between early and delayed starters (16.6% vs 14.2%), which did not reach statistical significance (hazard ratio 0.97, 95% confidence interval 0.61-1.55, P = .90). Stratification according to baseline disease activity or propensity score matching did not alter the results. Main reason for AZA discontinuation was intolerance to treatment (14.0% vs 13.2%, P = .78) with nausea and vomiting as main side effects. AIH remission rates were comparable among groups. CONCLUSION The discontinuation rate of AZA in AIH treatment is ~15% in the first year of treatment. Early or delayed AZA initiation does not differ in remission and discontinuation rates in AIH induction therapy. Our data suggest that either strategy may be used as part of AIH treatment.
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Affiliation(s)
- Simon Pape
- Department of Gastroenterology and HepatologyRadboud University Medical CenterNijmegenThe Netherlands,European Reference Network RARE‐LIVERHamburgGermany
| | - Tom J. G. Gevers
- Department of Gastroenterology and HepatologyRadboud University Medical CenterNijmegenThe Netherlands,European Reference Network RARE‐LIVERHamburgGermany
| | - Jan Maarten Vrolijk
- Department of Gastroenterology and HepatologyRijnstate HospitalArnhemThe Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and HepatologyLeiden University Medical CenterLeidenThe Netherlands
| | - Gerd Bouma
- Department of Gastroenterology and HepatologyVU University Medical CenterAmsterdamThe Netherlands
| | | | - Richard Taubert
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany,European Reference Network RARE‐LIVERHamburgGermany
| | - Elmar Jaeckel
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany,European Reference Network RARE‐LIVERHamburgGermany
| | - Michael P. Manns
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany,European Reference Network RARE‐LIVERHamburgGermany
| | - Maria Papp
- Division of GastroenterologyDepartment of Internal MedicineFaculty of MedicineUniversity of DebrecenDebrecenHungary
| | - Nora Sipeki
- Division of GastroenterologyDepartment of Internal MedicineFaculty of MedicineUniversity of DebrecenDebrecenHungary
| | - Felix Stickel
- Department of Gastroenterology and HepatologyUniversity Hospital of ZurichZurichSwitzerland
| | - Cumali Efe
- Department of GastroenterologyHarran University HospitalUrfaTurkey
| | - Ersan Ozaslan
- Department of GastroenterologyNumune Research and Education HospitalAnkaraTurkey
| | - Tugrul Purnak
- Department of GastroenterologyHacettepe UniversityAnkaraTurkey
| | - Frederik Nevens
- Department of Gastroenterology and HepatologyUniversity Hospital KU LeuvenLeuvenBelgium,European Reference Network RARE‐LIVERHamburgGermany
| | - Dominik J. N. Kessener
- Department of Gastroenterology and HepatologyUniversity Clinic of Essen DuisburgEssenGermany
| | - Alisan Kahraman
- Department of Gastroenterology and HepatologyUniversity Clinic of Essen DuisburgEssenGermany
| | - Heiner Wedemeyer
- Department of Gastroenterology and HepatologyUniversity Clinic of Essen DuisburgEssenGermany
| | - Johannes Hartl
- 1st Department of Internal MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany,European Reference Network RARE‐LIVERHamburgGermany
| | - Christoph Schramm
- 1st Department of Internal MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany,Martin Zeitz Centre for Rare DiseasesUniversity Medical Centre Hamburg‐EppendorfHamburgGermany,European Reference Network RARE‐LIVERHamburgGermany
| | - Ansgar W. Lohse
- 1st Department of Internal MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany,European Reference Network RARE‐LIVERHamburgGermany
| | - Michael A. Heneghan
- Institute of Liver StudiesKing's College HospitalLondonUK,European Reference Network RARE‐LIVERHamburgGermany
| | - Joost P. H. Drenth
- Department of Gastroenterology and HepatologyRadboud University Medical CenterNijmegenThe Netherlands,European Reference Network RARE‐LIVERHamburgGermany
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8
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Pape S, Gevers TJG, Vrolijk JM, van Hoek B, Bouma G, van Nieuwkerk CMJ, Taubert R, Jaeckel E, Manns MP, Papp M, Sipeki N, Stickel F, Efe C, Ozaslan E, Purnak T, Nevens F, Kessener DJN, Kahraman A, Wedemeyer H, Hartl J, Schramm C, Lohse AW, Drenth JPH, Heneghan MA. Rapid Response to Treatment of Autoimmune Hepatitis Associated With Remission at 6 and 12 Months. Clin Gastroenterol Hepatol 2020; 18:1609-1617.e4. [PMID: 31715274 DOI: 10.1016/j.cgh.2019.11.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 08/09/2019] [Revised: 10/21/2019] [Accepted: 11/04/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Changes in serum levels of transaminases immediately after initiation of treatment for autoimmune hepatitis (AIH) might be associated with biochemical markers of remission and liver-related events. We assessed the outcomes of patients with vs without rapid response to treatment of AIH in a large international cohort. METHODS We performed a retrospective cohort study, collecting data from 2 independent cohorts of adults with AIH from 12 centers in 7 countries in Europe. We collected information on patient demographics; serologic, histologic, and biochemical analyses; and treatment. We used a receiver operating characteristic curve and Youden index to calculate the optimal percentage decrease in level of aspartate aminotransferase (AST) after 8 weeks of treatment that associated with normalization of transaminase levels after 26 weeks of treatment with predniso(lo)ne (primary outcome) in the first (discovery) cohort (n = 370). We evaluated the results in the second (validation) cohort (n = 370). Secondary outcomes were liver-related death or transplantation. We performed univariate and multivariable logistic and Cox regression with correction for confounders. RESULTS A significant decrease in level of AST after 8 weeks of treatment was significantly associated with normalization of transaminase levels at 26 and 52 weeks (P < .001); a decrease of more than 80% in level of AST was associated with optimal normalization. In both cohorts, rapid responders (≥80% decrease in level of AST after 8 weeks) were more likely to achieve normalization of transaminases at 26 and 52 weeks when compared to non-rapid responders. Rapid responders in the discovery cohort had lower risk of liver-related death or transplantation (adjusted hazard ratio 0.18; 95% CI 0.05-0.63; P = .007), although this was not confirmed in the validation cohort. Results from measurement of alanine aminotransferase did not differ significantly from those of AST for the primary outcome. Slow responders (without normalization of transaminases after 1 year) had the highest risk of liver transplantation or liver-related death. CONCLUSIONS In a retrospective study of patients with AIH, we found that a rapid response to treatment, based on level of AST after 8 weeks, associates with normalization of transaminase levels in the following year. Patients with a rapid response also have a lower risk of liver-related death or transplantation than patients without this rapid response.
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Affiliation(s)
- Simon Pape
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tom J G Gevers
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Maarten Vrolijk
- Department of Gastroenterology and Hepatology, Rijnstate hospital, Arnhem, The Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gerd Bouma
- 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
| | - Richard Taubert
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Elmar Jaeckel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Maria Papp
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Nora Sipeki
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Felix Stickel
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich, Switzerland
| | - Cumali Efe
- Department of Gastroenterology, Harran University Hospital, Urfa, Turkey
| | - Ersan Ozaslan
- Department of Gastroenterology, Numune Research and Education Hospital, Ankara, Turkey
| | - Tugrul Purnak
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospital KU Leuven, Leuven, Belgium
| | - Dominik J N Kessener
- Department of Gastroenterology and Hepatology, University Clinic of Essen Duisburg-Essen, Duisburg-Essen, Germany
| | - Alisan Kahraman
- Department of Gastroenterology and Hepatology, University Clinic of Essen Duisburg-Essen, Duisburg-Essen, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology and Hepatology, University Clinic of Essen Duisburg-Essen, Duisburg-Essen, Germany
| | - Johannes Hartl
- 1(st) Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Schramm
- 1(st) Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- 1(st) Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
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9
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Hartl J, Miquel R, Zachou K, Wong GW, Asghar A, Pape S, Sebode M, Peiseler M, Zenouzi R, Ehlken H, Krech T, Weiler-Normann C, Drenth JPH, Oo YH, Dalekos GN, Heneghan M, Schramm C, Lohse AW. Features and outcome of AIH patients without elevation of IgG. JHEP Rep 2020; 2:100094. [PMID: 32280942 PMCID: PMC7139106 DOI: 10.1016/j.jhepr.2020.100094] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 01/28/2020] [Accepted: 01/31/2020] [Indexed: 12/27/2022] Open
Abstract
Background & Aims High IgG levels are considered a hallmark of autoimmune hepatitis (AIH). A subgroup of patients with AIH has IgG within the normal range despite evidence of clinical disease activity. The clinical significance of this biomarker has not been explored. Methods In a European multicentre study we compared biochemical, clinical and histological features from patients with AIH and normal IgG-values at diagnosis to an age- and sex-matched control group of patients with typical AIH presenting with elevated IgG. Data were assessed at diagnosis, after 12 months of therapy and at last follow-up. Results Out of 1,318 patients with AIH, 130 (10%) had normal IgG at presentation. Histological and biochemical parameters at diagnosis, as well as treatment response, showed no difference between groups. Stable remission off treatment was achieved more commonly in the normal IgG group than in the typical AIH group (24 vs. 8%; p = 0.0012). Patients of the control group not only had higher IgG levels (29.5 ± 5.8 vs. 12.5 ± 3.2 g/L; p <0.0001), but also a higher IgG/IgA ratio (9.3 ± 6.9 vs. 5.4 ± 2.4; p <0.0001) at diagnosis. The IgG/IgA ratio only declined in patients with typical AIH and was no longer different between groups after 12 months (6.3 ± 4.3 vs. 5.5 ± 2.2; p = 0.1), indicating a selective increase of IgG in typical AIH and its suppression by immunosuppression. Autoantibody titres were higher in the typical AIH group, but not when controlled for IgG levels. Conclusions Compared to AIH with typical biochemical features, patients with normal IgG levels at diagnosis (i) show similar biochemical, serological and histological features and comparable treatment response, (ii) appear to lack the selective elevation of serum IgG levels observed in typical active AIH disease, (iii) may represent a subgroup with a higher chance of successful drug withdrawal. Lay summary A characteristic feature of autoimmune hepatitis (AIH) is an elevation of immunoglobulin G (IgG), which is therefore used as a major diagnostic criterion, as well as to monitor treatment response. Nevertheless, normal IgG does not preclude the diagnosis of AIH. Therefore, we herein assessed the features of patients with AIH and normal IgG in a large multicentre study. This study demonstrates that about 10% of all patients with AIH have normal IgG; these patients are indistinguishable from other patients with AIH with respect to biochemical markers, liver histology, disease severity and treatment response, but might represent a subgroup with a higher chance of remission after drug withdrawal. Patients with AIH and normal IgG comprise around 10% of all patients with AIH. These patients are indistinguishable from patients with typical AIH by biochemical markers or liver histology. They have no selective IgG elevation, with lower IgG and IgA levels than patients with typical AIH. These patients might represent a subgroup in whom there is a high chance of successful drug withdrawal.
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Key Words
- AIH, autoimmune hepatitis
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AMA, anti-mitochondrial antibody
- ANA, anti-nuclear antibody
- AST, aspartate aminotransferase
- Anti-SLA/LP, anti-soluble liver antigen and anti-liver-pancreas antibodies
- INR, international normalized ratio
- LKM, liver kidney microsomal antigen
- SMA, smooth muscle antibody
- autoimmune hepatitis
- drug withdrawal
- hypergammaglobulinemia
- immunoglobulin G
- immunoglobulins
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Affiliation(s)
- Johannes Hartl
- First Department of Internal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network on Hepatological Diseases
| | - Rosa Miquel
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Kalliopi Zachou
- Institute of Internal Medicine and Hepatology, Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa, Greece
| | - Guan-Wee Wong
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Asma Asghar
- Centre for Liver and Gastroenterology Research, NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, United Kingdom
| | - Simon Pape
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands.,European Reference Network on Hepatological Diseases
| | - Marcial Sebode
- First Department of Internal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network on Hepatological Diseases
| | - Moritz Peiseler
- First Department of Internal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network on Hepatological Diseases
| | - Roman Zenouzi
- First Department of Internal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network on Hepatological Diseases
| | - Hanno Ehlken
- Department of Interdisciplinary Endoscopy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network on Hepatological Diseases
| | - Till Krech
- Department of Pathology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christina Weiler-Normann
- First Department of Internal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network on Hepatological Diseases
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands.,European Reference Network on Hepatological Diseases
| | - Ye H Oo
- Centre for Liver and Gastroenterology Research, NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, United Kingdom.,Liver Transplant and Hepatobiliary Unit, University Hospital of Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Centre for Rare Diseases, Institute of Translational Medicine, University of Birmingham, Birmingham, United Kingdom.,European Reference Network on Hepatological Diseases
| | - George Nikolaos Dalekos
- Institute of Internal Medicine and Hepatology, Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa, Greece
| | - Michael Heneghan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Christoph Schramm
- First Department of Internal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network on Hepatological Diseases
| | - Ansgar Wilhelm Lohse
- First Department of Internal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network on Hepatological Diseases
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10
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Pape S, Gevers TJG, Belias M, Mustafajev IF, Vrolijk JM, van Hoek B, Bouma G, van Nieuwkerk CMJ, Hartl J, Schramm C, Lohse AW, Taubert R, Jaeckel E, Manns MP, Papp M, Stickel F, Heneghan MA, Drenth JPH. Predniso(lo)ne Dosage and Chance of Remission in Patients With Autoimmune Hepatitis. Clin Gastroenterol Hepatol 2019; 17:2068-2075.e2. [PMID: 30625402 DOI: 10.1016/j.cgh.2018.12.035] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [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: 10/08/2018] [Revised: 11/30/2018] [Accepted: 12/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with autoimmune hepatitis (AIH) commonly receive induction therapy with predniso(lo)ne followed by maintenance therapy with azathioprine. European Association for Study of the Liver clinical practice guidelines advise a predniso(lo)ne dose range of 0.50-1 mg/kg/day, which leaves room for practice variation. We performed a multicenter study to determine the efficacy of different dose ranges of predniso(lo)ne induction therapy in a large European cohort of patients with AIH. METHODS We performed a retrospective cohort study using a comparative effectiveness design. We collected data from 451 adults with AIH who began treatment from 1978 through 2017 at 9 centers in 5 European countries. We assigned patients to a high-dose group (initial predniso(lo)ne dose ≥0.50 mg/kg/day; n = 281) or a low-dose group (<0.50 mg/kg/day; n = 170). Logistic regression was performed to determine difference in outcomes between the groups. The primary outcome was normal serum levels of transaminases at 6 months after initiation of therapy. RESULTS There was no significant difference in rates of normalization of transaminases between the high-dose predniso(lo)ne group and the low-dose group (70.5% vs 64.7%; P = .20). After multivariable logistic regression with correction for confounders, there was no difference in the likelihood of normalization of transaminases between the groups (odds ratio, 1.21; 95% CI, 0.78-1.87; P = .38). Patients given an initial high dose of predniso(lo)ne received more predniso(lo)ne over time than patients started on a lower dose (median doses over 6 months: 3780 mg vs 2573 mg) (P < .01). CONCLUSIONS In a retrospective study of patients with AIH in Europe, we found that the dose of predniso(lo)ne to induce remission in patients with AIH is less relevant than assumed. An initial predniso(lo)ne dose below 0.50 mg/kg/day substantially decreases unnecessary exposure to predniso(lo)ne in patients with AIH.
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Affiliation(s)
- Simon Pape
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tom J G Gevers
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michail Belias
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ilyas F Mustafajev
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Maarten Vrolijk
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gerd Bouma
- 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
| | - Johannes Hartl
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Christoph Schramm
- 1(st) Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- 1(st) Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Richard Taubert
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Elmar Jaeckel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Maria Papp
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Felix Stickel
- Department of Gastroenterology and Hepatology, University Hospital of Zurich, Zurich, Switzerland
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.
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11
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Abstract
Autoimmune hepatitis is a rare and chronic liver disease that is characterised by increased serum transaminases and immunoglobulin G, inflammatory liver histology and presence of circulating autoantibodies. An autoimmune hepatitis diagnosis justifies life-long treatment in most patients in order to prevent development of cirrhosis and end-stage liver disease. The cornerstone of treatment is steroid induction therapy followed by maintenance therapy with azathioprine, which is effective in most cases. For patients who do not respond to standard treatment, second-line treatment with other immunosuppressants can be effective. Treatment should be aimed at biochemical remission of the disease, which is defined as normalization of transaminases and immunoglobulin G. Patients should be monitored intensively during the first months of treatment in order to monitor side-effects, assess symptoms and individualise treatment. Specialist consultation should be sought in difficult-to-treat patients. Future studies and networking initiatives should result in optimization of current treatment strategies in autoimmune hepatitis.
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Affiliation(s)
- Simon Pape
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.,European Reference Network Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Christoph Schramm
- European Reference Network Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany.,1st Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Tom Jg Gevers
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.,European Reference Network Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
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12
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Smolders EJ, Pape S, de Kanter CTMM, van den Berg AP, Drenth JPH, Burger DM. Decreased tacrolimus plasma concentrations during HCV therapy: a drug-drug interaction or is there an alternative explanation? Int J Antimicrob Agents 2017; 49:379-382. [PMID: 28185946 DOI: 10.1016/j.ijantimicag.2016.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 11/23/2016] [Accepted: 12/03/2016] [Indexed: 12/13/2022]
Abstract
Chronic hepatitis C virus (HCV) infection can cause severe liver cirrhosis, for which liver transplantation is the only therapy. To prevent organ rejection, transplanted patients are treated with immunosuppressive agents. We describe two transplanted patients treated with tacrolimus who were simultaneously treated with direct-acting antivirals (DAAs) for their chronic HCV infection. No pharmacokinetic drug-drug interactions (DDIs) were expected between tacrolimus and the selected DAAs. However, in both patients, tacrolimus plasma concentrations decreased during HCV treatment. We hypothesise that decreased plasma concentrations were not caused by a DDI but were an indirect result of the clearance of the HCV infection. During chronic HCV infection, pro-inflammatory cytokines may inhibit cytochrome P450 (CYP) enzymes, which are primarily responsible for tacrolimus metabolism. If this is true, then with clearance of the virus the activity of these enzymes will normalise and tacrolimus metabolism will increase. These changes were clinically relevant because the tacrolimus dosage needed to be adjusted. Therefore, physicians should be aware that CYP substrates with narrow therapeutic ranges might require dose adaption during HCV therapy with DAAs.
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Affiliation(s)
- E J Smolders
- Department of Pharmacy, radboud university medical center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands.
| | - S Pape
- Department of Gastroenterology and Hepatology, radboud university medical center, Nijmegen, The Netherlands
| | - C T M M de Kanter
- Department of Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - A P van den Berg
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - J P H Drenth
- Department of Gastroenterology and Hepatology, radboud university medical center, Nijmegen, The Netherlands
| | - D M Burger
- Department of Pharmacy, radboud university medical center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
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13
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Pape S, Daukšaitė L, Lucks S, Gu X, Brunner H. An in Situ Generated Palladium on Aluminum Oxide: Applications in Gram-Scale Matsuda-Heck Reactions. Org Lett 2016; 18:6376-6379. [PMID: 27978675 DOI: 10.1021/acs.orglett.6b03268] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In situ generated palladium on aluminum oxide provides an active catalytic system for Matsuda-Heck reactions in gram-scale. The novel catalyst proceeded through a significantly higher catalytic activity compared to the classical Pd/C system. Based on the high catalytic activity the first α,β,β-triarylation of methyl acrylate in good yields could be provided in one-step.
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Affiliation(s)
- Simon Pape
- Atotech Deutschland GmbH, Erasmusstrasse 20, D-10553 Berlin, Germany
| | - Lauryna Daukšaitė
- Atotech Deutschland GmbH, Erasmusstrasse 20, D-10553 Berlin, Germany
| | - Sandra Lucks
- Atotech Deutschland GmbH, Erasmusstrasse 20, D-10553 Berlin, Germany
| | - Xiaoting Gu
- Atotech USA Inc., c/o Case Western Reserve University, 2111 Martin Luther King Jr. Drive, Cleveland, Ohio 44106, United States
| | - Heiko Brunner
- Atotech Deutschland GmbH, Erasmusstrasse 20, D-10553 Berlin, Germany
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14
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Pape S, Wessig P, Brunner H. Iron Trichloride and Air Mediated Guanylation of Acylthioureas. An Ecological Route to Acylguanidines: Scope and Mechanistic Insights. J Org Chem 2016; 81:4701-12. [DOI: 10.1021/acs.joc.6b00600] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Simon Pape
- Atotech Deutschland GmbH, Erasmusstrasse
20, D-10553 Berlin, Germany
| | - Pablo Wessig
- Universität Potsdam, Institut für Chemie, Karl-Liebknecht-Straße 24-25,
Haus 25, D-14476 Potsdam, Germany
| | - Heiko Brunner
- Atotech Deutschland GmbH, Erasmusstrasse
20, D-10553 Berlin, Germany
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15
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Abstract
A new synthetic approach for the guanylation of aroylthioureas using iron trichloride is presented.
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Affiliation(s)
- Simon Pape
- Atotech Deutschland GmbH
- D-10553 Berlin
- Germany
- Universität Potsdam
- Institut für Chemie
| | - Pablo Wessig
- Universität Potsdam
- Institut für Chemie
- D-14476 Potsdam
- Germany
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16
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Abstract
New materials with moderately high porosity are accessible by polyacetalization under very mild conditions.
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Affiliation(s)
- Pablo Wessig
- Institut für Chemie
- Universität Potsdam
- 14476 Potsdam, Germany
| | - Maik Gerngroß
- Institut für Chemie
- Universität Potsdam
- 14476 Potsdam, Germany
| | - Simon Pape
- Institut für Chemie
- Universität Potsdam
- 14476 Potsdam, Germany
| | - Philipp Bruhns
- Institut für Chemie
- Universität Potsdam
- 14476 Potsdam, Germany
| | - Jens Weber
- Department of Colloid Chemistry
- Max Planck Institute of Colloids and Interfaces
- D-14476 Potsdam, Germany
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17
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Chipp E, Pape S. Iron burns: a problem in adults as well as children. Ann Burns Fire Disasters 2013; 26:171-174. [PMID: 24799845 PMCID: PMC3978587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Indexed: 06/03/2023]
Abstract
Burns from domestic irons are potentially preventable injuries which can result in significant morbidity. Several studies have reported these injuries in children but there are no reports to date in adults. Epidemiology, management and outcome of these injuries is described, and possible preventative strategies are discussed. We present a retrospective case note review of 50 adult and paediatric patients with electric iron burns. Cases were identified from data collected for a national burns database. Information regarding demographics, burn characteristics, treatment and long term outcome was gathered from the medical records. 42 children and 8 adults sustained a burn from an iron during the 4-year study period. The majority of paediatric patients were under 4 years of age. Most burns were small (< 1% TBSA) but despite this 30 (60%) patients were admitted to hospital and 13 (26%) required at least one surgical procedure. In children, most burns occurred at home and were commonly due to pulling the flex or knocking the iron from its surface. In adults, 50% of injuries were associated with epilepsy. Burns from domestic irons are relatively common and cause significant morbidity despite their small size. A bimodal presentation is seen with injuries occurring either before the age of 4 years or during adulthood, when they are typically associated with an underlying medical condition. Education campaigns and design features such as a retractable cord may further reduce the incidence of this type of burn.
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Affiliation(s)
- E. Chipp
- North East and Cumbria Regional Burns Unit, Royal Victoria Infirmary, United Kingdom
| | - S. Pape
- North East and Cumbria Regional Burns Unit, Royal Victoria Infirmary, United Kingdom
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18
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Mauss S, Berger F, Schober A, Moog G, Heyne R, John C, Pape S, Hueppe D, Pfeiffer-Vornkahl H, Alshuth U. Screening for autoantibodies in chronic hepatitis C patients has no effect on treatment initiation or outcome. J Viral Hepat 2013; 20:e72-7. [PMID: 23490392 DOI: 10.1111/jvh.12011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [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: 04/01/2012] [Accepted: 08/01/2012] [Indexed: 12/13/2022]
Abstract
Autoantibodies in hepatitis C virus-infected patients may indicate autoimmune hepatitis or other immune-mediated diseases. This may impact safety and efficacy of interferon-based therapy of chronic hepatitis C. We investigated the association between a positive test result for a variety of autoantibodies and the initiation and efficacy of therapy for chronic hepatitis C. We analysed an observational cohort of 24 306 patients for an association between autoantibodies and treatment outcome. 8241 patients were tested simultaneously for antinuclear antibodies (ANA), liver kidney microsomal antibodies (LKM), smooth muscle antibodies (SMA) and antimitochondrial antibodies (AMA). Matched-pair analysis was performed matching one autoantibody-positive patient to three controls. Control patients had negative tests for all four antibodies. Analyses were performed for patients with a single positive autoantibody test and for patients with multiple positive autoantibody tests. A positive test result for ANA, LKM, SMA or AMA did not affect the physician's decision to initiate therapy with pegylated interferon and ribavirin. In addition, a positive test for one or multiple autoantibodies did not adversely affect sustained virologic response. There was no difference in fibrosis stage or alanine transaminase at baseline or during therapy irrespective of antibody status. Thyroid dysfunction was more frequent in patients with positive LKM antibodies (P = 0.004). Initiation of therapy for chronic hepatitis C and outcome were not affected by the presence of ANA, LKM, SMA or AMA. Routine testing of these autoantibodies seems not warranted. Determination of autoantibodies should be guided by individualized clinical decisions.
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Affiliation(s)
- S Mauss
- Center for HIV and Hepatogastroenterology, Dusseldorf, Germany.
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19
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Margolina E, Torrent Despouy J, Grisanti S, Pape S, Ewert I, Neppert B, Müller M. [Severe secondary scleritis after pseudomonas aeruginosa induced corneal ulcer]. Klin Monbl Augenheilkd 2010; 227:987-9. [PMID: 21157667 DOI: 10.1055/s-0029-1245620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- E Margolina
- Augenheilkunde, Klinik für Augenheilkunde, UK-SH, Lübeck.
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20
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Eisenbeis C, Neppert B, Menke T, Pape S, Schrader S, Geerling G, Müller M. [Anatomic and subjective success of structured surgical treatment strategy in the management of chronic epiphora - a postoperative analysis of contentment]. Klin Monbl Augenheilkd 2010; 227:879-86. [PMID: 20845260 DOI: 10.1055/s-0029-1245455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Epiphora is the result of hypersecretion or reduced tear outflow because of relative or absolute obstruction of the lacrimal system. For the treatment a specific surgical procedure is usually required. Herein we present the subjective and objective findings of 243 consecutive patients with non-irritative induced epiphora, who underwent an operation in a standardised therapy scheme, which is used at the eye departments of the Universities of Lübeck and Würzburg. PATIENTS AND METHODS In a retrospective cohort study 243 patients were included who underwent lateral tarsal strip (n = 72), external dacryocystorhinostomy (DCR) in the case of an absolute nasolacrimal duct obstruction (NLDO) (n = 116) and relative NLDO (n = 25), DCR with canalicular surgery (n = 18) and simple canalicular surgery (n = 12) with a follow-up of at least 6 month. Common patient and cosmetical satisfaction, intensity of symptoms and further symptoms of 168 patients were evaluated by sending a questionnaire with subsequent telephone survey. Objective findings were recorded from hospital charts. RESULTS 59.5% of the patients were free of complaints, 19.6% had an absolute decrease of symptoms (epiphora outside and in windy weather) and 20.8 % persistent epiphora (symptoms both in- and outside persisted). 81% of patients with absolute NLDO and 57% with relative NLDO were graded as being free of symptoms, 7% (24%) as a relative decrease and 12% (19%) as a persistence of symptoms. There was a significant difference in success between these indications (p = 0.018). Patency of the lacrimal system assessed by irrigation was found in 95% (absolute NLDO). Commonly, 73.8% were satisfied, 7.7% indifferent and 18.4 % not satisfied. 4 patients were cosmetically not satisfied. CONCLUSIONS Use of a standardised therapy scheme reduces the symptoms in 79.1% of the patients. In patients with absolute NLDO external DCR achieves an anatomic success rate of 95% and a subjective improvement in 88% with excellent cosmetic results. In comparison with absolute NLDO the success rate of relative NLDO is lower, but still with a subjective improvement in 81%. Our results show that postoperative success depends on the preoperative cause of the epiphora.
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Affiliation(s)
- C Eisenbeis
- Augenheilkunde, Klinik für Augenheilkunde, UK-SH, Campus Lübeck
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21
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Müller M, Brüggemann A, Pape S. Trabekulektomie versus Kanaloplastik – eine Kosten- und Aufwandsanalyse. Klin Monbl Augenheilkd 2010. [DOI: 10.1055/s-0030-1249547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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22
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Hüppe D, Zehnter E, Mauss S, Böker K, Lutz T, Racky S, Schmidt W, Ullrich J, Sbrijer I, Heyne R, Schober A, John C, Hey KH, Bokemeyer B, Kallinowski B, Möller B, Pape S, Gutmann M, Alshuth U, Niederau C. [Epidemiology of chronic hepatitis C in Germany--an analysis of 10,326 patients in hepatitis centres and outpatient units]. Z Gastroenterol 2008; 46:34-44. [PMID: 18188814 DOI: 10.1055/s-2007-963691] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Little is known about the epidemiology of chronic hepatitis C (CHC) in Germany and especially about the importance of transmission, duration of infection, genotypes, symptoms and quality of life of the patients. The current study prospectively evaluates epidemiological and clinical data of patients infected with the hepatitis C virus (HCV). Using online data entry, various characteristics of 10,326 untreated patients with CHC were documented from March 2003 until May 2006 in 352 centres all over Germany. Mean age of patients was 43.4 years. Patients infected by i.v. drug abuse were considerably younger (36.5 years) than the remaining patients (49.2 years). As indicated by their native language, 64.4% of the patients came from Germany and 19.2% from Russia. 61.7% were infected with genotype 1 and 34.9% with genotype 2 or 3. 45.5% of the patients had been infected by i.v. drug abuse. In at least 5.4% of the patients liver cirrhosis had been proved by biopsy. 63.5% of the patients felt an impairment of quality of life caused by CHC. In many patients infected with hepatitis C socio-economic issues are existent. This is reflected, i.e., in very high rates of unemployment in special subpopulations. Coinfections with hepatitis B and HIV occurred in 1.5% and 4.7%, respectively. Nearly 80% of patients were managed near their homes. The data of the 10 326 patients represent about 2% of all German patients with CHC. This database is up to now the largest of its kind and gives a representative insight into the epidemiological situation of CHC in Germany.
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Affiliation(s)
- D Hüppe
- Gastroenterologische Gemeinschaftspraxis Herne, Herne.
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23
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Abstract
BACKGROUND Evaluation of needling and 5-fluorouracil (5-FU) injections more than 4 months after preceding filtration surgery. PATIENTS AND METHOD Retrospective analysis of 17 eyes in 14 patients who underwent needling of the filtering bleb and administration of 5-FU by injection at least 4 months after trabeculectomy (TE) with mitomycin C (MMC; same surgeon throughout). Complete success was defined as a reduction of intraocular pressure (IOP) by >30% from the baseline value without further medication and, in cases of primary open-angle glaucoma, IOP of 18 mmHg. The mean period of follow-up was 8.1 months (3-24 months). RESULTS One to four needlings (Ø 1.6) with one to five injections (Ø 3.1) of 5-FU were performed as required according to clinical need an average of 31.3 months (4-108 m) after TE. The mean baseline IOP was 25 mmHg (+/-SD 6.02; median 25 mmHg). After needling and 5-FU injection the mean IOD at the last hospital visit was 13.64 mmHg (+/-SD 5.2, median 13 mmHg; p<0,001). Complete success was achieved in 82.4% of these cases. The mean reduction in IOP was 11.2 mmHg (0-22 mmHg). In the cases with successful outcome (14 of 17 eyes) the mean IOP reduction from baseline was 55%. Three eyes required further treatment. Complications encountered were hyphaema (2 cases), subconjunctival bleeding (1 case) and corneal erosion (3 cases). CONCLUSION Late needling and injections of 5-FU can restore filtering bleb function even over 4 months after initial surgery. The high success rate and low incidence of complications together with the simple procedure justify regarding this approach as an alternative that can be used before passing on to more invasive interventions.
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Affiliation(s)
- M Müller
- Klinik für Augenheilkunde, Universitätsklinikum Schleswig-Holstein,Campus Lübeck, Lübeck, Deutschland.
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25
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Bülow M, Pape S, Hoerauf H. Therapieversuch eines retinalen Hämangioms mit einem VEGF-Rezeptor-Inhibitor. Klin Monbl Augenheilkd 2005. [DOI: 10.1055/s-2005-871597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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26
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Pape S, Müller M, Hoerauf H, Geerling G, Winter C, Laqua H. 1-Jahres-Ergebnisse funktionierender Sickerkissen in der OCT-Darstellung. Klin Monbl Augenheilkd 2004. [DOI: 10.1055/s-2004-828738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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27
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Amminger GP, Pape S, Rock D, Roberts SA, Squires-Wheeler E, Kestenbaum C, Erlenmeyer-Kimling L. The New York High-Risk Project: comorbidity for axis I disorders is preceded by childhood behavioral disturbance. J Nerv Ment Dis 2000; 188:751-6. [PMID: 11093377 DOI: 10.1097/00005053-200011000-00005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The relationship between childhood behavioral disturbance and comorbidity for adult psychiatric disorders has not been sufficiently investigated. Subjects of this report (N = 185) were offspring of parents with schizophrenia or affective disorder and of normal parents from the New York High-Risk Project. Data on childhood behavior at the mean age of 9.5 years were obtained in a parent interview at initial assessment in 1971-72. Adulthood outcomes were assessed through standardized interviews, and lifetime axis I diagnoses were based on Research Diagnostic Criteria. Subjects with comorbidity for axis I disorders exhibited significantly more behavioral problems as children, compared with those who developed either one or no psychiatric disorder in adulthood. This association was not biased by gender or parental diagnosis of psychiatric disorder. The findings emphasize that psychiatric comorbidity can be traced back to childhood and underline the importance of longitudinal observations in psychiatric research.
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Affiliation(s)
- G P Amminger
- University Hospital for Child and Adolescent Neuropsychiatry, Vienna, Austria
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Amminger GP, Pape S, Rock D, Roberts SA, Ott SL, Squires-Wheeler E, Kestenbaum C, Erlenmeyer-Kimling L. Relationship between childhood behavioral disturbance and later schizophrenia in the New York High-Risk Project. Am J Psychiatry 1999; 156:525-30. [PMID: 10200729 DOI: 10.1176/ajp.156.4.525] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE An association between childhood behavioral disturbance and adulthood schizophrenia has been seen previously in retrospective or follow-back studies and in prospective studies. The authors examined the relationship between childhood behavioral problems and adulthood schizophrenia-related psychoses. Because a high rate of childhood behavioral problems is known to be associated with adult substance abuse, these analyses controlled for substance abuse. METHOD The subjects of this investigation (N = 185) were offspring of parents with schizophrenia or affective disorder and of normal parents from the New York High-Risk Project (sample A). Data on childhood behavioral problems were obtained in a parent interview at initial assessment in 1971-1972. Adulthood outcomes (schizophrenia-related psychoses, affective disorders, anxiety disorders, substance abuse) were based on lifetime axis I diagnoses according to the Research Diagnostic Criteria. RESULTS Substance abuse had a significant interaction with the clinical outcome groups. In subjects without substance abuse, those with schizophrenia-related psychoses had exhibited significantly more behavioral problems as children than had adult offspring with affective or anxiety disorder or with substance abuse only or no disorder. CONCLUSIONS These results support the view that schizophrenia-related psychoses can be followed back to early behavioral disturbances. The confounding effects of substance abuse should be statistically controlled in studies of longitudinal associations between childhood behavioral disturbance and axis I outcomes.
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Affiliation(s)
- G P Amminger
- University Hospital for Child and Adolescent Neuropsychiatry, University of Vienna, Austria.
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Erlenmeyer-Kimling L, Adamo UH, Rock D, Roberts SA, Bassett AS, Squires-Wheeler E, Cornblatt BA, Endicott J, Pape S, Gottesman II. The New York High-Risk Project. Prevalence and comorbidity of axis I disorders in offspring of schizophrenic parents at 25-year follow-up. Arch Gen Psychiatry 1997; 54:1096-102. [PMID: 9400345 PMCID: PMC3188309 DOI: 10.1001/archpsyc.1997.01830240052008] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The New York High-Risk Project is a study of offspring of patients with schizophrenia (HRSz group) or affective illness (HRAff group) and psychiatrically normal parents (NC group) observed prospectively from childhood to adulthood. We herein present lifetime prevalence and comorbidity rates of Axis I disorders in subjects and their siblings from sample A of the project. METHODS Schedule for Affective Disorders and Schizophrenia-Lifetime Version interviews conducted with the offspring in adulthood were used to obtain diagnoses of Axis I disorders. RESULTS Schizophrenia and unspecified psychoses occurred only in the HRSz group. However, schizoaffective and psychotic affective disorders occurred equally in the HRSz and HRAff groups. Total rates of psychosis in these groups were significantly higher than in the NC group. All groups had similar rates of nonpsychotic affective and substance abuse disorders. The HRAff group, however, had significantly more total affective illness than the NC group and tended to have more anxiety disorders than the other groups. Comorbidity rates in the HRSz and HRAff groups were nearly twice those of the NC group. CONCLUSIONS The familial liabilities to schizophrenia and affective disorders show specificities and commonalities, differing markedly from each other in their expression of some disorders and sharing others. Patterns of comorbidity are generally, although not entirely, similar to these liabilities.
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Abstract
The GRAFTAC skin stapler with absorbable tacs has been used to attach split-skin grafts in 28 patients, under a variety of clinical situations, and the outcomes studied. This knowledge has been reviewed in the light of our existing experience with the more familiar metal staple. Details of the patients and their conditions are presented, with two illustrative case histories, including one where both Graftac and metal staples were used. The relative costs were analysed and an attempt made to compare the cost-effectiveness of tacs and staples. A rationale for use of the more expensive GRAFTAC stapler is presented.
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Affiliation(s)
- M V McKiernan
- Department of Plastic, Reconstructive and Burns Surgery, Newcastle General Hospital, Newcastle upon Tyne, UK
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Kaemmerer H, Pape S. [Ultrasonics in intensive care and emergency medicine]. Krankenpfl J 1988; 26:503-7. [PMID: 3060677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Dias Wickramanayake P, Klein HO, Pape S, Meyer-Hofmann H. [Chemotherapy protocol for metastasizing colorectal carcinoma. Methotrexate, 5-fluorouracil and cytarabine]. Dtsch Med Wochenschr 1985; 110:487-91. [PMID: 3979285 DOI: 10.1055/s-2008-1068850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
A new treatment protocol was developed for colorectal carcinomas consisting of sequential administration of methotrexate, 5-fluorouracil and cytarabine. The latter was included into the protocol in order to suppress the DNA salvage pathway of tumour cells. The sequential high-dosage combination was administered to 34 patients with metastatic colorectal carcinoma, 23 patients had been pretreated with cytostatics. Remission could be achieved in 14 out of the 34 patients. Two patients with carcinoma of the rectum have complete clinical remission lasting for 7 months. Eight of the 14 patients responding to treatment had had cytostatic pretreatment. The median time of survival of patients in remission is 15 months, median survival of non-responders 4,3 months. Combination treatment was well tolerated. Leuko- and thrombocytopenia according to grade 3 and 4 of the WHO classification were only rarely observed.
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