Multiparametric MR mapping in clinical decision-making for diffuse liver disease.

Accurate diagnosis, monitoring and treatment decisions in patients with chronic liver disease currently rely on biopsy as the diagnostic gold standard, and this has constrained early detection and management of diseases that are both varied and can be concurrent. Recent developments in multiparametric magnetic resonance imaging (mpMRI) suggest real potential to bridge the diagnostic gap between non-specific blood-based biomarkers and invasive and variable histological diagnosis. This has implications for the clinical care and treatment pathway in a number of chronic liver diseases, such as haemochromatosis, steatohepatitis and autoimmune or viral hepatitis. Here we review the relevant MRI techniques in clinical use and their limitations and describe recent potential applications in various liver diseases. We exemplify case studies that highlight how these techniques can improve clinical practice. These techniques could allow clinicians to increase their arsenals available to utilise on patients and direct appropriate treatments.

Ethnicity and body mass index are associated with hepatitis C presentation and progression.

BACKGROUND & AIMS: Ethnicity and the metabolic syndrome are believed to affect progression of hepatitis C virus (HCV) infection, but the interaction between these factors is unknown. We evaluated the association between elements of the metabolic syndrome and ethnicity in the histologic progression of HCV in a large, diverse cohort. METHODS: We retrospectively evaluated clinical data and liver biopsy samples from 812 patients who had no cause of liver disease other than HCV infection. Liver biopsies were scored for steatosis, necroinflammatory activity, and fibrosis. For each patient with a known risk factor for viral acquisition, fibrosis index was calculated as an indicator of disease progression. RESULTS: Hispanics had significantly higher fibrosis index (0.13 +/- 0.09) than non-Hispanic whites (0.11 +/- 0.07) and African Americans (0.10 +/- 0.06; P = .001). Fibrosis index correlated with body mass index (BMI), older age at infection, ethnicity, and degree of steatosis. Cirrhosis was present in 50% of Hispanics, 38% of non-Hispanic whites, and 24% of African Americans (P < .001). The presence of cirrhosis was associated additionally with older age, longer duration of infection, BMI, alcohol consumption, and diabetes. In multivariate analysis, only BMI and ethnicity were associated with both fibrosis index and presentation with cirrhosis. Patients with higher BMIs, diabetes mellitus, and steatosis had higher degrees of necroinflammation. CONCLUSIONS: Ethnicity and BMI each were associated with the progression of fibrosis and the presence of cirrhosis. Hispanics had the highest fibrosis index and prevalence of cirrhosis, whereas African Americans had the lowest. Ethnic differences in fibrosis index and cirrhosis persisted after controlling for elements of metabolic syndrome.

Indications for liver transplantation.

Patients should be considered for liver transplantation if they have evidence of fulminant hepatic failure, a life-threatening systemic complication of liver disease, or a liver-based metabolic defect or, more commonly, cirrhosis with complications such as hepatic encephalopathy, ascites, hepatocellular carcinoma, hepatorenal syndrome, or bleeding caused by portal hypertension. While the complications of cirrhosis can often be managed relatively effectively, they indicate a change in the natural history of the disease that should lead to consideration of liver transplantation. Referral to a liver transplant center is followed by a detailed medical evaluation to ensure that transplantation is technically feasible, medically appropriate, and in the best interest of both the patient and society. Patients approved for transplantation are placed on a national transplant list, although donor organs are allocated locally and regionally. Since 2002, priority for transplantation has been determined by the Model of End-Stage Liver Disease (MELD) score, which provides donor organs to listed patients with the highest estimated short-term mortality.

Laboratory diagnosis and nonoperative management of biliary complications in living donor liver transplant patients.

BACKGROUND: Biliary complications associated with living donor liver transplantation (LDLT) remain a major problem. Information regarding biochemical abnormalities helpful for the diagnosis and the nonoperative management of such complications are limited. METHODS: Adult patients who underwent LDLT were retrospectively studied for biliary complications. Clinical findings and laboratory studies, that is, serum bilirubin, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase were evaluated. Diagnostic percutaneous transhepatic cholangiogram or endoscopic retrograde cholangiogram followed by therapeutic interventions such as endoscopic sphincterotomy, stone extraction, balloon dilation, or stent placement were done as indicated. Follow-up data on clinical and biochemical outcomes were assessed. RESULTS: Among the first 29 patients who underwent LDLT, 7 patients (24%) developed biliary complications. Nonoperative treatment was undertaken through endoscopic retrograde cholangiogram in 4 cases, percutaneous transhepatic cholangiogram in 3 cases with a successful clinical outcome in 6 cases (84%). All patients with biliary stricture had a bilirubin level >1.5 mg/dL with 100% sensitivity. CONCLUSIONS: A number of patients developed biliary complications after LDLT. Nonoperative treatments were successful in most patients. Elevated serum bilirubin level may be helpful in the diagnosis of biliary stricture complicating LDLT.

The prevalence of hepatitis C virus infection in Texas: implications for future health care.

Chronic hepatitis C is often asymptomatic and undiagnosed yet can progress to liver failure or hepatocellular carcinoma. This study determined the prevalence of hepatitis C in Texas and estimated the progression of disease in this cohort. National Health and Nutrition Evaluation Survey III data on the national prevalence of an antibody to the hepatitis C virus were extrapolated to Texas using census data weighted for local characteristics. A Markov model estimated the progression of liver disease. Results showed that 387,395 Texans (1.79%) are infected with the hepatitis C virus. County prevalence varied from 1.25% to 2.63%, with higher rates concentrated along the US-Mexico border. However, most cases of infection were located near major Texas cities. The number of infected persons will decline in the future. However, the proportion of cases progressing to cirrhosis will increase, resulting in more complications such as liver failure and hepatocellular carcinoma. Thus, chronic hepatitis C is common in Texas and will result in an increase in complications of cirrhosis in coming years. The disease will tax health care facilities and transplant units in the state.

Forkhead box M1B transcriptional activity requires binding of Cdk-cyclin complexes for phosphorylation-dependent recruitment of p300/CBP coactivators.

Previous liver regeneration studies demonstrated that the mouse forkhead box M1B (FoxM1B) transcription factor regulates hepatocyte proliferation through expression of cell cycle genes that stimulate cyclin-dependent kinase 2 (Cdk2) and Cdk1 activity. In this study, we demonstrated that disruption of the FoxM1B Cdk1/2 phosphorylation site at Thr residue 596 significantly reduced both FoxM1B transcriptional activity and Cdk phosphorylation of the FoxM1B T596A mutant protein in vivo. Retention of this FoxM1B 596 Cdk phosphorylation site was found to be essential for recruiting the histone acetyltransferase CREB binding protein (CBP) to the FoxM1B transcriptional activation domain. Consistent with these findings, dominant negative Cdk1 protein significantly reduced FoxM1B transcriptional activity and inhibited FoxM1B recruitment of the CBP coactivator protein. Likewise, Cdc25B-mediated stimulation of Cdk activity together with elevated levels of the CBP coactivator protein provided a 6.2-fold synergistic increase in FoxM1B transcriptional activity. Furthermore, mutation of the FoxM1B Leu 641 residue within an LXL motif (residues 639 to 641) inhibited recruitment of Cdk-cyclin complexes and caused significant reduction in both FoxM1B transcriptional activity and in vivo Cdk phosphorylation of the FoxM1B Thr 596 residue. We demonstrated that FoxM1B transcriptional activity requires binding of either S-phase or M-phase Cdk-cyclin complexes to mediate efficient Cdk phosphorylation of the FoxM1B Thr 596 residue, which is essential for recruitment of p300/CBP coactivator proteins.

Rapid hepatocyte nuclear translocation of the Forkhead Box M1B (FoxM1B) transcription factor caused a transient increase in size of regenerating transgenic hepatocytes.

The Forkhead Box (Fox) proteins are an extensive family of transcription factors that shares homology in the winged helix DNA binding domain. Liver regeneration studies with the -3 kb transthyretin (TTR) promoter-driven FoxM1B transgenic (TG) mice demonstrated that premature hepatocyte nuclear localization of the FoxM1B transgene protein at 16 h following partial hepatectomy (PHx) caused an 8-h acceleration in the onset of hepatocyte DNA replication (S-phase) and mitosis by stimulating earlier expression of cell cycle genes. Whether the FoxM1B transgene protein participates in immediate early events during liver regeneration remains to be determined. Here, we found that the FoxM1B transgene protein translocated to hepatocyte nuclei immediately following PHx, that its nuclear staining persisted for the first 6 h after surgery, and that this translocation was associated with an increase in size of regenerating TG hepatocytes. However, regenerating TTR-FoxM1B liver did not exhibit altered expression of proteins that have been implicated in mediating increased cell size, including serum-and-gucocorticoid-inducible protein kinase (SGK), protein kinase-B/Akt, the tumor suppresser gene PTEN (negative regulator of the PI3K/Akt pathway), c-Myc, or peroxisome proliferation. Moreover, we demonstrated that hepatocyte nuclear translocation of the FoxM1B transgene protein was rapidly induced during the hepatic acute phase response, which occurs during the immediate early stages of liver regeneration. Analysis of cDNA expression arrays identified a number of genes such as immediate early transcription factors (ID-3, Stat3, Nur77), matrix metalloproteinase-9 (MMP-9), and several glutathione S-transferase (GST) isoforms and stress response genes, whose expression is elevated in regenerating TTR-FoxM1B TG livers compared with regenerating wild-type (WT) liver. These liver regeneration studies demonstrate that hepatocyte nuclear translocation of the FoxM1B transgene protein was sustained for the first 6 h after PHx, and was associated with transient hypertrophy of regenerating TG hepatocytes and increased expression of genes that may enhance hepatocyte proliferation.