Alkaline phosphatase is independently associated with renal function in normoalbuminuric type 1 diabetic patients.

Nonalcoholic fatty liver disease (NAFLD) is associated with an increased prevalence of chronic kidney disease in patients with type 1 diabetes. The aim of this study was to explore the relationship between markers of NAFLD, namely concentrations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALK), γ-glutamyltransferase (GGT), bilirubin, and renal function in type 1 diabetic patients. This study included 313 normoalbuminuric type 1 diabetic patients with estimated glomerular filtration rate (eGFR) >60 mL/min/1.73 m(2), without clinical evidence of cirrhosis or other causes of chronic liver disease and before any interventions with statins, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers. ALT, GGT, and bilirubin levels were significantly higher in subjects in the highest quartile of serum creatinine compared to those in lowest quartile (21 vs. 20 U/L, 18 vs. 14 U/L, and 14 vs. 10 µmol/L, respectively, for all p < 0.05). ALK levels were significantly higher in subjects in the highest quartile of urinary albumin excretion rate compared to those in lowest quartile (71 vs. 69 U/L, p = 0.03), as well as in hyperfiltrating subjects compared to those with normal or mildly impaired eGFR (81 vs. 68 and 64 U/L, p < 0.001). In a multiple logistic regression model adjusted for age, sex, duration of diabetes, HbA1c, and body mass index (BMI), only ALK levels were significantly associated with disturbances in serum creatinine and eGFR in our subjects (p ≤ 0.007), with odds ratios of 0.98-1.02. NAFLD associated markers, particularly ALK, are associated with renal function in normoalbuminuric type 1 diabetic patients.

[Croatian guidelines for diagnostics and treatments of Helicobacter pylori infection]. / Hrvatski postupnik za dijagnostiku i terapiju infekcije Helicobacterom pylori.

In the past 30-year period of investigations, the crucial role of Helicobacter pylori in chronic gastritis, gastric and duodenal ulcer development, and subsequently in gastric cancer and MALT lymphoma pathogenesis, has been recognized. During the first meeting of European Helicobacter Study Group in 1996 in Maastricht, the first recommendations for diagnostics and treatments of Helicobacter pylori infection were published, later reviewed in 2000, 2007 and 2010. The first meeting of Croatian doctors focusing on the same topics, but suitable to specific national circumstances, was held as early as 1998. The need for updating the old guidelines has emerged during the last years. The working expert group of gastroenterologists was formed and gathered on Consesus Conference in December 2012 in Zagreb, to arrive to current guidelines for the clinical management of Helicobacter pylori infection in Croatia. The following topics relating to Helicobacter pylori infection were examined: 1. indications and contraindications for diagnostics and treatments; 2. diagnostic methods and 3. treatments applicable in our country.

[Treatment guidelines for patients with genotype 1 chronic hepatitis C infection]. / Preporuke za lijecenje bolesnika s kronicnim hepatitisom C genotipa 1.

Dual therapy based on the combination of pegylated interferon-alpha 2a or 2b (PEG IFN-alpha2) and ribavirin has been considered standard-of-care treatment for chronic hepatitis C genotype 1 up to 2011. The first generation of protease inhibitors, boceprevir and telaprevir, have been approved for clinical use in Europe and USA since 2011. Therefore, national guidelines for the treatment of chronic hepatitis C genotype 1 have been updated to include new and more efficient therapeutic options. Croatian guidelines are based on the results of registration clinical trials for boceprevir and telaprevir, national guidelines of several EU countries (United Kingdom, Sweden, Germany, France and Italy), EASL and AASLD recommendations, as well as on the results of chronic hepatitis C genotype 1 treatment with dual therapy at the national level. The Croatian guidelines include recommendations for treatment-naïve and treatment-experienced patients (based on the type of virologic response to the first-line treatment). In treatment-naïve patients with mild fibrosis and favorable predictors of treatment outcome, dual therapy is the recommended treatment option. In treatment-naïve patients with advanced fibrosis (F3 and F4) as well as in patients with moderate fibrosis (F2) and unfavorable predictors of treatment outcome (age > 40 years, non-CC IL-28B genotype, non-RVR), triple therapy is recommended. Triple therapy is also recommended for relapsers (irrespective of fibrosis stage) and partial responders with advanced fibrosis (F3 and F4). Lead-in treatment strategy during triple therapy is recommended for null-responders.

[Classical medications in the treatment of inflammatory bowel diseases]. / Klasicni lijekovi koji se upotrebljavaju u lijecenju upalnih bolesti crijeva.

The treatment of inflammatory bowel diseases is complex and requires individual approach to every single patient. Traditionally, the approach is based on introduction of so called "classical" medication into the treatment regimen, from ones less potent and with fewer side effects to the ones more toxic but also therapeutically more effective. Aminosalicylates were the first choice of treatment for a long time. However, the role of aminosalicylates is becoming more and more diminished, although they are still the drug of choice in the treatment of mild to moderate ulcerative colitis. Corticosteroids are the therapy of choice in treatment of active IBD for achieving remission in moderate to severe disease. Azathioprine and 6- mercaptopurine belong to a group of thiopurines with an immunomodulatory effect which, in Crohn's disease as well as in ulcerative colitis, primarily have a role in a steroid dependant or steroid refractory type of disease and in maintenance of remission. Lately, early introduction of these medications is proposed to enhance the number of patients that remain in remission. Methotrexate is used for the therapy of active and relapsing Crohn's disease and represents an alternative in patients who do not tolerate or do not respond to azathioprine or 6-mercaptopurine therapy. Cyclosporine is used in treating steroid refractory ulcerative colitis and in some patients can postpone the need for colectomy. Antibiotics do not have a proven effect on the course of inflammatory bowel diseases and their primary role is to treat septic complications. Classic medications today represent a standard in the management of inflammatory bowel diseases, and the combination of the previously mentioned drugs often has a more potent effect on the course of the disease than any medication on its own and their combination is still an object of investigations and clinical studies.

[Croatian consensus on the treatment of inflammatory bowel diseases with biologic therapy]. / Hrvatski konsenzus o lijecenju upalnih bolesti crijeva bioloskom terapijom.

Introduction of biologic therapy in clinical practice represented significant progress in the treatment of inflammatory bowel diseases (IBD) because of its proven efficacy and due to the fact that biologics are the first drugs used in the treatment of IBD that can change the natural course of this diseases. At the same time, biologics are very expensive drugs with complex mechanism of action and important side effects and their use requires evidence-based clinical guidelines. These were the reasons that Referral Center of the Croatian Ministry of Health for IBD and the IBD Section of the Croatian Society of Gastroenterology organised Croatian consensus conference that defined guidelines for the treatment of IBD with anti-TNF drugs. The text below includes definitions of IBD, general principles of IBD therapy, comments on the importance of mucosal healing, analysis of reasons for nonresponse and loss of response to anti-TNF drugs, recommendation for the duration of anti-TNF therapy, rules of screening for opportunistic infections prior to anti-TNF therapy, comments on the problems with reproduction in IBD and finally guidelines for the treatment of various phenotypes of IBD including extraintestinal manifestations with anti-TNF therapy.

[Viralhepatitis. Croatian Consensus Statement 2013]. / Virusni hepatitis. Hrvatska konsenzus konferencija 2013.

Croatian Consensus Conferences on Viral Hepatitis took place in 2005 and 2009. Considering the numerous novel concepts on the epidemiology, diagnosis and management of viral hepatitis (chronic hepatitis C genotype 1 in particular) that have emerged in the past four years, a new Croatian Consensus Conference on Viral Hepatitis was held in Zagreb on February 28, 2013. The abridged text of the Croatian Consensus Conference on Viral Hepatitis 2013 presents the new concepts on the epidemiology of viral hepatitis, serologic and molecular diagnosis of viral hepatitis, determination of the IL-28 gene promoter polymorphism, fibrosis grading, algorithm for patient diagnostic follow up, treatment of chronic hepatitis C (genotypes 1-6) and hepatitis B, treatment of special populations (children, dialysis patients, transplanted patients, individuals with HIV/HCV co-infection), and therapy side effects.

Acid inhibition and the acid rebound effect.

Acid secretion from gastric parietal cells is a result of a complex interaction between different stimulatory and inhibitory mediators. One of the most important mediators is gastrin, which stimulates gastric acid secretion from parietal cells mostly indirectly, by the release of histamine from enterochromaffin-like (ECL) cells. Therapy with antisecretory agents leads to hypergastrinemia, mucosal hyperplasia and increased ECL cell mass, which results in increase of gastric acid secretion capacity. This increased secretion capacity has been shown to manifest itself after antisecretory therapy withdrawal as rebound acid hypersecretion (RAH). Various studies have quantified acid hypersecretion after the cessation of therapy with H(2) antagonists and proton-pump inhibitors (PPIs). While most of those studies had small patient numbers, the findings generally demonstrate that RAH after H(2) antagonist therapy is of low magnitude, short duration, and has questionable clinical significance. On the contrary, acid hypersecretion after PPI therapy is more pronounced, lasts longer, and could possibly be the cause of acid-related symptoms. Potential for causing symptoms has recently been confirmed in two randomized placebo-controlled studies, and while we witness the increasing use of PPIs, RAH could become a proven cause of failure to withdraw therapy in a proportion of patients with reflux or dyspeptic symptoms.

Nonalcoholic fatty liver disease markers are associated with insulin resistance in type 1 diabetes.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) has been associated with the insulin resistance. AIMS: To explore the relationship between markers of NAFLD, namely concentrations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALK), γ-glutamyltransferase (GGT), ferritin and bilirubin and insulin resistance in type 1 diabetes. METHODS: Our study included 353 patients with type 1 diabetes. Insulin sensitivity was measured with estimated glucose disposal rate calculated using the equation: eGDR = 24.31 - (12.22 × WHR) - (3.29 × HT) - (0.57 × HbA1c); WHR = waist to hip ratio, HT = hypertension. Correlations and multiple logistic regressions analysis were performed to identify the relationships between NAFLD associated markers and eGDR, individual components of insulin resistance and risk of insulin resistance. RESULTS: AST, ALT, AST-to-ALT ratio, ALK and ferritin significantly correlated with insulin resistance measured by eGDR (r = -0.13, -0.14, 0.13, -0.18, and -0.24, respectively; all P < 0.05), and with individual components of insulin resistance, most notably WHR. In a multiple logistic regression model adjusted according to age, sex, duration of diabetes and BMI, increased levels of AST, ALT and ALK resulted in an increased risk for the development of insulin resistance in our subjects (OR = 1.03, 1.02, and 1.01, respectively; all P < 0.05). CONCLUSIONS: These findings indicate that higher levels of ALT, AST and ALK are additional markers of insulin resistance in type 1 diabetes and suggest that those subjects must be considered as potentially affected not only by a hepatic but also by a multisystemic disease through altered insulin sensitivity.

New Drugs on the Block-Emerging Treatments for Nonalcoholic Steatohepatitis.

Patients with nonalcoholic steatohepatitis (NASH) are at higher risk of progression to advanced stages of fibrosis, cirrhosis, hepatocellular carcinoma and other end-stage liver disease complications. When addressing treatment of NASH, we have limited approved options, and the mainstay of therapy is lifestyle intervention. Extensive research and revelation in the field of pathogenesis of NASH has offered new possibilities of treatment and emerging new drugs that are being tested currently in numerous preclinical and clinical trials. These drugs target almost all steps in the pathogenesis of NASH to improve insulin sensitivity, glucose and lipid metabolism, to inhibit de novo lipogenesis and delivery of lipids to the liver, and to influence apoptosis, inflammation and fibrogenesis. Although NASH is a multifactorial disease, in the future we could identify the predominating pathological mechanism and, by choosing the most appropriate specific medication, tailor the treatment for every patient individually.

Expression of adipokine ghrelin and ghrelin receptor in human colorectal adenoma and correlation with the grade of dysplasia.

BACKGROUND: Ghrelin is an adipokine that plays an important role in energy balance. Expression of ghrelin and ghrelin receptor has been investigated in different tissues and tumors. Studies regarding expression of ghrelin and ghrelin receptor in colorectal tumors are scarce and no data on expression of ghrelin and its receptor in colorectal adenomas has been published. Ghrelin and ghrelin receptor were highly expressed in colon carcinoma cells while expression was decreased in less differentiated tumors, presuming that ghrelin might be important in early phases of tumorigenesis. AIM: To investigate the expression of ghrelin and ghrelin receptor in human colorectal adenomas and adjacent colorectal tissue. METHODS: In this prospective study (conducted from June 2015 until May 2019) we included 92 patients (64 male and 28 female) who underwent polypectomy for colorectal adenomas in the Department of Gastroenterology and Hepatology, "Sestre milosrdnice" Clinical Hospital Center in Zagreb, Croatia. After endoscopic removal of colorectal adenoma, an additional sample of colon mucosa in the proximity of the adenoma was collected for pathohistological analysis. Adenomas were graded according to the stage of dysplasia, and ghrelin and ghrelin receptor expression were determined immunohistochemically in both adenoma and adjacent colon tissue using the polyclonal antibody for ghrelin (ab150514, ABCAM Inc, Cambridge, United States) and ghrelin receptor (ab48285, ABCAM Inc, Cambridge, United States). Categorical and nominal variables were described through frequencies and proportions and the difference between specific groups were analyzed with Fisher's and Fisher-Freeman-Halton's method respectively. Spearman's rank correlation coefficient was determined for correlation of expression of ghrelin and ghrelin receptor in adenoma and adjacent colon tissue with the grade of adenoma dysplasia. RESULTS: Among 92 patients with colorectal adenoma 43 had adenomas with high-grade dysplasia (46.7%). High expression of ghrelin was 7 times more common in high-grade adenoma compared to low-grade adenomas (13.95% to 2.04%, P = 0.048), while the expression of ghrelin in adjacent colon tissue was low. We found no correlation between ghrelin receptor expression in adenoma and adjacent colon tissue and the grade of colorectal adenoma dysplasia. The most significant correlation was found between ghrelin and ghrelin receptor expression in adenomas with high-grade dysplasia (rho = 0.519, P < 0.001). CONCLUSION: Ghrelin and ghrelin receptor are expressed in colorectal adenoma and adjacent tissue with ghrelin expression being more pronounced in high grade dysplasia as a possible consequence of increased local synthesis.

The role of endoscopic ultrasound in evaluation of gastric subepithelial lesions.

A subepithelial mass is a common finding during endoscopic procedures. Endoscopic ultrasound (EUS) is an important diagnostic modality in the evaluation of subepithelial lesions of the gastrointestinal tract. EUS is the diagnostic test of choice to assess the size, margins, the layer of origin, echotexture, and to differentiate between an intramural and extramural lesion. However, the EUS imaging lacks the specificity. EUS-guided fine needle aspiration (EUS-FNA) or core biopsy can help establish a tissue diagnosis and potentially characterize malignant risk. The aim of this article is to review the diagnosis and management of the most common subepithelial gastric lesions with an emphasis on the role of endoscopic ultrasound.

[Treatment of naive patients with chronic hepatitis C]. / Lijecenje kronicnog hepatitisa C u nelijecenih (naivnih) bolesnika.

According to published data, 60% of hepatitis C virus (HCV)-infected patients in Croatia have HCV genotype 1. The second most common genotype is 3a (36%). Standard treatment regimen for patients with chronic hepatitis C is a combination of pegylated interferon alfa (2a or 2b) with ribavirin, in duration guided by genotype: patients with genotype 1 are treated for 48 weeks and patients with genotypes 2 and 3 for 24 weeks in order to achieve virus elimination defined as HCV RNA undetectability 24 weeks after the treatment period (SVR). These treatment regimens fail to achieve SVR in 50% of patients with genotype 1 and 25% of patients with genotype 3. On the other hand, patients with low viral load (<600 000 IU HCV RNA/mL) and rapid viral response (RVR) could benefit from shortened treatment. Recent studies and meta-analyses have shown the importance of liver fibrosis, viral kinetics and viremia as predictors of SVR. Currently, treatment of chronic hepatitis C should be individualized (treatment guided) according to the genotype, liver fibrosis, early viral kinetics and viremia. In patients with genotype 1 who are late responders (pEVR), therapy should be prolonged to 72 weeks in order to achieve 12% better SVR. In patients with genotype 2,3 with low viremia who are rapid responders (RVR+), therapy can be shortened to 16 weeks. Patients with higher fibrosis rates (presence of fibrotic septa) should not be treated according to the level of viremia, as it has been shown that viremia does not correlate with SVR in these patients. Liver biopsy is still recommended in the pretreatment evaluation protocol for its prognostic features. In patients with acute hepatitis C, treatment should be started if HCV RNA is still present at week 12. The suggested treatment regimen is monotherapy with pegylated interferon alfa (2a or 2b) for 24 weeks.

[Ultrasonography in the diagnosis of nonalcoholic fatty liver disease]. / Ultrazvuk u dijagnostici nealkoholne masne bolesti jetre.

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in Western countries. Although no specific studies have been performed, the estimated prevalence of NAFLD in Croatia correlates with the prevalence in other countries, ranging from 20% to 40%. It encompasses a histological spectrum that ranges from simple steatosis to steatohepatitis, which can progress to cirrhosis in up to 20% of patients. Unfortunately, accurate noninvasive modalities for diagnosing nonalcoholic steatohepatitis (NASH) and monitoring disease progression or regression are unavailable. Therefore, liver biopsy remains the gold standard in diagnosing NASH but it is also associated with risks and possible sampling errors. Since liver biopsy cannot be performed as a screening method to detect NAFLD in general population, abdominal ultrasonography as a noninvasive modality has been widely used. Although sonographic characteristics of NAFLD were first described 20 years ago, larger studies have been conducted over the past few years as a result of the rising interest in NAFLD among investigators. The aim of these studies was to simplify the diagnosis of NASH. Abdominal ultrasonography has been shown to have a sensitivity of 60%-94% and specificity of 84%-95% for detecting fatty liver and it is used as a screening method in patients with incidental elevation of liver enzymes. Ultrasonographic scoring system developed by Hamaguchi et al. included hepatorenal echo contrast, liver brightness, deep attenuation, and vascular blurring. Score > or = 2 corresponded to NAFLD with a high, 92% sensitivity and 100% specificity, and a high level of intraobserver reliability.The inability to distinguish different forms of NAFLD and staging hepatic fibrosis limits the use of ultrasonography as a stand alone modality for detecting NAFLD. In the future, serum markers together with advancements in imaging modalities may potentially diminish or obviate the need of liver biopsy.

[Endoscopic ultrasonography in the diagnosis of choledocholithiasis]. / Znacenje endoskopskog ultrazvuka u dijagnostici koledokolitijaze.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) has been considered a gold standard in the diagnosis of choledocholithiasis; however, the incidence of complications is high. In literature reports, the morbidity rate ranges from 5% to 19% and mortality rate from 0.1% to 1.3%, therefore an effective but less invasive new method of diagnosing choledocholithiasis is required. In a number of trials, endoscopic ultrasonography (EUS) has been shown to be a less invasive method with excellent sensitivity of 94% and specificity of 95%. The aim of this study was to estimate the sensitivity and specificity of EUS in patients with suspected choledocholithiasis and to establish its role in the algorithm for diagnosing choledocholithiasis. PATIENTS AND METHODS: Patient files were retrospectively reviewed in 209 patients with a clinical picture and ultrasonography findings suggestive of choledocholithiasis, admitted to Sestre milosrdnice University Hospital during a six-month period (Sep 1, 2007 - Feb 29, 2008) and submitted to ERCP within 72 hours of admission. RESULTS: In 125 patients with abdominal ultrasonography findings suggestive of choledocholithiasis (biliary obstruction without clear evidence of calculi), EUS was performed before ERCR. Choledocholithiasis or biliary sludge was identified in 66 (62.3%) patients, 29 (27.3%) patients were free from biliary abnormalities, and 11 (10.4%) patients had stenosis of different etiology. In 64 of 66 (96.9%) patients, the diagnosis was confirmed by ERCP. Another two (3.1%) patients had no evidence of choledocholithiasis on ERCP. There were no complications related to EUS. CONCLUSIONS: EUS is an effective method for diagnosing choledocholithiasis with a sensitivity and specificity comparable to ERCP. Therefore, it is reasonable to use EUS as the first method of choice in patients with suspected choledocholithiasis.

[Evaluation of upper gastrointestinal submucosal lesions by endoscopic ultrasonography]. / Karakterizacija subepitelnih lezija gornjeg dijela gastrointestinalnog sustava endoskopskim ultrazvukom.

Endoscopy is an established method for diagnosing gastrointestinal tract diseases, however, suspected subepithelial lesions usually cannot be appropriately evaluated by this technique alone. The prevalence of suspected submucosal gastric lesions at routine endoscopy has been estimated to 0.5%-1%. In this review, we evaluated the role of endoscopic ultrasonography (EUS) in the diagnosis of and management strategy for submucosal lesions. EUS has emerged as the most reliable investigative procedure of choice for evaluating submucosal tumors. EUS is the method of choice to differentiate between true intramural tumors and lesions caused by extraluminal compressions due to normal or pathologic structures. It can determine the originating layer(s) of intramural lesions; can differentiate echogenicity (anechoic, hypoechoic, hyperechoic, isoechoic), vascularity, size, shape, and border characteristics. Some endoscopic findings (color, consistency, mobility, 'pillow sign') can be helpful in narrowing the differential diagnosis. On the other hand, determination of the histologic layer and the internal echo patterns of some submucosal tumors are also predictive of benign or malignant tumors. EUS can provide an accurate diagnosis in 80% of patients with benign lesions and 64% of those with malignant lesions. Hypoechoic lesions in the 3rd and 4th layer are most prone to misclassification. If these cannot be differentiated exactly, EUS can serve as a guide on fine needle aspiration (FNA) biopsy or histologic core biopsies, providing samples for cytologic or histologic analysis. After that, the endoscopist can decide whether the lesion should be periodically followed up, or removed by endoscopy, endoscopic submucosal resection (EMR) or surgery.

[The role of endoscopic ultrasonography in the evaluation of pancreatic cancer]. / Uloga endoskopskog ultrazvuka u evaluaciji karcinoma gusterace.

Pancreatic cancer has a dismal prognosis and complete surgical removal remains the only potential curative treatment. The principle goal of preoperative evaluation is to identify patients with potentially resectable disease while avoiding surgical exploration in those with unresectable disease. There is no evidence-based consensus on the optimal preoperative imaging assessment of patients with suspected pancreatic cancer. Because of its widespread availability, computed tomography (CT) is usually the initial study for this indication, although endoscopic ultrasonography (EUS) is the most sensitive imaging modality for the detection of pancreatic masses. Due to anatomical limitations, CT and magnetic resonance (MR) are superior to EUS for detection of metastatic disease. EUS is superior to CT and angiography for detection of tumor invasion of the portal vein or confluence. Most studies found no significant differences between EUS, CT and MRI in determination of pancreatic cancer resectability. The optimal place of EUS within the diagnostic algorithm remains dependent on local referral modalities and availability.

[Viral hepatitis. Croatian consensus conference--2009]. / Virusni hepatitis. Hrvatska konsenzus konferencija 2009.

Summarized text of Croatian Consensus Conference on Viral Hepatitis of 2009 comprises the following chapters: 1) Epidemiology, 2) Clinical Picture, 3) Diagnostic Procedure, 4) Aims of Treatment of Viral Hepatitis, 5) Terminology, 6) Medicaments (6.1. Interferon, 6.2. Analogues of Nucleozides and Nucleotides), 7) Hepatitis B (7.1. Serologic and Molecular HBV Diagnostics, 7.2. Terminology, 7.3.Whom to Treat? 7.4. Therapy), 8) Hepatitis C (8.1. Serologic and Molecular HCV Diagnostics, 8.2. Terminology, 8.3. Whom to Treat? 8.4. Therapy). Clinical, laboratory and histologic assessment of patients with chronic viral hepatitis (algorythm of pretherapeutic treatment; histologic evaluation) and notions related to therapy of viral hepatitis (category of the patient and category of the response to treatment) are presented in related tables.

Human uridine-cytidine kinase phosphorylation of ribavirin: a convenient method for activation of ribavirin for conjugation to proteins.

Ribavirin is a synthetic nucleoside analog that is used for the treatment of hepatitis C virus (HCV) infection. Its primary toxicity is hemolytic anemia, which sometimes necessitates dose reduction or discontinuation of therapy. Selective delivery of ribavirin into liver cells would be desirable to enhance its antiviral activity and avoid systemic side effects. One approach to liver-specific targeting is conjugation of the ribavirin with asialoglycoprotein that is taken up specifically by liver cells. Human uridine-cytidine kinase-1 (UCK-1) was used for ribavirin phosphorylation to its monophosphate form. 1-Ethyl-3-diisopropylaminocarbodiimide (EDC) was used as a coupling agent. The best results were obtained using direct conjugation protocol with a molar ratio of 6.5 ribavirin monophosphate (RMP) molecules per one asialoorosomucoid (AsOR) molecule. Our findings show that ribavirin is a potential substrate of UCK-1, and RMP formed could be chemically coupled to AsOR to form a conjugate for liver specific targeting.

Diagnostic specificity and sensitivity of PIVKAII, GP3, CSTB, SCCA1 and HGF for the diagnosis of hepatocellular carcinoma in patients with alcoholic liver cirrhosis.

Introduction Despite some new treatment possibilities, the improvement in survival rate for hepatocellular carcinoma (HCC) patients is still poor due to late diagnosis. The aim of this study was to investigate the diagnostic sensitivity and specificity of protein induced by vitamin K absence or antagonist-II (PIVKAII), Glypican-3 (GP3), Cystatin B (CSTB), squamous cell carcinoma antigen 1 (SCCA1) and hepatocyte growth factor (HGF) as potential tumour markers for HCC in patients with alcoholic liver cirrhosis (ALC) using imaging techniques (MSCT and MRI) as reference standards. Patients and methods Eighty-three participants were included: 20 healthy volunteers, 31 patients with ALC and 32 patients with HCC. Peripheral blood sampling was performed for each participant, and serum concentrations of PIVKAII, GP3, CSTB, SCCA1 and HGF were determined using commercial ELISA kits. Results Only serum concentrations of PIVKAII were significantly higher in HCC patients as compared with ALC and healthy controls (cut-off: 2.06 µg/L; AUC: 0.903), whereas individual diagnostic performance of other individual compounds was inadequate. The 'best' combination of tumour markers in our study includes all tested markers with AUC of 0.967. Conclusion While novel diagnostic tumour markers are urgently needed, the examined potential tumour markers, with the exception of PIVKAII seem to be inadequate for diagnosing HCC in ALC. Furthermore, probably the future is in finding the best optimal combination of tumour markers for diagnosing HCC based on cost-effectiveness.

Pathogenesis and management issues for non-alcoholic fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) has, although it is a very common disorder, only relatively recently gained broader interest among physicians and scientists. Fatty liver has been documented in up to 10 to 15 percent of normal individuals and 70 to 80 percent of obese individuals. Although the pathophysiology of NAFLD is still subject to intensive research, several players and mechanisms have been suggested based on the substantial evidence. Excessive hepatocyte triglyceride accumulation resulting from insulin resistance is the first step in the proposed 'two hit' model of the pathogenesis of NAFLD. Oxidative stress resulting from mitochondrial fatty acids oxidation, NF-kappaB-dependent inflammatory cytokine expression and adipocytokines are all considered to be the potential factors causing second hits which lead to hepatocyte injury, inflammation and fibrosis. Although it was initially believed that NAFLD is a completely benign disorder, histologic follow-up studies have showed that fibrosis progression occurs in about a third of patients. A small number of patients with NAFLD eventually ends up with end-stage liver disease and even hepatocellular carcinoma. Although liver biopsy is currently the only way to confirm the NAFLD diagnosis and distinguish between fatty liver alone and NASH, no guidelines or firm recommendations can still be made as for when and in whom it is necessary. Increased physical activity, gradual weight reduction and in selected cases bariatric surgery remain the mainstay of NAFLD therapy. Studies with pharmacologic agents are showing promising results, but available data are still insufficient to make specific recommendations; their use therefore remains highly individual.