Graft-vs-host disease after small bowel transplantation in children.

PURPOSE: Graft-vs-host disease (GVHD) is a rare complication of transplantation of organs rich in immunocompetent cells. The goal of this study was to report the features of GVHD after small bowel transplantation (SBTx) in children. METHODS: The study involved a retrospective review of patients undergoing SBTx between 1999 and 2009 who had GVHD. RESULTS: Of 46 children receiving 52 intestinal grafts (2 liver-intestine and 3 multivisceral), 5 (10%) developed GVHD. Median age at transplant was 42 (19-204) months. Baseline immunosupression consisted of tacrolimus and steroids supplemented with thymoglobulin (n = 2) or basiliximab (n = 3) for induction. Median time between transplantation and GVHD was 47 (16-333) days. All patients had generalized rash, 2 had diarrhea, and 2 had respiratory symptoms. Other symptoms were glomerulonephritis (n = 1) and conjunctivitis (n = 1). Four developed severe hematologic disorders. The diagnosis was confirmed by skin biopsy in 4 patients and supported by chimerism studies in two. Colonoscopy and opthalmoscopic findings were also suggestive in one. Treatment consisted of steroids and decrease of tacrolimus, with partial response in four. Other immunosuppressants were used in refractory or recurrent cases. Three patients died within 4 months after diagnosis. CONCLUSION: Graft-vs-host disease is a devastating complication of SBTx, with high mortality probably associated with severe immunologic dysregulation.

KRAS mutations in primary colorectal cancer tumors and related metastases: a potential role in prediction of lung metastasis.

BACKGROUND: KRAS mutations in colorectal cancer primary tumors predict resistance to anti-Epidermal Growth Factor Receptor (EGFR) monoclonal antibody therapy in patients with metastatic colorectal cancer, and thus represent a true indicator of EGFR pathway activation status. METHODOLOGY/PRINCIPAL FINDINGS: KRAS mutations were retrospectively studied using polymerase chain reactions and subsequent sequencing of codons 12 and 13 (exon 2) in 110 patients with metastatic colorectal tumors. These studies were performed using tissue samples from both the primary tumor and their related metastases (93 liver, 84%; 17 lung, 16%). All patients received adjuvant 5-Fluorouracil-based polychemotherapy after resection of metastases. None received anti-EGFR therapy. Mutations in KRAS were observed in 37 (34%) of primary tumors and in 40 (36%) of related metastases, yielding a 94% level of concordance (kappa index 0.86). Patients with primary tumors possessing KRAS mutations had a shorter disease-free survival period after metastasis resection (12.0 vs 18.0 months; P = 0.035) than those who did not. A higher percentage of KRAS mutations was detected in primary tumors of patiens with lung metastases than in patients with liver metastases (59% vs 32%; p = 0.054). To further evaluate this finding we analyzed 120 additional patients with unresectable metastatic colorectal cancer who previously had their primary tumors evaluated for KRAS mutational status for clinical purposes. Separately, the analysis of these 120 patients showed a tendency towards a higher degree of KRAS mutations in primary tumors of patients with lung metastases, although it did not reach statistical significance. Taken together the group of 230 patients showed that KRAS was mutated significantly more often in the primary tumors of patients with lung metastases (57% vs 35%; P = 0.006). CONCLUSIONS/SIGNIFICANCE: Our results suggest a role for KRAS mutations in the propensity of primary colorectal tumors to metastasize to the lung.

Recurrence of bile salt export pump deficiency after liver transplantation.

Severe bile salt export pump (BSEP) deficiency is a hereditary cholestatic condition that starts in infancy and leads to end-stage liver disease. Three children who underwent orthotopic liver transplantation for severe BSEP deficiency had post-transplantation episodes of cholestatic dysfunction that mimicked the original disease. Remission of all episodes was achieved by intensifying the immunosuppressive regimen. The phenotypic recurrence of the disease correlated with the presence of circulating high-titer antibodies against BSEP that inhibit transport by BSEP in vitro. When administered to rats, these antibodies targeted the bile canaliculi and impaired bile acid secretion.

[Factors associated with hepatic steatosis in human immunodeficiency virus and hepatits C virus coinfected patients]. / Factores asociados con esteatosis hepática en pacientes coinfectados por los virus de la inmunodeficiencia humana y de la hepatitis C.

BACKGROUND AND OBJECTIVE: To determinate the prevalence and factors associated with hepatic steatosis and severity of steatosis in human immunodeficiency virus (HIV) and hepatits C virus (HCV) coinfected patients. PATIENTS AND METHOD: Liver histology was assessed in 163 HIV-HCV coinfected patients. Exclusion criteria included positive hepatitis B surface antigen and prior anti-HCV therapy. Steatosis was scored by a single pathologist according to the percentage of affected hepatocytes. Necroinflammatory activity and fibrosis was scored by the Scheuer system. Logistic regression analyses were used to evaluate variables associated with hepatic steatosis. RESULTS: Steatosis was present in 65% of biopsy samples. Moderate-severe steatosis (>30% of hepatocytes) was detected in 17% of patients. 78.5% of patients were under high active antiretroviral therapy at the time of biopsy. In a multivariate analysis, steatosis was associated with body weight, alcohol, advanced fibrosis, stavudine use and non-use of lopinavir/ritonavir. In a multivariate analysis, severity of steatosis (>30% of hepatocytes) was associated with alcohol, HCV genotype 3, HCV load >1,400,000 copies/ml and advanced fibrosis. CONCLUSIONS: The presence of hepatic steatosis and severity of steatosis were associated with advanced fibrosis in patients coinfected with HIV and HCV. Body weight, consumption of alcohol and antiretroviral therapy (stavudine use and absence of exposure to lopinavir/ritonavir) were modifiable factors associated with the presence of steatosis. Characteristics of HCV infection were associated with the severity of steatosis in this population.

Factores asociados con esteatosis hepática en pacientes coinfectados por los virus de la inmunodeficiencia humana y de la hepatitis C / Factors associated with hepatic steatosis in human immunodeficiency virus and hepatits C virus coinfected patients

Fundamento y objetivo: determinar la prevalencia y los factores asociados con la presencia de esteatosis hepática y con su intensidad en los pacientes coinfectados por los virus de la inmunodeficiencia humana (VIH) y de la hepatitis C (VHC).Pacientes y método: se han evaluado las biopsias hepáticas de 163 pacientes coinfectados por el VIH y VHC. Se excluyó a aquéllos con antígeno de superficie del virus de la hepatitis B y tratamiento previo del VHC. El grado de esteatosis se evaluó según el porcentaje de hepatocitos afectados. La actividad necroinflamatoria y el grado de fibrosis se clasificaron según el sistema de Scheuer. Mediante regresión logística se valoraron los factores asociados con la presencia e intensidad de la esteatosis en la biopsia. Resultados: un 65% de las biopsias presentaba esteatosis, que era moderada-intensa (>30% de los hepatocitos) en un 17%. Un 78,5% de los pacientes recibía tratamiento antirretroviral de gran actividad en el momento de realizar la biopsia. Los factores asociados con la presencia de esteatosis fueron: el peso corporal, el consumo de alcohol, la presencia de fibrosis avanzada, la exposición a estavudina y la ausencia de exposición a lopinavir/ritonavir. Los factores asociados con la intensidad de la esteatosis (>30% de hepatocitos) fueron: el consumo de alcohol, el genotipo 3 del VHC, la carga vírica del VHC mayor de 1.400.000 copias de ARN/ml y la presencia de fibrosis avanzada. Conclusiones: la presencia de esteatosis y su intensidad se asociaron a un mayor grado de fibrosis hepática en los pacientes coinfectados por el VIH y VHC. El peso, el consumo de alcohol y el tratamiento antirretroviral (tratamiento con estavudina y ausencia de tratamiento con lopinavir/ritonavir) son factores modificables que se asociaron a la presencia de esteatosis. Las características de la infección del VHC estaban asociadas a la intensidad de la esteatosis en esta población (AU)

Background and objective: To determinate the prevalence and factors associated with hepatic steatosis and severity of steatos is in human immunodeficiency virus (HIV) and hepatits C virus (HCV) coinfected patients. Patients and method: Liver histology was assessed in 163 HIV-HCV coinfected patients. Exclusion criteria included positive hepatitis B surface antigen and prior anti-HCV therapy. Steatosis was scored by a single pathologist according to the percentage of affected hepatocytes. Necroinflammatory activity and fibrosis was scored by the Scheuer system. Logistic regression analyses were used to evaluate variables associated with hepatic steatosis. Results: Steatosis was present in 65% of biopsy samples. Moderate-severe steatosis (>30% of hepatocytes) was detected in 17% of patients. 78.5% of patients were under high active antiretroviral therapy at the time of biopsy. In a multivariate analysis, steatosis was associated with body weight, alcohol, advanced fibrosis, stavudine use and non-use of lopinavir/ritonavir. In a multivariate analysis, severity of steatosis (>30% of hepatocytes) was associated with alcohol, HCV genotype 3, HCV load >1,400,000 copies/ml and advanced fibrosis. Conclusions: The presence of hepatic steatosis and severity of steatosis were associated with advanced fibrosis in patients coinfected with HIV and HCV. Body weight, consumption of alcohol and antiretroviral therapy (stavudine use and absence of exposure to lopinavir/ritonavir) were modifiable factors associated with the presence of steatosis. Characteristics of HCV infection were associated with the severity of steatosis in this population (AU)

TWIST1 overexpression is associated with nodal invasion and male sex in primary colorectal cancer.

BACKGROUND: TWIST1 is a basic helix-loop-helix (bHLH) transcription factor that has been involved in tumor progression and metastasis in several cancer types, although no evidence has been provided yet on its implication in colorectal carcinogenesis. METHODS: We examined the expression pattern of TWIST1 messenger RNA (mRNA) in 54 colorectal cancer biopsies compared with each respective adjacent normal mucosa by real-time reverse-transcriptase polymerase chain reaction (RT-PCR) methodology. RESULTS: TWIST1 mRNA was found significantly overexpressed in colorectal cancer samples compared to nontumorous colon mucosa (P < 0.0001). Receiver operating characteristic (ROC) curve analysis demonstrated that TWIST1 mRNA levels are significantly increased in patients with nodal invasion and, interestingly, a significant correlation with patient sex was also found. CONCLUSIONS: Evidence for upregulation of TWIST1 mRNA in colorectal cancer is provided, suggesting its implication in the onset of malignant progression of this disease. In addition, significant higher levels of TWIST1 mRNA were found in men than in women, suggesting a possible transcriptional regulation of TWIST1 by sexual hormones. The use of TWIST1 as a new prognostic marker of advanced malignancy, and as a potential therapeutic target in colorectal cancer, is proposed.

EPO-R expression patterns in resected gastric adenocarcinoma followed by adjuvant chemoradiation treatment.

The primary aim was to determine whether Epo-R immunohistochemical expression is related to disease free survival (DFS) in specimens of GC from patients who underwent adjuvant chemoradiation. Specimens of gastric adenocarcinomas obtained from 44 patients who had undergone curative gastrectomy and adjuvant treatment were investigated immunohistochemically expression of Epo-R. Three patterns for Epo-R staining were defined: Pattern A (secretory cells-like staining), Pattern B (parietal-like staining) and Pattern C (chief-like staining). Median DFS was 38 months (CI 95%: 33-43) and 15 months (IC 95%: 3-27) in the pattern B and C, respectively, but it was not reached in the pattern A (p = 0.06). Our findings suggest that there may be a relationship between Epo-R expression and DFS in the patients with GC resected.

Efficacy and safety of peginterferon-alpha2b and ribavirin combination therapy in children with chronic hepatitis C infection.

BACKGROUND: Interferon (IFN)-alpha2b plus ribavirin is approved for treatment of hepatitis C in children; however, little is known about efficacy and tolerability of pegylated IFN (PEG-IFN)-alpha2b in this population. The objective of this study was to test the efficacy and safety of PEG-IFN-alpha2b plus ribavirin in children with chronic hepatitis C. METHODS: Thirty children 3-16 years of age who had detectable hepatitis C virus (HCV) RNA for >or=3 years after exposure and elevated alanine aminotransferase values received PEG-IFN-alpha2b 1.0 microg/kg/wk plus ribavirin 15 mg/kg/d for 24 weeks (genotype 2/3) or 48 weeks (genotype 1/4). The primary endpoint was sustained virologic response (SVR), defined as undetectable HCV RNA (<50 IU/mL) at week 24 of follow-up. RESULTS: SVR was achieved in 50% of patients (3/3 genotype 3; 12/27 genotype 1/4). At week 12, 52% of patients were HCV RNA negative and 72% had a >2 log10 decrease in viral load, compared with baseline; 87% and 71% of these patients, respectively, attained an SVR. Therapy was discontinued in 3 patients as a result of adverse events. No patient required ribavirin dose reduction; PEG-IFN-alpha2b dose was reduced in 23% of patients to manage neutropenia. CONCLUSIONS: Combination therapy with PEG-IFN-alpha2b and ribavirin treatment was effective in children with chronic hepatitis C. Virologic status at week 12 identified future responders and nonresponders. PEG-IFN-alpha2b and ribavirin were reasonably well tolerated, with no unexpected or permanent adverse effects. Further studies are needed to identify the optimum treatment regimen for this patient population.

Esophageal granular cell tumor and eosinophilic esophagitis: two interesting entities identified in the same patient.

We illustrate the case of a 41-year-old male with allergic manifestations since childhood. He sought medical attention for intermittent, progressive dysphagia from which he had been suffering for a number of years, having felt the sensation of a retrosternal lump and a self-limited obstruction to the passage of food. Endoscopy detected a submucosal tumor in the upper third of the esophagus, which was typified, via biopsy, as a granular cell tumor with benign characteristics and probably responsible for the symptoms. Two years later, the patient sought medical attention once again as these symptoms had not abated, hence digestive endoscopy was repeated. This revealed stenosis of the junction between the middle and lower thirds of the organ which had not been detected previously but was passable under gentle pressure. Eosinophilic esophagitis was detected after biopsies were taken. Esophageal manometry identified a motor disorder affecting the esophageal body. Following three months of treatment using fluticasone propionate applied topically, the symptoms went into remission, esophageal stenosis disappeared and the esophageal biopsies returned to normal. This is the first documented case of the link between granular cell tumors and Eosinophilic esophagitis, two different disorders which could cause dysphagia in young patients.

Immunophenotypic characterization and quantification of the epithelial inflammatory infiltrate in eosinophilic esophagitis through stereology: an analysis of the cellular mechanisms of the disease and the immunologic capacity of the esophagus.

Eosinophilic esophagitis (EE) is an emerging disease caused by dense infiltration of the esophageal epithelium by eosinophilic leucocytes. It is originated from local hypersensitivity to food or airborne allergens. Although the physiopathologic mechanisms of the illness have not been fully discovered, EE is a loss of immunologic tolerance by the esophagus, meaning that it should be considered as an active immunologic organ. In our study, we investigated the immunologic capacity of the epithelium using immunohistochemistry and stereology, to determine the cellular density of eosinophils, T and B lymphocytes, Langerhans cells, mast cells, and cells manufacturing immunoglobulin E in endoscopic biopsies of patients with EE (taken before and after topical treatment with fluticasone propionate) compared with normal individuals and patients suffering from gastroesophageal reflux disease (GERD). We have observed that the density of eosinophils in EE is 300 times greater than in normal conditions and it is only in this disease where eosinophils show signs of activation and degranulation (positivity to major basic protein immunostaining). The number of T intraepithelial lymphocytes also significantly rose in EE, compared with other entities, where CD8 cells were predominant. However, the human esophagus is deficient in B lymphocytes and we only found intraepithelial plasma cells that excreted immunoglobulin E in EE. Under normal conditions mast cells exist in the thickness of the epithelium that are slightly higher in GERD and multiply in density by 17 in EE. Langerhans cells did not show any significant variation in density under the different tested conditions. After topical treatment with steroids, the density of the different cell components fell to similar levels to GERD. Using our study, we can conclude that the human esophagus may contribute to the development of local immunologic responses as it contains all the necessary cell components. EE represents growth of this esophageal capacity and its pathogeny could respond to mixed cellular and humoral mechanisms.

Reduced hepatic expression of farnesoid X receptor in hereditary cholestasis associated to mutation in ATP8B1.

Farnesoid X receptor (FXR) is a transcription factor that controls bile acid homeostasis. The phenotype of Fxr null mice is characterized by hypercholanaemia, impaired secretion of bile acids and failure to thrive. Human disorders with these characteristics include FIC1 disease (caused by mutations in ATP8B1, which encodes a putative aminophospholipid translocase, FIC1, whose function in bile handling is unknown) and bile salt export pump (BSEP) disease (caused by mutation in ABCB11, which encodes BSEP, the primary canalicular bile salt export pump). We investigated the possibility of hepatic down-regulation of FXR in FIC1 disease and BSEP disease. Three siblings with this phenotype, born to consanguine parents, were initially studied. The children were demonstrated to be compound heterozygotes for missense and nonsense mutations in ATP8B1. Expression of specific genes in liver was analysed, comparing one of these siblings with a child homozygous for missense mutation in ABCB11, as well as with a child having idiopathic cholestatic liver disease, a child with extrahepatic biliary atresia and a normal organ donor. The expression of two main FXR isoforms was specifically decreased in the liver of the FIC1 disease patient. A consistent and concomitant reduction in messenger RNA levels of FXR targets, such as BSEP and small heterodimer partner, was also found. Gene-profiling experiments identified 163 transcripts whose expression changed significantly in FIC1-disease liver. Of note was that several genes involved in synthesis, conjugation and transport of bile acids were down-regulated. A cluster of genes involved in lipid metabolism was also differentially expressed. Our findings suggest that hepatic down-regulation of FXR contributes to the severe cholestasis of FIC1 disease.

Fibrosis in chronic hepatitis C acquired in infancy: is it only a matter of time?

OBJECTIVE: The natural history of chronic hepatitis C acquired in infancy is not well understood. The progression of fibrosis was analyzed in untreated children with chronic hepatitis C virus infection and no other hepatotoxic cofactors. METHODS: A total of 112 pediatric patients (13 with paired liver biopsies) were considered. Fibrosis was assessed by METAVIR score (i.e., stage F1 to F4). The ratio between the stage of fibrosis (METAVIR units) and the presumed duration of infection represented the "estimated" rate of fibrosis progression per year. In patients with paired biopsies, the "observed" rate of fibrosis progression was defined as the difference between the stage of fibrosis in the two biopsies divided by the time interval between them. RESULTS: Both age of patients at biopsy and duration of infection correlated with stage of fibrosis (p < 0.002 and p < 0.0005, respectively). Stage of fibrosis differed significantly between patients with infection lasting less or more than 10 yr (p < 0.0006). Sex, hepatitis C virus genotype, and route of infection did not correlate with stage of fibrosis. Among the 13 patients with paired biopsies, stage of fibrosis increased in seven and did not change in six; the median rate of estimated fibrosis progression per year was 0.142. The difference between estimated and observed fibrosis progression rates was significant (coefficient of determination, r(2) = 0.031), which demonstrated that the prediction of the fibrosis progression was unreliable in 97% of patients. CONCLUSIONS: Chronic hepatitis C acquired in childhood is a progressive, slow-moving, fibrotic disease. Fibrosis progression inferred on the basis of linear mathematical models should be critically evaluated in the clinical practice.