ß-arrestin-2 predicts the clinical response to ß-blockers in cirrhotic portal hypertension patients: A prospective study.

BACKGROUND: Portal hypertension, a common complication associated with liver cirrhosis, can result in variceal bleeding, which greatly impacts patient survival. Recently, ß-arrestin-2 has been shown to predict the acute hemodynamic response to nonselective ß-blocker therapy for cirrhotic portal hypertension. However, more data is needed on the long-term effects of and changes in ß-arrestin-2 following nonselective ß-blocker therapy. AIM: To investigate the expression and role of ß-Arrestin-2 in predicting the long-term response to nonselective ß-blockers in cirrhotic portal hypertensive patients. METHODS: We prospectively enrolled 91 treatment-naïve patients with cirrhotic portal hypertension. Baseline clinical and laboratory data were obtained. Gastroscopy was performed for grading and treating varices and obtaining gastric antral biopsies. We measured the serum and antral expression of ß-arrestin-2 and obtained Doppler measurement of the portal vein congestion index. Treatment with nonselective ß-blockers was then started. The patients were followed up for 18 mo, after which they have undergone a repeat antral biopsy and re-evaluation of the portal vein congestion index. RESULTS: A higher serum level and antral expression of ß-arrestin-2 was associated with longer bleeding-free intervals, greater reduction in the portal vein congestion index, and improved grade of varices. Among patients with a low ß-arrestin-2 expression, 17.6% were nonselective ß-blocker responders, whereas, among those with high expression, 95.1% were responders (P < 0.001). A serum ß-arrestin-2 value ≥ 2.23 ng/mL was associated with a lower likelihood of variceal bleeding (90% sensitivity and 71% specificity). ß-arrestin-2 expression significantly decreased after nonselective ß-blocker therapy. CONCLUSION: ß-arrestin-2 expression in cirrhotic portal hypertension predicts the clinical response to long-term nonselective ß-blocker treatment. Serum ß-arrestin-2 is a potential noninvasive biomarker for selecting the candidate patients for nonselective ß-blockers.

Modulation of Memory B Cell Phenotypes and Toll-Like Receptor-7 in Chronic Hepatitis C Virus Infection During Direct-Acting Antiviral Interferon-Free Therapy: Correlation with Interleukin-7.

Hepatitis C virus (HCV) infection is a major worldwide problem with the highest incidence rates in Egypt. It affects B cells that serve as reservoirs for persistent HCV, resulting in phenotypic B cell alterations. Interleukin-7 (IL-7) is a cytokine with antiviral activity, important for B cell physiology. In addition, B cell-intrinsic toll-like receptor-7 (TLR7) signaling is required for optimal B cell responses during chronic viral infection, and the deficiency of TLR7 in B cells is sufficient to significantly impact antibody responses. Based on their known immunomodulatory effects, we hypothesized that direct-acting antiviral interferon-free therapy may affect TLR7 expression and the exhausted peripheral B cell compartment with the possibility of their restoration in patients who achieved a sustained virological response and their correlation to IL-7 level. This prospective study was accomplished on 80 Egyptian HCV patients and 75 controls. Frequencies of peripheral B cell subsets, TLR7 gene expression, TLR7 protein, and serum IL-7 levels were investigated by flow cytometry, quantitative polymerase chain reaction, and enzyme-linked immunosorbent assay, respectively. B cell subpopulations were exhausted and partially restored among HCV patients after receiving treatment, but not recovered with regard to activated mature or resting memory B cells. Almost all responders to direct antiviral drugs showed upregulation of TLR7 gene expression and correlated with the frequency of memory B cell, but not with IL-7. Moreover, IL-7 was not significantly different between groups although correlated with immature transitional B cells. Results may indicate the interplay between TLR7 and B cells during remission or progression of HCV. Thus, TLR7 could be used as a promising biomarker for assessment of antiviral treatment efficacy among chronically infected HCV patients, and that targeting TLR7 may be used as a potential prophylactic and/or therapeutic agent during chronic HCV as well as immune-potentiation of memory B cells.

The clinical significance of serum miRNA-224 expression in hepatocellular carcinoma.

AIM OF THE STUDY: Micro-ribonucleic acids (miRNA) are small single stranded RNA molecules. They act as key regulators of several cellular processes such as proliferation, apoptosis, tumor differentiation, invasion and metastasis. Hepatocellular carcinoma (HCC) represents the most common primary liver cancer. miRNA-224 is an oncomiR that is highly upregulated in HCC tissues. The aim of the present study was to measure the relative expression of circulating miRNA-224 in the serum of patients with HCV-related liver cirrhosis and HCC and to assess its usefulness in the diagnosis of HCC. MATERIAL AND METHODS: Forty-eight patients were classified into two groups: 24 HCV-related HCC patients (HCC group), and 24 HCV-related liver cirrhosis patients (LC group). A third group included 24 healthy volunteers (control group). Clinical examination, imaging studies and routine laboratory investigations, including serum α-fetoprotein (AFP), were done. Quantification of serum miRNA-224 expression was performed using real time reverse transcription polymerase chain reaction (RT-PCR). RESULTS: The relative expression of serum miRNA-224 was significantly higher in HCC patients compared to LC patients and healthy control subjects. Its level correlated positively with the serum concentration of AFP and with Barcelona Clinic Liver Cancer (BCLC) stage of HCC. By combining miRNA-224 relative expression with AFP, their diagnostic sensitivity, specificity and accuracy increased significantly (95.0%, 92.1% and 93.2%, respectively) compared with either of the two markers alone in discriminating HCC from liver cirrhosis. CONCLUSIONS: Serum miRNA-224 relative expression may aid in the diagnosis of HCC. Better diagnostic performance is obtained if miRNA-224 is combined with other tumor markers such as AFP.

Seattle protocol vs narrow band imaging guided biopsy in screening of Barrett's esophagus in gastroesophageal reflux disease patients.

Barrett's esophagus has 0.5% to 7% risk of progression to esophageal adenocarcinoma. The method of obtaining biopsies to diagnose Barrett's is challenging. Seattle protocol has been considered as the gold standard, however its difficulty limits its applicability in practice. Narrow band imaging guided biopsy has been proposed as an alternative.To investigate the accuracy, sensitivity, specificity and applicability of Narrow band guided biopsy as a screening tool for Barret's esophagus in gastroesophageal reflux patients.Endoscopy was done in 2 different sessions 2 weeks apart for 100 patients in Alexandria, Egypt. Patients had at least one of the following: Chronic Gastroesophageal reflux disease, frequent Gastroesophageal reflux disease, or two or more risk factors for Barrett's esophagus. All patients with known Barrett's esophagus were excluded.Seventeen patients had Barrett's esophagus either by one of the two techniques or by both, 4 patients by both methods, 7 patients by narrow band imaging alone and 6 patients by Seattle protocol alone (P < .001, κ = 0.461). Sensitivity, specificity, negative predictive value and positive predictive value for Seattle protocol were 58.8%, 100%, 92.2%, 100% vs 76.5%, 100%, 95.4%, 100% respectively for narrow band imaging. A mean of 7.73 samples/patient was taken in Seattle protocol vs 3.42 samples in narrow band imaging (P < .001). A mean of 8.63 minutes was consumed in Seattle protocol vs 2.65 minutes in narrow band imaging (P < .001).Narrow band imaging guided biopsy might have higher accuracy, sensitivity and negative predictive value as well as fewer number of biopsies and shorter time of the procedure compared to Seattle protocol which might increases its applicability as screening protocol for Barrett's esophagus. However, further larger multicentric studies are needed.

MicroRNA signature in patients with hepatocellular carcinoma associated with type 2 diabetes.

BACKGROUND: Nonalcoholic steatohepatitis-related cirrhosis is one of the liver complications in type 2 diabetes mellitus (T2DM) and reported to be a risk factor for developing hepatocellular carcinoma (HCC). A reliable screening biomarker of liver cirrhosis (LC) and HCC among T2DM patients is important to reduce the morbidity and mortality of this disease. MicroRNA (miRNA) is considered a key player in HCC and T2DM, and it might be a hidden culprit in diabetes-associated HCC, making it a promising reliable prognostic tool. AIM: To investigate the signature of serum miRNAs as early biomarkers for the screening of HCC among diabetic patients. METHODS: Expression profiles of miRNAs in serum samples of diabetic LC and diabetic HCC patients were assessed using Illumina sequencing; then, RT-qPCR was used to validate significantly altered miRNAs between the two groups. Candidate miRNAs were tested in serum samples of 200 T2DM patients, 270 LC patients, 200 HCC patients, and 225 healthy control subjects. Additionally, receiver operating characteristic (ROC) analysis, with area under the curve (AUC), was performed to assess the diagnostic performance of the screened miRNAs for discriminating HCC from LC and nonmalignant patients (LC + T2DM). RESULTS: Expression of the sequenced miRNAs in serum was different in HCC vs LC-positive T2DM patients. Two miRNAs (miR-34a, miR-221) were significantly up-regulated and five miRNAs (miR-16, miR-23-3p, miR-122-5p, miR-198, miR-199a-3p) were significantly down-regulated in HCC compared to LC patients. Analysis of ROC curve demonstrated that the combination of these seven miRNAs can be used as a reliable biomarker for detection of HCC in diabetic patients, as it could identify HCC with high diagnostic accuracy in diabetic LC patients (AUC = 0.993) and in diabetic nonmalignant patients (AUC = 0.961). CONCLUSION: This study validates a panel of serum miRNAs that can be used as a reliable noninvasive screening biomarker of HCC among T2DM cirrhotic and noncirrhotic patients. The study recommends further research to shed light on a possible role of c-Met in T2DM-associated HCC via the miRNA regulatory pathway.

Hepatocellular Carcinoma Occurrence/Recurrence after Direct-Acting Antivirals for Hepatitis C in Egyptian Cohort: Single-Center Experience.

BACKGROUND: Conflicting data have been published about the risk of hepatocellular carcinoma (HCC) following direct-acting antivirals (DAAs). We investigated the incidence of HCC occurrence/recurrence after DAAs therapy. PATIENTS AND METHODS: Retrospectively, we analyzed data of 392 patients with F3-4 fibrosis and cirrhosis treated by DAAs during the period from August 2015 to May 2018. In HCC-experienced patients, HCC treatment modality, and the duration between HCC management and DAAs initiation were recorded. In all patients, pretreatment clinicolaboratory evaluation, and imaging before, during and after DAAs were done. RESULTS: De novo HCC occurred in 7.6% of naïve patients, while recurrence appeared in 28% of patients with previous HCC. Pretreatment alpha-fetoprotein was an independent predictor of HCC occurrence, while the time between HCC ablation and the beginning of DAAs was the only predictor of HCC recurrence (p < 0.001). Half of the patients who started DAAs before 6 months had HCC recurrence, while patients who started DAAs at ≥6 months had no recurrence (p< 0.0001). CONCLUSIONS: Although HCC occurrence after DAAs was not high, recurrence was apparently high. Pretreatment alpha-fetoprotein is a predictor for de novo HCC. The time between HCC ablation and DAAs was the strongest predictor of recurrence.

Irritable bowel syndrome in Egyptian patients: plausible risk factors and association with intestinal protozoa.

The pathogenesis of irritable bowel syndrome (IBS) is not yet clear. Our study suggested parasitic infection and other plausible risk factors among Egyptian IBS patients. We studied 40 IBS patients diagnosed according to Rome III criteria (Group I), 40 with other gastrointestinal symptoms (Group II) and 40 healthy controls (Group III). Stool samples were examined using direct wet smear, sedimentation technique, trichrome stain and immune-chromatographic tests for Cryptosporidium parvum. IBS patients displayed a significantly greater percentage of Blastocystis hominis infection (45%) than non-IBS patients (20%) and healthy controls (10%). Dientamoeba fragilis was identified in two IBS patients. Detection of B. hominis was independent of demographic characters, IBS subtype, Helicobacter pylori infection or medications, but with a positive association with a history of antibiotic intake with IBS.

Clinical utility of urinary neutrophil gelatinase-associated lipocalin and serum cystatin C in a cohort of liver cirrhosis patients with renal dysfunction: a challenge in the diagnosis of hepatorenal syndrome.

OBJECTIVES: This study aimed to assess urinary neutrophil gelatinase-associated lipocalin (uNGAL) and serum cystatin C (sCys C) in liver cirrhosis patients with renal dysfunction and to evaluate their role in the diagnosis of the hepatorenal syndrome (HRS). PATIENTS AND METHODS: Forty-five liver cirrhosis patients were enrolled in the study and they were divided into three groups; the first group included 15 patients with normal renal function, the second group included 15 patients with HRS; and the third group included 15 patients with chronic kidney disease (CKD). There was a fourth group, which included 15 healthy controls. Liver and renal function tests, as well as the estimated glomerular filtration rate were determined. uNGAL was measured using the enzyme-linked immunosorbent assay, and the uNGAL/urinary creatinine concentration (UCC) ratio was calculated. sCys C was measured using the particle-enhanced immunoturbidimetric assay. RESULTS: The ratios of uNGAL and uNGAL/UCC were the highest among HRS patients. The combined uNGAL/UCC ratio and sCys C improved the sensitivity of diagnosis to 93.33% and specificity to 76.67%, with the highest area under the curve of 0.944, 95% confidence interval of 0.879-1.0 (P<0.001). The three biomarkers could successfully identify HRS at the following cutoffs: 84.94 ng/ml, 0.6 ng/mg, and 1.6 mg/l, respectively. Significant positive correlations were found between uNGAL, uNGAL/UCC ratios as well as sCys C and KDIGO stage in liver cirrhosis patients with CKD. CONCLUSION: uNGAL and a better uNGAL/UCC ratio can be used alone or together with serum cystatin C as early biomarkers for HRS among patients with decompensated liver cirrhosis. Moreover, uNGAL, uNGAL/UCC as well as serum cystatin C could aid the prognostic assessment of cirrhotic patients with CKD.

Profiling of plasma metabolomics in patients with hepatitis C-related liver cirrhosis and hepatocellular carcinoma.

AIM OF THE STUDY: The diagnosis of hepatocellular carcinoma (HCC) is usually late, due to the lack of early detection of biomarkers for HCC. Metabolomics analysis has emerged as a useful tool for studying human diseases. The objective of the study was to investigate the differences in plasma metabolites between hepatitis C virus (HCV)-induced cirrhosis and HCC. MATERIAL AND METHODS: 22 subjects with HCV-related liver cirrhosis and 22 subjects with HCC were enrolled. Clinical, routine laboratory and imaging studies were done. Gas chromatography/mass spectrometry (GC/MS) was used for metabolomics analysis of patients' plasma samples. RESULTS: 34 known metabolites were detected, of which five metabolites were identified to have the strongest discriminatory power for separation between HCC and cirrhosis groups: octanoic acid (caprylic acid), decanoic (capric acid), oleic acid, oxalic acid and glycine. These are 3 fatty acids (FA), a dicarboxylic acid and a glucogenic amino acid, respectively. No significant correlation was found between the relative intensities of the five metabolites and any of the patient or tumor characteristics (Child-Turcotte-Pugh (CTP) score, Barcelona Clinic Liver Cancer (BCLC) stage, number of focal lesions and size of largest focal lesion). ROC curve analysis was performed and area under the curve (AUC) was calculated, revealing that oleic acid, octanoic (caprylic) acid and glycine had higher positive predictive value than α-fetoprotein. CONCLUSIONS: The study of metabolomics (particularly involving FA) may help define distinct metabolic patterns to distinguish HCV-induced liver cirrhosis from HCC patients. Future research in this field is still needed, particularly concerning HCC treatment strategies which target fatty acid-related metabolic pathways.

Tolerability and effectiveness of generic direct-acting antiviral drugs in eradication of hepatitis C genotype 4 among Egyptian patients.

BACKGROUND: We investigated tolerability and effectiveness of generic, less expensive direct antiviral drugs in the treatment of hepatitis C virus genotype 4 (HCV GT-4) in an Egyptian cohort. PATIENTS AND METHODS: Retrospectively, we analysed data from 648 patients with HCV GT4 attending Alexandria Main University Hospital from January 2016 to May 2017 [488 treatment naïve/160 treatment-experienced/288 with chronic hepatitis/360 with cirrhosis]. Patients received generic sofosbuvir/ledipasvir (n = 168, treatment naïve = 136, treatment-experienced = 32) or sofosbuvir/daclatasvir (n = 480, treatment naïve = 352, treatment-experienced = 128) ± ribavirin. We assessed sustained virologic response 12 weeks after treatment, non-response, relapse, treatment discontinuation and drug adverse reactions. RESULTS: An overall sustained virologic response 12 weeks after treatment was achieved in 97.8%, non-response in 0.6%, relapse in 0.3% and discontinuation of treatment in 1.3% of patients. Sofosbuvir/ledipasvir ± ribavirin regimen attained an overall sustained virologic response 12 weeks after treatment in 96.4% of patients (100% of treatment-experienced vs 95.6% of treatment naïve, P = 0.28), vs 98.3% for sofosbuvir/daclatasvir ± ribavirin regimen (100% of treatment-experienced vs 97.7% of treatment naïve, P = 0.08). No severe drug adverse events or deaths were reported except anaemia due to ribavirin. CONCLUSION: Generic direct antiviral drugs used in treating Egyptian patients with HCV GT-4 demonstrated equal potency, safety and tolerability compared to original brands, with low cost which would help to provide treatment to a larger scale of patients.