Two Cases with Isolated Splenic Sarcoidosis Diagnosed by an Ultrasound-guided Fine-needle Aspiration Biopsy.

Asymptomatic splenic nodules were detected incidentally in two middle-aged women at an annual checkup. They showed no abnormalities on laboratory tests, but imaging studies revealed splenic nodules. No other localized lesions were found. Splenic nodules were hypoechoic on ultrasonography (US), hypovascular on contrast-enhanced computed tomography, and showed a low intensity on T2-weighted magnetic resonance imaging. We performed US-guided percutaneous aspiration biopsies using 21-gauge needles without complications, including bleeding. Pathological specimens showed noncaseating granulomas, so both patients were diagnosed with isolated splenic sarcoidosis. A US-guided fine-needle aspiration biopsy is a safe and useful method for diagnosing splenic nodules.

Impact of Interferon-Free Direct-Acting Antivirals on the Incidence of Extrahepatic Malignancies in Patients with Chronic Hepatitis C.

BACKGROUND: The incidence of extrahepatic malignancies (EHMs) after hepatitis C virus (HCV) eradication by interferon (IFN)-based and IFN-free direct-acting antivirals (DAAs) treatment remains unclear. AIMS: The aim was to evaluate the cumulative incidence of EHMs diagnosed for the first time after the antiviral treatments. METHODS: We analyzed a total 527 patients with chronic HCV infection and without prior history of any malignancies who achieved sustained virological response by antiviral treatments, including IFN-based (n = 242) or IFN-free DAAs (n = 285). The baseline predictors for EHM occurrence were analyzed using Cox regression analysis. RESULTS: Thirty-two patients were diagnosed with EHMs, 14 in IFN-based and 18 in IFN-free DAAs, respectively. The total duration of follow-up was 1,796 person-years in IFN-based and 823 person-years in IFN-free DAAs. The incidence of EHMs in IFN-based and IFN-free DAAs was 7.8 and 21.9 per 1,000 person-years, respectively. The cumulative incidence of EHMs was significantly higher in IFN-free DAAs than IFN-based (p = 0.002). IFN-free DAAs was a single independent predictor for incidence of EHMs (p = 0.012). As for gender, the incidence of EHMs was significantly higher in IFN-free DAAs only in the female cohort (p = 0.002). After propensity score matching, IFN-free DAAs was a single independent predictor for incidence of EHMs in the female patients (p = 0.045). CONCLUSIONS: The incidence of EHMs after HCV eradication is higher in IFN-free DAAs than IFN-based regimens, especially in female patients. We should carefully follow-up not only HCC but also EHMs after IFN-free DAAs regimens.

Hepatic Cyst Infection Following Recurrent Biliary Obstruction in Polycystic Liver Disease.

An 89-year-old man with polycystic liver disease (PCLD) received uncovered self-expandable metallic stent (SEMS) placement above the papilla for malignant biliary obstruction caused by cholangiocarcinoma. He developed cholangitis ten months later due to SEMS occlusion caused by tumor ingrowth, and 2 plastic biliary stents were placed inside the SEMS across the papilla. Fever and right costal pain appeared two weeks after reintervention. Suspecting hepatic cyst infection based on imaging studies, percutaneous transhepatic cyst drainage was performed. Increased inflammatory cells and the presence of pathogens in the cyst fluid led to a definitive diagnosis of hepatic cyst infection. Following drainage, the hepatic cyst shrank with resolution of the symptoms. SEMS occlusive-related cholangitis or retrograde infection due to duodenal-biliary reflux after reintervention was considered as the cause of the hepatic cyst infection. Careful clinical and imaging evaluation should be performed in patients with PCLD undergone biliary stenting, because cyst infection may occur following stent occlusion or subsequent biliary reintervention.

Airborne fine particulate matter in Japan induces lipid synthesis and inhibits autophagy in HepG2 cells.

Inhalation of particulate matter with a diameter less than 2.5 µm has been reported to exacerbates fatty liver disease. However, the components and mechanisms of particulate matter involved in hepatic lipid metabolism and autophagy have not been fully elucidated. We found that atmospheric particulate matter in Japan stimulated lipogenesis in hepatocytes even when its lipid component was removed. Furthermore, we demonstrated that particulate matter did not promote autophagosome formation but inhibited autophagic degradation in hepatocytes. In previous toxicity experiments, particulate matter collected from atmosphere often contained contaminants originating from filters. In this study, we exposed the powdery particulate matter with less contaminants collected using a cyclone and impactor system to HepG2 cells, human hepatocyte. This particulate matter induced lipogenesis and endoplasmic reticulum stress in HepG2 cells as well as previous reports of particulate matter in the USA and China. On the other hand, when autophagic flux were examined in detail, the particulate matter did not promote autophagosome formation, but inhibited autophagic degradation. Since these effects were similar to those of palmitate, a fatty acid, we prepared particulate matter in which lipid component was removed by acetone and compared the effects on HepG2 cells with those of untreated one. The particulate matter without lipid component induced lipid droplets as well as did the untreated one although it induced less endoplasmic reticulum stress. These results suggest that hepatic lipid synthesis is stimulated not only by the uptake of lipid but also by other components in the particulate matter.

Early Enteral Nutrition is Related to Decreased In-hospital Mortality and Hospitalization in Patients with Acute Pancreatitis: Data from the Japanese Diagnosis Procedure Combination Database.

Management of early nutrition plays an important role in the treatment of acute pancreatitis patients, but the sample sizes of randomized control trials that have compared enteral and parental nutrition were small. From the data of Diagnostic Procedure Combination, we identified patients who had been diagnosed with acute pancreatitis and discharged from the hospital between 2014 and 2015. We compared the length of hospital stay and hospital mortality among patients with acute pancreatitis that was managed with and without enteral nutrition within 7 days from hospitalization. The results showed a significant decrease in the in-hospital mortality rate of 56% (odds ratio 0.444, 95% confidence interval [CI] 0.358 - 0.551, P < 0.001) and length of hospital stay by 8.6 days (95% CI -9.05 - -8.13, P < 0.001) when enteral nutrition was administered within 7 days. According to multivariate analysis, early enteral nutrition was independently associated with in-hospital mortality rate and length of hospitalization. Enteral nutrition is an important management method for the treatment of acute pancreatitis patients.

Association of frailty on treatment outcomes among patients with suspected infection treated at emergency departments.

BACKGROUND: The clinical frailty scale (CFS) score has been validated as a predictor of adverse outcomes in community-dwelling older people. Older people are at a higher risk of sepsis and have a higher mortality rate. However, the association of frailty on outcomes in patients with sepsis has not been completely examined. OBJECTIVE: This study evaluated the association between CFS and outcomes in patients with sepsis. DESIGN: This was a multicenter prospective cohort substudy. SETTINGS AND PARTICIPANTS: The study included 37 emergency departments from across Japan. The patients (age ≥16 years) were included in this study if they had suspected infection at an emergency department during December 2017-February 2018. OUTCOME MEASURE AND ANALYSIS: The primary outcome was 28-day mortality, stratified by the CFS score categories. The secondary outcomes were the duration of hospital stay, number of ICU-free days (ICUFDs) and number of ventilator-free days (VFDs). MAIN RESULTS: A total of 917 patients were included. The median age was 79 years. The CFS score was associated with an increased risk of 28-day mortality and with a higher likelihood of long-term hospital stay and short-term VFDs and ICUFDs. Multivariate logistic regression analysis indicated that the CFS score was a predictor of 28-day mortality [odds ratio (OR), 1.26; 95% confidence interval (CI), 1.11-1.42]. CONCLUSIONS: This study reported that in patients with suspected sepsis in the emergency department, frailty may be associated with poor prognosis and length of hospital stay.

Possible contribution of hepatocyte secretion to the elevation of plasma exosomal arginase-1 in high-fat diet-fed mice.

AIMS: The elevation of arginase in vascular tissues decreases nitric oxide production, which is considered as an early step of atherosclerosis in obesity. Previously, we found that arginase-1, one of arginase isozymes, was elevated in the blood plasma of obese adults. The purpose of this study is to elucidate the mechanism by which obesity increases arginase-1 levels in the blood. MAIN METHODS: C57/BL6J male mice fed a high-fat diet (HFD) for 12 weeks were analyzed for factors related to nitric oxide/arginine metabolism and plasma exosomes. To explore the arginase secretory organs, the protein expression levels were analyzed in several organs. To further investigate the relationship between exosomal arginase-1 in plasma, blood glucose levels and arginase-1 in the liver, HepG2 (the human hepatoma cell line) was analyzed after treatment with high glucose. KEY FINDINGS: The increase in arginase activity in the plasma of HFD-fed mice was positively corelated with blood glucose levels and was accompanied by an increase in exosomal arginase-1 levels. Among the organs that highly express arginase, the liver of HFD-fed mice showed a significant increase in arginase-1. The expression of arginase-1 in exosomes and total lysates of HepG2 cells were increased by high glucose exposure. SIGNIFICANCE: Increased exosomal arginase-1 in plasma contributes to increased plasma arginase activity in obesity. The liver is a candidate organ for the secretion of exosomal arginase-1 into plasma, and the p38 pathway induced by high glucose levels may be involved.

Role of HO-1 against Saturated Fatty Acid-Induced Oxidative Stress in Hepatocytes.

Increased circulating levels of free fatty acids, especially saturated ones, are involved in disease progression in the non-alcoholic fatty liver. Although the mechanism of saturated fatty acid-induced toxicity in the liver is not fully understood, oxidative stress may be deeply involved. We examined the effect of increased palmitic acid, the most common saturated fatty acid in the blood, on the liver of BALB/c mice via tail vein injection with palmitate. After 24 h, among several anti-oxidative stress response genes, only heme oxygenase-1 (HO-1) was significantly upregulated in palmitate-injected mice compared with that in vehicle-injected mice. Elevation of HO-1 mRNA was also observed in the fatty liver of high-fat-diet-fed mice. To further investigate the role of HO-1 on palmitic acid-induced oxidative stress, in vitro experiments were performed to expose palmitate to HepG2 cells. SiRNA-mediated knockdown of HO-1 significantly increased the oxidative stress induced by palmitate, whereas pre-treatment with SnCl2, a well-known HO-1 inducer, significantly decreased it. Moreover, SB203580, a selective p38 inhibitor, reduced HO-1 mRNA expression and increased palmitate-induced oxidative stress in HepG2 cells. These results suggest that the HO-1-mediated anti-oxidative stress compensatory reaction plays an essential role against saturated fatty acid-induced lipotoxicity in the liver.

Correlation of hepatitis C virus-mediated endoplasmic reticulum stress with autophagic flux impairment and hepatocarcinogenesis.

Hepatitis C virus (HCV) infection has been known to use autophagy for its replication. However, the mechanisms by which HCV modulates autophagy remain controversial. We used HCV-Japanese fulminant hepatitis-1-infected Huh7 cells. HCV infection induced the accumulation of autophagosomes. Morphological analyses of monomeric red fluorescent protein (mRFP)-green fluorescent protein (GFP) tandem fluorescent-tagged LC3 transfection showed HCV infection impaired autophagic flux. Autophagosome-lysosome fusion assessed by transfection of mRFP- or GFP-LC3 and immunostaining of lysosomal-associated membrane protein 1 was inhibited by HCV infection. Decrease of HCV-induced endoplasmic reticulum (ER) stress by 4-phenylbutyric acid, a chemical chaperone, improved the HCV-mediated autophagic flux impairment. HCV infection-induced oxidative stress and subsequently DNA damage, but not apoptosis. Furthermore, HCV induced cytoprotective effects against the cellular stress by facilitating the formation of cytoplasmic inclusion bodies as shown by p62 expression and by modulating keratin protein expression and activated nuclear factor erythroid 2-related factor 2. HCV eradication by direct-acting antivirals improved autophagic flux, but DNA damage persisted. In conclusion, HCV-induced ER stress correlates with autophagic flux impairment. Decrease of ER stress is considered to be a promising therapeutic strategy for HCV-related chronic liver diseases. However, we should be aware that the risk of hepatocarcinogenesis remains even after HCV eradication.

Rapid Progression of Liver Fibrosis Induced by Acute Liver Injury Due to Immune-related Adverse Events of Atezolizumab.

A 72-year-old woman with advanced lung cancer had received systemic chemotherapy including atezolizumab. About three months after the initial administration of atezolizumab, her liver enzyme levels increased. The histopathological findings of the initial liver biopsy revealed acute inflammatory infiltrate, predominantly CD3+, CD4+ and CD8+ T lymphocytes, in the hepatic lobules. We diagnosed her with atezolizumab-induced immune-related acute hepatitis. Oral corticosteroid therapy successfully improved the elevation of serum aminotransferases. A sequential liver biopsy demonstrated the rapid progression of liver fibrosis. Because hepatocellular carcinoma occurs most often in advanced cases of chronic liver disease, we should pay close attention to immune-related acute hepatic injury when treating patients with advanced liver diseases using atezolizumab.

Importance of a Liver Biopsy in the Management of Wilson Disease.

A 37-year-old Wilson disease patient treated with D-penicillamine visited our hospital for the evaluation of his liver function. Laboratory data showed a low serum copper level and ceruloplasmin. The ratio of urinary copper to urinary creatinine in a spot urinary analysis after 4 days' cessation of D-penicillamine was under 0.1. We concluded that the copper chelation was excessive and changed D-penicillamine to zinc acetate. However, his liver function test results did not normalize. We performed a liver biopsy and discovered a high copper content. The liver dysfunction was improved after resuming chelating therapy. Accurate measurement of the hepatic copper content via a biopsy is important for the adequate management of this disease.

Involvement of sarco/endoplasmic reticulum calcium ATPase-mediated calcium flux in the protective effect of oleic acid against lipotoxicity in hepatocytes.

Elevated free fatty acids, particularly saturated ones such as palmitic acid, may play an important role in the lipotoxic mechanism of nonalcoholic fatty liver disease (NAFLD). Saturated fatty acids induce autophagy dysfunction and endoplasmic reticulum (ER) stress leading to apoptosis in hepatocytes. However, unsaturated fatty acids, such as oleic acid, are nontoxic and can even prevent saturated fatty acid-induced toxicity in vitro. Although emerging evidence has suggested that ER calcium flux disruption in hepatocytes is involved in NAFLD pathogenesis, the roles of fatty acids in autophagy and ER calcium flux still remain unclear. We demonstrated that oleic acid ameliorated palmitic acid-induced autophagy arrest and ER stress in parallel with ER calcium depletion in hepatocytes. Moreover, we found that the effect of oleic acid against autophagy arrest was reversed by the pharmacological inhibition of sarcoplasmic reticulum Ca2+-ATPase (SERCA), which influxes calcium to ER. These data suggest that SERCA-mediated ER calcium flux is greatly involved in fatty acid-induced lipotoxicity in hepatocytes, and the prevention of ER calcium depletion may restore saturated fatty acid-induced autophagy arrest in hepatocytes.

Zinc Attenuates the Cytotoxicity of Some Stimuli by Reducing Endoplasmic Reticulum Stress in Hepatocytes.

Zinc is an essential trace element and plays critical roles in cellular integrity and biological functions. Excess copper induced both oxidative stress and endoplasmic reticulum (ER) stress in liver-derived cultured cells. Excess copper also induced impairment of autophagic flux at the step of autophagosome-lysosome fusion, as well as Mallory-Denk body (MDB)-like inclusion body formation. Zinc ameliorated excess copper-induced impairment of autophagic flux and MDB-like inclusion body formation via the maintenance of ER homeostasis. Furthermore, zinc also ameliorated free fatty acid-induced impairment of autophagic flux. These results indicate that zinc may be able to protect hepatocytes from various ER stress-related conditions.

Effect of direct-acting antivirals on platelet-associated immunoglobulin G and thrombocytopenia in hepatitis C virus-related chronic liver disease.

BACKGROUND & AIMS: Hepatitis C virus (HCV) infection has been known to cause various extrahepatic autoimmune disorders. The prevalence of platelet-associated immunoglobulin G (PA-IgG) has been high in patients with HCV infection. Because thrombocytopenia in HCV-related liver diseases is a notable problem, we performed prospective study on the effect of direct-acting antivirals (DAAs) treatment on PA-IgG and platelet count. METHODS: A total of 215 patients with HCV-related liver disease were enrolled in this study. The patients who discontinued DAAs or did not undergo adequate laboratory examinations and who did not achieve sustained virologic response were excluded and finally a total of 187 patients were investigated. RESULTS: A total of 171 patients (91.4%) were PA-IgG positive (>46 ng/107 cells) before starting DAAs (baseline). The PA-IgG level elevation was significantly correlated with higher liver inflammation and fibrosis markers (P < 0.05) and lower platelet count (P = 0.000019). The platelet count of the patients with low PA-IgG titer tended to be higher at baseline, end of treatment (EOT), and at 12 and 24 weeks after EOT. The platelet count increased at EOT (P < 0.05) and 24 weeks after EOT (P < 0.01). The PA-IgG levels were significantly decreased at EOT, 12 and 24 weeks after EOT (P < 0.01). Multiple regression analysis found that only platelet count at baseline was closely associated with negative conversion of PA-IgG at 24 weeks after EOT (P = 0.004). CONCLUSIONS: Eradication of HCV by DAAs treatment successfully decreased PA-IgG level and increased platelet count.

A Young Adult Patient with Nonalcoholic Steatohepatitis Developed Severe Gastroesophageal Varices Associated with Severe Obesity and Diabetes Mellitus.

Obesity is a major contributor to insulin resistance and nonalcoholic fatty liver disease, which is the most common cause of chronic liver diseases. Nonalcoholic steatohepatitis (NASH) can progress to liver cirrhosis and end-stage liver diseases. Some cases already show severe liver fibrosis at the time of diagnosis. We present the case of a 44-year-old male with overt obesity who was admitted with hematemesis due to the rupture of gastric varices. We diagnosed him with NASH with severe liver fibrosis. This case shows that we should be concerned about the progression of liver fibrosis due to NASH associated with severe obesity even in young patients.

Treatment of hepatocellular carcinoma with Child-Pugh C cirrhosis.

BACKGROUND: In most guidelines, no other interventional therapy but liver transplantation is recommended for the treatment of hepatocellular carcinoma (HCC) with Child-Pugh C cirrhosis (CP-C). However, in Japan, patients were sometimes treated with expectation of benefit. SUMMARY: A workshop was conducted to explore the state of treatments for CP-C HCC in Japan. After the workshop, a questionnaire on therapies was given to the panelists. Clinical data of 769 patients with CP-C HCC from 8 hospitals as well as analyses of data collected by the Liver Cancer Study Group of Japan (LCSGJ) consisting of 1,344 CP-C HCC cases were presented. Patients who underwent liver transplantation were excluded. In total, 424 out of the 769 patients (55.1%) from the 8 hospitals and 537 out of 828 CP-C HCC cases (64.8%) from the LCSGJ data received interventional therapies, such as local ablation and transcatheter arterial chemoembolization. All panelists agreed that there was a subgroup of CP-C patients who benefitted from the locoregional therapies. The major goals for the therapies were to prevent HCC rupture and avoid obstruction of major vessels by tumor growth, which can lead to a sudden deterioration of the patients' condition. Patient liver function and tumor stage are both important factors for the decision to undergo treatment; however, the inclusion criteria for the treatments varied among the centers. Key Message: There exists a subgroup of CP-C patients who benefit from interventions for HCC.