Neurologic Disorders in Immunocompetent Patients with Autochthonous Acute Hepatitis E.

Neurologic disorders, mainly Guillain-Barré syndrome and Parsonage­Turner syndrome (PTS), have been described in patients with hepatitis E virus (HEV) infection in industrialized and developing countries. We report a wider range of neurologic disorders in nonimmunocompromised patients with acute HEV infection. Data from 15 French immunocompetent patients with acute HEV infection and neurologic disorders were retrospectively recorded from January 2006 through June 2013. The disorders could be divided into 4 main entities: mononeuritis multiplex, PTS, meningoradiculitis, and acute demyelinating neuropathy. HEV infection was treated with ribavirin in 3 patients (for PTS or mononeuritis multiplex). One patient was treated with corticosteroids (for mononeuropathy multiplex), and 5 others received intravenous immunoglobulin (for PTS, meningoradiculitis, Guillain-Barré syndrome, or Miller Fisher syndrome). We conclude that pleiotropic neurologic disorders are seen in HEV-infected immunocompetent patients. Patients with acute neurologic manifestations and aminotransferase abnormalities should be screened for HEV infection.

Management of failures of first line treatments.

Up to 70% of the patients treated to prevent rebleeding will experience a bleeding episode within 2 years. The response should be adapted to the delay after the index bleed, the source and the severity of the haemorrhage, the underlying liver disease and the initial treatment to prevent rebleeding. Bleeding can be caused by endoscopic techniques themselves, which should incitate to complete obliteration rather than to switch to another therapy. Failure of drug therapy can be secondary to ineffectiveness, to a lack of compliance, or to an insufficient dosage. The two latter conditions may be corrected. Whenever a patient rebleeds in spite of optimal treatment, liver transplantation should be considered. When such a procedure is contra-indicated and in patients on the waiting list, a Transjugular intra-hepatic porto-systemic shunt (TIPS) should be performed.

Transient elastography accurately predicts presence of significant portal hypertension in patients with chronic liver disease.

BACKGROUND: Hepatic venous pressure gradient (HVPG) is a prognostic marker in patients with cirrhosis. Transient elastography measures liver stiffness (LS). AIM: To assess the correlation between LS and HVPG and to investigate the performance of transient elastography for the diagnosis of significant portal hypertension (PHT). METHODS: Liver stiffness was measured by Fibroscan in 150 consecutive patients who underwent a liver biopsy with haemodynamic measurements. Usual clinical and biological data were collected. Significant PHT was defined as a HVPG > or = 10 mmHg. RESULTS: Hepatic venous pressure gradient was found to be > or = 10 mmHg in 76 patients. Cirrhosis was diagnosed in 89 patients. HVPG was found to be correlated with: LS (rho = 0.858; P < 0.001) and inversely correlated with prothrombin index (rho = -0.718; P < 0.001). Regarding significant PHT, AUROC for LS and prothrombin index were 0.945 [0.904-0.987] and 0.892 [0.837-0.947] respectively. The cut-off value of 21 kPa accurately predicted significant PHT in 92% of the 144 patients for whom LS was successful. CONCLUSION: Liver stiffness measurement is correlated with HVPG and transient elastography identifies patients with significant PHT.

Fulminant liver failure from acute autochthonous hepatitis E in France: description of seven patients with acute hepatitis E and encephalopathy.

Fulminant hepatitis E has not been well characterized in industrialized countries. The aim of this study was to prospectively describe patients with acute hepatitis E presenting as fulminant hepatic failure, i.e. with encephalopathy and prothrombin index <50%. Between February 1997 and April 2005, seven patients with encephalopathy were diagnosed with acute hepatitis E using viral RNA detection. These patients were compared with 33 patients diagnosed with a mild form (absence of encephalopathy) of acute hepatitis E during the same time period. Patients were 65 +/- 11 years old. Five were active drinkers and six had chronic liver disease. All hepatitis E virus sequences evaluated (5/7) were of genotype 3. All patients but two died (71%). Four patients had no travel history. When compared with patients with a mild form of acute hepatitis E, active alcohol abuse and chronic liver disease were more frequent in patients with the severe form. Duration of hospitalization was longer. Aspartate transferase and bilirubin levels were significantly higher. Prothrombin index and accelerin levels were lower and death was more frequent. Acute nontravel-associated hepatitis E can appear as fulminant hepatitis with encephalopathy and coagulation disorders. Prognosis is severe and this may be due to the age at which it occurs and frequent underlying chronic liver disease.

KLF6 transcription factor protects hepatocellular carcinoma-derived cells from apoptosis.

Hepatocellular carcinoma (HCC) is a major public health concern because of the absence of early diagnosis and effective treatments. Efficient diagnosis modalities and therapies to treat HCC are needed. Kruppel-like factor (KLF) family members, such as KLF6, are involved in cell proliferation and differentiation. KLF6 is inactivated in solid tumors, which may contribute to pathogenesis. However, KLF6 status in HCC is controversial. Thus, we undertook the characterization of KLF6 expression and function in HCC and HCC-derived cell lines. We found that HCC, HepG2 and HuH7 cells expressed KLF6 messenger ribonucleic acid and protein. Next, using RNA interference, we demonstrated that inhibiting KLF6 expression in vitro strongly impaired cell proliferation-induced G1-phase arrest, inhibited cyclin-dependent kinase 4 and cyclin D1 expression, and subsequent retinoblastoma phosphorylation. Finally, KLF6 silencing caused p53 upregulation and inhibited Bcl-xL expression, to induce cell death by apoptosis. Taken together, these data demonstrated that KLF6 is essential for HCC-derived cells to evade apoptosis.

Treatment of experimental murine pancreatic peritoneal carcinomatosis with fibroblasts genetically modified to express IL12: a role for peritoneal innate immunity.

BACKGROUND: Peritoneal carcinomatosis from pancreatic cancer has a poor prognosis with a median survival of 3.1 months. This is mainly due to lack of effective treatment. Interleukin 12 (IL12) is a proinflammatory cytokine that has a potent antitumoral effect by stimulating innate and adoptive immunity. AIM: To examine the antitumoral effect and toxicity of intraperitoneal delivery of IL12 using an ex vivo gene therapy approach in a murine model of pancreatic peritoneal carcinomatosis. METHODS: Peritoneal carcinomatosis was generated by direct intraperitoneal inoculation of the pancreatic cancer cell line Capan-1 in athymic mice. Syngenic fibroblasts were genetically modified in vitro to secrete IL12 using a polycistronic TFG murine IL12 retroviral vector coding for both p35 and p40 murine IL12 subunits. Ex vivo gene therapy involved injection of the genetically modified fibroblasts intraperitoneally twice a week for 4 weeks. RESULTS: Treatment of pre-established peritoneal carcinomatosis with fibroblasts genetically modified to express IL12 induced a marked inhibition of tumour growth as measured by comparison of the weights of the intraperitoneal tumour nodules in the treated and control animals (3.52 (SD 0.47) v 0.93 (SD 0.21) g, p<0.05) and improved survival. This effect was associated with infiltration of the peritoneal tumour nodules with macrophages. Peritoneal lavage confirmed enhancement of the innate peritoneal inflammatory activity, with an increased number of activated macrophages and natural killer cells. Moreover, macrophages harvested from animals with peritoneal carcinomatosis and treated with IL12-expressing fibroblasts expressed an activated proinflammatory antitumoral M1 phenotype that included strongly enhanced reactive oxygen species and nitric oxide production. There was no treatment-related toxicity. CONCLUSION: Multiple injections of genetically modified fibroblasts to express IL12 is an effective and well-tolerated treatment for experimental murine pancreatic peritoneal carcinomatosis via activated innate immunity and in particular activated M1 macrophages.

Pilot study of interferon-alpha-ribavirin-interleukin-2 for treatment of nonresponder patients with severe liver disease infected by hepatitis C virus genotype 1.

The aim of this randomized prospective study was to assess the efficacy and safety of a triple therapy with interferon-alpha (IFN-alpha)-ribavirin-interleukin-2 (IL-2) for the treatment of patients with genotype 1 infection and high viral load nonresponsive to primary IFN-ribavirin therapy. Twenty hepatitis C virus (HCV) genotype 1 patients with high viral load and Metavir fibrosis score >or=2 without HIV co-infection who were previously nonviral responders to standard treatment with IFN plus ribavirin were intensively re-treated with IFN-alpha2a (3 millions (M) IU every 2 days) combined with ribavirin (1000-1200 mg/day) for a 24-week period. Patients were randomized to receive four cycles of subcutaneous injection of IL-2 (3 MIU/day, 5 days a week every 3 weeks) during either the first 12 weeks (group 1, n = 10) or the last 12 weeks (group 2, n = 10) of combination therapy. At the end of triple therapy, six patients (30%) achieved a biochemical response and 4 (20%) a viral response followed by a relapse after triple therapy withdrawal. After 12 weeks of therapy, no difference in viral load was observed between the groups. The decrease in viral load in group 2 was not raised after the addition of IL-2 to IFN plus ribavirin combination therapy. No serious adverse effects were observed. In conclusion, in patients with poor predictive factors of response, the addition of IL-2 to IFN ribavirin combination therapy does not exert a favourable impact on HCV treatment.

Pegylated interferon and ribavirin therapy for chronic hepatitis C virus genotype 4 infection.

Hepatitis C Virus (HCV) is classified into six genotypes. Genotype 4 is now spreading in Europe, especially among drug users, who are often infected with both HCV and the human immunodeficiency virus (HIV). Previous studies have shown that HCV-4 responds poorly to interferon. Pegylated interferon (peg-IFN) associated with ribavirin is now the most effective treatment for eradicating the virus. We have now studied the response of HCV-4 to peg-IFN and ribavirin and investigated the influence of HIV infection on anti-HCV therapy. Twenty-eight patients infected with HCV-4 were given peg-IFN plus ribavirin for 48 weeks. Patients infected with HCV alone tended to have a better initial response (66%) than patients infected with both HCV and HIV (30%, P = 0.06) and eradication was better (50%) than in doubly infected patients (15%, P = 0.06). After controlling for major factors influencing virus response, the virus response 12 weeks after the beginning of treatment in patients infected with HCV-4 (50%) was similar to that of patients infected with genotype 1 (53%) and lower than that of patients infected with genotypes 2 or 3 (82%, P < 0.05). The response 24 weeks after the end of therapy in patients infected with HCV-4 (32%) was similar to that of patients infected with HCV-1 (28%) and lower than that of patients with HCV-2 or HCV-3 (62% P < 0.05). These results indicate that HCV-4 patients should be considered to be difficult-to-treat.

Hepatitis C virus genotype 5: epidemiological characteristics and sensitivity to combination therapy with interferon-alpha plus ribavirin.

Twenty-six patients living in the Midi-Pyrenees region of France who were infected with hepatitis C virus (HCV) genotype 5 were investigated. Most of these patients were of advanced age and had been infected nosocomially or by blood transfusion. Our case-control study, in which we treated patients with interferon- alpha plus ribavirin, indicated that, 24 weeks after the beginning of treatment, the virus response in patients infected with HCV genotype 5 was better than that in patients infected with HCV genotype 1 (100% of patients negative for detectable HCV RNA vs. 36.3%, respectively; P < .01); furthermore, 48 weeks after the end of treatment, the virus response in patients infected with HCV genotype 5 was better than that in patients infected with HCV genotype 1 (63.6% vs. 22.7%, respectively; P < .05) and was similar to that in patients infected with HCV genotype 2 or 3 (66.6%). These results show that HCV genotype 5 might have good intrinsic sensitivity to combination therapy with interferon- alpha plus ribavirin.

Maintenance therapy with gradual reduction of the interferon dose over one year improves histological response in patients with chronic hepatitis C with biochemical response: results of a randomized trial.

BACKGROUND/AIMS: Our aim was to assess whether histological response was improved by continuing interferon-alpha (IFN) treatment in patients with chronic hepatitis C (HCV) with a biochemical response and no viral clearance after a usual IFN treatment. METHODS: Fifty-seven patients with normal alanine aminotransferase (ALAT) levels and positive HCV RNA at the end of a 1 year IFN treatment were randomly assigned to either group 1 (n = 28) where IFN was stopped, or group 2 (n = 29) where IFN was continued for 1 more year with gradual reduction of the dose to keep serum ALAT activity below the upper limit of normal. Liver biopsies were obtained before, and then 6 months after the end of treatment. RESULTS: Knodell's index improved between paired biopsies in group 2 (8.2+/-2.4 vs. 5.5+/-2.1), but not in group 1 (8+/-2.3 vs. 6.5+/-2). In post-treatment biopsies, the METAVIR activity score was significantly lower in group 2 than in group 1 (0.7+/-0.2 vs. 1.1+/-0.3, P < 0.05). In group 2, an improvement of the METAVIR fibrosis score was observed (1.3+/-0.4 vs. 1.1+/-0.2), whereas fibrosis progressed in group 1 (1.3+/-0.4 vs. 1.6+/-0.4). CONCLUSIONS: Maintenance therapy by the minimal dose of IFN able to maintain biochemical response prevents histological progression in the sub-group of patients without virological response.

Nonstructural 3 protein of hepatitis C virus triggers an oxidative burst in human monocytes via activation of NADPH oxidase.

It has been shown that oxidative stress occurs in chronic hepatitis C. Release of reactive oxygen species (ROS) from sequestered phagocytes and activated resident macrophages represents the predominant component of oxidative stress in the liver. However, little is known about the ability of the monocyte to produce ROS in response to protein of hepatitis C virus. In this study, we investigated the ROS production in human monocytes stimulated by several viral proteins of hepatitis C virus. Human monocytes from healthy blood donors were incubated with recombinant viral protein: Core, NS3, NS4, and NS5. ROS production was measured by chemiluminescence. Only NS3 triggered ROS production in human monocytes. Generated ROS were mainly the anion superoxide. NS3 also induced a rapid and transient increase in intracellular calcium concentration measured by a video digital microscopy technique. By using different metabolic inhibitors, we showed that ROS production requires calcium influx, tyrosine kinases, and the stress-activated protein kinase, p38. The study of p47(PHOX) phosphorylation and translocation showed that NADPH oxidase was activated and involved in ROS production induced by NS3. In a second experiment, NS3 inhibited the oxidative burst induced by phorbol 12-myristate 13-acetate. These results indicate that NS3 activates NADPH oxidase and modulates ROS production, which may be involved in the natural history of hepatitis C infection.

Prospective study on the application of the Baveno II Consensus Conference criteria in patients with cirrhosis and gastrointestinal bleeding.

BACKGROUND/AIMS: This study aimed to evaluate the Baveno II criteria defining key events in variceal bleeding. METHODS: These criteria were applied to 196 patients with cirrhosis admitted for upper gastrointestinal bleeding due to portal hypertension and enrolled in a trial. Blood pressure, heart rate, hematocrit and clinical signs of upper digestive tract hemorrhage were recorded for 5 days. The blind overall clinical judgment of hemodynamic stability was recorded separately by the Steering Committee. RESULTS: The evaluation of several hemodynamic criteria was left to the judgment of the clinician. The first time point for the control of bleeding, fixed at 6 h after admission, was impractical since 13% of the patients had not yet received specific treatment. The independent judgment did not agree in 38% of 82 cases without control of bleeding. In 15% of cases this was due to tachycardia. Calculation of several judgment criteria was not defined in the Baveno II criteria: survival without bleeding at 5 days, transfusion rate, and length of hospital stay. CONCLUSIONS: Although the Baveno II criteria have improved the definitions of key events, the criteria are hampered by limits such as false positive criteria of failure to control bleeding. We make several proposals for improvement.